Evelina London Childrens Hospital Induction Pack

September 2015

Welcome to ELCH Neonatal Unit. We hope you’ll enjoy your time here. The purpose of this document is to help you familiarise yourself with the unit and the way we work. Your learning, development and enjoyment are fundamental parts of what we hope to achieve as an educational and clinical team.

ContentsCONTENTS 3

ABOUT THE NEONATAL UNIT 5

Map of the Neonatal Unit 6

The rest of the hospital and facilities 7

The teams 7

Team role descriptions 8

The rota and leave 13

POSTNATAL WARD & BIRTH CENTRE 14

Birth centre checklist 14

Postnatal ward orientation 14

Transitional care on the postnatal ward 14

EDUCATION & TRAINING 16

Supervisors 16

List of educational supervisors 16

Resources 17

Teaching and meeting programme 17

Presentations 18

Clinics 18

Workplace-based assessments 19

Buddy groups 20 Green: Infection 21 Blue: Education 21 Red: Risk and safety 22 Yellow: Quality of care 22

Senior trainee administrative roles 23

COMMUNICATION AND HELP 24

Handover and team structures 24

Consultants 24

SBAR 25

Other useful bits of information 25

Antenatal folder 25 EPR and the labs 25 Contact numbers 26 Crash call and emergency buzzer 26

DOCUMENTATION & BADGERNET 28

Documentation standards 28

Badgernet 28 What is Badgernet for? 28 Accessing Badgernet 29 Getting Started with Badgernet 29 Selecting a baby 32 Admission 32 The summary of stay and daily updates 33 Patient discharge 33 NNAP: The national neonatal audit project 35 Badgernet reports 35

PRESCRIBING & MEDICINES SAFETY 36

Prescribing 36

Core standards for NICU prescribing 36

Gentamicin prescribing 37

Guidance for infusions 39

GOVERNANCE & GUIDELINES 41

Guidelines 41

Adverse incidents 41

Quality of Care 42 Resuscitation and transfer 42 Initial stabilisation on NICU 45 Initial respiratory support 47 Standards of care 48

Infection Control 50

Central line care package 50 Central Line Insertion Guideline 51 List of items for long line insertion 52 Assisting with central line insertion guideline 52 Central line dressing change guideline 55 Aseptic Non-Touch Technique 57

Nuggets and guidelines of the week 57

Introduction to postnatal ward feeding policies 57

NEONATAL UNIT INDUCTION CHECKLIST 59

About the Neonatal Unit The Neonatal Unit is on the 6th floor of the North Wing at St Thomas’ Hospital. There are currently 16 NICU cots, 6 HDU cots and up to 24 SCBU cots. We currently have building works on the unit which will increase our capacity, as well as improve the seminar room, junior doctors hub and parents’ spaces.

Consultants: • Grenville Fox • Anthony Kaiser • Camilla Kingdon • Tim Watts (head of service) • Karen Turnock • Susern Tan • Geraint Lee • Hammad Khan • Professor David Edwards • Gosia Radomska

The consultants take turns being the admitting physician to NICU, HDU or SCBU for 2 weeks at a time. During the other weeks, the consultants will have other commitments, but are able to offer support if the designated consultant is not around at the time.

Associate Specialist: Gosia Radomska is an associate specialist in neonatal medicine, with particular responsibility for lower dependency areas: SCBU and the postnatal wards.

Specialty trainees / clinical fellows: There are up to 25 whole time equivalent trainees /trust doctors and fellows. All of the trainees and fellows work on full shift rotas.

Nurses: Alex Phillips and Claire Alexander are the matrons. They lead a team of over 150 nurses.

ANNPs: Some of the nurses are Advanced Neonatal Nurse Practitioners, who carry out a mixture of medical and nursing roles including participation in medical rotas.

Others: Pharmacists, radiologists, physiotherapists, speech therapists, social workers, chaplains, paediatric specialists especially surgeons and cardiologists, dieticians and a host of others visit the Unit more or less regularly. Please be aware that some of these visitors may not be very familiar with the Unit, and be prepared to help them find their way around.

Map of the Neonatal Unit

The rest of the hospital and facilities The birth centres are on the 7th floor of the North Wing, the antenatal wards on the 8th, and the postnatal wards are on the 6th floor. The private obstetric Unit, the Westminster Suite, is on the 12th floor. Other children’s specialties and facilities are based in the Evelina London Children’s Hospital. The main exception to this is cardiac theatres, in East Wing. You will be shown round the neonatal unit and the maternity unit as part of your orientation, if transferring babies to other areas you need to have a porter with you, and do take time to explore routes to theatres and the Evelina. Not all doors are opened by your security pass, especially through East Wing.   There are plenty of places to eat or buy food on the ground floor. The Neonatal Unit staff room always has tea/coffee, plus fridges and microwaves. Please label all food you leave in the fridge with your name and date, and please wash-up and clear up after yourself!

The teams The work of the Unit can be considered as four clinical teams: ITU team: NICU consultant                                               Monday-Friday 08:00-17:30 or Consultant on-call                                            Evenings and weekends Shift Coordinator                                              08:00-20:30 Blue and Yellow Caseload Doctors                08:00-20:30 DA Doctor                                                          Monday-Friday 08:30-17:30

High dependency team: HDU Consultant                                               Monday-Friday 08:30-17:30 Consultant  on-call                                           Evenings and weekends HC doctor         (room 3 NICU)                      Monday-Friday 08:30-17:30 HDU doctor      (HDU room)                          Monday-Friday 08:30-20:30

Lower dependency team: Consultant and/or associate specialist         Monday-Friday 08:30-17:30 Consultant  on-call                                           Evenings and weekends Low dependancy coordinator (LC)                08:30-17:30 Postnatal ward doctor (PN)                            08:30-17:30 Special care doctor (SC)                                  Monday-Friday 08:30-17:30

Night team: Consultant on-call Shift coordinator                                                20:00- 09:00 Blue and yellow caseload doctors                   20:00- 09:00

Team role descriptions These descriptions are guidance: roles should be flexible, allowing for service needs to be covered and skill development needs to be addressed.

ICU Team ICU start: 08:00      finish: 20:30 Yellow caseload doctor:

• Is responsible for a ‘caseload’ of babies in the NICU, generally one room, and works closely with the shift coordinator.

• Attends 08:00 handover in seminar room • Attends teaching sessions • Ensures results flow charts are up-to-date before the ward round • Participates in NICU ward round • Undertakes tasks and plans from the round • Ensures fluids and TPN prescribed, drug charts up-to-date and

accurate • Takes the delivery bleep off the DA doctor at 16:00, and may need to

hold the delivery bleep during the day: especially weekends • Reviews results and babies as necessary • Participates in evening handover from 20:00

Blue caseload doctor: • Is responsible for a ‘caseload’ of babies in the NICU, generally one

room, and is expected to take more responsibility for these babies, dependent on experience

• Attends 08:00 handover in seminar room • Attends teaching sessions • Ensures results flow charts are up-to-date before the ward round • Participates in NICU ward round • Undertakes tasks and plans from the round • Ensures fluids and TPN prescribed, drug charts up-to-date and

accurate • May need to hold the delivery bleep, especially at weekends • Reviews results and babies as necessary • Participates in evening handover from 20:00

Green ICUc • Is the shift coordinator, with consultant support • Leads caseload allocation and task delegation • Supervises the yellow caseload doctor primarily but maintains an

awareness of all that is happening, including room 3. • Attends 08:00 handover in seminar room: ensures handover starts on

time • Attends teaching sessions • Participates in NICU ward round • Undertakes tasks and plans from the round • Holds the middle grade crash bleep

• Organises team briefing for preterm deliveries and ensures quality of care guidance followed

• Reviews results and babies as necessary • Ensures SEND is updated and accurate, especially for ‘ad hoc events’ • Takes handover from lower dependency team with HDU doctor:

delegates evening tasks if necessary and ensures these are undertaken • Participates in evening handover from 20:00, ensuring night team are

aware of SCBU/HDU and postnatal ward issues

DA Doctor start 08:30  finish 17:30

• Provides support for the ITU team during weekdays • Should join the end of handover to establish contact with the shift

coordinator • Generally holds the delivery bleep from 08:30-17:00 • Attends deliveries on midwifery request as per guidance • May form part of the team attending complex deliveries, dependent

on the shift coordinator • Undertakes tasks for babies on the birth centre (infection screens,

managing infants born to mothers with viral illness etc.) • Assists with administrative tasks related to admission, such as

entering details from maternal notes onto SEND • Ensures umbilical line packs are restocked • May cover a NICU room to allow the caseload doctor to transfer a

baby within the hospital

High dependency team All members of the high dependency team are expected to attend teaching sessions If the Unit is short-staffed it is expected that the high dependency team will take over the delivery bleep and DA role, or assist either the ITU or special care teams as necessary, as this tends to be the quietest area. Make use of any spare time with buddy group projects, audit work, preparation of presentations, or undertake workplace based assessments.

High dependency doctor HDU   start 08:30      finish 20:30

• Responsible for high dependency care babies room 1 SCBU • Attends morning handover from 08:30 to retrieve HDU worklists from

night team. • Attends teaching sessions • Communicates effectively with the phlebotomy team concerning

routine bloods, and ensures TPN bloods are coordinated with prescriptions, avoiding ‘night time’ bloods as much as possible: stable TPN bloods can be taken in the afternoons.

• Undertakes daily ward round, and if consultant not present on ward round liaises with consultant after round

• Keeps SEND up-to-date: daily data, ad hoc forms and summary of stay

• From 17:00 liaises with ITU shift coordinator to take joint handover from SCBU, postnatal ward doctor and HC (room 3 ITU), and undertakes tasks as necessary.

• Ensure updated written task list for night team for postnatal ward, special care and high dependency ready to give to night team at 20:00, using EPR handover facility for HDU and SCBU.

• Unless previously agreed with shift coordinator, provides verbal handover of room 3 NICU babies to night team at 20:00, and then leaves.

High care doctor HC start 08:30     finish 17:30

• Responsible for room 3 NICU under supervision of HDU consultant. • Attends morning handover from 08:30 • Attends teaching sessions • Ensures results flow charts are up-to-date before the ward round • Participates in room 3 ward round as directed by HDU consultant • Undertakes tasks and plans from the round • Ensures fluids and TPN prescribed, drug charts up-to-date and

accurate • Reviews results and babies as necessary • Hands over to HDU doctor with shift coordinator from 17:00.

Lower dependency team Low care coordinator LC start 08:30     finish 17:30

• Generally a more senior member of the team • Should aim to communicate briefly with the night coordinator at the

end of ITU handover for any significant changes or admissions over the night

• Provides support as required to SCBU and HDU areas: may need to prioritise discharge and transfer coordination or admit new babies to allow rounds to proceed smoothly on weekdays.

• Ensures SEND stay summaries are up-to-date and discharge summaries prepared accurately.

• Ensures ‘routine’ care is coordinated: retinopathy screening, immunisations, head scans, and undertakes head scans for lower dependency babies as needed.

• Supports postnatal ward doctor as necessary, working closely with associate specialist, reviewing transitional care babies as needed. Must be prepared to assist with discharge examinations when the postnatal ward doctor needs help

• Attends neonatal follow-up clinic on TUESDAY AFTERNOONS • At weekends:-

1. Undertakes review round on HDU and SCBU, following weekend plans. 2. Ensures postnatal ward doctor is supported and reviews postnatal ward

problems as necessary 3. Updates on call consultant about lower dependency areas and seeks consultant

review when necessary

4. Coordinates team handover to shift coordinator of babies that may need out-of-hours review or tasks that need undertaking: this must always be a clearly written handover using the EPR handover facility.

  Special care SCBU start 08:30     finish 17:30

• Responsible for special care babies • Prioritises discharges, working with LC. • Participates in consultant round on Monday and Friday, and leads a

review  round other days, maintaining liaison with outreach team in discharge preparation

• Communicates effectively with the phlebotomy team concerning routine bloods

• Ensures SEND data collection is up-to-date and that discharge summaries are prepared

• Hands over to the shift coordinator especially concerning blood results that need reviewing.

Postnatal ward and transitional care  PN start: 08:30     finish: 17:30

• A midwife is allocated to undertake examinations of the newborn every day as well as an ST2/3 doctor.

• There is phlebotomy support on weekdays, and you need to coordinate with this service for any blood tests needed

• The midwife will ensure babies are allocated to the correct list, and will bring birth centre HDU babies to your attention

• If there is no midwife:- 1. Fill in an IR1 form 2. Contact birth centre HDU, and visit any babies that need review 3. Contact Home from Home, babies there need adding to your list 4. Your role is to examine all the babies on your list, and to review transitional

care babies • Use the Neonatal Manual, especially chapter 14. • You will be based in the neonatal surgery on Postnatal East • A health care assistant will bring babies, parents and notes to you…. • If there is no HCA, contact the postnatal ward manager to find out

what alternative arrangements have been made • Liaise with the associate specialist, low care coordinator or SCBU

consultant every day. Try to make a list of problems to discuss with them in one go, unless a baby is unwell and needs immediate senior review

• Attend postnatal review round on Monday and Thursday with the associate specialist or SCBU consultant, and the postnatal ward manager: discuss babies who have been in several days, such as withdrawing babies needing review of social services issues.

• The Lansdell Suite is a private ward, you will be asked to do checks on babies not under full private care.

• The postnatal wards can be very busy. Do enlist help to admit babies or undertake investigations on a baby when necessary.

• Antibiotics on postnatal wards are given at 10:00 and 22:00, the doctor will need to give the first dose.

• Provide a full written handover to the shift coordinator of any tasks that need doing

Night team: N start: 20:00     finish: 09:00 3 doctors working in a similar way to the daytime ITU team. All members of the team may stay for morning teaching but this is your choice. Yellow

• Is responsible for a ‘caseload’ of babies in the NICU, generally one room, and works closely with the shift coordinator doctor

• Usually carries the delivery bleep • Attends handover at 20:00 and updates the workbook • Does a ‘night round’ of their caseload with the shift coordinator • Completes ‘blue sheets’ for all their caseload and completes SEND

daily updates • Carries out plans and tasks for babies and reviews babies as necessary,

including SCBU and PN jobs delegated by the shift coordinator • Performs daily bloods on babies that need them: ‘routine’ bloods

should NEVER be taken between midnight and 05:00 • Leads the 08:00 handover for their caseload

Blue • Is responsible for a ‘caseload’ of babies in the NICU, referring to the

shift coordinator or consultant with any concerns • May carry the delivery bleep • Attends handover at 20:00 and updates the workbook • Does a ‘night round’ and reports briefly after this to the shift

coordinator • Completes ‘blue sheets’ for all their caseload and completes SEND

daily updates • Carries out plans and tasks for babies and reviews babies as necessary,

including SCBU and PN jobs delegated by the shift coordinator • Performs daily bloods on babies that need them: ‘routine’ bloods

should NEVER be taken between midnight and 05:00 • Leads the 08:00 handover for their caseload

Green • Is the shift coordinator, with consultant support • Leads caseload allocation and task delegation. • Attends 20:00 handover in seminar room • Takes handover about SCBU and postnatal ward from day shift

coordinator and ensures necessary tasks are undertaken • Supervises the yellow doctor primarily but maintains an awareness of

all that is happening (on intensive care, HDU, special care and in maternity areas)

• Ensures team co-ordinates breaks. • Leads a night round with the yellow doctor, supports the blue doctor

as necessary • Undertakes tasks and plans from the round

• Helps update SEND and at weekends coordinates weekly stay summary update

• Holds the middle grade crash bleep and is available to junior doctors, nursing staff, midwives and referring hospitals at all times

• Generally contacts the consultant for help or advice: always call the consultant if you are detained away from the Unit for a long period of time

• Participates in handover from 08:00, ensuring day team are aware of SCBU and postnatal ward issues

Other shifts Audit / Research days AR  start 08:30     finish 16:30 These are for senior trainees working on specific projects, or to attend clinics for training purposes. Use of this time when allocated needs to be discussed with your supervisor.  Some senior fellows are contracted for 25% of their time for professional development and will have more AR days. You are expected to be in the hospital, unless agreed in advance with your supervisor, and in unavoidable circumstances (the most likely one being unexpected sickness) you may be asked to take on a clinical role.

The rota and leave You will already know a bit about how the rota works. The nature of the work on the Unit dictates a heavy weekend and night workload, which makes swaps and changes difficult. You are given the opportunity to request annual leave and study leave, please ensure you do, and comply with the time scales you are given. Study leave requests need to be followed by a completed study leave form: in general personal study time is NOT approved. We do not expect you to change from the rota except in exceptional circumstances, which need to be discussed with Karen Turnock. If Karen is unavailable, then please discuss with Geraint.   If you need to take sick leave, please let us know early, you need to ring NICU (88847) and speak to the most senior person available, consultant during the day, the shift co-ordinator out-of-hours. Do NOT leave a message with the nursing staff.  Please try and estimate how long you will be off, and make arrangements to keep us informed of the day you will return to work. You must complete a self-certification form and hand it to the secretaries on your return. A GP certificate will be required for longer periods off. For sick leave, every effort will be made to rearrange shifts or obtain a locum, but sometimes it may be necessary to run without a full team. Please check Trust guidance on the Intranet for applying for compassionate and other forms of leave.

Postnatal Ward & Birth Centre

Birth centre checklist The NNU induction programme will cover much of the information to enable neonatal junior medical staff to function independently on Birth Centres. In addition, there will be an orientation session for the Birth Centres. The aim is to ensure the doctor is able to carry out their role on Birth Centre in resuscitation, assessment and management of the newly born baby, to communicate appropriately with midwifery staff and to obtain senior help.

Postnatal ward orientation All ST2/3s have an orientation to the postnatal ward, including mandatory breastfeeding training.       Friday 11th September Monday 14th September    Postnatal ward orientations are run by Dr Gosia Radomska (associate specialist). Please make sure you have spoken to her about starting times and meeting places. The people allocated to each day will be on the initial rota.

Transitional care on the postnatal ward Personnel Postnatal Ward (PNW) neonatologist (bleep 0681) allocated to Postnatal Transitional Care clinic; supported by Low Care shift doctor (bleep 0682) Senior responsibility: Gosia Radomska, Neonatal Associate Specialist; SCBU Neonatal Consultant when Dr Radomska not available.

Inclusion criteria for Transitional Care: The following babies who are being cared for on the Postnatal Ward or Birth Centres are classified as Transitional Care:

1.    Prematurity <37 weeks until discharge home 2.    IUGR <2nd centile plotted at actual gestational age until discharge home 3.    Jaundice requiring phototherapy, from commencement of phototherapy until the day following discontinuation of phototherapy (ie while bilirubin levels are still being monitored) 4.    Infection or infection risk requiring antibiotics, from day of commencement of antibiotics until day of discontinuation

5.    Infant of a diabetic mother, from birth until the day of discontinuation of glucose level monitoring 6.    Withdrawal observation, from birth until discharge 7.    Readmission from community for neonatal reasons, from admission until discharge from PNW 8.    All babies discharged to PNW after SCBU admission, until discharge from PNW 9.    Babies with concomitant medical concerns. This may include requirement for major feeding support (eg Down’s Syndrome, cleft palate, hypernatraemic dehydration) or known medical conditions (eg cardiac, renal), until discharge from PNW

Please note: Infants of HIV positive mothers and babies with renal pelvic dilatation on Trimethoprim are not TC cases. Every baby has to have “Full examination of the Newborn” (so called baby check) within 72 hours of life.

Process & documentation Any babies identified as TC by midwives or neonatologists on PNW are added and any baby discharged from TC are crossed off the PiMS list by Postnatal Ward Clerks (8:30 – 17:00) and by Postnatal Customer Care Receptionist after 17:00. PNW neonatologist should liaise with WC/CCR at the end of their shift. Copy of the Handover List is stored in the folder in the PNW surgery.

Clinical review Neonatologist & EON midwife organise daily work using the handover list. Prioritisation should be by clinical need and requirement for discharge to ensure patient flow. a)    Baby for TC care – babies to be seen daily until discharged from TC (ie no longer meet criteria for TC) b)    Baby for review for midwife concerns c)    Baby for routine newborn examination – all babies in this group should be seen by the EON midwife allocated to the PN clinic. If there is no midwife allocated for the clinic, the neonatologist should complete an IR1 and inform either the Low Care doctor or Dr Radomska to ensure workload is able to be covered.

Discharge from TC This will may be at discharge from PNW (home, to NNU or other destination eg ECH), when the neonatal team consider the baby is no longer requiring TC or at the end of TC as stipulated in the criteria (eg criteria 3-5). The TC/PN neonatologist will complete an electronic discharge letter on EPR.

Education & training

Supervisors You will have been given details about education and training during your induction.  You need to arrange to meet your supervisor within the first couple of weeks. All consultants will provide clinical supervision to all trainees as necessary, and all will undertake work place based assessments on request. Senior trainees wishing to undertake assessments are advised to attend training if they have not already done so. You are advised to review your self-assessment of competency with your supervisor, especially concerning equipment training. There are regular multi-professional equipment training sessions advertised on the board in the seminar room, please attend these.

List of educational supervisors ST2/3 Harry Dougherty Su Tan Ahtzaz Hassan Tim Watts Emily Hassler Grenville Fox Hannah Mills Geraint Lee Madhuja Mitra Camilla Kingdon Tariq Nawaz Camilla Kingdon Megan Peng Anthony Kaiser Catherine Sikorski Hammad Khan Emily Titherington Anthony Kaiser Hannah Zhu Tim Watts

Fellows Neil Atkinson Su Tan Irina Branescu Geraint Lee Ioanna Dumitrascu Hammad Khan Sorana Galu Grenville Fox Anastasia Katana Geraint Lee Anna Paltrinieri Karen Turnock

ST6/7/8 Prathiba Chandershekar Hammad Khan David Cox Karen Turnock Mari Evans Anthony Kaiser Tatiana Hyde Grenville Fox Charlotte Jackson Karen Turnock Siobhan Jacques Geraint Lee Jonathan Keene Tim Watts

Bethany Smith Camilla Kingdon Maria Stiles Su Tan

Resources The seminar room cupboard will hold a number of books and some simulation equipment. There are a number of books in the doctors’ office, plus a KCL computer, which allows ready access to a wide number of on-line journals. The Neonatal Unit has a blog – Evelinanicuteaching.wordpress.com, which is intended to be owned by the trainees. Teaching timetables, learning objectives, teaching outcomes, journal articles and induction material will be placed on the blog. News is shared on the notice board in the staff room and the Top Tips board in the seminar room. Quality improvement projects are also shown on the “Big Blue Board” outside the staff room.

Teaching and meeting programme There are plentiful teaching opportunities on NICU and across ELCH. The principle sessions are Tuesday and Thursday mornings. There is a weekly postgraduate meeting on Wednesday mornings. These all take place in the seminar room. We have a weekly multiprofessional unit meeting at 13.30 on Wednesday. This is a forum for sharing staff news, unit plans etc.

Presentations You are likely to be asked to present on Fridays at the perinatal meeting, and sometimes at the GGKT. Perinatal meeting presentations need to be concise: do ask a senior trainee or your supervisor to go through your presentation if you need help. Senior trainees can become involved in teaching medical students and junior trainees. The education buddy group will also allocate journal clubs and literature reviews for presentation in teaching slots.

Clinics With shift work it can sometimes be difficult to find time to attend clinics.  In the current rota, the Audit/Research shifts are a good time to attend clinics.  It may also be possible to attend clinics on an ‘LC’ shift, especially when Dr Radomska is around but not covering SCBU: please negotiate with the rest of the team. The LDc shift on a Tuesday includes the commitment to attend the Tuesday afternoon clinic, held in Evelina Ocean Outpatients. The neonatal team clinics are listed in the weekly timetable. Subspeciality paediatric and fetal medicine clinics are detailed below:- Neurology Movement Therapy Clinic  (ECH OPD) Lower limb – every Thursday 9 – 12.30 Upper limb – every Thursday 14.15 – 16.15 (Contact : Dr JP Lin)

Feeding Clinic  (ECH OPD) Monday 10h00 – please contact SALT prior to attending on 86232

Clinical Genetics Dysmorphology Clinic Every Friday morning in the Genetics Dept, 7th Floor New Guy’s House (Contact : Dr Shehla Mohammed – please let her know if you want to attend on 81373)

General nephrology Most Tuesday afternoons in ECH OPD (Contact : Dr Chris Reid on bleep 1041) Combined Fetal Medicine/Nephrology Monthly on Thursdays at St Thomas’

Fetal Medicine There are 3 consultants with various lists between them. Dr Sri Sankaran

Dr Dhamintra Pasupathy Prof Pippa Kyle You will be welcome at any of them but please contact the consultant in advance to make sure others are not already attending.

Metabolic Medicine General Metabolic clinic    Every Friday morning, ECH OPD PKU Clinic                            2nd and 4th Monday afternoons Please liaise with Dr Mike Champion on 84694

Cardiology There are frequent cardiology clinics. Please contact Dr Owen Miller on 84561

Workplace-based assessments The guidance here is to encourage you to undertake as many assessments as you can: junior trainees should aim to be assessed the first time they undertake any procedure here, and these can be completed as DOPS. DOPS Assessments need to be undertaken by a senior trainee (ST6+ or equivalent), an ANNP or consultant. The procedures in the ‘unlikely’ list are usually consultant assessments. Expected list: (inexperienced trainees should focus on this list)

• Intravenous cannulation (preterm / term / exprem) • Venepuncture • Heel prick sampling • Arterial line sampling • Immunisations – im injections • Lumbar puncture • Umbilical arterial catheter insertion • Umbilical venous catheter insertion • Term endotracheal intubation • Administration of surfactant

Possible list: (all should try and gain these skills and perform for DOPS) • Preterm endotracheal intubation • Percutaneous central venous line insertion • Peripheral arterial line • Basic cranial ultrasound

Unlikely list: (make the most of any opportunity to undertake a DOPS for these skills, especially more senior trainees)

• Exchange transfusion • Needle thoracocentesis • Chest drain insertion • Ventricular tap

Mini CEX

Here are some suggestions, but just about any of your roles on the Unit can be assessed as a mini CEX. Again you assessor needs to be senior to you and at least some need to be undertaken by consultants.

• Normal newborn examination (can be done by junior trainees during postnatal orientation)

• Talking to a parent about a common neonatal issue (eg. jaundice or hypoglycaemia)

• Handover • Admission summary • Presenting a baby on a ward round • Evaluating a blood gas and adjusting ventilator parameters • Neurological assessment of a cooled infant • Starting and interpreting CFM • Assessment of fluid balance

CBDs All consultants are very happy to undertake CBDs, and we like at least one CBD to be undertaken with your educational supervisor. You do need to plan a bit in advance and book time with the consultant, usually email is the most efficient way to do this. Junior trainees are encouraged to use their ‘allocated’ patients and CBDs can be a good way to identify a case to present during the teaching sessions. Just about any baby you have been involved with can be used as the basis for a CBD, it is helpful if you let the assessor know who you have chosen in advance.

DOC Senior trainees requiring DOC assessments are reminded that discharge summaries can be used in addition to clinic letters. These need to be summaries you have finished off for babies you have discharged.

Buddy groups You have been allocated to one of four ‘buddy groups’. These groups are made up of a mixture of junior and senior trainees and nurse practitioners. The intention is to provide you with a smaller supportive structure by encouraging these groups to take an interest in each other: for example by checking competency progression for the junior trainees. Each group is given a project area to work on to provide a focus and encourage the development of the team. All the senior trainees have individual administrative roles, some of which may be related to the buddy group project. Audit projects are likely to be part of the buddy group remit: these may be part of your ‘project’, be suggested by the consultant team, or developed by yourselves. The audit lead for the unit is Karen Turnock, she can provide support and advice about audit proposal and approval. Access to the online audit system for proposal and approval is through the Intranet, GTi. The four buddy groups are known by colour, project areas are:

1. Green: Infection

2. Blue: Education 3. Red: Risk and Safety 4. Yellow: Quality of Care

In the past, face-to-face meetings have been attempted and are not actively discouraged, but using hospital email to circulate discussion and ideas amongst your group works well.

Green: Infection Leads: Dr Tim Watts (consultant with interest in infection) Dr Hammad Khan Sister Maria Guzman (infection control link nurse) Sister Margaret Gannon (infection control link nurse) Team members:

• Ahtzaz Hassan • Hannah Zhu • Jonathan Keene • Emily Hassler • Sorana Galu • Mari Evans • Tatiana Hyde

Suggested areas for buddy group involvement: • Regular audit and observation of practice in preventing hospital

acquired infection • Hand hygiene • Documentation of intravenous and arterial lines, peripheral and

central Peer educators and ‘policing’ medical team in encouraging best practice to prevent hospital acquired infection. Audit of percutaneous long line documentation and establishment of standard for documentation that will allow monitoring of infection as indication for removal of long lines Audit of antibiotic use on postnatal ward. Participation in Matching Michigan project to reduce long line infection rates.

Blue: Education Leads: Dr Hammad Khan Dr Geraint Lee Dr Su Tan Marcia Chilton (practice development nurse) Team members:

• Maria Stiles • Ioanna Dumitrascu • Neil Atkinson • Prathiba Chandershekar

• Catherine Sikorski • Harry Dougherty • Megan Peng • Laura Govender

Suggested areas for buddy group involvement: Organising teaching for Tuesday and Thursday morning sessions Organising and leading skills teaching and simulation sessions on Friday morning Establishing ‘scenario bank’ from real life experiences to use in future simulation sessions Developing feedback to ensure needs of junior doctor team at all levels addressed by teaching programme Evolution and maintenance of website

Red: Risk and safety Lead: Dr Karen Turnock (lead for risk management) Team members: • Anna Paltrineri • David Cox • Charlotte Jackson • Madhuja Mitra • Emily Titherington • Bethany Smith

Suggested areas for buddy group involvement: Regular audit of prescribing standards and implementation of NHSLA care bundle for gentamicin Multi professional work to support high standard of medicine administration safety Documentation Handover strategies Issues from incident forms

Yellow: Quality of care Lead: Dr Geraint Lee Team members:

• Norie Williams • Siobhan Jacques • Irina Branescu • Anastasia Katana • Hannah Mills • Tariq Nawaz

Suggested areas for buddy group involvement:

Regular review of compliance with standards outlined in ‘quality of care of preterm infant’ Peer education to encourage knowledge of guidance and compliance Development of feedback to multiprofessional team Full audit of guidance

Senior trainee administrative roles Each senior trainee has a specific administrative role to fill. This may or may not tie in to the buddy group role. Jonathan Keene Neonin database Bethany Smith Fetal medicine liaison Sorana Galu Fetal medicine liaison Anna Paltrinieri Head scan & imaging Maria Stiles  Education subgroup – Tuesday/Thursday teaching Ioanna Dumitrascu Education subgroup – Simulation Tatiana Hyde Planet 2 Prathiba Chandershekar X-ray meeting David Cox Perinatal meeting Siobhan Jacques Preterm Quality of Care  Irina Branescu Preterm Quality of Care Mari Evans Trainees Forum Charlotte Jackson Trainees Forum

Similar to buddy group roles, these are not the only things you can be involved in!

Communication and help

Continuity of care is dependent on good team communication

Handover and team structures Handover of NICU babies is held in the seminar room at 08:00 and 20:00 and should start promptly. The coordinator for the shift that is ending with the handover needs to start the handover on time and should ensure that if team members need to attend deliveries or undertake emergency tasks, a full handover can still proceed.The structure of the morning handover follows that of the night summary sheets, but trainees should develop awareness of the need for greater depth of background history for some babies and for brief updates on other babies, depending on the structure of the team receiving handover and the individual baby. It is perfectly acceptable to ask what is needed, and you can expect to receive feedback on your handover. Evening handover should be similar to the morning in structure, but does not involve written sheets. There is a neonatal handover list function within EPR that should be used to generate handover lists, do not make handwritten lists and take care to shred any printed lists.Remember that SEND gives accurate background information about all the babies in the Unit and is easy to refer to.  Patient information can be projected during handovers. Handover from the lower dependency areas needs to be printed. Use the EPR handover list function.  These lists need to be handed to the HDU doctor on weekdays, with involvement the shift coordinator, and the shift co-ordinator directly at weekends. In the mornings, the lower dependency team should receive an up-to-date written handover for each lower dependency area and there should be opportunity at the end of the NICU handover for a brief verbal update for any complex events over the night.

Consultants The attending consultant is available at any hour of day or night: usually out-of-hours the shift coordinator will contact the on call consultant although in an emergency any member of nursing or medical staff can call. All consultant contact numbers are displayed in the doctors’ office and are with switchboard. The consultant is generally present in morning handover and on the ward round to discuss and clarify management plans. On occasions when this has not been the case, particularly at weekends, you can expect to have the opportunity to sit and go through all the babies with the consultant: use this to clarify any concerns or questions you may have.

SBAR SBAR is a useful tool for communicating effectively with all members of the multidisciplinary team:

• Situation: Identify self, patient, location and concern • Background: History, current treatment • Assessment: Vital signs, lab results, changes that have given rise to

concerns • Recommendations: “What I need from you is……”, clarify and define

time/reason to call back

Other useful bits of information

Antenatal folder • Kept behind the NICU desk. • Updated after the weekly meeting with fetal medicine • Details of all cases notified antenatally where the baby is likely to

need paediatric input, e.g. because of fetal abnormality such as renal pelvic dilatation or congenital heart disease, or because of adverse maternal circumstances such as drug abuse.

• Summary list in the front, detailed plans filed in alphabetical order, which should be transferred to the baby’s notes.

• Usually have a plan of management for after birth; read them before baby is born if possible.

EPR and the labs • Check through the Nugget on the admission process • If the system is down, or you need urgent tests before a baby is on

EPR, use paper request forms (with allocated number) but expect results to come through RRS. You should have an RRS access number, if not you are likely to find another member of the team has access, or contact the lab staff o If the whole system is down for maintenance, check your

hospital email for information on accessing results. • Take care labelling samples - it needs to be possible to see the

amount of blood in the sample tube. • Send everything except blood cultures and respiratory secretions

through the chute: do check it goes. • If the chute is not working call the porters or take the sample to the

5th floor yourself. • Make sure you phone the lab if it is out of hours

Contact numbers Frequently used numbers are kept on the desks on NICU and SCBU. Other numbers can be found from the Trust Intranet, or the voice recognition switchboard. Consultant home and mobile numbers are on the board in the registrars’ office.

- Crash       2222 and say “Neonatal crash call” and destination - Security    3333 - Bleep numbers      Phone 737–wait for response–bleep no–extension

no Coordinator               0241 Birth Centre bleep    0678

Blue caseload Dr.       0680 Postnatal                    0681 Low care                     0682 Bleeps must be carried! Crash bleeps are 0241 and 0678 + nurse-in-charge

Dr Radomska             2198 Dr Fox                         1134 Dr Kaiser                    2151 Dr Kapetanakis          2197 Dr Khan                      1311 Dr Kingdon                 2178 Dr Lee                         2199 Dr Tan                        2212 Dr Turnock                1477 Dr Watts                    1764

Pagers (757) 861881

Other numbers • NICU                   84051   88847 • SCBU                  84021    88846 • Secretaries        84030    83944 • Antenatal ward       80676  80677 • Birth Centre                82975 86867 • Postnatal wards     South   85154    West  85151

              East  85149

Crash call and emergency buzzer The crash call alerts the middle grade crash bleep, the delivery bleep holder, and the nurse in charge of NICU. The system is tested each morning: you must respond by speaking clearly into the bleep, and the nurse in charge needs to phone switchboard. If there is a real crash call, remember to speak into the bleep to acknowledge you are responding.  

The emergency buzzer can be operated from any cot space on the neonatal unit, use it to call for immediate senior assistance, and if you hear the buzzer, do respond unless you are in the middle of another task – a light will be on outside the room you need to get to.

Documentation & Badgernet

Documentation standards • All entries in Health Records should be in black ink • Every entry must be legible • Every entry must have:

o Date e.g. dd/mm/yy o Time, using 24hr clock e.g. (18:30) o Your name in block capitals o Your signature o Your job title o Your GMC number

• Corrections must be crossed through with a single straight line, signed and dated

See Trust Health Records Policy on the Intranet for more information. Some documentation is routine: night summaries, ward rounds. Please also make sure you document reviews, procedures, and discussions contemporaneously. Blue paper is used for all inpatient notes, and pink paper for parental communication.   Take time to look through a set of notes, particularly the Neonatal Record that all babies born here have. Also review the charts, especially those you will use to record test results.

Badgernet Our data management system has migrated to Badgernet from SEND. The next subsections give you important information on how Badgernet is used on this Unit. Please make sure you read them, as you will find it is subtly different from SEND. All our admission and discharge documentation is done through Badgernet. Daily data updates need to be completed every day! When completing this, information can be inputted for the discharge summary, leading to a more thorough summary and less work for the discharging doctor.

What is Badgernet for? Badgernet is used to generate summaries at admission and on discharge to home, another hospital or another part of this hospital. Badgernet provides benchmarking data to compare us to other UK neonatal units through the National Neonatal Audit Project (NNAP) Badgernet records activity: counts the number of intensive care, high dependency and special care days, plus diagnoses entered into Badgernet

are used for coding. This proves what we have been up to and informs funding streams – so the service is paid for. Badgernet can also be very useful to you. If completed well, it provides a rapid overview of any baby on the Unit, it will remind you of routine tasks that may be needed, and identifies essential information missing from the data you have entered. Completing Badgernet is a team effort; data entry should not be routinely delegated down, and should not be handed over, except for admissions that happen immediately before handover.

Accessing Badgernet Badgernet can be found as an icon on the desktop of all computers on the Neonatal Unit and Hospital Birth Centre. If you are a current SEND user your user name and password will be the same. You may find you still have access to the data from your previous place of work. If this is the case, please contact them and ask to be removed from their users list. New users will be given their username during induction. IF YOU CAN NOT LOG ON TO SEND IT IS VITAL THAT YOU CONTACT GERAINT LEE, KAREN TURNOCK OR GRENVILLE FOX TO SORT OUT YOUR ACCESS.

Getting Started with Badgernet Accessing the BadgerNet Platform Accessing the BadgerNet Platform is a simple process. Your local IT department will have installed a BadgerNet Client onto each workstation within a care location as part of the implementation process. Users will be able to see a BadgerNet icon on their desktop as illustrated in the screen shot to the left. By double clicking on the icon, users will then be taken to the BadgerNet home page. Once users have opened the BadgerNet Platform, they must then log on to be able to view or amend patient data.

Logging-in Logging-in is a simple process and is fundamental to ensure the security of the BadgerNet Platform. As an authenticated BadgerNet User, you will only have permission to create, update, or and/or view patient records from specific care locations as determined by your local BadgerNet User Manager. Users will only be able to update patient records for units they have access to. To log-in, a Username and Password is required. These will be allocated to all users by the local BadgerNet User Manager at your care location. When logging into the BadgerNet Platform for the first time, use the username and the password provided by your local BadgerNet User Manager. You will then be required to change this password to one of your own choice. The log-in screen can be initiated in one of three ways as described and illustrated in the screen shot below:

1. A user can select to log in Under “User Details” by clicking on “User log-in….” 2. Under the heading “Patient Selection”, click on “Select existing baby care episode” and the log-in screen will appear. 3. The bar at the very bottom of the System Menu, which is visible in every view of the system, allows users to log in by clicking on “click here to log in”.

Once the log-in screen has been initiated, enter your Username and Password. Remember that passwords are case sensitive. Training Exercise: Try logging-in using various methods. Find where your username appears on the system once you are logged in.

Important Notes about Passwords The BadgerNet Platform provides a safe and robust framework for managing patient data. In order to ensure that the password controls are as effective as possible, users should be aware of the following Your Username and initial Password will have been given to you by your Local BadgerNet User Manager.  Your Username will always remain the same.  You will be prompted to change your Password on your first log-in to BadgerNet.

• A password should be at least 5 characters long and should be a combination of letters and numbers in either lower or upper case • Your Username will appear as text on the screen. • Your Password is encrypted for security reasons and will appear as a series of dots to enable you to keep it private and safe  • Keep your Username and Password safe and do not let other people know your password. • Each individual user must have their own Username. Do not use generic usernames such as “doctors”, or “frontdesk”. Always use your own login and your own password.

Training Note: Passwords are integral in both protecting data as well as creating an audit trail for BadgerNet. It must be emphasised that users must use their own logins and passwords at all times.

How to Change your password To change your password, select the ‘change your password’ option under user details and simply follow the instructions on the screen. These will prompt the user to:

1. Type the old password 2. Type the new password 3. Type the new password again to confirm

Forgotten Passwords If you forget your password, you should contact your Geraint Lee, Karen Turnock or Grenville Fox and ask them to reset your password. Note

: Clevermed support staff will not have access to your password and are not authorised to reset user passwords if forgotten.

Logging out To log out of the BadgerNet Platform when you have finished working, either: • Select “Log out” from the BadgerNet System Menu – this will log you out without any confirmation requirement. • Your name will always appear on the bottom left hand side of the screen when you are logged onto the system. You will always see this no matter which page you are on in the BadgerNet Platform. If you click on your name you will be prompted to log-out. Automatic logout Note: If after four minutes a logged-in user has not used the BadgerNet Platform their username on the bottom left hand side of the screen will start flashing to warn them that the system will time automatically log them out. After a total of five minutes of not using the BadgerNet Platform, logged-in users will be automatically logged out.

Selecting a baby The following is a hyperlink to the instructions from Badgernet. They can also be found on the opening page of the Badger login.

NNUSelectingABaby

Admission Background information is provided in the Badgernet summary (see below) but you must still provide a narrative of your examination, assessment and plan. If you choose to include this in Badgernet you must ensure it is a full and detailed account. Do not use abbreviations. Admission forms Hints

General baby details form These forms are at least partially completed from the hospital system Fill it in! Take care time and date of birth correct. Don’t need length. Blood group and worst base excess in first 12 hours need completing later. ‘Final outcome’ needs to be left blank. Centiles can be read off the growth chart once you have entered weight and head circumference

Parents details form Usually in maternal notes but good opportunity to ask, especially father’s details.

GP/Contacts details form Always search the GP database-use maternal GP details from notes or EPR, search with  postcode and GP name.

DON’T TAKE NOTES AWAY FROM THE MOTHER: USE THE COMPUTERS ON THE BIRTH CENTRE TO TRANSFER INFORMATION INTO BADGERNET

The person best placed to complete the discharge summary is often not the SCBU doctor, rather the team taking care of a patient in intensive care. Therefore the information recorded in the daily ”comments for discharge summary” is very important.

The summary of stay and daily updates The following is the hyperlink to the Badgernet guidance. This can also be found on the Badgernet help page:

NNUDailySummary

The summary of stay fields need to be updated regularly to avoid trawling through enormous sets of notes prior to discharge. It is a team responsibility. This can now be completed by the person completing each daily summary and carried forward to the next day. Please remember to input ad-hoc events such as ROP screens, cranial ultrasound, blood cultures, immunisations etc.

Patient discharge The below is a description of how to discharge a patient on Badgernet (again also on Badgernet help page).

Pregnancy details form All information in maternal notes. Complete fully. Hospital of booking should be the original place of booking. Tick ‘unknown’ for any serology that isn’t done as part of screen here, if no results in notes always search on EPR.

Labour and delivery details form Some from maternal notes, remainder from team at delivery: avoid abbreviations in free text, and check by reading through afterwards.

Previous pregnancy details form Please be circumspect in listing ToPs etc: on-going pregnancies into 2nd trimester likely to be of most importance for here, others can be included in ‘total number’

Admission details form Complete. Primary reason for admission should identify specialist referrals…Again, avoid abbreviations in the free text and read it through – don’t repeat resuscitation information. Always add your name at the end

Routine examination of the newborn

Tick off all aspects of examination you have undertaken – omissions will then be clearly listed in the summary.

At the end check the DATA QUALITY CHECKLISTS: check through any red crossed items and fill in where possible: don’t enter ’unknown’! THERE MAY HAVE TO BE SOME RED CROSSES eg. retinopathy screening date

NNUPatientDischarge

It is incredibly important to discharge to the correct destination, so that the patient can be properly admitted on their new unit and the information is shared accurately.

NNAP: The national neonatal audit project The data submitted for NNAP is from within Badgernet. Much of it you will be prompted to complete from the data quality checklist: just fill in the areas you are directed to, do not use ‘UNKNOWN’, if it hasn’t happened yet, leave it blank! Some NNAP data comes from other parts of Badgernet, particularly ad hoc event forms for infection screens. Fill these in contemporaneously including all symptoms or signs that have prompted the infection screen, and respond to the prompts for culture results. Encephalopathy data is generated from the neurology daily data so take particular care to complete this for term babies over the first 3 days. Line days and feeding data are the subject of current NDAU (Neonatal Data Analysis Unit) projects.

Badgernet reports NNUReports

Admission and discharge documentation for our notes consist of printouts of the admission and discharge summaries from Badgernet. Therefore the data needs to be as detailed and complete as possible. Once a report is completed, please preview it to check it’s accuracy, before printing it off. Once it is printed then it should be dated and signed, before filing in the notes.

Prescribing & Medicines Safety

Prescribing Prescribing for neonates is a challenge, as the dose of many drugs depends not only on weight but also on gestation and age. Do NOT try to memorise doses, always use the formulary: there are plenty of them around and if supplies are running low, speak to the ward pharmacist – Nikesh Gudka. Please familiarise yourself with the core standards, most of them are basic, but none of us wants to be involved in a serious medication error. The following pages contain core standards, specific guidelines regarding gentamicin prescription and also guidance for infusions.

Core standards for NICU prescribing All charts should have:

• Patient sticker or name / date of birth / hospital number • Ward • Attending consultant • Date of admission • Date chart written • Working weight

All charts should have drug allergy box completed, signed and dated.

If the patient has a penicillin allergy a ‘penicillin allergic’ sticker must be attached to the chart. All prescriptions should be legible, written in black ink, dated (dd/mm/yy) and signed, print your name and registration number.

• Avoid brand names • Do not use abbreviated names (e.g. sodium chloride not NaCl) • Document administration times clearly, in consultation with nursing staff

Follow guidance for using gentamicin stickers. • Prescribe ‘prn’ intubation drugs routinely for all admissions to NICU. • Prescribe ‘prn’ flush 0.9% sodium chloride 1ml routinely for all babies with iv

access. Transcribed prescriptions (on a new drug chart or page) should have:

• Actual start date documented in the date box • Updated working weight documented

At the point of transcription, review medication dosages if there has been a change in working weight Changes to route or dose need to be documented fully: it is not acceptable to have iv/ng as alternative routes.  Use chart to prescribe standard infusions in 50mls: if more or less concentrated infusion required document “double strength” or “half strength” alongside prescription. Follow guidance on how to prescribe infusions and leave a blank line before starting a fresh date. These core standards are monitored and you should be asked to re-write prescriptions if you are not meeting the standards.

Medicines must not be prescribed, dispensed or administered unless the allergy status has been completed appropriately.

Micrograms, nanograms and units must not be abbreviated

Gentamicin prescribing • Stickers need to be placed on the inside of the drug chart, in the

regular prescriptions section. • Always use the 24 hours clock (HrHr:MinMin) and check dates and

times very carefully especially with 36 hour dosing. Dosing as per formulary: < 32 weeks 5mg/kg 36hourly 32 weeks and over 5mg/kg 24hourly

• Only sign for a dose you definitely want to be administered (i.e. you don’t want to re-check any levels or clinical parameters before it is given)

• Initially prescribe first two doses and time for first level: 6 hours before third dose would be due.

• If that level is less than 2.0mg/l then prescribe next two doses (if needed) at same time interval plus the time for next level: 6 hours before 5th dose would be due. Continue this pattern until course completed.

Renal Impairment: If there are concerns regarding renal function prescribe only ONE dose and the time for a level: 6 hours before SECOND dose (according to dosing schedule above).  If level <2.0mg/l then prescribe next two doses and a level. High Levels: If levels are greater than 2.0mg/l, repeat the level after 12 hours. Additional doses should not be given until level <2.0mg/l, subsequent dose interval needs to be decided considering renal function and indication for continued treatment. This should be discussed and documented on the ward round. Peak levels: Peak levels are only required to ensure dose is effective in complex cases and should be taken exactly one hour after the end of infusion. This will not be recorded on the stickers NEVER PRESCRIBE ANYTHING MORE THAN TWO DOSES AND ALWAYS DEFINE THE TIME THE NEXT LEVEL IS DUE Worked example for using gentamicin stickers for prescribing and monitoring:

Guidance for infusions The below is a quick and easy infusion prescribing guide. It can be found in the back of the GSTT paediatric formulary:

Although the standard infusion chart is very useful, calculating infusions ‘from scratch’ is also an important skill. You may already have developed

this skill, but if you find this a challenge there is a self-teaching package under the archived teaching tab or you can ask Geraint for a copy. You will be directed to this package if you are noted to be having difficulty prescribing infusions. Prescribing infusions (weight = 1 kg)

• Suggested use of infusion prescribing chart • Use two lines if necessary

Governance & Guidelines

Guidelines The neonatal unit has a comprehensive and useful set of guidelines. Although these are guidelines and not protocols, we generally expect you to follow the basics.  If you have chosen to proceed outside the guidelines it must be clear from your documentation that you know the local guidance and the reason behind your decision not to follow this guidance. The Guidelines are based on the Intranet with a couple of printed versions on the Unit. You are encouraged to access the Guidelines through the Intranet as this is up-to-date.

1. Access the Intranet 2. Click ‘search clinical guidance’, in small print at the top right hand

side of the home page 3. Enter ‘Neonatal Manual’ in the search box, open the clinical

directorates list, select children’s services and tick the box by ‘neonatal unit’ so you only find neonatal unit guidelines.

4. Find the chapter you want, open it and scroll down to the correct page.

Once you have used the system a few times you will find your way around the guidelines without too much difficulty. You can use other search terms, this is more successful if you limit your search to neonatal unit guidelines as above, but doesn’t always produce the results you may expect.

Adverse incidents • You are encouraged to complete incident forms (IR1s) • To help you, the Unit has a ‘Trigger List’ (see next page) which lists

events that should always generate incident forms. • Access electronic IR1 forms from the front page of the Intranet (GTi) • You have to fill in all the fields:

1. Directorate is ‘Children’s Services’ 2. Specialty is ‘Neonatology’

• Make sure you describe the incident, get the specialty and location correct and put ‘Karen Turnock’ as the manager. The classification and grading can be altered later so put what you think fits best at the time.

• Ask for help rather than avoiding filling in the form! • You may be asked to provide a written statement: this is to assist the

governance team in understanding why things do not always go well and you can approach any member of the senior medical team if you need help with this.

• There is a regular meeting for incident reviews, usually on a Thursday afternoon, and you are welcome to attend.

• You will be invited to attend monthly governance meetings if you are on AR, LC or DA shifts: please try to attend at least one of these.

• A summary of all incident forms is kept in the staff room, and always ask if you would like additional feedback on a situation you have reported.

Quality of Care These are a set of multidisciplinary guidelines designed in order to standardise our quality of care for infants born less than 30 weeks gestation. They encompass birth centre management, transfer, stabilisation, early respiratory support and communication with parents. They also encourage the use of a brief – rebrief – debrief process in order to facilitate and enhance effective teamwork and communication. This is the only neonatal unit guideline not in the neonatal manual: click search ‘clinical guidance’ on GTi then search for: Immediate Care of the Preterm Newborn < 30 weeks gestation A summary of the guidelines is shown in the flowchart below:-

Resuscitation and transfer Birth Centre management  1. Team briefing Team attending delivery should meet and decide on resuscitation plan

• Allocate team leader: < 30 weeks gestation, either at least one Rota C trainee or consultant; ≥ 30 weeks, at least one rota B or C trainee or consultant

• At least 3 members of neonatal team per baby • Clarify roles within team and competencies eg intubation • If consultant not present (eg at night), ensure they are made aware as

soon as possible (before delivery where possible) of baby < 28 weeks

2. Preparation • Resuscitation box • Surfactant: prepare surfactant for use if baby <28 weeks • Hat ready, plastic bag prepared • ET tube, CPAP prongs • Saturation monitor & probe, temperature probe • Resuscitaire: autobreath if possible; prewarmed, stocked and

prepared, warm towels for resuscitaire transfer if necessary. • Transport incubator(s) taken to Birth Centre

3. Temperature control • Plastic bags for all babies < 30 weeks (see Appendix 3) • Hat on the baby after the plastic bag and before airway manoeuvres • Do not cover the baby with anything other than the plastic bag while

the resuscitaire is on • Place temperature probe under baby and connect to resuscitaire to

monitor temperature (as soon as possible, after airway/breathing control is achieved)

4. Airway • Only by a member of staff assessed as competent to intubate preterm

babies • ≤ 27+6 weeks – intubate all babies • ≥ 28 weeks – jaw thrust and mask CPAP, intubate if significant signs of

respiratory distress (see supplemental oxygen algorithm)

5. Breathing • Start in air, use oxygen as per supplemental oxygen guideline to

maintain saturations 85-92% • Poor respiratory effort/no cry, HR>100

1. Intubate immediately (in babies ≥28 weeks, can consider mask inflation initially, proceed to intubation if respiratory effort doesn’t improve quickly thereafter); then

2. Inflation breaths (pressures 20/5) via ET tube until chest wall movement noted (maximum 5 initial breaths before reassessment as per NLS); then

3. Ventilation breaths, pressures 16-20/5, 40/minute, 1:1 I:E ratio. Reduce PIP if possible according to chest wall movement.

• Poor respiratory effort/no cry, HR<100

1. Consider appropriateness of resuscitation in baby <25 weeks; then

2. 5 inflation breaths as per NLS via mask, pressures 20/5; then

3. Intubate once HR>100; then 4. Ventilation breaths as above.

NB Difficulty in getting HR response may necessitate intubation before HR>100.

• Good respiratory effort/cry 1. Babies < 28 weeks gestation – intubate immediately, then

ventilation breaths as above 2. Babies ≥ 28 weeks

- Immediate jaw thrust and mask CPAP and observe - If significant respiratory distress, intubate and ventilate as above

6. Surfactant • All babies < 28 weeks and babies ≥ 28 weeks requiring intubation for

resuscitation or respiratory distress • Immediately after fixation of ET tube and re-checking of position by

auscultation

Transfer from Birth Centre to NNU  1. Stabilise respiratory support

1. Reduce FiO2 if possible so that saturations are 85-92% (see supplemental oxygen algorithm)

2. Set ventilatory parameters on transport incubator 3. For babies stable on CPAP, fit nasal CPAP prongs immediately on

placing baby into transport incubator

2. Stabilise baby’s temperature If temperature <36 prior to transfer and transferring on resuscitaire, consider delaying transfer to warm the baby

3. Personnel • Transfers to involve at least 3 personnel (eg senior trainee, junior

trainee and nurse) • Use porter to assist with transport incubator when available – BC

porter available 9am-5pm Monday to Friday

4. Resuscitaire transfers Resuscitaires may need to be used for transfers in some circumstances eg if multiple transfers (eg multiple births), several transfers in quick succession or transfers of larger babies.

• Ventilated transfers if at all possible on autobreath resuscitaires • Temperature control:

i.   Prewarmed resuscitaires – anticipate preterm delivery, ensure resuscitaire plugged in and prewarmed towels available

ii.  Baby covered with warm towels immediately prior to resuscitaire being unplugged for transfer iii. Consider using transwarmer for transfer in babies <30 weeks

The use of oxygen for should be considered according to the following

guideline:-

Initial stabilisation on NICU 1. Team rebriefing On arrival on NICU team should briefly assemble to discuss initial stabilisation plan

• Ventilation or early extubation • Observations & initial investigations • Line insertion, including team competencies • Documentation of resuscitation and transfer

NB Gestation and stability dictate initial respiratory and vascular access plans and therefore timing of initial blood investigations (eg blood gas, blood sugar).

2. Guidelines for stabilisation

Baby < 27 weeks or unstable baby 27-29+6 weeks Preparation

1. Giraffe incubator warmed and humidified 2. All monitoring (including TC) ready 3. Trolley set up for lines – bag containing all equipment to always be

available 4. Fluids prepared for UAC & UVC

Admission

• Place baby in incubator and weigh • Plastic bag remains until admission procedures complete and

temperature stabilised 36.5-37.5°C • Temperature with digital thermometer, temperature probe applied • Monitoring (including TC on all babies unless skin condition poor)

commenced, admission observations recorded. Take care with application and positioning of leads (line insertion & X-ray)

• IM vitamin K • Review need for initial bloods. Risk of hypoglycaemia (eg significant

IUGR, hypoxia-ischaemia) may necessitate early blood glucose measurement and prioritisation of IV access and glucose infusion (this may be by insertion of peripheral cannula or expedited insertion of UVC).

• Insertion of UAC and double lumen UVC by skilled operator (previously demonstrated competence in inserting umbilical lines, and happy to proceed without supervision) or if baby felt to be sufficiently stable, by less skilled operator with supervisor scrubbed, assisting and ready to take over if procedure unsuccessful after first attempt.

• Blood for arterial gas, blood glucose, basic neonatal profile, CRP, FBC, first cross match, culture and clotting

• Lines secured, infusions commenced and sterile drapes removed • Antibiotics given via second lumen of UVC • Baby then made as comfortable as possible and X ray requested • Failure to establish umbilical access:

o If becoming prolonged (20 minutes from start of insertion and no progress), establish peripheral access and obtain capillary gas

o Allow recovery time then most senior person to attempt umbilical access again. Peripheral arterial access and percutaneous long line should be established if this is unsuccessful once baby felt to be sufficiently stable and rested.

• Ensure continuous reassessment during initial procedures to monitor stability and time taken

• Any altering of central lines requires new sterile field and procedure • Head scan – within 12 hours of birth, once baby stable • Vamin and dextrose solution (no electrolytes) within 12 hours if

available   Stable baby ≥ 27 weeks (Babies ≥27 weeks who are unstable should be managed as for babies <27 weeks)   Preparation

• Cot space prepared with humidified incubator • All monitoring ready (including TC)

Admission • Weigh, place in incubator

• Plastic bag remains until admission procedures complete and temperature stabilised 36.5-37.5°C

• Admission observations including digital temperature • Peripheral IV access, bloods for blood culture, profile, FBC, first cross

match • Commence 10% dextrose infusion • Capillary gas, blood glucose • IM vitamin K and IV antibiotics (when indicated) • Consider umbilical access / alternative access as for <27 week baby if

concerns about stability • Head scan – within 12 hours of birth, once baby stable • For babies <28 weeks or <1500g, commence PN as above within 12

hours if available

3. Documentation • Admission summary from SEND

       i. Details of resuscitation (with times)        ii. Details of transfer ventilator settings

• Written admission assessment / examination and plan • Written documentation of all procedures, successful and unsuccessful,

and the time of those procedures • Nursing admission documentation – admission observations should

include the time observations were obtained

 4. Communication • Mother and father spoken to by nurse looking after baby within 4

hours. This meeting should be documented on pink initial parent communication sheet.

       i. To be given BLISS booklet, photo of baby and Unit information pack        ii. Mother should be introduced to milk expression

• Parents to be seen by consultant or nominated senior trainee within 24 hours of birth, and this discussion documented on pink initial parent communication sheet and on SEND

 

5. Team debriefing On completion of stabilisation, the team should assemble to review:

1. Subsequent management, including ventilation plans, head scans etc 2. Plan for parent communication from nurses and doctors 3. Documentation of admission, including Badger,  baby’s examination,

lines, plotting (see below) 4. Good practice and learning points from resuscitation, transfer and

admission Learning points discussed at re-briefing should be entered into ‘Rebrief Book’ behind NICU desk.

Initial respiratory support General principles

• Synchronised ventilation mode (SIMV or assist control) • Tidal volume limitation (preferably ‘volume guarantee’, but ‘volume

limited pressure control’ if pressure limited ventilation is to be used) • Tight saturation limits (86-94%) and rapid reduction in FiO2 as

tolerated • Consider early extubation in all babies, particularly ≥ 27 weeks • Decision to extubate should always include a time frame and should

be clearly communicated between medical and nursing staff. Extubation does not necessarily need to wait for caffeine load. Separate guidelines are available in Neonatal Manual (Respiratory Chapter) for non-invasive respiratory support

• Consult separate nursing guidelines for intubation and extubation • Consult separate guidelines for guidance on when to perform blood

gas analysis • Consideration can be given to nursing babies prone after extubation

with careful observation after reviewing security of the lines and following senior review

• Transcutaneous monitoring is recommended on babies of all gestations • Transcutaneous monitoring should be continued for at least 24 hours

after extubation

Standards of care 1. Intubation

• Babies < 28 weeks – intubated by 5 minutes of age • Babies ≥ 28 weeks:-        i. Assessment of need for intubation should be complete by 10 minutes of age        ii. Intubated by 5 minutes after decision; by 15 minutes of age

 2. Surfactant given by 5 minutes after intubation • By 10 minutes in babies < 28 weeks and babies where decision to

intubate is taken from birth • By 20 minutes in babies not intubated immediately ie assessment of

need for intubation & surfactant on Birth Centre in babies ≥ 28 weeks should be complete by 10 minutes

3. Temperature • Temperature probe on baby within 5 minutes • All babies arrive on NNU with temperature > 36°C

4. Admission observations and procedures (including UAC/UVC) should be completed within an hour 5. Ventilation – all babies commenced on conventional ventilation should be on a synchronised mode 6. Communication

• Parents have received a photo, an update and the Bliss Parent Information Guide from the nurse looking after their baby within 4 hours

• Parents spoken to by a senior member of the medical team within 24 hours of birth

7. Documentation • Ventilator settings at resuscitation and on transfer documented in all

babies • Time of admission and time of admission observations documented on

all babies • Line documentation (with times of insertion) documented on all

babies • Parent communication (nurse & doctor) documented on all babies

Infection Control This is a reminder: you will have your hand cleaning assessed during your orientation, there are regular observational audits of hand hygiene practice and sporadic hand plating is undertaken.

1. Wash your hands in the troughs on the left hand side of the entrance corridor every time you arrive at work at the beginning of your day/shift.

2. If you are arriving in your outside clothes you should put coats, bags etc. in a safe place as soon as practicable after arrival.

3. Remove all arm and hand jewellery and wristwatches (plain wedding ring only is acceptable).

4. Sleeves should end, or be rolled up, above the elbow. 5. Clean your hands any time that you enter and before you leave any of

the clinical rooms. 6. Hands must be cleaned and gloves and an apron worn for all direct

patient contact. 7. Use alcohol rub immediately before touching a baby and immediately

after: even when wearing gloves! 8. If you have trouble with condition of your skin, the procedure should

be as follows a. Wet hands. b. Wash hands with liquid soap and rinse. c. While hands still wet, apply moisturiser (in dispensers). d. Dry hands with paper towel. e. Rub in alcohol gel.

9. You should re-wash your hands at the entrance of the Unit if you have been out of the hospital or out of the Unit for a significant time e.g. following meals etc.

10.We must all to remember that we are setting examples for parents and visitors (including visiting staff) and we should be seen to be observing these guidelines.

All staff should encourage others to observe these guidelines, regardless of who or how senior they are. Avoid consuming food in the clinical rooms, although light snacks are permitted if essential. Drinks, chocolates, etc. may be taken in. All babies admitted from outside hospitals will be barrier nursed until swabs are negative. Occasional babies need to be barrier nursed because of multiresistant organisms or RSV. Wear gloves and an apron to approach the cot space, use the pens left at the cot side to write in the notes, not your own, and leave the notes at the cot side. Clean your gloved hands with gel before examining these babies, remove gloves and gown as you leave the cot space then wash your hands thoroughly.

Central line care package This is a project looking to reduce our incidence of catheter-associated sepsis and the morbidities associated with infection. New guidelines are

available for inserting and accessing central lines. You will also receive training in ANTT (Aseptic non-touch technique) during your induction. The Central care package includes the following resources:

1. Central line insertion guideline 2. Central line check list 3. Assisting with central line insertion guideline 4. Central line dressing change guideline 5. Aseptic Non-Touch Technique

The guidelines are currently going through the trust clinical governance process, but the provisional guidelines are available on the attached pages.

Central Line Insertion Guideline Long line insertion-Preparation

• Discuss with the nurse looking after the baby with regards to the appropriate time for long line insertion in non-emergency situations. Also inform the parents regarding the procedure.

• Prepare the trolley by cleaning it with clinell surface wipes. • Identify the limb that the line will be inserted into. (Accurately

measure the length of the line that needs to be inserted for the line to be in an appropriate position.)

• Swaddle the baby leaving the limb free. • Give appropriate analgesia and sedation- see guidelines

Long line insertion- Cleaning • After thoroughly scrubbing you hands upto the elbows with Hibiscrub

handwash put on sterile gloves and gown. (If not in the clinical area, Hibiscrub is available in the Omnicell and in the Sluice room).

• Please wear a mask for babies in an open incubator • Hold the limb with sterile gauze and place a sterile paper drape

underneath. Clean the limb with 0.5% aqueous chlorhexidine solution. Please make sure you clean the whole limb including the joint above and below the insertion point.

• The area should then be left to air dry. • Cover the child’s body and the surrounding area with sterile sheets

and drape creating as large a sterile field as possible. • Change your gloves. • Prepare the long line by flushing the line and the IV connector. • Ensure assistant is present to help with positioning and maintenance

of sterile field prior to starting insertion Long line insertion- Procedure

• Insert the introducing cannula into the vein until a flash back of blood is seen and then remove the metal introducer.

• Introduce the long line into the vein through the cannula using the plastic forceps using non-touch technique.

Long line insertion- Securing • Cover the insertion site with steristrips. • Curl any excess silastic round and secure with steristrips.

• Place a piece of duoderm on the skin where the hub of the line rests on the skin. Please do not use guaze as padding.

• Cover the whole line with tegaderm ensuring not to encircle the whole limb.

Long line insertion- After care • Ensure the line flushes easily and connect the line to the IV connector

using a 10 ml syringe and run 0.9% saline at 0.5ml/hr

List of items for long line insertion This list is meant as a guide and a “minimum set” you may use other equipment whilst inserting lines – as long as your practice is safe you should use whatever you are comfortable with.

• Sterile dressing pack • Long line • 0.5% Chlorhexidine • 0.9% saline (10ml) • Syringe (10ml and 5ml) • IV connector • Sterile scissors • Plastic forceps • Sterile Artery forceps • Sterile drape • Sterile gloves (2 pairs) • Needle • Sterile guaze • Steristrips (1 long, 1 short) • Duoderm • Tegaderm • Omnipaque

Assisting with central line insertion guideline You should always be supported when attempting central line insertion, both to improve the odds of success and to ensure strict aseptic technique. Below is the nursing guideline regarding line insertion.  

Introduction

  • Central lines are an essential part of the provision of neonatal intensive care,

allowing the safe delivery of nutrition, concentrated solutions and inotropic medications. However, central lines also present several risk factors, the most notable of these being the risk of catheter related sepsis, which greatly increases morbidity among NICU patients.

• The insertion of central lines presents a significant opportunity for contamination of the line and therefore strict, full barrier (gown, gloves, mask), sterile precautions are utilised to minimise this risk.

• It is not possible to consistently maintain strict, full barrier, sterile precautions without assistance. Therefore no central line may be attempted without assistance.  

Central Line Insertion : A Two Person Procedure   

• In addition to a competent practitioner, successful central line insertion requires both adequate preparation and adequate assistance.

-          Preparation of the baby requires attention to developmental care principles and is the responsibility of the nurse caring for the baby. -          Assistance with insertion requires attention to patient monitoring and comfort, and attention to maintenance of the sterile field. This role is also the responsibility of the nurse caring for the baby but may be delegated by them to another qualified health care practitioner. 

Preparing for the procedure

  • Once it has been identified that a patient requires a central line, the practitioner

who will be inserting the line and the nurse responsible for that patient negotiate a mutually convenient time. The practitioner will examine the patient, and identify potential line sites.

• The practitioner is responsible for assembling all necessary equipment prior to the time agreed.

• The nurse will prepare the patient, swaddling where appropriate and positioning the baby to allow access to the insertion site identified by the practitioner. Breast milk or 24% sucrose may be used if appropriate (see Neonatal Nursing Guideline: Breast milk/24% sucrose administration for procedural pain in babies greater or equal to 32 weeks gestation).

• Elective procedures are limited to 3 attempts or 60 minutes on one limb.  Central lines requiring longer than 60 minutes to insert have been found to have a greater risk of non-infectious complications such as phlebitis and skin inflammation. Both the practitioner and the nurse/assistant must delegate other tasks that may be required of them during this period to their colleagues, as both will be involved in a sterile procedure.

• No sterile field may be used for more than one limb. If a practitioner would like to move locations, they must stop the procedure and allow the baby to rest. A new sterile field and equipment set up must be assembled before starting again.

• If after 60 minutes or 3 attempts the practitioner has not been successful, the baby is left to rest, and the next attempt should be made by a different practitioner wherever possible.

• No time limit applies to emergency situations where securing central access is urgent (e.g. in a patient that requires inotropic support). In these cases, the most experienced practitioner available is to attempt the line.

 

Nursing/Assisting Role

  There are 2 primary nursing/assisting roles during the insertion of central lines:  

1.  Assessment, ongoing monitoring and providing comfort measures to the baby -      Support the baby in a developmentally appropriate position that allows access to the desired insertion site and stabilize the limb if required. -      Provide containment and other comfort measures (e.g. swaddling, non-nutritive sucking). -      Continually monitor patient tolerance of the procedure; turn on monitor’s QRS volume which will aid the practitioner is making their own assessments while focused on the line. -      If the baby is not tolerating the procedure, pause and allow time for recovery. If their condition does not quickly improve, stop the procedure.

2. Monitoring and assisting in maintenance of sterile barriers -      Monitor and draw attention to any unnoticed breaches in sterile procedures made by the practitioner. Unknowingly contaminating a glove or piece of equipment is easily done, but can lead to serious complications for the infant. -      Provide any additional or replacement equipment for the practitioner after they have assembled the initial sterile field. -      As the nurse/assistant is not directly involved in the insertion, they do not need to wear full sterile barrier, unlike the practitioner, but if the baby is in an open cot, then both the nurse and the practitioner must wear a mask. -      Monitor the time. When focused on the line insertion, the practitioner is likely to be unaware of how much time has passed. Unless the line is nearly sited and secured at 60 minutes, the procedure is to be stopped and the baby allowed to rest. -      Similarly if 3 unsuccessful attempts on that limb have been made before 60 minutes have passed, the procedure is to be stopped and the baby allowed to rest.

Post Procedure

  • When the line insertion has been successful, assist the practitioner in applying a

dressing according to the unit standard (see Neonatal Guideline: Long line dressing changes).  Set up an infusion of 0.9% Sodium Chloride at 0.5ml/hr to maintain the line, using a 2-way octopus to allow a site for omnipaque administration.

• Purge the 0.9% Sodium Chloride syringe from the pump prior to connecting the infusion to the line.

• Once connected give a 0.5ml 0.9% NaCl bolus from the pump to ensure forward motion through the line.

• A 10ml syringe containing omnipaque is attached to the second arm of the octopus while the practitioner is still sterile, in preparation for the arrival of Xray.

• Remove all sterile drapes as soon as the procedure is complete and before the Xray is taken.

• Just prior to taking the Xray, the omnipaque is given, and after the Xray a 0.5 ml flush given of 0.9% Sodium Chloride from the pump to clear the line.

• If the line requires adjustment a new sterile set up must be assembled, while the nurse again prepares the patient. Refer to Neonatal Guideline: Long line dressing changes.

• Adjustments to the line, as well as subsequent dressing changes are also a minimum of 2 person procedures.

  Exposure of a Central Line Insertion Site : A Two Person Procedure

  • A central line insertion site may never be exposed without the assistance of

another health care professional who monitors and comforts the patient while stabilizing the limb and monitors the maintenance of sterile procedures.

Central line dressing change guideline Introduction

• Long lines provide long term stable access for the delivery of concentrated solutions and total parenteral nutrition in neonates who are acutely unwell, on bowel rest or establishing feeds. While an essential part of the delivery of intensive care, long lines have several potential complications. The most significant of these is the risk of catheter related sepsis, which is a common source of increased morbidity in NICU patients.

• Over time dressings become dirty, develop a build up of old blood and/or begin to lift, all of which may increase the risk of long line related sepsis if the dressing is left unchanged.

• With each dressing change there is a risk that the line will be accidentally dislodged and the exposure of the insertion site creates a significant opportunity for contamination. Appropriate line care is therefore critically important in order to maintain the long term sustainability of the line and decrease the risk of the patient acquiring long line sepsis.

Exposure of a Central Line Insertion Site : A Two Person Procedure  

Procedure

Who? -Any neonatal nurse or doctor who has been trained and signed off as competent may complete long line dressing changes when they are required. -A second health care professional is also needed to complete the procedure but this person may be learning to complete dressing changes, and is not required to be competent. -In older babies who are very active, a third person may be needed to help settle the baby during the procedure, this may be a parent or additional health care professional

• When? -In adult populations, increasing the frequency of routine dressing changes and site care has shown no improvement in overall line sepsis rates. -Given the fragile nature of preterm skin and the associated risk of skin breakdown with frequent dressing changes, long line dressings are to be changed only as required. -Indications for dressing changes include but are not limited to: dressing lifting and revealing the insertion site, high line pressures and the suspicion of a kinked line underneath the dressing, and new bleeding under the dressing. -If you are unsure if a dressing change is required, request a review by a Neonatal Infection Prevention (NIP) group member or senior medical staff member.

• How? -For detailed step by step instructions refer to the Long Line Dressing Change Rationale Sheet. -This is a sterile procedure. -The baby is swaddled and sterile field is prepared. -Both the primary practitioner and the assistant wash their hands with chlorhexidine and apply sterile gloves. -Using an adhesive removal product, the old dressing is removed, pulling in the opposite direction from the direction of insertion to decrease the risk of dislodging the line. Once exposed, the insertion site is secured by the assistant. -The primary practitioner cleans their hands and puts on new sterile gloves. -The insertion area is inspected for signs of infection, irritation or skin breakdown. -The area is cleaned with 0.5% Chlorhexidine Aqueous solution and allowed to dry. -The insertion site is secured with a steri strip, line coiled and new dressing applied according to the unit standard. -If any deviation is made from the standard unit dressing than this must be clearly documented to inform the next practitioner who comes to change the dressing. -The procedure is documented on the Central Vascular Device Record.

Potential Complications  • Request a senior medical review as soon as any complication is observed

and before the new dressing is applied. • Infection: Surface infection does not guarantee line infection, a swab may

be taken and the baby treated prophylactically. It is possible the line may need to be replaced.

• Irritation: This may be the result of the recent dressing removal, document clearly and monitor.

• Skin Breakdown: It may be possible to readjust the dressing so the damaged skin is no longer covered. If this is not possible consider duoderm as a barrier.

• Bleeding: Apply firm pressure to the insertion site with sterile gauze. If bleeding slows but does not stop consider applying the dressing which will maintain firm pressure but will need to be monitored closely.

• Dislodged Line: If this has been considerable, stop all infusions and clamp the line. It is likely it will need to be removed. If the line has only come out by a few centimeters, it is possible it may still be safe to use, depending on its original position. Apply the new dressing and X-Ray the line.

• Document all complications or concerns clearly.

Aseptic Non-Touch Technique • A trust wide evidence based initiative to improve line care, launched

in June 2011

• Key parts (any part whose contamination can compromise the line) are protected

• Audit in January 2011 shows good practice but there is still room for improvement.

• Please remember to utilize these principles when inserting peripheral lines You will receive training on ANTT during your induction.

Nuggets and guidelines of the week If there have been particular issues around management of a particular baby, or a problem highlighted through the incident reporting system, then a guideline may be printed off and displayed as the guideline of the week. This is an opportunity to flick through a guideline you may not have encountered, so do check the ‘Top Tips’ board in the seminar room, or use the references supplied in your e mailed monthly reminder. Nuggets are small posters used:

• to highlight changes in guidance • as a reminder if there have been persistent issues about not using

guidance • to highlight risk issues

Do familiarise yourself with the Nuggets, especially new ones, as they are likely to be of use. Two informative ones are included within your induction pack.

Introduction to postnatal ward feeding policies Please read the Breastfeeding policy on the intranet, this will give you an over view of what we expect our staff to do:

1. There is a Breastfeeding drop-in most week day mornings between 10 and 11 on the postnatal ward in the day room. This is primarily an opportunity for women to come and learn the basics of breastfeeding and to ask any questions they may have. If there is time the Midwife running the session will spend some one to one time with those women needing extra support. If not they will be referred back to the Midwife looking after them. All women are encouraged to attend, not just those having problems with feeding.

2. All babies should have a completed breastfeeding observation chart and feeding plan in their notes. If they don’t, please request that one is done.

3. A copy of the Hypoglycaemia Policy is on display in the postnatal ward neonatal surgery. Please note we DO NOT perform random blood glucose estimations on any babies, there needs to be a clear clinical indication, most of which are covered by the hypoglycaemia policy.

4. If a baby is considered vulnerable e.g. on or below 2nd centile, preterm or compromised at birth (see neonatal manual for full list) they should not be discharged before day 4. This is especially relevant if feeding has not been established.

5. Babies who have been recorded as being on or below the 2nd centile should have this confirmed by their birth weight being plotted on a full weight chart (preferably a WHO low birth weight chart). The charts in the current neonatal notes can be inaccurate.

6. Daily weights should NOT be done. They offer very little reliable information and are very anxiety provoking for the parents. If there is concern about the weight feeding needs to be assessed by someone qualified to do so and a suitable plan made and reviewed on a daily basis. Alternate day weights are acceptable but should be stopped when an upward trend is noted.

7. There are very few clinical indications why babies on the postnatal ward would require artificial milk supplementation. Most babies take a while to establish breastfeeding and if they are healthy and term they can use alternate fuel sources such as ketones until their feeding is established. They will need a feeding plan and their mothers shown how to breastfeed and hand express (if these have not been done please ask the midwife to do so), they DO NOT need artificial milk.

8. If artificial milk supplementation is deemed necessary please ensure that the parents understand that the baby should always be offered the breast first and then offered expressed breast milk and then offered artificial milk up to the amount stated, rather than breastfeeding and then supplementing the full amount stated. The following statement could be used.

9. “Please breastfeed from both breasts, then give EBM and then if necessary artificial milk up to ….mls until baby appears full”.

10.Never tell a mother to limit the time at the breast; most breastfeeds take at least 20 minutes. The baby needs to access all the milk available before moving to the second if necessary. Zoe Chadderton, Breastfeeding Co-ordinator pager 846260, ext 87564.

Email :breastfeedingteam@gstt.nhs.uk

Neonatal Unit Induction Checklist Paperwork: You’ve been sent…. Induction timetable Equipment competencies Invitation to join EvelinaNicuTeaching blog You should be shown…. Unit notes and observation charts Daily ITU sheets Antenatal problems folder Prescription charts Postnatal notes Badgernet database: admission and discharge documentation, daily

data and other data entry Unit Guidelines folder and intranet link Electronic IR1s Tour of the Unit: You should be shown…. On call rooms Staff room Neonatal Intensive Care rooms HDU and Special Care rooms Gas machine room Seminar room Quiet rooms Outpatient room / Outreach office Offices: consultants, juniors and secretaries Postnatal wards and neonatal surgery Birth centres Work: You should be told about… Roles and responsibilities Teams and communication Postnatal ward management Sick leave arrangements Requesting leave / rota rules You should be shown… Equipment for basic procedures How to use the gas machine Neonatal resuscitation Cranial ultrasound (level 3 trainees) Infection control: Information and assessment