NNAP

National Neonatal
RCPCH Audits

Audit Programme

National Neonatal Audit Programme 2020

Annual report on 2019 data

“This is a photo of my son,

Benjamin (born at 33+4
weeks) being soothed
by his older sister as he
receives phototherapy in
his incubator.”

Rebecca Owen, Mother

RCPCH
Royal College of
Paediatrics and Child Health
National Neonatal Audit Programme (NNAP)
2020 annual report on 2019 data

Version 2: Updated 12 April 2021

The National Neonatal Audit Programme is commissioned by the

Healthcare Quality Improvement Partnership (HQIP) as part of the
National Clinical Audit and Patient Outcomes Programme (NCAPOP).
HQIP is led by a consortium of the Academy of Medical Royal Colleges,
the Royal College of Nursing, and National Voices. Its aim is to promote
quality improvement in patient outcomes, and in particular, to
increase the impact that clinical audit, outcome review programmes
and registries have on healthcare quality in England and Wales. HQIP
holds the contract to commission, manage and develop the NCAPOP,
comprising around 40 projects covering care provided to people with
a wide range of medical, surgical and mental health conditions. The
programme is funded by NHS England, the Welsh Government and, with
some individual projects, other devolved administrations and crown
dependencies www.hqip.org.uk/national-programmes.

Data management, analysis and statistical services are provided by the

Neonatal Data Analysis Unit, Imperial College London.

© 2020 Healthcare Quality Improvement Partnership (HQIP)

Published by RCPCH November 2020.

The Royal College of Paediatrics and Child Health is a registered charity
in England and Wales (1057744) and in Scotland (SCO38299)

Cite as: National Neonatal Audit Programme (NNAP) 2020 annual report on 2019 data.
RCPCH: London, 2020.
National Neonatal Audit Programme 2020 report on 2019 data

Table of contents
Executive summary 5
NNAP Recommendations 7
1. Introduction 14
1.1. Scope 14
1.2. NNAP governance 14

2. Results, key findings and recommendations 16

2.1. Antenatal steroids 16
2.2. Antenatal magnesium sulphate 19
2.3. Birth in a centre with a neonatal intensive care unit (NICU) 22
2.4. Promoting normal temperature on admission for very preterm babies 24
2.5. Parental consultation within 24 hours of admission 27
2.6. Parental presence at consultant ward rounds 30
2.7. On-time screening for retinopathy of prematurity (ROP) 32
2.8. Late onset infection 36
2.9. Bronchopulmonary dysplasia (BPD) 40
2.10. Necrotising enterocolitis (NEC) 45
2.11. Minimising separation of mother and baby (term and late preterm) 48
2.12. Maternal breastmilk feeding 50
2.13. Follow-up at two years of age 56
2.14. Mortality until discharge in very preterm babies 59
2.15. Nurse staffing on neonatal units 64
2.16. Spine Plots 68

3. Local quality improvement case studies 69

4. Methods 82
4.1. Audit measures and measure development 82
4.2. Data flow 85
4.3. Case ascertainment and unit participation 86
4.4. Data quality and completeness 86
4.5. Outlier identification and management 87
4.6. Managing small numbers in the NNAP 87
4.7. Developing key findings and recommendations 87

5. Driving improvements in neonatal care 88

5.1. Recommendations and action plan development 88
5.2. Useful resources 88
5.3. Information for parents, carers and families 89
5.4. Future developments in the NNAP 90

Index of appendices 91

4
National Neonatal Audit Programme 2020 report on 2019 data
National Neonatal Audit Programme 2020 report on 2019 data

Executive summary
Executive summary
Background
Background
11in
in 77 babies
babies have
havetoo
toolow
lowa abirth weight
birth weightor have a
or have a medical
medical condition
condition that requires
that requires specialist
specialist treatment.
treatment. InInthis report
the National
this report Neonatal
the National Audit Programme
Neonatal (NNAP) focuses
Audit Programme
on key measures of the care provided
(NNAP) focuses on key measures of the care to babies in 2019 in
the 181 neonatal
provided to babies services
in 2019 inintheEngland, Wales, Scotland and
181 neonatal
the Isle of Man.
services in England, Wales, Scotland and the Isle of
Man.
The NNAP uses routine data collection to report on a range
The NNAP uses routine data collection to reportofoncare processes
a range of care and outcomes
processes throughout the pathway
and outcomes
of neonatal
throughout care, from
the pathway antenatal
of neonatal care, interventions to follow-up
from antenatal interventions of developmental
to follow-up outcomes after
of developmental
discharge from neonatal care. For most audit measures, this 2020 report looks
outcomes after discharge from neonatal care. For most audit measures, this 2020 report looks at care at care provided to
babies with
provided a final
to babies discharge
with from neonatal
a final discharge care between
from neonatal care between1 January
1 January2019 andand
2019 31 December
31 2019. This
report includes network level reporting of mortality until discharge from the
December 2019. This report includes network level reporting of mortality until discharge from the neonatal unit, and
adherence to neonatal nurse staffing standards, for only the second time. In this report we also
neonatal unit, and adherence to neonatal nurse staffing standards, for only the second time. In this
describe the rates of maternal breastmilk feeding at 14 days of age, for the first time.
report we also describe the rates of maternal breastmilk feeding at 14 days of age, for the first time.

Conclusion
Conclusion
UK neonatal professionals, together with the NNAP team, have demonstrated that aspects of neonatal
UK neonatal professionals, together with the NNAP team, have demonstrated that aspects of
care continue to improve. Examples include ongoing improvements in use of magnesium sulphate,
neonatal care continue to improve. Examples include ongoing improvements in use of magnesium,
and improvements in thermal care of very preterm infants – which is as good or better than any
and improvements in thermal care of very preterm infants – which is as good or better than any nation
nation in the world. Such improvements show that we can modernise our care. Processes, such as
inmeasures
the world. of
Such improvements
parental show that
partnership we canon-time
in care, modernise our care. for
screening Processes, such as
retinopathy of prematurity and
measures of parental partnership in care, on-time
developmental follow-up, are also improving. screening for retinopathy of prematurity and
developmental follow-up, are also improving.
Neonatal professionals, working with parents and others, need to use this demonstrated ability to
Neonatal professionals, working with parents and others, need to use this demonstrated ability to
deliver improvement to address the marked variations in care that this report highlights. The
deliver improvement
important to address
variations the in
observed marked variations
measures in care that
of process are this
nowreport
clearhighlights.
in outcomesThe important
such as infection,
variations observed in measures
bronchopulmonary dysplasia,ofnecrotising
process are enterocolitis
now clear in outcomes such
and death. as infection,
Neonatal care should continue to
bronchopulmonary
improve and we dysplasia, necrotising
need to learn enterocolitis
from one anotherand – todeath. Neonatal
be partners incare should continue to
improvement.
improve and we need to learn from one another – to be partners in improvement.
The recommendations this report makes are designed to support networks and hospitals in planning
The recommendations this report makes are designed to support networks and hospitals in planning
and delivering improvements to their care. They have been developed by a large multi-professional
and deliveringgroup
consensus improvements to their
with wide care. They have
representation. been developed
Careful attentionbyhasa large
beenmulti-professional
given to describing, and
consensus
making recommendations about improving, neonatal unit nurse staffing. Someand
group with wide representation. Careful attention has been given to describing, recommendations
making recommendations about improving, neonatal unit nurse staffing. Some
may not be applicable or helpful to every service, but all networks and units should recommendations mayrelate each
not be applicable or helpful
recommendation to every
to their own service, butand
priorities all networks and results.
their audit units should
Unitrelate
and each
network level results are
recommendation
visible on NNAP toOnline.
their own priorities and their audit results. Unit and network level results are
visible on NNAP Online.

5
 National Neonatal Audit Programme 2020 report on 2019 data

Key Messages
Key message 1: Mortality until discharge home in
very preterm babies
Rates of mortality in very preterm babies (less than 32 weeks’ gestational age) vary widely among the
14 networks, from 4.5% to 9.0%. Variations in case mix do not explain differences in mortality.

Key message 2: Neonatal outcomes

This audit shows that outcomes, such as bronchopulmonary dysplasia (BPD), necrotising enterocolitis
e (NEC) and late onset neonatal infection, vary strikingly between neonatal units and networks in a way
that is unlikely to be explained by patient characteristics.

age given magnesium

Key message 3: Ongoing improvement in care processes
Improvements in care processes, such as thermoregulation (cold babies
erm baby experience more complications) and administration of intravenous
he NICE magnesium sulphate (which improves neurodevelopmental outcome in
ho may the least mature babies) demonstrate the ability of perinatal teams to
esium alter their care in light of published quality improvement objectives.
of eligible However, unwarranted variation in these and other measures of care
e target in persists among neonatal units and networks, which identifies further
check opportunities for improvement of care. Nurse staffing, in particular,
remains well below nationally agreed desired levels.

s by 179
unit. If the mother delivered
nit not allied to an NNAP
Figure 6 does not include
Key message4:
Rates of breastmilk feeding
el.
The proportion of very preterm infants fed with
someMissing
of their mother’s own milk at the time of
gnesium not (% of eligible
discharge has remained persistently low over
en mothers)
5 years, with marked geographical variation.
(71.3%) 3 (3.1%)
(27.4%) 3 (1.7%)
0 (18.8%) 13 (1.2%)

3 (15%) 12 (0.5%)
9 (17.9%) 31 (0.8%)

t not allied to an NNAP

6
National Neonatal Audit Programme 2020 report on 2019 data

NNAP Recommendations
Recommendation (1) – Antenatal Steroids (Key Finding A):
Neonatal units and obstetric services should work as a perinatal team to:

• Optimise the timing and dosing of antenatal steroids for eligible babies
• Avoid the inappropriate use of multiple courses
• Adopt evidence-based practices to predict preterm birth, by using the following guidance and
methodologies to guide improvement:
- BAPM Perinatal Optimisation Care Pathway Toolkit
- Prevention of Cerebral Palsy in PreTerm Labour (PReCePT) quality improvement programme
- Scottish Patient Safety Programme

To help reduce the severity of respiratory disease and other serious complications in preterm babies.

The National Maternity and Perinatal Audit (NMPA) should:

Consider developing reporting of antenatal steroid use in order to encourage timely exposure of
eligible infants to it.

Recommendation (2) – Antenatal magnesium sulphate

(Key finding B):
Neonatal networks, units and obstetric services should work as a perinatal team to:

• Ensure that all women who may deliver their baby at less than 30 weeks’ gestational age are
offered magnesium sulphate where possible
• Adopt and implement the following guidance and methodologies to guide improvement:
- BAPM Perinatal Optimisation Care Pathway Toolkit
- Prevention of Cerebral Palsy in PreTerm Labour (PReCePT) quality improvement programme
- Scottish Patient Safety Programme

To help reduce the risk of babies who are born prematurely developing cerebral palsy.

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National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (3) – Birth in a centre with a NICU

(Key finding C):
Departments of Health in England, Scotland and Wales and Neonatal Networks should:

Prioritise structural changes and operational management to ensure that babies who require
intensive care are cared for in the units best equipped to deliver it.

Local Maternity Systems (LMS) and equivalent bodies in devolved nations should:

• Ensure that appropriate clinical pathways exist

To enable delivery of intensive care to all infants where this is required, with a minimum of postnatal
transfers.

Recommendation (4) – Parental consultation within 24 hours of

admission (Key finding D, E):
Neonatal units with lower rates of parental consultation, and particularly those with low outlying
performance, should:

• Reflect on their rates of parental consultation

• Use a quality improvement approach and consider using novel means such as video calls
where parents are unable to enter the neonatal unit

In order to improve parental partnership in care.

Recommendation (5) – Parental presence at consultant ward

rounds (Key findings F, G):
Neonatal units, in collaboration with parents, should:

Build relationships and trust between parents, family members and neonatal unit staff by:

• Understanding the unique role of parents as partners in care, and involving them in developing
and updating care plans and decision making
• Empowering parents to feel comfortable and able to contribute to discussions about their
baby’s care
• Taking the time to explain to parents why decisions about aspects of care are being suggested
• Reflecting on audit results with parents, identifying the reasons for any gaps in parental
presence on ward rounds, any lack of consultant wards or documentation of consultant ward
rounds, and working with parents to address any barriers to participation identified

So that parents are partners in the care of their baby in the neonatal unit.

8
National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (6) – On-time screening for retinopathy of

prematurity (ROP) (Key findings H, I J, K):
Neonatal Intensive Care Units (NICUs) with persistently low levels of ROP screening should ensure
that:

• Babies requiring ROP screening are accurately identified

• Safety systems for appropriate ROP screening are in place

So that babies who are at the highest risk of loss of vision, can be screened and receive timely
treatment if required.

Neonatal Networks with low rates of ROP screening should:

• Implement a mechanism for real time measurement of their unit’s adherence to ROP screening
guidelines

So that they can identify where related quality improvement activities need to be undertaken.

Recommendation (7) – Infection (Key Findings L, M, N, O):

Neonatal units with higher reported rates of infection should:

• Compare practices with units with lower rates of infection, identified via NNAP Online and
consider whether their rates of infection could be decreased
• Ensure that their use of evidence-based infection reduction strategies is optimised

In order to minimise the number of babies infected in their units.

Neonatal networks and units with both low and high rates of infection should:

• Facilitate invitations for units with higher rates of infection to visit units with lower rates in
order to jointly agree whether potentially better practices could be used and consider requiring
units to participate in such quality improvement activity
• Ensure that the proposed visits should be multidisciplinary and focussed on identification and
implementation of potentially better practices including “infection prevention bundles”

In order to reduce the risk of exposing sick and premature babies to infection.

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National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (8) – Bronchopulmonary dysplasia (BPD) (Key

Finding P):
Neonatal units with high treatment effect should:

• Seek to identify potentially better practices from neonatal units with lower treatment effect

Neonatal units and networks should:

• Seek to understand the extent to which care practices explain the differences in rates of BPD
• Implement potentially better care practices, including any identified from NICE guidance
about specialist respiratory care

The British Association of Perinatal Medicine (BAPM) should:

• Consider developing a care pathway identifying potentially better practices and the optimal
means for their implementation

In order to reduce the proportion of babies affected by bronchopulmonary dysplasia.

Recommendation (9) – Necrotising entercolitis (NEC) (Key

findings Q, R):
Units with validated NEC data should:

• Compare their rates of NEC to those of other comparable units with validated data, and if their
rates of NEC are relatively high, seek to identify and implement potentially better practices

In order to reduce the associated higher risk of mortality and, for those babies who survive, the risk of
longer term developmental, feeding and bowel problems.

All neonatal units should:

• Ensure the accurate recording of NEC diagnoses

In order to facilitate valid comparisons of the rates of NEC, and the development of preventative
measures based on variations in rates of NEC.

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National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (10) – Minimising separation of mother and

baby (term and late preterm) (Key finding S):
Neonatal networks should:

• Review the admission durations of their units, alongside admission rates, as part of planning
maximally effective use of neonatal bed days

Neonatal and maternity teams should:

• Ensure discharge practices minimise inappropriate separation of mother and baby

• Consider introducing measures to facilitate timely discharge such as criterion-based discharge
• Consider delivering some care as transitional care

So that babies born at term and late preterm admitted to neonatal units are not separated from their
mothers for longer than is necessary.

Recommendation (11) – Breastmilk feeding at discharge home

(Key findings T, U, V):
Neonatal units and networks should:

Focus on both the early initiation and sustainment of breastmilk feeding in conjunction with
parents by:

• Reviewing data and processes in order to undertake selected quality improvement activities
suited to the local context
• 
Removing barriers to successful breastmilk feeding by ensuring that appropriate and
comfortable areas are provided with adequate, regularly cleaned expressing equipment
• 
Seeking and acting on feedback from local parents on their experience of starting and
sustaining breast feeding
• 
Working to achieve and sustain both UNICEF UK Baby Friendly Initiative Neonatal Unit
accreditation and Bliss Baby Charter accreditation
• Implementing the guidance and evidence-based care practices set out in the BAPM Maternal
Breastmilk Toolkit
• 
Working with local parents to review and improve local practices around the early
communication of the benefits of breastmilk, ideally prior to birth wherever possible

So that the many health benefits to the preterm baby and the mother of breastfeeding can be
realised.

11
National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (12) – Follow-up at two years of age

(Key finding W):
Neonatal units should:

Produce detailed plans to provide or organise follow up of care for preterm babies in accordance with
NICE guidance and consider arrangements for:

• Communicating with families about follow up at discharge

• Families who live far from the hospital of care
• Families who do not attend appointments
• Families who move to different areas
• Completing and documenting assessments made

So that very preterm babies can be monitored and checked for any problems with movement, the
senses, delays in development or other health problems and so that parents can get reassurance
about how their baby is developing, and any support that they might need.

The British Association for Neonatal Neurodevelopmental Follow Up (BANNFU) should:

• Describe and promote best practice and successful models of delivery of high rates of follow
up using appropriate instruments

To improve the long-term outcomes of all babies that have had neonatal care.

Recommendation (13) – Mortality until discharge home in very

preterm babies (Key finding X):
Neonatal networks and their constituent neonatal units should, following a review of local mortality
results, take action to:

• Consider whether a review of network structure, clinical flows, guidelines and staffing may be
helpful in responding to local mortality rates
• Consider a quality improvement approach to the delivery of evidence-based strategies in the
following areas to reduce mortality: timely antenatal steroids, deferred cord clamping,
avoidance of hypothermia and management of respiratory disease
• Ensure that shared learning from locally delivered, externally supported, multi-disciplinary
reviews of deaths (including data from the local use of the Perinatal Mortality Review Tool)
informs network governance and unit level clinical practice

The patient safety team in NHS Improvement and equivalent bodies in the devolved nations
should:

•  Facilitate national dissemination of learning from mortality reviews

12
National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (14) – Nurse staffing in neonatal units

(Key finding Y):
Departments of Health in England, Scotland and Wales should:

• Ensure that sufficient resources are available for the education and employment of suitably
trained professionals to meet and maintain nurse staffing ratios described in service
specifications

Universities and Health Education England or equivalent bodies in the devolved nations should:

• Consider revising, renewing and standardising models of specialist neonatal nursing education

In order that future rises in numbers of nurses who are qualified in speciality result in the comparable
increments in nursing expertise in different neonatal networks, universities and Health Education
England

Neonatal Units and Neonatal Networks should:

• Prioritise data quality assurance in submitting nurse staffing data

• Monitor adherence to recommended nurse staffing standards
• Develop action plans to address any deficits in nursing staffing and skill mix

So that babies and their parents are cared for at all times by the recommended number of trained
professionals.

13
National Neonatal Audit Programme 2020 report on 2019 data

1. Introduction
Established in 2006, the National Neonatal Audit Programme (NNAP) is a national clinical
audit of NHS-funded care for babies admitted to neonatal services in England, Scotland,
Wales and the Isle of Man. Approximately 1 in 7 babies will require neonatal care because
they are born too early, have too low a birth weight or have a medical condition that needs
specialist treatment.

 The audit reports on key measures of the process and outcomes of neonatal care and
supports professionals, families and commissioners to improve the care provided to babies
requiring specialist treatment. The NNAP aims to assess the care given to babies admitted
to neonatal units and identify areas for quality improvement. For more about our aims, see
Appendix I: Aims of the NNAP.

The NNAP is delivered by the Royal College of Paediatrics and Child Health (RCPCH),
commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by
NHS England, the Scottish Government and the Welsh Government.

This is the 12th annual NNAP report published by the RCPCH. Previous reports can be
downloaded from: www.rcpch.ac.uk/national-neonatal-audit-programme.

1.1. Scope
 Since starting in 2006, the scope of the audit has evolved to reflect developments in care
delivery and progress made by neonatal services in delivering that care. Progress in data
completeness and national compliance in the audit measures from the point of their
introduction show the power of national reporting to drive change. Long-standing measures
such as administration of antenatal steroids and on-time retinopathy of prematurity (ROP)
screening now achieve high rates of data completeness and high rates of compliance
nationally. Variation still exists regionally and locally, highlighting the importance of
continuing to report and benchmark through audit.

The audit continues to evolve. Measures included in the audit are reviewed and developed in
consultation with stakeholders and with consideration of new guidelines and evidence. A full
guide to the audit measures for the 2019 data year is available at: https://www.rcpch.ac.uk/work-
we-do/quality-improvement-patient-safety/national-neonatal-audit-programme-nnap/about

1.2. NNAP governance

The audit is governed by a Project Board, chaired by the RCPCH Vice President for Science
and Research. It comprises members from key stakeholder organisations and groups,
including several parent representatives. The Methodology and Dataset Group assists the
Project Board with technical matters, such as analysis planning, presentation of results, and
development and review of measures.

14
National Neonatal Audit Programme 2020 report on 2019 data

The Project Board is responsible for overseeing the audit and providing oversight and advice
to the programme. Clinical accountability is provided by the Vice President for Science and
Research. Clinical leadership is provided by the NNAP Clinical Lead and organisational and
contractual accountability is provided by the RCPCH Director of Research and Quality
Improvement. The Neonatal Data Analysis Unit (NDAU) provide data analysis, statistical
expertise, data management and data storage.

Appendix D includes more information about governance of the NNAP and a list of Project
Board and Methodology and Dataset members.

15
 2. Results, key findings and
recommendations
National Neonatal Audit Programme 2020 report on 2019 data

2.2.1.RAntenatal
esults, steroids
key findings and
recommendations
Is a mother who delivers a baby between 23 and 33 weeks’ gestational age inclusive
given at least one dose of antenatal steroids?
2.1. Antenatal steroids
Babies born at less than 34 weeks gestational age
sometimes
 have breathing
Is a mother difficultiesainbaby
who delivers the first few days
between
23 and 33 weeks’ gestational age inclusive
after they are born. Antenatal steroids are a powerful
health given at least
intervention, given toone dose
mothers of antenatal
by obstetricians and
midwivessteroids?
before delivery of a preterm baby. Antenatal
steroids help reduce breathing difficulties (respiratory
Babies bornand
distress syndrome) at less thanthe
reduce 34likelihood
weeks’ gestational
of other
age sometimes have breathing difficulties
serious complications, such as bleeding into the brain.
in the first few days after they are born.
The NNAP developmental standard is that 85% of eligible
Antenatal steroids are a powerful health
mothers should receive at least one dose of antenatal
intervention, given to mothers by
steroids. For more information on this measure, check
obstetricians and midwives before delivery of a preterm baby. Antenatal steroids help reduce
out ourbreathing
measures guide.
difficulties (respiratory distress syndrome) and reduce the likelihood of other
serious complications, such as bleeding into the brain. The NNAP developmental standard is
Resultsthat 85% of eligible mothers should receive at least one dose of antenatal steroids. For more
information on this measure, check out our measures guide.
12,397 eligible mothers were identified from data submitted for 14,182 babies by 181 neonatal units

and 22Results
places of birth not allied with an NNAP participating unit. If the mother delivered at home, in
transit, in an unknown location or in a maternity unit not allied to an NNAP participating unit, these

results 12,397
are noteligible
includedmothers
in Figurewere
1 andidentified from data
Figure 2. Figure submitted
2 does not includefor
the14,182
Isle ofbabies
Man. by 181 neonatal
units and 22 places of birth not allied with an NNAP participating unit. If the mother delivered
Table 1.at Administration
home, in transit, in an unknown
of antenatal steroids,location or inunit
by neonatal a maternity
level. unit not allied to an NNAP
participating unit, these results are not included in Figure 1 and Figure 2. Figure 2 does not
include Eligible
the Isle of Man. With data
Unit Level mothers entered Steroids given Steroids not given Missing data
Other*Table 1. 251
Administration 243 103 (42%)
of antenatal steroids, by neonatal141 (58%)
unit level. 7 (2.8%)
SCU 1,061 1,048 930 (88.7%) 118 (11.3%) 13 (1.2%)
LNU Unit 4,667 Eligible 4,653 With data4,300 (92.4%) Steroids 353Steroids
(7.6%) 14 (0.3%)
Missing
NICU level 6,418 mothers 6,404 entered 5,944 (92.8%) given 460not given
(7.2%) data14 (0.2%)
Total Other* 12,397 250 12,348 243 11,277 102
(91.3%)
(42%) 1,072
141(8.7%)
(58%) 48 (0.5%)
7 (2.8%)

SCUat home, in transit,

*Delivered 1,056 in an unknown
1,043location or in9,26 (88.8%) unit not
a maternity 117 (11.2%) 13 (1.2%)
allied to an NNAP
participating
LNU unit. 4,673 4,659 4,305 (92.4%) 354 (7.6%) 14 (0.3%)
NICU 6,418 6,404 5,944 (92.8%) 460 (7.2%) 14 (0.2%)
Total 12,397 12,349 11,277 (91.3%) 1,072 (8.7%) 48 (0.4%)

16
* Delivered at home, in transit, in an unknown location or in a maternity unit not allied to an
NNAP participating unit.

16
National Neonatal Audit Programme 2020 report on 2019 data

Figure 1. Caterpillar plot of the rates of administration of antenatal steroids: neonatal

units, 2019.

Rates of administration of antenatal steroids are presented by dots. NICUs are shown in pink,
LNUs in blue and SCUs in grey. The 95% confidence intervals for a unit are shown by a vertical
line with each dot. The developmental standard is shown by a bold dashed line, and the
national rate is indicated by a grey dotted line. Neonatal units are presented in the ascending
order of the rates and can be identified on NNAP Online.

 Figure 2. Caterpillar plot of the rates of administration of antenatal steroids: neonatal

networks, 2018 and 2019.

Rates of administration of antenatal steroids are presented by black dots and the 95%
confidence intervals are indicated by vertical bars. The networks are presented in the
ascending order of the rates. The national rate is represented by the line with short dashes
and the developmental standard is represented by the line with long dashes.

17
National Neonatal Audit Programme 2020 report on 2019 data

 Figure 3. Administration of antenatal steroids, cases with data entered, by NNAP

reporting year (2009 to 2019).

100%
90.5% 91.3%
87.1% 88.6%
90% 84.3% 85.3% 85.8%
82.0%
77.9% 79.0%
80% 75.6%

70%

60%

50%

40%

30% 0.244 0.221 0.21

0.18 0.157
20% 0.147 0.142 0.129 0.114 0.095
0.073 0.087
10% 0.036 0.033 0.021 0.013 0.008 0.007 0.011 0.015 0.005 0.004
0%
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Antenatal steroids administered Antenatal steroids not administered

Missing data Developmental standard

 ote: The gestational age inclusion criteria changed in 2018 from 24 to 34 weeks inclusive
N
to 23 to 33 weeks inclusive.

Key Findings and Recommendations

Key finding (A) – Antenatal Steroids

At least one dose of antenatal steroids was administered to 91.3% (11,277 of 12,397) of women
whose baby was born at 23-33 weeks’ gestation and was admitted for neonatal care. This national
level coverage was higher than in 2018 (90.5%). Some rapid improvements since 2018 can be
seen in many networks, but low outliers can also be detected at both unit and network levels.

Recommendation (1):

Neonatal units and obstetric services should work as a perinatal team to:

• Optimise the timing and dosing of antenatal steroids for eligible babies
• Avoid the inappropriate use of multiple courses
• Adopt evidence-based practices to predict preterm birth, by using the following
guidance and methodologies to guide improvement:
– BAPM Perinatal Optimisation Care Pathway Toolkit
– Prevention of Cerebral Palsy in PreTerm Labour (PReCePT) quality improvement
programme
– Scottish Patient Safety Programme

To help reduce the severity of respiratory disease and other serious complications in preterm babies.

The National Maternity and Perinatal Audit (NMPA) should:

Consider developing reporting of antenatal steroid use in order to encourage timely exposure
of eligible infants to it.

18
National Neonatal Audit Programme 2020 report on 2019 data

2.2. Antenatal magnesium sulphate

2.2. Antenatal magnesium sulphate
Is a
mother who delivers
Is a mother a babyabelow
who delivers 30 weeks
baby below gestational
30 weeks’ age given
gestational agemagnesium
given magnesium
sulphate in the 24 hours prior to delivery?
sulphate in the 24 hours prior to delivery?

Giving Giving
 magnesium sulphate to
magnesium women who
sulphate are at risk
to women whoof delivering
are at riska of
preterm baby
delivering
i
reduces a the chancebaby
preterm that their baby will
reduces thedevelop
chancecerebral palsy by
that their 32%.
baby The
will NICE
develop
quality cerebral
standard Preterm
palsy byLabour
32%. and
i
TheBirth
NICErecommends that all women
quality standard PretermwhoLabour
may
deliver and
their Birth recommends
baby at that all
less than 30 weeks women age
gestational whoaremay deliver
offered their baby
magnesium
ii
sulphateat where
less than 30 The
possible. weeks’
NNAPgestational age
developmental are offered
standard magnesium
is that 85% of eligible
sulphate where possible. ii
The NNAP developmental standard
mothers should receive antenatal magnesium sulphate, which maps to the target is that
in
85% of eligible mothers should receive antenatal
the NHSE PRECEPT programme. For more information on this measure, check magnesium
sulphate, which maps to the target in the NHSE PRECEPT
out our measures guide.
programme. For more information on this measure, check out our
measures guide.
Results
Results
3,991 eligible mothers were identified from data submitted for 4,469 babies by 179
neonatal
 units
3,991 and 12mothers
eligible places of were
birth not allied with
identified an NNAP
from participatingfor
data submitted unit. If thebabies
4,469 motherby delivered
179 neonatal
at home, in transit,
units and 12inplaces
an unknown
of birthlocation, Islewith
not allied of Man
anor in a maternity
NNAP unit not
participating allied
unit. to an
If the NNAP delivered
mother
participating
at home,unit, in
these results
transit, areunknown
in an not included in FigureIsle
location, 4 and Figure
of Man or 5.
inFigure 6 does unit
a maternity not include
not allied to an
the IsleNNAP
of Man.participating unit, these results are not included in Figure 4 and Figure 5. Figure 6
does not include the Isle of Man.
Table 2. Administration of magnesium sulphate, by neonatal unit level.
Table 2. Administration of magnesium sulphate, by neonatal unit level.
Missing
Eligible With data Magnesium Magnesium not (% of eligible
Missing
Unit Level
Unit mothers Eligible
entered With datagiven Magnesium givenMagnesium mothers)
(% of eligible
Other* level 98 95
mothers entered 27 (28.7%)
given 68 (71.3%)
not given 3 mothers)
(3.1%)
SCU Other*
178 97
175 94
127 (72.6%)
27 (28.7%)
48 (27.4%)
67 (71.3%)
3 3(1.7%)
(3.1%)
LNU 1,080 1,067 867 (81.2%) 200 (18.8%) 133 (1.7%)
(1.2%)
SCU 176 173 125 (72.3%) 48 (27.7%)
NICU LNU 2,635 1,083 2,623 1,070 2,230 (85%)
869 (81.2%) 393 (15%)
201 (18.8%) 1213(0.5%)
(1.2%)

Total NICU 3,991 2,635 3,960 2,623 3,251 (82.1%)

2,230 (85%) 709 (17.9%)
393 (15%) 3112(0.8%)
(0.5%)

Total 3,991 3,960 3,251 (82.1%) 709 (17.9%) 31 (0.8%)

*Delivered at home, in transit, in an unknown location or in a maternity unit not allied to an NNAP
participating unit.
*Delivered at home, in transit, in an unknown location or in a maternity unit not allied to an
NNAP participating unit.

20

19
National Neonatal Audit Programme 2020 report on 2019 data

 Figure 4. Caterpillar plot of the rates of compliance for administration of magnesium

sulphate: neonatal units, 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation.

Figure 5. Caterpillar plot of the rates of compliance for administration of magnesium

sulphate: neonatal networks, 2018 and 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation.

20
National Neonatal Audit Programme 2020 report on 2019 data

 igure 6. Antenatal magnesium sulphate administered, by NNAP reporting year (2015-

F
2019).

100%
90% 82.1%
80% 72.0%
65.0%
70%
60% 53.0%
47.0%
50%
35.0%
40% 28.0%
30% 19.0% 17.9%
20% 8.0%
10% 3.4% 0.8%
0%
2016 2017 2018 2019

Antenatal magnesium sulphate administered (% of cases with valid data)

Antenatal magnesium sulphate not administered (% of cases with valid data)
Missing data (% of eligible mothers)
Developmental standard

Key Findings and Recommendations

Key finding (B) – Antenatal magnesium sulphate

The rate of administration of antenatal magnesium sulphate has risen markedly by over 10%
since 2018 (2016 – 53%; 2017 – 64%; 2018 – 72%; 2019 – 82%). Rates of missing 2019 data are very
low (<1%). The lower rates of magnesium sulphate administration in the Wales and Scotland
neonatal networks in 2019 may be indicative of the effectiveness of the PReCePT quality
improvement programme, which is centrally funded and regionally delivered in England.

Recommendation (2):

Neonatal networks, units and obstetric services should work as a perinatal team to:

• Ensure that all women who may deliver their baby at less than 30 weeks’ gestational
age are offered magnesium sulphate where possible
• Adopt and implement the following guidance and methodologies to guide
improvement:
- BAPM Perinatal Optimisation Care Pathway Toolkit
- Prevention of Cerebral Palsy in PreTerm Labour (PReCePT) quality improvement
programme
- Scottish Patient Safety Programme

To help reduce the risk of babies who are born prematurely developing cerebral palsy.

21
National Neonatal Audit Programme 2020 report on 2019 data

2.3. Birth in a centre with a neonatal intensive

2.3. Birth in a centre with a neonatal intensive
care unit (NICU)
care unit (NICU)
Is an admitted
baby born
Is an admitted at born
baby less at
than 27
less weeks
than gestational
27 weeks’ age delivered
gestational in a in a maternity
age delivered
maternityservice onon
service thethe
same
same site as as
site a designated
a designatedNICU?
NICU?


Babies whoBabies who
are born arethan
at less born at less
27 weeks than 27
gestational ageweeks’
are at
gestational
high risk of death and seriousage areillness.
at high risk of recommendations
National death and serious
in Englandillness.
iii iv
, stateNational recommendations
that neonatal networks shouldinaimEngland and
to configure
Scotland , ,
iii iv 5
state that neonatal networks
and deliver services to increase the proportion of babies at this should
aim
gestational agetobeing
configuredelivered and
in adeliver
hospitalservices to increase
with a neonatal
the proportion of babies at this
intensive care unit (NICU) on site. This is because there is gestational age
being delivered in a hospital with a neonatal
evidence that outcomes improve if such premature babies are
intensive care unit (NICU) on site. This is because
cared for in a NICU from birth. At least 85% of babies born at less
there is evidence that outcomes improve if such
than 27 weeks gestational age should be delivered in a maternity
premature babies are cared for in a NICU from
service on the same site as a NICU. Whether networks are
birth. At least 85% of babies born at less than 27
optimally weeks’
configured should be considered
gestational age should when
beinterpreting
delivered high
in a
rates of performance on this measure. For
maternity service on the same site as a NICU.more information on
Whether
this measure, check networks are optimally
out our measures guide. configured should
be considered when interpreting high rates of
Results performance on this measure. For more information
on this measure, check out our measures guide.

Figure 7. Caterpillar plot of the rates of birth of babies of less than 27 weeks gestation in a
Results
centre with a NICU: neonatal networks, 2018 and 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and Interpretation. The Isle of
 Figure 7. Caterpillar plot of the rates of birth of babies of less than 27 weeks’ gestation in
Man is not included in this figure.
a centre with a NICU: neonatal networks, 2018 and 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation. The Isle of Man is not included in this figure.
100

●
90

●
●
Developmental standard 85.0%
Rate of compliance

● ●●
80

1545 77.5%
● ● ● ●
● ●
●
● ●
● ●
1620 74.3%
●
●
70

●
●
●

●
● ● 2019
60

●●
2018
●
●
50

106 82 90 122 116 149 78 104 68 133 113 204 82 98

121 103 84 141 127 170 90 113 54 131 107 218 69 92

d s st er s s st sx t
lan land We mb & NE and NW ou
th
ale Ea W es hern land
g l n S W t t
n
fE tM
id uth Hu NC Mid ndo on W th & th Nor Sco
o o & o n t o d S ou s V Nor
st s S s s L n e
Ea rk nd We Lo am
Ea Yo Lo Th
23
Network (ODN)

22
National Neonatal Audit Programme 2020 report on 2019 data

Table 3. Birth of babies of less than 27 weeks’ gestation in a centre with a NICU by NNAP
reporting year, 2018-2019. Isle of Man is included here.

Delivery location
Hospital with
Year Babies Designated NICU (%) Other (%)

2018 1,620 1,204 (74.3%) 416 (25.7%)

2019 1,546 1,198 (77.5%) 348 (22.5%)

Key findings and Recommendations

Key finding (C) – Birth in a centre with a neonatal intensive care unit (NICU)

The proportion of babies born at less than 27 weeks’ gestation in a hospital with an on-site
NICU has improved only marginally from 2018 to 2019 (from 74.3% to 77.5%). This is a major
concern because of the evidence that outcomes are improved when the least mature babies
are cared for in a NICU. Most networks have improved only marginally since 2018, although
the London North Central and East, and Wales networks have achieved improvements of
more than 12% in a single year.

Recommendation (3):

Departments of Health in England, Scotland and Wales and Neonatal Networks should:

Prioritise structural changes and operational management to ensure that babies who
require intensive care are cared for in the units best equipped to deliver it.

Local Maternity Systems (LMS) and equivalent bodies in devolved nations should:

• Ensure that appropriate clinical pathways exist

To enable delivery of intensive care to all infants where this is required, with a minimum of
postnatal transfers.

23
 2.4. Promoting normal temperature on
admission
National Neonatal for
Audit Programme 2020 reportvery preterm babies
on 2019 data

2.4. Promoting normal temperature on

Does an admitted baby born at less than 32 weeks gestational age have a first
temperature on admission that is both between 36.5–37.5°C and measured within
admission
one hour of birth? for very preterm babies
Does antemperature
Low admission admitted is baby born with
associated at less
an than
32 weeks’ gestational age have
increased risk of illness and death in preterm babies.a first
temperature on admission that is both
Low temperature (or hypothermia) is a preventable
between 36.5–37.5°C and measured within
condition in vulnerable newborn babies. Staff on the
one hour of birth?
neonatal unit need to know if a baby is too cold or too
hot, so they can take appropriate action.
Low admission temperature is associated with
an increased
This NNAP risk of neonatal
measure assesses illness andunits’ death
success in
in achieving a normal first temperature within
preterm babies. Low temperature (or hypothermia) is a preventable condition in vulnerable
an hour of birth in very preterm babies. The NNAP developmental standard is that temperature should
newborn babies. Staff on the neonatal unit need to know if a baby is too cold or too hot, so
be taken within an hour of birth for all eligible babies. At least 90% of babies should have a
they can take appropriate action.
temperature taken within an hour of birth with the result in the normal range. For more information on
this measure,
 This NNAPcheck out our measures
measure guide.
assesses neonatal units’ success in achieving a normal first temperature
within an hour of birth in very preterm babies. The NNAP developmental standard is that
Results
temperature should be taken within an hour of birth for all eligible babies. At least 90% of
babies should have a temperature taken within an hour of birth with the result in the normal
range. For more information on this measure, check out our measures guide.
7,435 babies were born very preterm (gestation less than 32 weeks) in 180 NNAP units and 8 ‘Other’
places of birth not associated with an NNAP participating unit. For 3 babies the temperature was
Results
reportedly not taken, and for 19 babies temperature and/or timing data were missing. Place of delivery
is classified as ‘Other’ if the mother delivered at home, in transit, in an unknown location or in a non-
7,435 babies were born very preterm (gestation less than 32 weeks) in 180 NNAP units and 8
NNAP unit. Figure 8 and Figure 9 do not include ‘other’ delivery locations and Figure 9 does not
‘Other’ places of birth not associated with an NNAP participating unit. For 3 babies the
include the Isle of Man.
temperature was reportedly not taken, and for 19 babies temperature and/or timing data
were missing. Place of delivery is classified as ‘Other’ if the mother delivered at home, in
transit, in an unknown location or in a non-NNAP unit. Figure 8 and Figure 9 do not include
‘other’ delivery locations and Figure 9 does not include the Isle of Man.

Table 4. Temperature on time and within normal range, by neonatal unit level.

Temperature taken on time

With
Unit data 32- 36- 36.5- After Not
Level Babies entered < 32°C 35.9°C 36.4°C 37.5°C > 37.5°C hour taken Unknown

Other* 85 83 2 (2.4%) 28 7 27 6 12 1 2
(33.7%) (8.4%) (32.5%) (7.2%)
SCU 446 443 0 (0%) 20 70 285 47 21 0 3
(4.5%) (15.8%) (64.3%) (10.6%)
LNU 2,472 2,469 0 (0%) 96 307 1,700 313 53 0 3
(3.9%) (12.4%) (68.9%) (12.7%)
NICU 4,432 4,421 2 (0%) 114 482 3,174 547 100 2 11
(2.6%) (10.9%) (71.8%) (12.4%)
25
Total 7,435 7,416 4 (0.1%) 258 866 5,186 913 186 3 19
(3.5%) (11.7%) (69.9%) (12.3%)

* Delivered at home, in transit, in an unknown location or in a maternity unit not allied to an

NNAP participating unit.

24
National Neonatal Audit Programme 2020 report on 2019 data

Figure 8. Caterpillar plot of the rates of compliance for very preterm infants’
temperature on admission (measured on time, and in normal range):
neonatal units, 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation. Units are presented in ascending order of the rates and can be identified on
NNAP Online.

Figure 9. Caterpillar plot of the rates of compliance for temperature on admission:

neonatal networks, 2018 and 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation.

25
National Neonatal Audit Programme 2020 report on 2019 data

Figure 10. Temperature on time and within normal range, very preterm infants, by NNAP
reporting year (2013-2019).

100%
90%
80%
67.4% 69.9%
70% 64.4%
58.1% 60.8%
60% 52.1% 51.3%
50%
40%
30%
20%
10% 2.1% 1.1% 0.7% 0.5% 0.3% 0.3% 0.3%
0%
2013 2014 2015 2016 2017 2018 2019

Normothermia (36.5-37.5°C) Missing data Developmental standard

 OTE: For 2015-2019 data babies born at less than 32 weeks were included in the audit
N
measure. In previous years, only babies born at less than 29 weeks were included.

Key findings
69.9% (5,186 of 7,416) of very preterm babies had a normal first temperature within an hour
of admission. This is a further improvement on previous years (2015 – 58.1%; 2016 – 60.8%; 2017
– 64.4%; 2018 – 67.4%) and was achieved without any increase in hyperthermia. All networks
except for one, have improved. Two networks have made striking improvements in
thermoregulatory management (East Midlands and Yorkshire and the Humber).

There has been a further reduction in marked hypothermia (temperature less than 36.0oC),
which has strongest relationship with adverse outcome (2015 – 8.8%; 2016 – 6.9%; 2017 – 5.6%;
2018 – 4.4%; 2019 – 3.1%)

Networks vary importantly, with three high outlying performers, and three low outlying
networks. At unit level, success in keeping babies warm varies strikingly by unit (60-80%). The
same unit was identified as a high performing outlier as in the 2018 data. Two low performing
outlier units are identified.

26
National Neonatal Audit Programme 2020 report on 2019 data

2.5. Parental consultation within 24 hours of

2.5. Parental consultation within 24 hours of ad-
admission
mission
Is there Ias there

documented consultation with parents by a senior member of the neonatal
a documented consultation with parents by a senior member of the neonatal
v,vi,vii
team within
team24 hours24
within ofhours
a baby’s
of afirst admission?
baby’s first admission?v,vi,vii

It is important
 that families that
It is important understand
familiesand are involvedand
understand in theare
care of their in
involved
baby. Thisthefirstcare
consultation provides an opportunity for a senior
of their baby. This first consultation provides an staff
member to meet
opportunitythe parents, listen tostaff
for a senior their member
concerns, explain
to meet how
thetheir baby
parents,
is being cared
listenfor toand respond
their concerns,to any questions.
explain howThis
theirmeasure
baby isof care cared
being
assessesfor and parents
whether respond haveto been
any spoken
questions.
to by aThis measure
senior member of care
of the
assesses
neonatal team withinwhether parents
the first 24 hours ofhave
theirbeen spoken
baby being to by It
admitted. a senior
applies tomember
all babies ofwhothe neonatal
require care onteam withinunit.
a neonatal theAfirst 24 hours of
consultation
should take place with 24 hours of first admission for every baby. For require
their baby being admitted. It applies to all babies who more
care on a neonatal unit. A consultation should take place with
information on this measure, check out our measures guide.
24 hours of first admission for every baby. For more
information on this measure, check out our measures guide.
Results
Results
There were 72,459 first episodes of care (lasting at least 12 hours) reported by 181 neonatal units
considered
 for this
There question.
were 72,459Babies who did not
first episodes of receive Healthcare
care (lasting Resource
at least Group
12 hours) (HRG) 1,2,
reported by or
1813 neonatal
on a neonatal
unitsunit during theirfor
considered first dayquestion.
this of care orBabies
whose admission was receive
who did not for less than 12 hoursResource
Healthcare were Group
excluded (HRG) 1,2,analysis;
from the or 3 on a neonatal
this unit
left 54,097 during
first their
episodes first day
eligible of care
for the auditormeasure.
whose admission
Data were was for less
missing orthan 12 hours
“unknown” for were excluded
862 episodes from the analysis; this left 54,097 first episodes eligible for the
(1.6%).
audit measure. Data were missing or “unknown” for 862 episodes (1.6%).
Figure 12 does not include the Isle of Man.
Figure 12 does not include the Isle of Man.
Table 5. Time of first consultation, by neonatal unit level.

Table 5. Time of first consultation,

With by neonatal
Time unit level.
of first consultation
Eligible data Within 24 Before After 24 No
Unit Time of first consultation
Level admissions entered hours Admission hours Consultation Unknown
Unit Eligible With data Within 24 Before After 24 No
level admissions 6,107
entered hours admission hours Consultation Unknown

SCU 6,456
SCU 6,330
6,456 (96.5%)
6,330 84 (96.5%)
6,107 97
84 42
97 42 126 126

LNU 22,962 22,007

22,695 22,007 (97%) 238 275 175 267
LNU 22,962
NICU 22,695
24,679 (97%)
24,210 238 (96.5%) 181
23,365 275 175
416 248267 469

Total 54,097 23365

53,235 51,479 (96.7%) 503 788 465 862 (1.6%)
NICU 24,679 24,210 (96.5%) 181 416 248 469
 51,479 862
Total 54097 53,235 (96.7%) 503 788 465 (1.6%)

29

27
National Neonatal Audit Programme 2020 report on 2019 data


Figure 11. Caterpillar plot of the rates of first consultation within 24 hours of admission:
neonatal units, 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation. Units are presented in ascending order of the rates and units can be
identified on NNAP Online
100

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

100.0%
●●●●●●
●●●●●●●●●

53235
●●●●●●●●●
●●●●●●●●●●●●
●●●●●
●●●●●●●●
●●●●●●●●●●
●●●
●●●●●
●●●●●

All 96.7%
●●●●
●●●●●
●●●●
●●●●●●●
●●●
Rate of compliance (%)

●●●●
●●●●●
●●
●●●●●●●●
●●
●●●
●●●●
●●●●
90

●
●●
●

●●
●
●

●●

●
80
70

● SCU
●
● LNU
● NICU
60

1 50 100 150 181

Rank of neonatal unit

 F
 igure 12. Caterpillar plot of the rates of first consultation within 24 hours of admission:
neonatal networks, 2018 and 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation.
100

●
●
●
●
Rate of compliance

98

● ●

●● ● ●
53160 96.7%
●
●

● ●
●
96

● ● ●

56048 ● ●
● 95.9%
●
●
● ●
94

●
● 2019
● 2018
●
92

2826 5243 6225 3387 1935 4381 4243 5788 3241 1986 4090 2366 3395 4054
3384 5457 6567 3619 2066 4687 4379 5901 3192 2114 4358 2518 3614 4192

t t r d st
ds nds es es her
n d
be tlan lan th W E les sx
l an l a W W r t u m o g S ou n N
C &N Wa h Ea W
i d i d h h n o t &
M tM rt ut No & H Sc of E don nd N u V
a st e s No So s t n Lo ndo
n So es
r k s L o m
E W Yo Ea Lo a
Th
Network (ODN)

28
National Neonatal Audit Programme 2020 report on 2019 data

Figure 13. Time of first consultation, by NNAP reporting year (2013 to 2019).

100% 91.7% 91.9% 94.0% 94.6% 95.9% 96.7%

89.1%
90%
80%
70%
60%
50%
40%
30%
20%
5.4% 3.3% 3.9% 3.7% 2.7% 1.9% 1.6%
10%
0%
2013 2014 2015 2016 2017 2018 2019

First consultation within 24 hours Missing data Developmental standard

Key Findings and Recommendations

Key finding (D) – Parental consultation within 24 hours of admission

Only 3.3% of babies have no record of a consultation between parents and medical staff
within 24 hours of admission to the neonatal unit. This is an improvement on 2018 (4.1%). Of
the five lowest performing networks in 2018, four have made substantial improvements in
2019, making an important contribution to the overall improvement across all networks.

Key finding (E) – Parental consultation within 24 hours of admission

Performance overall at unit level was generally good, but there was a wide variation in how
successful units were at meeting this standard (range 82 – 100%, with one exception of 67%).
Units of all levels have good and bad performance, and 33 are identified as having unusually
low (outlying) performance.

Recommendation (4):

Neonatal units with lower rates of parental consultation, and particularly those with low
outlying performance, should:

• Reflect on their rates of parental consultation

• Use a quality improvement approach and consider using novel means such as video calls,
where parents are unable to enter the neonatal unit

In order to improve parental partnership in care.

29
2.6. Parental presence at consultant ward
rounds
National Neonatal Audit Programme 2020 report on 2019 data

2.6. P
 arental presence at consultant ward
For a baby admitted for more than 24 hours, did at least one parent attend a
consultant ward round at any point during the baby’s admission?v,vi,viii
rounds
Neonatal care is very stressful for babies and parents. Professionals,

parents’ For aand
advocates, baby admitted
parents agreefor more
that thanparents
including 24 hours, in did at
least one parent attend a consultant ward
consultant ward rounds supports parental partnership in care.
round at
any point during the baby’s admission? 6,7,viii
Consultant ward rounds occur regularly (usually daily) on neonatal
units. This measure looks at the proportion of admissions where
 Neonatal care is very stressful for babies and
parents were present on a consultant ward round on at least one
parents. Professionals, parents’ advocates, and
occasion during a baby’s stay. We acknowledge that this measure is
parents agree that including parents in consultant
an imperfect and incomplete
ward rounds description of this element
supports parental of parental
partnership in care.
partnership in care, but feel that
Consultant ward therounds
measureoccur
has potential utility
regularly in
(usually
assessing the spread of shared
daily) on neonatal careunits. This For
planning. more information
measure looks at the
proportion
on this measure, check out ourof measures
admissions guide.where parents were
present on a consultant ward round on at least one occasion during a baby’s stay. We
Results acknowledge that this measure is an imperfect and incomplete description of this element
of parental partnership in care, but feel that the measure has potential utility in assessing
the spread of shared care planning. For more information on this measure, check out our
66,577 babies measures
were admitted for more than 24 hours. Of these admissions, 5,203 (7.8%) had missing
guide.
data for every day of their stay, leaving 61,374 admissions for inclusion in this measure.

Table Results
6: Parent present on one or more consultant ward rounds, by length of stay.

66,577 babies were admitted for more than 24 hours. Of these admissions, 5,203 (7.8%) had
missing data for every day of their stay, leaving 61,374 admissions for inclusion in this measure.

Table 6: Parent present on one or more consultant ward rounds, by length of stay.

Parental presence on one or

more ward rounds

Length of stay Eligible With data Parent not Parent

(days) admissions entered present present Missing data

≤7 days 35,666 31,147 7,279 (23.4%) 23,868 (76.6%) 4,519 (12.7%)

8-14 days 12,240 11,762 1,535 (13.1%) 10,227 (86.9%) 478 (3.9%)

15-21 days 6,361 6,239 657 (10.5%) 5,582 (89.5%) 122 (1.9%)

22-28 days 3,501 3,467 315 (9.1%) 3,152 (90.9%) 34 (1%)

>28 days 8,809 8,759 538 (6.1%) 8,221 (93.9%) 50 (0.6%)

Total 66,577 61,374 10,324 (16.8%) 51,050 (83.2%) 5,203 (7.8%)

Key findings and recommendations

Key finding (F) – Parental presence at consultant ward rounds
32

The reduction in missing data (2018 – 11.6%; 2019 – 7.8%) and the fact that in 2019 parents
joined a consultant ward round on one or more occasion for more than 75% of all eligible
admissions, suggests that this practice is gaining wider acceptance in neonatal care.

30
National Neonatal Audit Programme 2020 report on 2019 data

Key finding (G) – Parental presence at consultant ward rounds

Rates of parental attendance at consultant ward rounds vary across all units as a whole and
across levels of units (e.g. NICUs vary from 45 – 100%). This illustrates that significant progress
remains to be made in prioritising this form of parental partnership in care.

Recommendation (5):

Neonatal units, in collaboration with parents, should:

Build relationships and trust between parents, family members and neonatal unit staff by:

• Understanding the unique role of parents as partners in care, and involving them in
developing and updating care plans and decision making
• Empowering parents to feel comfortable and able to contribute to discussions about
their baby’s care
• Taking the time to explain to parents why decisions about aspects of care are being
suggested
• Reflecting on audit results with parents, identifying the reasons for any gaps in parental
presence on ward rounds, any lack of consultant wards or documentation of consultant
ward rounds, and working with parents to address any barriers to participation identified

So that parents are partners in the care of their baby in the neonatal unit.

31
feel prepared to provide ongoing care for their baby post-discharge home.
National Neonatal Audit Programme 2020 report on 2019 data
2.7. On-time screening for retinopathy of
prematurity
On-time(ROP)
2.7.  screening for retinopathy of
prematurity (ROP)
Does an admitted baby born weighing less than 1501g, or at gestational age of less
weeks,Dundergo
than 32 oes an admitted baby born weighing
the first retinopathy less than
of prematurity 1501g,
(ROP) or at gestational
screening in age of less
than 32 weeks, undergo the first retinopathy of prematurity (ROP) screening in
accordance with the NNAP interpretation of the current guideline
accordance with the NNAP interpretation of the current guideline recommendations?xi
recommendations?ix
Babies born very early or with a very low birth weight
Babies born very early
are at or risk
with of
a very low birth weight
retinopathy are at risk (ROP).
of prematurity of This
retinopathy of prematurity
condition (ROP).
affectsThis
thecondition affectsof
development the
thedevelopment
blood vessels
of the blood vesselsin the back
in the backofofthe
the eye.
eye. ROP
ROP can lead to
can lead toloss
lossofofvision,
vision,
but this is usually but this is
prevented by usually prevented
timely treatment. by timely
Therefore, treatment.
screening
babies for ROP atTherefore,
the right timescreening babies
is important for ROP
to help babiesathave
the right time
the best
is important to help babies have the best vision in the
vision in the future. By ‘on time’ we mean within a three-week period
future. By ‘on time’ we mean within a three-week
centred on the target week. All eligible babies should be screened ‘on
period centred on the target week. All eligible babies
time’. For more information
should beon this measure,
screened check
‘on time’. Forout our information
more measures on
guide. this measure, check out our measures guide.

Results
Results

There were 9,047 babies born with a birth weight less than 1,501g or with a gestational age at
There were 9,047 birth
babies born
less with32
than a birth
weeks weight
in anless than contributing
NNAP 1,501g or withunit.
a gestational
Of theseage at birth
babies, 17 were excluded
less than 32 weeks in an NNAP
because they contributing
did not haveunit. Of theseepisode
a recorded babies, 17 wereinexcluded
of care a neonatal because they after the closure
unit until
did not have a recorded
of the episode of care inwindow.
ROP screening a neonatal
24unit untilwere
babies after the closureas
removed ofathe ROP screening
responsible unit could not be
window. 24 babiesassigned. Further,
were removed as a25responsible
babies were unitexcluded
could not because theyFurther,
be assigned. were transferred
25 babies to non-neonatal
units before,
were excluded because or during,
they were the ROP
transferred screening window.
to non-neonatal Finally,
units before, 567 babies
or during, were excluded because
the ROP
they died before the closure of the screening window. This left 8,414 babies eligible for ROP
screening in 181 neonatal units.

The Isle of Man is not included34

in Figure 15.

Table 7. Timing of ROP screening, by neonatal unit level.

Screened on time
Unit Eligible Any Screened During After On time Screened No
level babies screen Early care discharge total late screen

SCU 795 774 4 (0.5%) 628 124 752 18 21

(97.4%) (94.6%) (2.3%) (2.6%)
LNU 3,214 3,187 15 (0.5%) 2,619 497 3,116 56 27
(99.2%) (97%) (1.7%) (0.8%)
NICU 4,405 4,345 13 (0.3%) 3,786 400 4,186 146 60
(98.6%) (95%) (3.3%) (1.4%)
Total 8,414 8,306 32 (0.4%) 7,033 1,021 8,054 220 108
(98.7%) (95.7%) (2.6%) (1.3%)

32
National Neonatal Audit Programme 2020 report on 2019 data

Figure 14. Caterpillar plot of the rates of on-time ROP screening: neonatal units, 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation. Units are presented in ascending order of the rates and units can be identified
on NNAP Online. 100

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

8414 100.0%
●●●
●●●●●●
●●●●●●●
●●●●●●●●●●
●●●●
●●●●●●●●●●
●●●●●●●●●●
●●●●●

All 95.7%
●●●●
●●●
●●
●●
●●●●
●●●●●
Rate of compliance (%)

●●●
●●●
90

●
●●●
●●
●●●
●
●●●
●
●●
●
●●●

●
●
80

●●
●
70

●
60

● SCU
● LNU
50

● NICU

1 50 100 150 180

Rank of neonatal unit

Figure 15. Caterpillar plot of the rates of compliance with on-time ROP screening:
neonatal networks, 2018 and 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation.
100

● ●
●
● ●● ●

8413 95.7%
●● ●
Rate of compliance

●● ● ●
● ● ● ●
95

● ●
8706 ● ● ● 95.6%
●
●
90

● ● 2019
● 2018
●
85

374 538 628 361 601 566 630 818 542 944 500 705 812 394
405 563 692 363 599 529 639 896 570 1030 507 699 838 376

er
n ds NE
s d th sx ds st st st nd be
r
th an & ale lan ou W lan Ea We We gla NW
r idl NC W cot n S & i d t h h h n u m
o n
No M S o V M u r t u t fE H nd
st on nd es est So No So st o ks & Lo
Ea nd Lo am W a r
Lo Th
E Yo
Network (ODN)

33
National Neonatal Audit Programme 2020 report on 2019 data

Figure 16. Timing of ROP screening, by NNAP reporting year (2009-2019).

100% 92.80% 93.30% 94.20% 94.40% 95.60% 95.70%

87.40%
90%
80%
67.30% 66.50%
70%
60% 53.80%

50%
40%
26.50%
30%
20%
10%
0%
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

On time screen Early screen Late screen No screen Developmental standard

Key findings and recommendations

Key finding (H) – On-time screening for retinopathy of prematurity (ROP)

After more than 10 years of measurement in the NNAP, 1.3% of babies still have no record of
screening at any time, and a further 2.6% (220 of 8,414) of babies were screened after the
NNAP interpretation of national screening guidance. Limited availability of ophthalmology
screening in SCUs might explain some missed or delayed screening, but the majority
(146/220) of late or missed screens were for babies in NICUs.

Key finding (I) – On-time screening for retinopathy of prematurity (ROP)

Networks also vary significantly in their delivery of on-time screening. Three networks can be
identified as low outliers, including one identified also in 2018 and 2017. Three NICUs in these
networks can be identified as low outliers in 2019, with on-time screening rates of 52%, 66%
and 73%, suggesting a role for leading units in driving regional quality improvement.

Key finding (J) – On-time screening for retinopathy of prematurity (ROP)

Ten un-screened babies were less than 30 weeks’ gestation and below 1,000g in birthweight,
and thus at a high risk of life-changing disease. For 49 babies we were unable to ascertain if
screening had happened at all, usually because of transfer to non-NNAP units.

Key finding (K) – On-time screening for retinopathy of prematurity (ROP)

70 out of 181 units (38.6%) screened all their babies on time, which is an improvement on 2018
data (33.9%).

34
National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (6):

Neonatal Intensive Care Units (NICUs) with persistently low levels of ROP screening should
ensure that:

• Babies requiring ROP screening are accurately identified

• Safety systems for appropriate ROP screening are in place

So that babies who are at the highest risk of loss of vision, can be screened and receive timely
treatment if required.

Neonatal Networks with low rates of ROP screening should:

• Implement a mechanism for real time measurement of their unit’s adherence to ROP
screening guidelines

So that they can identify where related quality improvement activities need to be undertaken.

35
National Neonatal Audit Programme 2020 report on 2019 data

2.8. Late onset infection

Sick and premature babies are prone to infection with a variety of germs, including some
that are normally harmless to healthy people. Infections increase the risk of death, can
lengthen the stay in the neonatal unit and may worsen the long-term developmental
outlook for babies.x Neonatal unit staff and parents can reduce the risk of infection by
following good infection prevention and control practice.

The NNAP reports two measures of late onset bloodstream infection. To look for infection in
babies, neonatal staff usually take blood cultures to check whether bacteria or other
organisms are present in their blood. Units are encouraged to report positive blood cultures:
that negative blood cultures are underreported is accepted as likely, or even inevitable. The
NNAP reports rates of blood cultures positive for bacteria, fungi or yeasts, as well as a measure
of bloodstream infection that occurs on the same day as a central line is present. Neither
measure takes account of case mix, so when comparisons between trusts are made, case
mix should be considered as one possible explanation for any differences in rates. A significant
strength of the bloodstream infection measure is that it is not undermined by any differences
in use of central venous access that might exist between units.

For more information on this measure, check out our measures guide.

Late onset bloodstream infection

 ate onset bloodstream infection: does an admitted baby have one or more episodes of
L
bloodstream infection, characterised by one or more positive blood cultures taken, after 72
hours of age?

Results
Some organisms grown may either represent true bloodstream infection or contamination
of the blood culture sample with skin organisms. For this reason, results for bloodstream
infection are presented in two columns. One column presents the number of babies from
whom a blood culture grew any organism. The other column presents the number of babies
for whom one or more culture grew an organism of clear pathogenicity. Clearly pathogenic
organisms were those whose growth indicates significant infection with or without the
presence of clinical confirmation. A list of such organisms is presented in Appendix E. Babies
contribute to the denominator for this measure for all units in which they were cared for,
after the age of 72 hours.

Overall, 15,030 blood cultures were reported from 53,230 babies who were admitted to 181
neonatal units at or after 72 hours of age. Of these blood cultures, 90.7% have a result entered.
For very preterm babies, 8,802 blood cultures were reported from 7,634 babies; for moderate
and late preterm and term babies, 6,228 blood cultures were reported from 45,596 babies.
Comparisons of rates of infections between years should not be made because of revised
methodology in this year’s report.

In 113 of 180 units, our survey of units told us that all positive blood cultures were reported to
the audit, with implications for the comparability of data between hospitals.

36
National Neonatal Audit Programme 2020 report on 2019 data

Table 8a. Positive blood cultures, by gestational age group

(<32 weeks and ≥32 weeks).

Number of babies with

Gestational age Number of babies with any growth of clearly
group Babies positive blood culture pathogenic organism

< 32 weeks 7,634 1,213 376

≥ 32 weeks 45,596 350 96

Total 53,230 1,563 472


Note: In previous years, rates of late onset bloodstream infection were presented using a
denominator of all admitted babies, not just those present on the unit at, or after, 72 hours
of age. In addition, a new organism list was used to classify cultures in this year’s report –
see Appendix E


Table 8b. Positive blood cultures, by gestational age group (<32 weeks and ≥32 weeks)
from units who confirmed validation of their positive blood cultures data.

Number of babies with

Gestational age Number of babies with any growth of clearly
group Babies positive blood culture pathogenic organism

< 32 weeks 5,459 916 342

≥ 32 weeks 27,381 232 66

Total 32,840 1,148 408


Note: In previous years, rates of late onset bloodstream infection were presented using a
denominator of all admitted babies, not just those present on the unit at, or after, 72 hours
of age.

Central Line Associated Bloodstream Infection (CLABSI):


Central line associated bloodstream infection: how many babies have a positive blood
culture (any species) with a central line present, after the first 72 hours of life, per 1000
central line days?

Results
53,230 babies who stayed for more than 72 hours in 181 neonatal units received 978,126 days
of care. In total, 15% of all care days included a central line and 979 bloodstream infections
were reported for these central line days. Line days were attributed to the unit in which they
occurred, and infections were attributed to the unit in which the blood culture was taken.
Comparisons of rates of infections between years should not be made because of revised
methodology in this year’s report.

37
National Neonatal Audit Programme 2020 report on 2019 data

Table 9a. Babies with central line associated bloodstream infections (CLABSI), by
gestational age group.

Babies with Babies with

central line one or more
Babies with associated CLABSIl
one or more bloodstream episode (any
CLABSI infection that growth) per
Gestational episode (any was clearly 1000 central
age group Babies growth) pathogenic Line days line days

< 32 weeks 7,634 630 187 101,084 6.23

≥ 32 weeks 45,596 132 35 45,930 2.87

Total 53,230 762 222 147,014 5.18

 ote: In previous years, rates of CLABSI were presented using a denominator of line days for
N
all admitted babies, not just those present on the unit at, or after,72 hours of age.

 T
 able 9b. Babies with CLABSI, in units who confirmed validation of their cultures data, by
gestational age.

Babies with Babies with

central line one or more
Babies with associated CLABSI
one or more bloodstream episode (any
CLABSI infection that growth) per
Gestational episode was clearly 1000 central
age group Babies (any growth) pathogenic Line days line days

< 32 weeks 5,459 476 139 63,632 7.48

≥ 32 weeks 27,381 95 27 28,359 3.35

Total 32,840 571 166 91,991 6.21

 ote: In previous years up to 2017, rates of central line associated bloodstream infection
N
were presented using a denominator of line days all admitted babies, not just those present
on the unit at or after 72 hours of age.

Key findings and recommendations

Key finding (L) – Late onset bloodstream infection

The rate of bloodstream infections is lower than in previous years, at least in part because of the
changes in how the NNAP reports infection rates and how it has revised the denominators and
improved and clarified the list of “clearly pathogenic organisms” - see Appendix E of this report.

Key Finding (M) – Late onset bloodstream infection

113 out of 181 (63%) units confirmed that all positive blood cultures had been submitted to the
audit. This is slightly lower than in 2018 (66%) and may be due to the onset of the COVID-19
pandemic as the data validation window was planned to end around the time that preparations
for COVID-19 were at their peak.

38
National Neonatal Audit Programme 2020 report on 2019 data

Key Finding (N) – Late Onset bloodstream infection

The proportion of very preterm infants experiencing infection with clearly pathogenic
organisms varied between 0% and 12.8% in the NICUs which reported all of their positive
blood cultures to the NNAP, variation which is very unlikely to be explained by case mix.

Key finding (O) – Central Line Associated Bloodstream Infection (CLABSI):

 he rate of CLABSI for babies born at less than 32 weeks’ gestation in the 39 of 54 NICUs
T
which have submitted all their positive blood cultures to the unit is 8.06. This is higher than
the comparable rate for all NICUs of 5.40, reflecting complete reporting.

Recommendation (7):

Neonatal units with higher reported rates of infection should:

• Compare practices with units with lower rates of infection, identified via NNAP Online
and consider whether their rates of infection could be decreased
• Ensure that their use of evidence-based infection reduction strategies is optimised

In order to minimise the number of babies infected in their units.

Neonatal networks and units with both low and high rates of infection should:

• Facilitate invitations for units with higher rates of infection to visit units with lower rates
in order to jointly agree whether potentially better practices could be used and consider
requiring units to participate in such quality improvement activity
• Ensure that the proposed visits should be multidisciplinary and focussed on
identification and implementation of potentially better practices including “infection
prevention bundles”

In order to reduce the risk of exposing sick and premature babies to infection.

39
 National Neonatal Audit Programme 2020 report on 2019 data
National Neonatal Audit Programme 2020 report on 2019 data

2.9.
2.9.  Bronchopulmonary
Bronchopulmonary dysplasia
dysplasia (BPD)
(BPD)
 Does
Does an admitted
an admitted babyat born
baby born at less
less than than develop
32 weeks 32 weeks’ gestational age develop
bronchopulmonary
bronchopulmonary dysplasia (BPD)?
dysplasia (BPD)?
Babies born preterm often do not have fully developed
Babies born preterm often do not have fully developed lungs
lungs and may require support with their breathing
and may require support with their breathing from a ventilator or
from a ventilator or another device. Simply being
another device. Simply being born early can cause some
born early can cause some ongoing breathing
ongoing breathing difficulties but being on a ventilator can
difficulties but being on a ventilator can cause
cause additional damage
additional damage totothe lungs.
the lungs.When
Whena babya babyneedsneeds
additional oxygen or support with breathing
additional oxygen or support with breathing untiluntil near term, their
condition is called bronchopulmonary dysplasia
near term, their condition is called bronchopulmonary (BPD)or
‘chronic lung disease’.
dysplasia (BPD)or BPD may belung
‘chronic associated
disease’.withBPDbreathing
may be
problems later in life
associated with and put these problems
breathing babies at increased
later in risklife of
and
chestput these babies
infections. NNAP at increased
reports on the risk of chest
proportion infections.
of babies born
very NNAP
pretermreports
who areon the
still proportion
receiving of babies
help with born very
their breathing orpreterm who are
supplementary still receiving
oxygen four weekshelp with
their
before theirbreathing
due date. or supplementary
Only oxygen
babies who survive theirfour weeks
early coursebefore their due
can develop BPD,date.
andOnly babies
therefore it who
survive their early course can develop BPD, and therefore it is important
is important that we consider rates of BPD alongside rates of death. For this reason, we report the that we consider
rates outcome
combined of BPD alongside rates of death. For this reason, we report the combined outcome of
of ‘BPD or death’.
‘BPD or death’.
Differing rates of BPD between units and networks might be the result of differing treatments or might
Differing
result, at least inrates
part,offrom
BPDdifferences
between units
in the and networks
readiness might be
of clinicians the result oxygen
to administer of differing treatments
to very
or might
preterm infants.result, at least in part, from differences in the readiness of clinicians to administer
oxygen to very preterm infants.
Where rates of BPD differ, it may also be that case mix explains the variation. For this reason, we

haveWhere
consideredratesthe
ofbaseline
BPD differ, it may alsoofbe
characteristics thethat case
babies mix for
cared explains
in unitsthe
andvariation.
networks.For this reason,
‘Treatment
we
effect’ is have considered
the difference the baseline
between the rate ofcharacteristics
BPD or death in ofbabies
the babies
caredcared
for in for in units
a unit and networks.
or network
‘Treatment effect’ is the difference between the rate of BPD or death
compared to the observed rate for a matched group of babies with very similar case mix, cared in babies cared for in a
for in
unit orunits.
all neonatal network compared
A positive treatmentto effect
the observed ratethe
indicates that forrate
a matched group
of significant BPDof or babies
death iswith very
similar case mix, cared for in all neonatal units. A positive treatment effect indicates
higher in the unit or network of interest than for a comparable group of babies cared for in all neonatal that the
rate of significant BPD or death is higher in the unit or network of interest than for a
units, which is not desirable. Where the 95% confidence interval for this effect does not include zero,
comparable group of babies cared for in all neonatal units, which is not desirable. Where the
the treatment effect is unlikely to be a chance finding. For more information on this measure, check
95% confidence interval for this effect does not include zero, the treatment effect is unlikely
out our
to bemeasures guide.
a chance finding. For more information on this measure, check out our measures
guide.
Results
Results
24,314 babies born at less than 32 weeks gestational age, discharged between 1 January 2017 and
 24,314 babies
31 December 2019 born at lessby
as reported than
18232 weeks’units,
neonatal gestational age, discharged
and 34 other between
places of birth 1 January
not associated with2017
an NNAP participating unit. Babies were assigned to their recorded place of birth for this analysis. In not
and 31 December 2019 as reported by 182 neonatal units, and 34 other places of birth
Tableassociated withare
10, responses anassigned
NNAP participating unit. Babies
‘Other’ if the mother were assigned
was recorded to their
as delivering recorded
the baby place of
at home,
birth for this analysis. In Table 10, responses are assigned ‘Other’ if the mother
in transit, in an unknown location, Isle of Man or in a maternity unit not allied with a NNAP was recorded
as delivering the baby at home, in transit, in an unknown location, Isle of Man or in a maternity
participating unit in the first neonatal unit admission. ‘Other’ responses are not included in Figure 17
unit not allied with a NNAP participating unit in the first neonatal unit admission. ‘Other’
and Figure 18 or the ‘Total’ row in Table 10. Of the 24,314 babies born at less than 32 weeks
responses are not included in Figure 17 and Figure 18 or the ‘Total’ row in Table 10. Of the
gestational age, 21,884 babies had enough data entered to attribute BPD and did not die before 36
24,314 babies born at less than 32 weeks’ gestational age, 21,884 babies had enough data
weeks corrected gestational age.
entered to attribute BPD and did not die before 36 weeks’ corrected gestational age.

42

40
National Neonatal Audit Programme 2020 report on 2019 data

Table 10. Rates of BPD or death, by neonatal network.

Death
before 36
weeks’
With corrected
Neonatal Eligible data No gestational Missing
Network babies entered BPD BPD age BPD or death data

East Midlands 1,513 1,511 1,023 366 122 488 (32.3%) 2

East of England 1,890 1,883 1,259 530 94 624 (33.1%) 7

North Central & 1,650 1,640 1,055 512 73 585 (35.7%) 10

North East London

North West London 1,097 1,095 718 301 76 377 (34.4%) 2

North West 2,865 2,853 1,735 841 277 1,118 (39.2%) 12

Northern 1,050 1,047 602 365 80 445 (42.5%) 3

Scotland 1,608 1,601 986 485 130 615 (38.5%) 7

South East Coast 1,670 1,664 1,043 486 135 621 (37.3%) 6

South London 1,478 1,476 887 491 98 589 (39.9%) 2

South West 1,439 1,435 880 467 88 555 (38.7%) 4

Thames Valley 1,885 1,878 1,242 514 122 636 (33.9%) 7

& Wessex

Wales 988 987 622 283 82 365 (37.0%) 1

West Midlands 2,375 2,354 1,449 657 248 905 (38.4%) 21

Yorkshire & Humber 2,264 2,259 1,504 581 174 755 (33.4%) 5

Total 23,772 23,683 15,005 6,879 1,799 8,678 (36.6%) 89

Other* 542 523 296 161 66 227 (43.4%) 19

* Includes deliveries at home, in transit, in an unknown location or in a maternity unit not

allied with a NNAP participating unit in the first neonatal unit admission. Also includes
Nobles Hospital, Isle of Man.

41
National Neonatal Audit Programme 2020 report on 2019 data

Figure 17. Caterpillar plot of the rates of BPD or death (2017-2019): neonatal units (TOP)
and ‘treatment effect’ on rates of BPD or death (BOTTOM). (LNUs and NICUs only) 2017 –
2019.

Rates of the combined outcome of significant BPD or death. Rates are marked with red
(NICUs) and blue dots (LNUs) and the 95% confidence intervals are indicated by vertical bars.
Neonatal units are presented in ascending order of the rates. For help interpreting these
caterpillar plots, please see appendix G: Methodology and Interpretation.

42
National Neonatal Audit Programme 2020 report on 2019 data

 F
 igure 18. Caterpillar plot of the rates of significant BPD or death (2017-2019): neonatal
networks (TOP) and ‘treatment effect’ on rates of significant BPD or death (BOTTOM).

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation.

Table 11. Rates of BPD only, and the combined outcome of BPD and death, by NNAP
reporting period (2013-2019).

With data
NNAP Year Babies entered BPD BPD or death Missing data

2013-2015 21,805 21,673 6,508 (30%) 132 (0.6%)

2014-2016 22,049 21,978 6,792 (30.9%) 71 (0.3%)

2015-2017 24,517 22,595 6,971 (30.9%) 8,851 (39.2%) 42 (0.2%)

2016-2018 23,849 23,773 6,931 (29.2%) 8,671 (36.5%) 76 (0.3%)

2017-2019 23,772 23,683 6,879 (29%) 8,678 (36.6%) 89 (0.4%)

Note: Prior to 2015-2017, the combined outcome of BPD or death was not reported.

43
National Neonatal Audit Programme 2020 report on 2019 data

Key findings and recommendations

Key finding (P) – Bronchopulmonary dysplasia (BPD)

Overall, about one third of surviving very preterm infants develop BPD. There is huge variation
in the rate of BPD or death between units (range 9.1 - 57%) and between networks (32-42%).
This variation occurs across both LNUs and NICUs and cannot be accounted for by case mix
(range of treatment effect attributable to neonatal network negative 3.1% to positive 4.5%).

Sixteen units are identified as having outlying high treatment effect, meaning that babies
born in these units are more likely than expected to be diagnosed with BPD, or die, than
comparable babies cared for in all units. Eight units have outlying low treatment effect,
suggesting that treatment in these units leads to lower rates of BPD or death.

Recommendation (8):

Neonatal units with high treatment effect should:

• Seek to identify potentially better practices from neonatal units with lower treatment
effect

Neonatal units and networks should:

• Seek to understand the extent to which care practices explain the differences in rates of
BPD
• Implement potentially better care practices, including any identified from NICE guidance
about specialist respiratory care

The British Association of Perinatal Medicine (BAPM) should:

• 
Consider developing a care pathway identifying potentially better practices and the
optimal means for their implementation

In order to reduce the proportion of babies affected by bronchopulmonary dysplasia.

44
 National Neonatal Audit Programme 2020 report on 2019 data

2.10. Necrotising enterocolitis (NEC)

2.10. Necrotising enterocolitis (NEC)
Does an admitted baby born at less than 32 weeks gestational age meet the NNAP
Does an admitted baby born at less than 32 weeks’ gestational age meet the NNAP
surveillance definition definition
surveillance for necrotising enterocolitis
for necrotising (NEC) on one
enterocolitis oron
(NEC) more
oneoccasions?
or more occasions?

Necrotising
 enterocolitis (NEC)
Necrotising is a devastating
enterocolitis (NEC)illness
is a
which can follow preterm birth. Bowel inflammation
devastating illness which can follow
prevents milk feeding and
preterm surgery
birth. may beinflammation
Bowel needed.
Babies whoprevents
develop NEC
milktypically
feeding stay in hospital
and surgeryformay
a
be needed.
long time. Rates Babies
of mortality who
in babies withdevelop
NEC are NEC
high,
at over 20%. typically staysurvive
Babies who in hospital for have
NEC can a long time.
developmentalRates
as of mortality
well in babies
as long-term feedingwith
and NEC
bowelare
high, at over 20%. Babies who
problems. Reporting of NEC is based on a surveillance survive
NEC
definition, and canand
cases have developmental
denominators as well toas
are attributed
long-term feeding and bowel problems.
the unit at which the baby is nursed at 48 hours. For
Reporting of NEC is based on a
more information on this measure,
surveillance check
definition, andoutcases
our and
measures guide.
denominators are attributed to the unit at which the baby is nursed at 48 hours. For more
information on this measure, check out our measures guide.
Results
Results
117 of 180 (65%) NNAP neonatal units provided assurance of the accuracy of their data for this

outcome. 117 of
This is 180 (65%)
a slight NNAP neonatal
decrease units71%
on 2018 when provided
of unitsassurance of the
provided such accuracy
assurance. ofnote
We their data for this
that the finaloutcome.
2 weeks ofThis is a slight
the planned decrease
data onwindow
assurance 2018 when 71% with
coincided of units providedofsuch assurance. We
the beginning
note that the final 2 weeks of the planned data assurance window coincided with the
lockdown measures to address COVID19. The window was extended to allow more time for data
beginning of lockdown measures to address COVID19. The window was extended to allow
assurance.
more time for data assurance.
There were 7,692 babies who were born very preterm and survived to 48 hours after birth. For 174

babies There
it was were 7,692
not possible babies who
to determine werethe
whether born very
baby hadpreterm
NEC at and survived
any point to neonatal
in their 48 hourscare.
after birth. For
413 of these174 babies
7,692 it was
(5.5%) are not possible
known to havetohad
determine whether
NEC according the
to the baby haddefinition
surveillance NEC at any
usedpoint in their
neonatal care. 413 of these 7,692 (5.5%) are known to have had NEC according to the
by NNAP. This is similar to previous years (2018: 410 of 7810, 5.5%; 2017: 428 of 8,228, 5.6%),
surveillance definition used by NNAP. This is similar to previous years (2018: 410 of 7810, 5.5%;
although incomplete and unvalidated data could affect all years.
2017: 428 of 8,228, 5.6%), although incomplete and unvalidated data could affect all years.
Table 12. NEC status, by neonatal unit level – all units.
Table 12. NEC status, by neonatal unit level – all units.
NEC status Missing data
Died prior NEC status Missing data
Unit to Died
level With discharge, prior to Death
at 48 Unit data but no No discharge, Total before Death be- Alive
Alive at
hours level at
Babies entered NEC With data
NEC but no
NEC missing Total
discharge fore
discharge at
48 hours Babies entered NEC No NEC NEC missing discharge discharge
Other 18 14 0 13 1 (7.1%) 4 (22.2%) 0 (0%) 4 (22.2%)
Other 18 14 0 13 1 (7.1%) 4 (22.2%) 0 (0%) 4 (22.2%)
SCU 158 154 0 150 4 (2.6%) 4 (2.5%) 0 (0%) 4 (2.5%)
LNU SCU 2,215158 16
2,261 154 0
2,129 150
70 (3.2%) 4 (2.6%)
46 (2%) 04(0%)
(2.5%) 046
(0%)
(2%) 4 (2.5%)
NICU 5,255
LNU 5,1352,261 334 2,215 4,463 16 338 (6.6%)
2,129 120 70
(2.3%)
(3.2%) 36
46(0.7%)
(2%) 084 (1.6%) 46 (2%)
(0%)

NICU 5,255 5,135 334 4,463 338 (6.6%) 120 (2.3%) 36 (0.7%) 84 (1.6%)

Total 7,692 7,518 350 6,755 413 (5.5%) 174 (2.3%) 36 (0.5%) 138 (1.8%)
47

45
National Neonatal Audit Programme 2020 report on 2019 data

Table 13. NEC status, units who provided assurance that their NEC diagnosis data was
complete.

Died
prior to
discharge
With data but no Total Missing Missing
Unit Level Babies entered NEC No NEC NEC missing died alive

SCU 109 107 105 0 0 (0%) 2 (1.8%) 2 (1.8%) 0

LNU 1,317 1,301 1,261 0 13 (1%) 16 (1.2%) 16 (1.2%) 0

NICU 3,630 3,596 3,122 12 235 (6.5%) 22 (0.6%) 22 (0.6%) 0

Total 5,056 5,004 4,488 12 248 (5%) 40 (0.8%) 40 (0.8%) 0

Table 14. NEC status, by network – all units.

NEC status Missing data

Died
prior to
discharge
With home, Death
data but no No Alive at before Total
Network Babies entered NEC NEC NEC discharge discharge missing

East Midlands 481 468 19 414 35 (7.5%) 10 (2.1%) 3 (0.6%) 13 (2.7%)

East of England 611 602 15 550 37 (6.1%) 7 (1.1%) 2 (0.3%) 9 (1.5%)

North Central & 28 20

525 505 20 457 15 (2.9%) 5 (1%)
North East London (5.5%) (3.8%)

North West London 394 391 16 359 16 (4.1%) 2 (0.5%) 1 (0.3%) 3 (0.8%)
39
North West 913 900 58 803 9 (1%) 4 (0.4%) 13 (1.4%)
(4.3%)
Northern 354 309 12 269 28 (9.1%) 35 (9.9%) 10 (2.8%) 45 (12.7%)
Scotland 569 556 29 498 29 (5.2%) 11 (1.9%) 2 (0.4%) 13 (2.3%)
South East Coast 526 513 29 456 28 (5.5%) 8 (1.5%) 5 (1%) 13 (2.5%)
South London 493 481 15 433 33 (6.9%) 11 (2.2%) 1 (0.2%) 12 (2.4%)
South West 451 445 20 409 16 (3.6%) 6 (1.3%) 0 (.%) 6 (1.3%)
Thames Valley &
576 572 17 524 31 (5.4%) 4 (0.7%) 0 (.%) 4 (0.7%)
Wessex
Wales 316 316 21 283 12 (3.8%) 0 (.%) 0 (.%) 0 (0%)
49
West Midlands 749 738 50 639 10 (1.3%) 1 (0.1%) 11 (1.5%)
(6.6%)
Yorkshire & Humber 715 707 29 647 31 (4.4%) 6 (0.8%) 2 (0.3%) 8 (1.1%)
Other* 19 15 0 14 1 4 0 0
413 174
Total 7,692 7,518 350 6,755 138 (1.8%) 36 (0.5%)
(5.5%) (2.3%)

*Includes Isle of Man

NB there are no networks for which all units confirmed they had validated data for all their
admissions.

46
National Neonatal Audit Programme 2020 report on 2019 data

Key findings and recommendations

Key finding (Q) – Necrotising enterocolitis (NEC)

5.5% of very preterm infants were diagnosed with NEC in 2019.

Rates of NEC appear to vary more than two-fold between neonatal networks, although
missing data, as much as ~13% in one neonatal network, can make comparisons between
networks imprecise. Differences between neonatal networks are unlikely to be fully explained
by differences in case mix but should be considered alongside mortality figures for the
networks – rates of NEC appear to be lower where mortality is higher, which you can see in
Appendix H.

Key Finding (R) – Necrotising enterocolitis (NEC)

117 out of 181 (64%) NNAP units confirmed that their submitted NEC data were validated as

accurate; this was less than in 2018 (129 – 71%). The overall rate of missing data decreased
from 5.4% in 2018 to 2.3% in 2019. Units who indicated that they had their NEC data included
38 out of 54 (70%) NICUs and these accounted for 5,056 out of 7,692 eligible babies across all
unit levels. Restricting measurement of the rate of NEC to NICUs with validated data did not
alter the rate of NEC substantially (6.5% compared to 6.4%).

Recommendation (9):

Units with validated NEC data should:

• Compare their rates of NEC to those of other comparable units with validated data, and
if their rates of NEC are relatively high, seek to identify and implement potentially better
practices

In order to reduce the associated higher risk of mortality and, for those babies who survive,
the risk of longer term developmental, feeding and bowel problems.

All neonatal units should:

• Ensure the accurate recording of NEC diagnoses

In order to facilitate valid comparisons of the rates of NEC, and the development of
preventative measures based on variations in rates of NEC.

47
2.11. Minimising
National separation
Neonatal Audit Programme of mother and
2020 report on 2019 data

baby (term and late preterm)

2.11. Minimising separation of mother and baby
1. For a baby (term and late
born at gestational preterm)
age greater than or equal to 37 weeks, who
neither had surgery, nor were transferred during any admission, how many
1. For a baby born at gestational age greater than or equal to 37 weeks, who neither
special care or normal care days were provided when oxygen was not
had surgery, nor were transferred during any admission, how many special care or
administered?
normal care days were provided when oxygen was not administered?

2. For
a baby
2. born
For a at 34-36
baby weeks
born gestational
at 34-36 age, who neither
weeks’ gestational hadneither
age, who surgeryhad
norsurgery nor were
were transferred duringduring
transferred any admission, how many
any admission, special
how many care or
special normal
care care care days were
or normal
provided when oxygen was not administered?
days were provided when oxygen was not administered?

Some  Some babies

babies admitted to neonatal admitted
units maytobeneonatal
separated fromunits may be
their mothers for separated from their
longer than necessary.
mothers for longer than
It may be possible to care for some such babies in necessary. It
may
transitional care, be possible
a setting which takesto care
an for some such
babies in transitional care, a setting
interdisciplinary approach with both midwives and
which takes an interdisciplinary
neonatal staff delivering high-quality care to both mother
approach with xi both midwives and
and baby, avoiding separation.
neonatal staff delivering high-quality
care to both
This measure describes the mother
number of and baby, avoiding
separation days
separation. xi
for each admission to a neonatal unit. Separation days are defined as days of low dependency care
when breathing support is not needed. Even when a neonatal unit admission is unavoidable, there
This measure describes the number of separation days for each admission to a neonatal unit.
may still be opportunities to reduce separation care days. Average numbers of separation days for a
Separation days are defined as days of low dependency care when breathing support is not
unit or network should be interpreted alongside the rates of admission of term, and late preterm
needed. Even when a neonatal unit admission is unavoidable, there may still be opportunities
babies per 1,000 live births. For more information on this measure, check out our measures guide.
to reduce separation care days. Average numbers of separation days for a unit or network
should be interpreted alongside the rates of admission of term, and late preterm babies per
Results 1,000 live births. For more information on this measure, check out our measures guide.

86.9% (25,110Results
of 28,893) of admitted babies born at 37 weeks gestational age or greater, who did not
have surgery and were not transferred, had some special care days on which oxygen was not
administered,
or some(25,110
86.9% normalofcare days.of57,273
28,893) special
admitted care days
babies bornand 27,420
at 37 weeks’normal care days
gestational age or greater, who
(84,693 days indid notwere
total) have surgerytoand
provided thesewere notbabies.
28,893 transferred, had some special care days on which oxygen
was not administered, or some normal care days. 57,273 special care days and 27,420 normal
93.8% (13,077care
of 13,936) of admitted
days (84,693 babies
days bornwere
in total) at 34provided
to 36 weeks gestation,
to these whobabies.
28,893 did not have
surgery and were not transferred, had some special care days on which oxygen was not
administered,
 or some(13,077
93.8% normalof
care days.of
13,936) 70,585 specialbabies
admitted care and 20,211
born normal
at 34 to 36care daysgestation,
weeks’ (90,796 who did not
days in total) were
haveprovided
surgerytoand
these 13,936
were not babies.
transferred, had some special care days on which oxygen was not
administered, or some normal care days. 70,585 special care and 20,211 normal care days
(90,796 days in total) were provided to these 13,936 babies.

51

48
National Neonatal Audit Programme 2020 report on 2019 data

Table 15. Term babies spending one or more days receiving special or normal care, by
neonatal unit level (includes only those special care days when oxygen was not
administered).

Babies who Number of eligible care days Average

spent one or number of
more eligible separation
days in normal or Special Normal Total days per
Unit Level Babies special care care care days baby

SCU 3,778 3,383 (89.5%) 7,369 3,769 11,138 2.9

LNU 11,988 10,552 (88%) 22,973 11,963 34,936 2.9
NICU 13,127 11,175 (85.1%) 26,931 11,688 38,619 2.9
Total 28,893 25,110 (86.9%) 57,273 27,420 84,693 2.9

 Table 16. Late preterm babies receiving special or normal care, by neonatal unit level
(includes only those special care days when oxygen was not administered)

Babies who Number of eligible care days Average

spent one or number of
more eligible separation
days in normal or Special Normal Total days per
Unit Level Babies special care care care days baby

SCU 2,052 1,981 (96.5%) 10,927 3,467 14,394 7

LNU 6,307 6,006 (95.2%) 33,794 10,321 44,115 7
NICU 5,577 5,090 (91.3%) 25,864 6,423 32,287 5.8

Total 13,936 13,077 (93.8%) 70,585 20,211 90,796 6.5

Key findings and recommendations

Key finding (S) – Minimising separation of mother and baby (term and late preterm)

Striking variation persists across 2018 and 2019 in the average number of term baby separation
days between units of all levels (range 1-5 days), which is very unlikely to be explained by case
mix alone.

There was a shorter average stay in NICUs compared to LNUs and SCUs (NICU 5.8 days,
n=5,557; LNU and SCU 7 days, n= 8,359) and a striking variation in the average duration of stay
between units of the same level (NICUs 1.5-10.4; LNUs 2.6 - 12; SCUs 2.6 – 10.4).

Recommendation (10):

Neonatal networks should:

• Review the admission durations of their units, alongside admission rates, as part of
planning maximally effective use of neonatal bed days

Neonatal and maternity teams should:

• Ensure discharge practices minimise inappropriate separation of mother and baby

• Consider introducing measures to facilitate timely discharge such as criterion-based discharge
• Consider delivering some care as transitional care

So that babies born at term and late preterm admitted to neonatal units are not separated
from their mothers for longer than is necessary.

49
National Neonatal Audit Programme 2020 report on 2019 data

2.12. Maternal breastmilk feeding

Breastmilk feeding is unquestionably beneficial to the baby and the mother. During neonatal
care it protects against necrotising enterocolitis and infection. It helps to protect babies
from later infection, diabetes, asthma, heart disease, obesity and sudden infant death
syndrome. Premature babies are vulnerable to infection, and their own mother’s milk
provides an important line of defence through protective antibodies. Breastfeeding also
helps to build the relationship between the mother and baby. For more information on this
measure, check out our measures guide.

Early Breastmilk Feeding


Does a baby born at less than 32 weeks’ gestational age receive any of their own mother’s
milk on day 14 of life? This measure is designed to help units understand their rates of
mothers’ own milk feeding during babies’ stay in greater detail, and is supported by the
publication of graphics describing milk use in very preterm infants for each unit and network
– see Figure 19 and NNAP Online.

Results
Of the 7,359 babies born at less than 32 weeks, 7,345 had data available from day 13-15 of life.
Of these 7,345 babies, 82.4% (6,054 babies) were receiving some of their own mothers’ milk
at 14 days of life. Data were missing for 14 (0.2%) eligible babies.

Table 17. Breastmilk feeding on day 14 of life, by neonatal unit level.

Enteral feeds at day 14

Unit level at 48 With data Any of own None of own

hours Babies entered mother’s milk mother’s milk Missing data

Other 1 1 1 (100%) 0 (0%) 0 (0%)

SCBU 154 153 116 (75.8%) 37 (24.2%) 1 (0.6%)

LNU 2,230 2,228 1,870 (83.9%) 358 (16.1%) 2 (0.1%)

NICU 4,974 4,963 4,067 (81.9%) 896 (18.1%) 11 (0.2%)

Total 7,359 7,345 6,054 (82.4%) 1,291 (17.6%) 14 (0.2%)

50
National Neonatal Audit Programme 2020 report on 2019 data

Table 18. Breastmilk feeding on day 14, by neonatal network.

Enteral feeds at day 14

With data Any of own None of own

Network Babies entered mother’s milk mother’s milk Missing

East Midlands 464 462 382 (82.7%) 80 (17.3%) 2 (0.4%)

East of England 596 592 484 (81.8%) 108 (18.2%) 4 (0.7%)
Isle of Man 1 1 1 (100%) 0 (0%) 0 (0%)
North Central &
504 501 439 (87.6%) 62 (12.4%) 3 (0.6%)
North East London
North West London 380 379 326 (86%) 53 (14%) 1 (0.3%)
North West 870 870 688 (79.1%) 182 (20.9%) 0 (0%)
Northern 335 335 256 (76.4%) 79 (23.6%) 0 (0%)
Scotland 541 539 443 (82.2%) 96 (17.8%) 2 (0.4%)
South East Coast 499 499 407 (81.6%) 92 (18.4%) 0 (0%)
South London 482 482 416 (86.3%) 66 (13.7%) 0 (0%)
South West 438 437 372 (85.1%) 65 (14.9%) 1 (0.2%)
Thames Valley & Wessex 557 556 488 (87.8%) 68 (12.2%) 1 (0.2%)
Wales 300 300 246 (82%) 54 (18%) 0 (0%)
West Midlands 703 703 576 (81.9%) 127 (18.1%) 0 (0%)
Yorkshire & Humber 688 688 529 (76.9%) 159 (23.1%) 0 (0%)
Total 7,358 7,344 6,053 (82.4%) 1,291 (17.6%) 14 (0.2%)

51
National Neonatal Audit Programme 2020 report on 2019 data

 Figure 19. Use of mother’s own milk in very preterm infants by day of life.
Neonatal networks, 2019.

These figures illustrate mother’s own milk use for very preterm infants (gestation at birth
less than 32 weeks), by the unit of care, on each day of life. Unit, and network, level figures are
available on NNAP Online and enable comparisons of changes over time in usage of mothers’
own milk.
East Midlands East of England London NC&NE
100

100

100
Percent (from 1375)

Percent (from 1807)

Percent (from 1561)

60

60

60
0 20

0 20

0 20
20 40 60 80 20 40 60 80 20 40 60 80
Postnatal day Postnatal day Postnatal day
London NW North West Northern
100

100

100
Percent (from 2384)
Percent (from 916)

Percent (from 888)

60

60

60
0 20

0 20

0 20
20 40 60 80 20 40 60 80 20 40 60 80
Postnatal day Postnatal day Postnatal day
Scotland South East London South
100

100

100
Percent (from 1419)

Percent (from 1487)

Percent (from 1254)

60

60

60
0 20

0 20

0 20

20 40 60 80 20 40 60 80 20 40 60 80
Postnatal day Postnatal day Postnatal day
South West Thames V & Wsx Wales
100

100

100
Percent (from 1266)

Percent (from 1598)

Percent (from 910)

60

60

60
0 20

0 20

0 20

20 40 60 80 20 40 60 80 20 40 60 80
Postnatal day Postnatal day Postnatal day
West Midlands Yorks & Humber NNAP (UK)
100

100

100
Percent (from 20896)
Percent (from 2051)

Percent (from 1970)

60

60

60
0 20

0 20

0 20

20 40 60 80 20 40 60 80 20 40 60 80
Postnatal day Postnatal day Postnatal day
Key
Black: nil by mouth
Dark grey: inpatient and not fed own mother’s milk
Green: inpatient and fed at least partially with own mother’s milk
Light grey: discharged home after receiving none of own mother’s milk on last day of hospitalisation
Light green: discharged home after receiving some own mother’s milk on last day of hospitalisation
White: missing data

52
 hospitalisation

Light green: discharged home after receiving some own mother’s milk on last day of
National Neonatal Audit Programme 2020 report on 2019 data
hospitalisation

White:Breastmilk
missing data feeding at discharge home

 oes a baby born at less than 32 weeks’ gestational age receive any of their own
D
mother’s milk at discharge to home from a neonatal unit?9
Breastmilk feeding at discharge home
DoesFor
 a baby born at less
very preterm than
babies 32 received
who weeks gestational ageinreceive
all their care any of unit
one neonatal theirwithout
own being
viii
mother’s milk at discharge
transferred this measureto home from a the
describes neonatal unit?
proportion
receiving any of their own mother’s milk when they were
For very preterm babies
discharged home.who received all their care in one neonatal
unit without being transferred this measure describes the proportion
Results
receiving any of their own mother’s milk when they were discharged
home.
Of the 6,756 eligible babies born at less than 32 weeks,
Results
there were 6,747 babies with data available from the final
or penultimate day of care. Data were missing for 9 (0.1%)
Of theeligible babies.
6,756 eligible Of the
babies born6,747
at lessbabies
than 32with
weeks,data entered,
there were
58.3% (3,935 babies) were receiving any of their mothers’
6,747 babies with data available from the final or penultimate day of
own milk at time of discharge.
care. Data were missing for 9 (0.1%) eligible babies. Of the 6,747
babies with data entered, 58.3% (3,935 babies) were receiving any of their mothers’ own milk at time
Table 19. Breastmilk feeding at discharge home, by neonatal unit level.
of discharge.
Enteral feeds at the
Table 19. Breastmilk feeding at discharge home, by neonataltime
unit of
level.
discharge

With data Enteral feeds at the time of discharge

With data
Unit Unit level Babies entered Any breast milk No breast milk Missing data
level Babies entered Any breast milk No breast milk Missing data
SCU 918
SCU 918 918 475 918
(51.7%) 475 (51.7%)
443 (48.3%) 443 (48.3%)
0 (0%) 0 (0%)

LNU LNU 3,013 3,013

3,010 3,010
1,825 (60.6%) 1,825
1,185(60.6%)
(39.4%) 1,185 (39.4%)
3 (0.1%) 3 (0.1%)

NICU NICU2,825 2,825

2,819 2,819
1,635 (58%) 1,635
1,184(58%)
(42%) 1,184 (42%)
6 (0.2%) 6 (0.2%)

Total Total6,756 6,756

6,747 6,747
3,935 (58.3%) 3,935
2,812 (58.3%)
(41.7%) 2,812 9(41.7%)
(0.1%) 9 (0.1%)

57

53
National Neonatal Audit Programme 2020 report on 2019 data


Figure 20. Breastmilk feeding at discharge home, by NNAP reporting year
(2013 to 2019), for very preterm babies

100%
90%
80%
70% 58.3%
55.6% 56.1% 53.8% 55.5% 55.2% 55.7%
60%
44.4% 43.9% 46.2% 44.5% 44.8% 44.3%
50% 41.7%
40%
30%
20%
10%
0%
2013 2014 2015 2016 2017 2018 2019

Any breast milk No breast milk

 ote: The eligibility for this measure has changed between 2018 and 2019. From 2019
N
onwards, only very preterm infants (those born at less than 32 weeks’ gestation) are included
in this measure, replacing previous eligibility of less than 33 weeks’ gestation.

Key findings
Key finding (T) – Early Breastmilk Feeding

82% of very preterm babies experienced the benefits of having received some of their own
mother’s milk on 14 days of age.

Key Finding (U) – Early Breastmilk Feeding

There is wide variation in the proportion of babies receiving some of their own mothers’ milk
on 14 days of age by neonatal network (76-88%), consistent with known geographical
variation in breastmilk feeding of term babies in the UK. This variation is seen in the plots
representing milk feeding of different networks and units in Figure 19.

It is of concern that NICUs do not, on average, have higher rates of babies receiving some of
own mother’s milk feeding at 14 days than SCUs or LNUs, given that smaller and sicker
babies are more likely to need and benefit from their own mother’s expressed breast milk.

There is wide variation among neonatal units in the proportion of babies fed some of their
own mother’s milk on day 14 (NICU range 68 – 92%), but only two NICUs can be identified to
have low outlying rates.

Key finding (V) – Breastmilk feeding at discharge home

Around 6 in 10 very preterm babies were receiving some of their own mother’s milk as part
of their feeding at discharge home. This has not changed significantly since 2013, which is
concerning given the importance of breastmilk to the health of preterm babies.

54
National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (11):

Neonatal units and networks should:

Focus on both the early initiation and sustainment of breastmilk feeding in conjunction with
parents by:

• Reviewing data and processes in order to undertake selected quality improvement

activities suited to the local context
• Removing barriers to successful breastmilk feeding by ensuring that appropriate and
comfortable areas are provided with adequate, regularly cleaned expressing equipment
• Seeking and acting on feedback from local parents on their experience of starting and
sustaining breast feeding
• Working to achieve and sustain both UNICEF UK Baby Friendly Initiative Neonatal Unit
accreditation and Bliss Baby Charter accreditation
• Implementing the guidance and evidence-based care practices set out in the BAPM
Maternal Breastmilk Toolkit
• 
Working with local parents to review and improve local practices around the early
communication of the benefits of breastmilk, ideally prior to birth wherever possible

So that the many health benefits to the preterm baby and the mother of breastfeeding can
be realised..

55
 National Neonatal Audit Programme 2020 report on 2019 data
National Neonatal Audit Programme 2020 report on 2019 data

2.13. Follow-up at two years of age

2.13. Follow-up at two years of age
Does a baby born at less than 30 weeks of gestational age receive medical follow-up
Does a baby born at less than 30 weeks’ of gestational age receive medical follow-up

at two years corrected age (18-30 months gestationally corrected age)?
at two years corrected age (18-30 months gestationally corrected age)?
It is important that the development of very preterm babies is
It is important that
monitored after the the
baby development
is discharged fromofthevery preterm
neonatal unit.
babiesThis
is monitored after the baby is discharged from
measure looks at whether there is a documented medical the
neonatal unit.consultation
follow-up This measureat two looks
years ofatage
whether
for babiesthere
born atis a
documented medical follow-up consultation at two
less than 30 weeks gestational age between July 2016 and years
of ageJune
for babies
2017 whoborn at less
survived thandischarged
and were 30 weeks’ gestational
home from the
age between July 2016 and June 2017 who survived and
neonatal unit.
were discharged home from the neonatal unit.
The follow-up consultation assesses whether there are any

 significant problems
The follow-up with movement,
consultation assesses thewhether
senses, andthere
general development
are or other health
any significant problems.
problems with
Babies born very early encounter these problems more often than those born at full-term. It is
movement, the senses, and general development or other health problems. Babies born
important for those involved in the care of babies to know how they are developing as they get older,
very early encounter these problems more often than those born at full-term. It is important
so that they can arrange appropriate treatment.
for those involved in the care of babies to know how they are developing as they get older, so
that they can arrange appropriate treatment.
Results
Results
There were 4,221 babies born at less than 30 weeks gestational age between July 2016 and June
2017 who survived and were discharged from a neonatal unit to home, to a ward or to foster care. Of
There these,
were 70.8%
4,221 babies
(2,987 ofborn
4,221)athad
less thansome
at least 30 weeks’
two-yeargestational agedata
follow-up health between
entered. July 2016 and
For more
June 2017 who survived and were discharged from a
information on this measure, check out our measures guide.neonatal unit to home, to a ward or to
foster care. Of these, 70.8% (2,987 of 4,221) had at least some two-year follow-up health data
Figure
entered. For 21.
moreCaterpillar plot of on
information the this
ratesmeasure,
of two-yearcheck
follow-up
out assessment:
our measures neonatal
guide. units, 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and Interpretation. Units are
Figurepresented
21. Caterpillar plot
in ascending ofofthe
order rates
the rates ofunits
and two-year follow-up
can be identified assessment:
on NNAP Online. neonatal units,
2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation. Units are presented in ascending order of the rates and units can be identified
on NNAP Online.
100

●●●●●●●●●●●

●●●

Developmental ●●●●
●●
●
●●
●●●●
●●●●●●●

standard ●

90.0%
Rate of compliance (%)

●●●●●●●●
●●●●●
●●●
●●
80

●●●●●
●●
●●●
●●●●
●●●
●●●●●

4202
●●●●●
●
●●●●●●●●●●
●●●
●●●●●●●
●●

70.7%
●●

All
●●●
●●
●●●●●●●
●●●
●●●
●
60

●●●●
●●●
●●
●●●●●
●●
●●●
●
●
●●
●●●●
●
●
●●
40

●
●●
●●
●

●
●
●

SCU
20

●
●

LNU
●
●
●

NICU
●●
●
●
●
●
0

●●●●

1 50 100 150 177

60
Rank of neonatal unit

56
National Neonatal Audit Programme 2020 report on 2019 data

Figure 22. Caterpillar plot of the rates of two-year follow-up assessment: neonatal
networks, 2019.

For help interpreting these caterpillar plots, please see appendix G: Methodology and
Interpretation.

Developmental standard 90.0%

90

● ● ●
80

●
Rate of compliance

●
●
● ● ●
4220 ● ●● ● 70.8%
70

4155 70.0%
●● ●
● ●
● ● ● ●
● ●
●
60

●
● 2019
● 2018
50

307 151 366 174 279 510 323 253 429 174 361 277 257 359
40

283 202 344 192 306 508 319 241 452 163 342 259 201 343

nd t t t ds r
ut
h
er
n W as es NE es les sx ds nd be
So r th ngla on N h E W C& W dlan Wa & W dlan otla um
n No of E ond ut or th n N ut
h
M
i V M
i Sc & H
ndo t L So N o So est es ast s
d
Lo Ea
s n W am E rk
Lo Th Yo
Network (ODN)

Figure 23. Two-year follow-up rates, by NNAP reporting year (2012-2019).

100%
90%
80% 69.9% 70.8%
70% 60.5% 60.9% 62.6%
58.1% 55.2% 54.5%
60%
41.9% 44.8% 44.5%
50% 39.5% 39.1% 37.4%
40% 30.1% 29.2%
30%
20%
10%
0%
2012 2013 2014 2015 2016 2017 2018 2019

Some health data entered No health data entered

Developmental standard

Key findings
Key finding (W) – Follow-up at two years of age

There is marked variation between neonatal networks in rates of follow up (range 48 – 82%).

No network is close to recording at least some clinical follow up data for all its babies. One
network has recorded a marked decline in follow-up rates since 2018.

Neonatal units record a wide range of follow up achievement from 0 – 100%. All unit types
show some exceptional, and low rates of follow up.

57
National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (12):

Neonatal units should:

Produce detailed plans to provide or organise follow up of care for preterm babies in
accordance with NICE guidance and consider arrangements for:

• Communicating with families about follow up at discharge

• Families who live far from the hospital of care
• Families who do not attend appointments
• Families who move to different areas
• Completing and documenting assessments made

So that very preterm babies can be monitored and checked for any problems with movement,
the senses, delays in development or other health problems and so that parents can get
reassurance about how their baby is developing, and any support that they might need.

The British Association for Neonatal Neurodevelopmental Follow Up (BANNFU) should:

• describe and promote best practice and successful models of delivery of high rates of
follow up using appropriate instruments

To improve the long-term outcomes of all babies that have had neonatal care.

58
National Neonatal Audit Programme 2020 report on 2019 data

2.14. Mortality until discharge in very preterm

babies
 hat proportion of very preterm babies die before discharge home, or before reaching
W
44 weeks’ of post-menstrual age (whichever occurs sooner)?

Mortality is a tragic outcome of neonatal care, that is unlikely to be preventable in all cases.
The NNAP reports mortality until discharge, or 44 weeks’ post-menstrual age (whichever
occurs sooner) for a three-year cohort of babies born at 24 to 31 weeks’ gestational age
inclusive, between 1 July 2016 and 30 June 2019.

We chose to report this measure of mortality to supplement other measures of mortality,
such as that reported by Mothers and Babies: Reducing Risk through Audits and Confidential
Enquiries in the UK (MBRRACE-UK). The NNAP measure focuses only on very preterm babies
(those born at less than 32 weeks’ of gestation), because they experience higher mortality.
MBRRACE-UK report mortality for all gestation ages. Also, unlike MBRRACE-UK, NNAP
reporting is limited to those babies born alive and admitted to neonatal units. An important
additional strength of NNAP mortality reporting is that it describes mortality rates up to the
point of hospital discharge. MBRRACE-UK report neonatal mortality, defined as that
occurring before 28 days of age, by centre. There is evidence that substantial numbers of
babies die after 28 daysxii. MBRRACE-UK have published data showing national rates of infant
mortality (death before a year of age) for a subset of very preterm babiesxiii.

We present both actual, or crude rates of mortality, as well as estimates of the treatment
effect. This treatment effect is defined by comparing the mortality of very preterm babies
within a network to the mortality of a group of babies in the whole country, matched for
background variables. These background variables are: birthweight; gestation; birth year;
maternal age; number of previous pregnancies; maternal ethnicity; multiplicity; maternal
smoking; medical problems of pregnancy; placental abruption; onset of labour. Deprivation
is not matched for in this analysis. This treatment effect measure presents an answer to the
question “what would the outcome for a network’s babies have been, had they been cared
for elsewhere”.

NNAP mortality reporting will facilitate mortality focussed quality improvement initiatives
between neonatal networks. Crude mortality alone is reported for Scotland because of
incomplete participation. Mortality is not reported for the Isle of Man as it is not part of a
neonatal network. For more information on this measure, check out our measures guide.

Results
23,906 babies were eligible for inclusion in this measure. One baby was excluded from the
analysis on the account of unknown birthweight and mortality outcome was unknown for
138 babies. The total number of babies included in the analysis was 23,767. Before the final
extract of data was taken, a review exercise was conducted with neonatal units to reduce the
number of babies with unknown mortality outcome.

59
National Neonatal Audit Programme 2020 report on 2019 data

 able 20. Rates of mortality before discharge of very preterm infants born 1st July 2016
T
– 30th June 2019: crude rates and treatment effect: neonatal networks.

Survived
to 44
Total Died weeks
Total Missing included before PMA or Crude
eligible survival in the 44 weeks discharge mortality Treatment Standard
Network babies status* analysis PMA home rate (%) effect error
East
1,484 8 1,476 108 1,368 7.32 1.28 0.71
Midlands
East of
1,883 9 1,874 84 1,790 4.48 -1.77 0.52
England
North
Central &
1,665 14 1,651 74 1,577 4.48 -2.46 0.53
North East
London
North West
1,087 4 1,083 65 1,018 6.00 -0.91 0.86
London
North West 2,924 14 2,910 221 2,689 7.59 0.62 0.48

Northern 1,065 19 1,046 70 976 6.69 -0.08 0.82

Scotland 1,662 21 1,641 113 1,528 6.89

South East
1,673 11 1,662 109 1,553 6.56 -0.54 0.58
Coast
South
1,468 4 1,464 88 1,376 6.01 -0.65 0.77
London

South West 1,425 4 1,421 85 1,336 5.98 -0.20 0.73

Thames
Valley 1,916 15 1,901 103 1,798 5.42 -0.98 0.56
& Wessex

Wales 981 3 978 65 913 6.65 1.01 0.81

West
2,405 7 2,398 215 2,183 8.97 2.62 0.61
Midlands
Yorkshire &
2,268 6 2,262 167 2,095 7.38 1.00 0.58
Humber
Total 23,906 139 23,767 1,567 22,200 6.59

* This includes 1 baby with missing birth weight

 

60
National Neonatal Audit Programme 2020 report on 2019 data

Figure 24. Caterpillar plot of crude mortality until discharge and treatment effect:
neonatal networks. Very preterm infants (<32 weeks’ gestational age) born 1st July 2016
to 30th June 2019

Dots indicate rates of crude mortality (upper panel) and treatment effect (lower panel). The
vertical lines indicate the 95% confidence intervals. Scotland is not included in the treatment
effect analysis.

Mortality − Network−level rates

10

●
Prevalence (%)

●
● ●
23767 ● ●
●
●
All 6.6%
6

● ● ●
●

● ●
4

1874 1651 1901 1421 1083 1464 1662 978 1046 1641 1476 2262 2910 2398

nd y t t s rn s r t s
la NE lle es W uth Eas ale r the an
d
nd be es nd
ng C& s V
a
t h W o nN So t h W o c otl i dla Hum r th W idla
E N e u d o n u N S M M
of on am So Lo
n
nd So st & No est
st nd Th Lo Ea rks
Ea Lo Yo W
Network (ODN)

Mortality − Network−level treatment effects

4
Treatment effect (%)

●
2

●
● ●
●
22126
0

●
All ● ●
●

● ●
−2

●
●
−4

1651 1874 1901 1083 1464 1662 1421 1046 2910 2262 978 1476 2398

E nd ey th st t rn t r s ds ds
&N ngla all
W
ou Ea es es be ale
nN W the h W um idl
an
idl
an
C sV do n S outh th or t W
nN o f E e n
nd
o
So
u N
No
r &
H
st
M t M
o st am Lo S es
nd
Ea Th Lo rks Ea W
Lo Yo
Network (ODN)

 

61
National Neonatal Audit Programme 2020 report on 2019 data

Figure 25. Caterpillar plot of crude mortality until discharge and treatment effect:
neonatal networks. Very preterm infants (< 28 weeks’ gestational age) born 1st July 2016
to 30th June 2019

Mortality − Network−level rates (< 28 weeks GA)

●
20
Prevalence (%)

● ●

● ●
●
6811
15.9%
15

All ● ●
● ●
● ●
●
10

508 534 327 466 548 515 382 250 303 884 384 430 604 676

NE nd th st lle
y st es rn st ds nd er s
la NW u Ea e al e e n tla b nd
& g n So Va W W r th W la o m la
NC En do on ut
h
es u th No r th M
id Sc Hu id
n
to
f
Lo
n
nd So am So No st & tM
do ks es
n
Ea
s Lo Th Ea r W
Lo Yo
Network (ODN)

Mortality − Network−level treatment effects (< 28 weeks GA)

10
Treatment effect (%)

●
5

●
●
●
6381 ● ●
0

All ● ●
● ●
●
●
−5

●
−10

508 327 534 466 548 382 515 250 884 303 384 604 676

nd t t y t r
NE NW ut
h as es lle es es er
n ds be nd
s
gl
a
Va al n
& n So E W W W r th la m la
NC nd
o
fE
n
on ut
h
ut
h es r th No M
id Hu id
on Lo o nd So So am No st & tM
nd st Lo Ea ks es
Lo Ea Th r W
Yo
Network (ODN)

Key findings and recommendations

Key finding (X) – Mortality until discharge home in very preterm babies

Mortality before discharge, or 44 weeks’ post-menstrual age, of very preterm infants admitted
for neonatal care, varies between neonatal networks from 4.5 – 9%. A similar pattern of
variation is seen in mortality of the least mature babies – those born at less than 28 weeks’ of
gestation, whose mortality varies from 9.5 – 21%.

The variation is not explained by differences in case mix. Where the mortality for a network’s
cases is compared to mortality of a similar group of babies cared for in the whole country,
significant differences in outcome are seen. These are presented as estimated treatment
effect for care of very preterm babies admitted in the units of each network, and vary from
negative 2.5% to positive 2.6%. Two networks can be identified as having “excellent” low
(outlying) mortality treatment effect, and one network can be identified as having high
(outlying) mortality treatment effect.

The rate of missing data in 2019 (0.5%) in this report is much lower than in the previous report
(1.4%).

62
National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (13):

Neonatal networks and their constituent neonatal units should, following a review of local
mortality results, take action to:

• Consider whether a review of network structure, clinical flows, guidelines and staffing
may be helpful in responding to local mortality rates
• Consider a quality improvement approach to the delivery of evidence-based strategies
in the following areas to reduce mortality: timely antenatal steroids, deferred cord
clamping, avoidance of hypothermia and management of respiratory disease
• Ensure that shared learning from locally delivered, externally supported,
multidisciplinary reviews of deaths (including data from the local use of the Perinatal
Mortality Review Tool) informs network governance and unit level clinical practice.

The patient safety team in NHS Improvement and equivalent bodies in the devolved
nations should:

• Facilitate national dissemination of learning from mortality reviews.

63
National Neonatal Audit Programme 2020 report on 2019 data

2.15. Nurse staffing on neonatal units

What proportion of nursing shifts are numerically staffed according to guidelines and

service specification?

What proportion of shifts have sufficient staff qualified in speciality (QIS)?

How many additional nursing shifts are required to be worked to meet guidelines and
service specification?

Neonatal units in England are commissioned according to the NHS England service
specification3,8. Services in Scotland and Wales are commissioned on a comparable basis
according to the British Association of Perinatal Medicine (BAPM) standardsxiv. Higher nurse
staffing levels are associated with improved outcomesxv. Direct caring staffing ratios of one
nurse per intensive care baby, one nurse to two high dependency babies, and one nurse for
four special care babies with an additional shift coordinator are recommended. Furthermore,
at least 70% of registered nursing staff on duty should have a neonatal specialist qualification.

Staffing variation may be due in part to the unplanned nature of neonatal care, with variation
in demand. Appointing, retaining and providing career progression for a highly specialised
nursing workforce also presents a challenge to neonatal services.

This measure describes the proportion of nursing shifts that met the service specification.
This is done by comparing the maximum number of babies on a neonatal unit during each
shift to the number and type of nurses working on that shift. We also report the average
number of additional nurses that would be required to address any shortfall. For more
information on this measure, check out our measures guide.

Results
173 units were eligible for inclusion in this measure; 7 units were excluded, as less than 25% of
their shifts were recorded and 1 unit did not enter any shifts for the period. Units where more
than 50% of shifts are staffed with three registered nurses or fewer are excluded from the
calculation of the number of shifts meeting the qualified in specialty (QIS) element of the
service specification; 55 units were excluded. This is because of the challenges of the audit
applying the QIS criterion of the recommendations to shifts with small numbers of nurses.

Table 21. Compliance with neonatal nurse staffing standards: neonatal unit level.

Additional
Shifts Shifts average
meeting meeting number
sufficient qualified in of nurses
staffing speciality Additional per unit
Eligible Eligible specification specification nurse shifts per shift
Unit level shifts QIS shifts (%) (%) required required

SCU 29,686 4,380 22,953 (77.3%) 2,519 (57.5%) 5,023.4 0.2

LNU 58,332 44,710 42,370 (72.6%) 21,706 (48.5%) 21,199.0 0.4

NICU 37,591 36,983 21,369(56.8%) 13,847 (37.4%) 41,630.4 1.1

Total 125,609 86,073 86,692 (69.0%) 38,072 (44.2%) 67,852.8 0.5

64
National Neonatal Audit Programme 2020 report on 2019 data

Table 22. Compliance with neonatal nurse staffing standards: neonatal networks.

Average
number of
Shifts Shifts additional
meeting meeting quali- nurses
Network sufficient fied in special- Additional per unit
(Neonatal Eligible Eligible staffing spec- ity specifica- nurse shifts per shift
ODN) shifts QIS shifts ification (%) tion (%) required required
East
7,300 5,840 5,587 (76.5%) 1,305 (22.3%) 3,039.6 0.4
Midlands
East of
12,410 8,760 9,621 (77.5%) 4,378 (50%) 2,721.95 0.2
England
Isle of Man 730 0 602 (82.5%) . (.%) 104.225 0.1
North
Central &
3,156 2,674 1,834 (58.1%) 1,875 (70.1%) 3,682.525 1.2
North East
London
North West
4,258 2,920 1,899 (44.6%) 1,392 (47.7%) 12,239.18 2.9
London
North West 15,330 10,950 10,619 (69.3%) 6,731 (61.5%) 7,802.825 0.5

Northern 7,786 2,190 5,267 (67.6%) 762 (34.8%) 2,240 0.3

Scotland 8,030 7,300 6,293 (78.4%) 3,858 (52.8%) 2,646.525 0.3

South
9,490 5,840 6,818 (71.8%) 2,213 (37.9%) 3,473.775 0.4
East Coast
South
7,300 5,840 4,148 (56.8%) 2,595 (44.4%) 4,888.125 0.7
London
South West 8,760 6,570 5,470 (62.4%) 2,783 (42.4%) 5,942.35 0.7

Thames Val-
10,220 5,840 6,847 (67%) 2,290 (39.2%) 4,863.25 0.5
ley & Wessex

Wales 7,480 5,290 6,071 (81.2%) 2,007 (37.9%) 2,664.625 0.4

West
10,220 7,300 5,945 (58.2%) 2,150 (29.5%) 7,780.8 0.8
Midlands
Yorkshire
13,139 8,759 9,671 (73.6%) 3,733 (42.6%) 3,763.025 0.3
& Humber
Total 125,609 86,073 86,692 (69.0%) 38,072 (44.2%) 67,852.8 0.5

65
National Neonatal Audit Programme 2020 report on 2019 data

 igure 26. Adherence to recommended nurse staffing levels. Neonatal units England,
F
Wales, Scotland, 2019.

On the horizontal axis is a measure of unit activity related to staffing – namely, the number
of nurse shifts required to deliver adequate staffing according to the guidelines for all 2019
shifts, based on the babies present on each shift. The vertical axis shows the proportion of
these nurse shifts reported to be staffed according to guidelines.

A unit’s annual workload is defined as the total number of shifts that would have been
necessary for adequate staffing over the year. For instance, a unit that required four nurses
to care for its babies for every one of its 730 shifts had a workload of 4 x 730 = 2920.

Nurse staffing 2019

100

●
●● ● ●
Adequately staffed shifts (%)

● ● ● ● ●
● ● ● ●
● ● ● ● ● ●●●
●
● ● ●●
●● ●
●
●
●
● ●
●
●
●

● ● ●●
●
●
● ● ●
● ● ● ●● ● ●
80

●
● ●
● ●● ●● ● ● ●
● ● ● ● ● ● ●
●
● ● ●
● ● ● ● ● ● ●
●●● ● ● ● ●
●● ●
● ●
●● ● ● ●
●●
●
● ● ●
● ● ●
●
● ● ●
60

●● ● ● ●
● ● ● ● ●
● ● ● ● ● ● ●
● ●● ●
●● ● ● ●
● ● ●
●
●
● ●
● ● ●
● ● ● ● ●
● ●
40

● ●
● ●
●
● ●
●
●
●
● ● ●
● ●
20

SCU
●
● ●

●● ● LNU
● NICU
●
0

0 5 10 15 20

Unit's annual workload (thousand nurse shifts)

Key findings and recommendations

Key Finding (Y): Nurse staffing in neonatal units

Nurse staffing on neonatal units in England, Scotland and Wales remains significantly below
nationally recommended levels. Overall, 69% of shifts are numerically staffed according to
national recommendations – showing modest improvement on 2018 data (64%), but such
high levels of understaffing in some units are a serious cause of concern.

As in 2018, NICUs experience the highest proportion of shifts not staffed according to the
recommendations when compared to SCUs and LNUs, although neonatal units of all levels
report increases in the proportion of shifts staffed adequately. This is of particular concern as
the babies in a NICU are usually the most unwell and require the most attention.

Considerable variation exists between neonatal units in their reported staffing. For example,
NICUs adherence to the numerical staffing criterion ranged from 3.4% to 99% of shifts.

The proportion of nursing shifts with sufficient staff with the relevant specialist qualification
remains problematic. Just 44% of shifts were staffed according to this element of the
recommendations. On average, NICU adherence to this element of national recommendations
has worsened, in contrast to modest improvements seen in other measurements of staffing.

66
National Neonatal Audit Programme 2020 report on 2019 data

Recommendation (14):

Departments of Health in England, Scotland and Wales should:

• Ensure that sufficient resources are available for the education and employment of
suitably trained professionals to meet and maintain nurse staffing ratios described in
service specifications

 Universities and Health Education England or equivalent bodies in the devolved nations
should:

• Consider revising, renewing and standardising models of specialist neonatal nursing

education

In order that future rises in numbers of nurses who are qualified in speciality result in the
comparable increments in nursing expertise in different neonatal networks, universities and
Health Education England

Neonatal Units and Neonatal Networks should:

• Prioritise data quality assurance in submitting nurse staffing data

• Monitor adherence to recommended nurse staffing standards
• Develop action plans to address any deficits in nursing staffing and skill mix

So that babies and their parents are cared for at all times by the recommended number of
trained professionals.

67
National Neonatal Audit Programme 2020 report on 2019 data

2.16. Spine Plots

In Figure 27 we present spine plots that allow neonatal networks and units to review their
performance in all NNAP measures in a single compact diagram.

Each network is presented as a panel alongside the other networks. Performance on each
measure is shown with a black disk positioned on a horizontal line for each measure. The line
extends from the lowest to the highest value for that measure among all the networks.

The rates are scaled so that the national rates are aligned to a single vertical line for all
measures and orientated so that better performance is to the right hand side. A grey bar
describes the expected range - two standard deviations either side of the national rate, akin
to a funnel plot. No standard deviations are presented for the nurse staffing measure.

The measures of “BPD or death” and “Mortality” are represented by ‘treatment effect’ – favourable
outcomes are presented as a dot to the right of the line. Unit level plots can be seen on NNAP Online.

Figure 27: Spine plots by neonatal network

East Midlands East of England London NC&NE

ANS ● ANS ● ANS ●
MAG ● MAG ● MAG ●
NIC ● NIC ● NIC ●
TMP ● TMP ● TMP ●
CON ● CON ● CON ●
ROP ● ROP ● ROP ●
BFD ● BFD ● BFD ●
BFE ● BFE ● BFE ●
FLW ● FLW ● FLW ●
NST ● NST ● NST ●
BPD ● BPD ● BPD ●
MRT ● MRT ● MRT ●

London NW North West Northern

ANS ● ANS ● ANS ●
MAG ● MAG ● MAG ●
NIC ● NIC ● NIC ●
TMP ● TMP ● TMP ●
CON ● CON ● CON ●
ROP ● ROP ● ROP ●
BFD ● BFD ● BFD ●
BFE ● BFE ● BFE ●
FLW ● FLW ● FLW ●
NST ● NST ● NST ●
BPD ● BPD ● BPD ●
MRT ● MRT ● MRT ●

Scotland South East London South

ANS ● ANS ● ANS ●
MAG ● MAG ● MAG ●
NIC ● NIC ● NIC ●
TMP ● TMP ● TMP ●
CON ● CON ● CON ●
ROP ● ROP ● ROP ●
BFD ● BFD ● BFD ●
BFE ● BFE ● BFE ●
FLW ● FLW ● FLW ●
NST ● NST ● NST ●
BPD ● BPD ● BPD ●
MRT MRT ● MRT ●

South West Thames V & Wsx Wales

ANS ● ANS ● ANS ●
MAG ● MAG ● MAG ●
NIC ● NIC ● NIC ●
TMP ● TMP ● TMP ●
CON ● CON ● CON ●
ROP ● ROP ● ROP ●
BFD ● BFD ● BFD ●
BFE ● BFE ● BFE ●
FLW ● FLW ● FLW ●
NST ● NST ● NST ●
BPD ● BPD ● BPD ●
MRT ● MRT ● MRT ●

West Midlands Yorks & Humber Legend

%
ANS ● ANS ● ANS Steroids 92.3
MAG ● MAG ● MAG Magnesium 83.4
NIC ● NIC ● NIC Born in NICU (< 27 weeks GA) 77.5
TMP ● TMP ● TMP Temperature 70.4
CON ● CON ● CON Consultation 96.7
ROP ● ROP ● ROP ROP screening 95.7
BFD ● BFD ● BFD Early BM feeding 58.3
BFE ● BFE ● BFE BM feeding at D 82.4
FLW ● FLW ● FLW 2−year follow−up 70.8
NST ● NST ● NST Nurse staffing 68.9
BPD ● BPD ● BPD BPD or death (treatment effect) 0.0
MRT ● MRT ● MRT Mortality (treatment effect) 0.0

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National Neonatal Audit Programme 2020 report on 2019 data

3. Local quality improvement case

studies
 ase study 1: Do all low gestation babies in the Yorkshire
C
and Humber Neonatal ODN receive all of the appropriate
early interventions; identified locally as the ‘Big 5’?
Presented by

Charlotte Bradford, Senior Information Manager, Yorkshire & Humber Neonatal ODN

Background:

o determine whether individual low gestation babies receive five, core, early care
T
interventions. Ultimately, to determine whether provision of the ‘Big 5’ impacts on BPD
outcome/mortality as well providing a focus for future QI projects.

Historically, the provision of individual clinical interventions has been reviewed in isolation;
to date reviewing interventions at baby level hasn’t been performed.

The network wanted to understand whether units achieving high rates of provision for one
element of care did so for all, or whether in fact concentrating on one element to improve
their rate of achievement meant that it was at the detriment of other elements of care.

Reviewing whether each low gestation baby receives the ‘Big 5’ identified as:

• Delivery in appropriate location for gestational age

• Antenatal steroids
• Maternal Magnesium Sulphate
• Physiologically-based cord clamping
• Normothermia on admission

 ll measures based on NNAP criteria apart from Deferred Cord Clamping (DCC) as that
A
was not a measure when this work was commenced but has subsequently been brought
in line with the NNAP criteria for DCC.

Measures:

 retrospective review of ‘Big 5’ data from BadgerNet from all 18 units in the Network, for all
A
infants born <32 weeks. Data collated by the ODN with unit level summaries and network
level, unit comparisons, to review the number of babies receiving 100% provision of the ‘Big 5’.

A quarterly review of the data at unit level, as well as Unit type, LMS footprint & Network
overviews are provided.

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National Neonatal Audit Programme 2020 report on 2019 data


The initial phase of the project was to determine what the baseline for the provision of the
‘Big 5’ was. Review and discussion has taken place around the ‘weighting’ given to some
elements and whether there should be ‘grades’ of compliance. These continue to be
reviewed.

Our improvement plan:

The main change that this project has brought about is the focus on the baby rather than
the individual elements of care.

Outcomes


This alternative approach to reviewing quality of care in individual babies is already
contributing to improving working relationships between obstetric and neonatal services.
Presenting the data in a relevant & easy to digest format supports clinicians to take
responsibility for the care they provide by reporting meaningful and measurable metrics
which can be linked to outcomes. There is scope for further extensive data review, which will
be used to direct QI initiatives both at Unit and Network level to improve clinical outcomes.

Initial results from Q1 19/20 data demonstrated that only 17% (32) of cases across the Network
had 100% provision of the ‘Big 5’.

• In NICUs the range was from 0% (0/23) to 38% (10/26)

• In LNUs the range was from 0% (0/9) to 33% (1/3)
• In SCUs all of the 4 units achieved 0%

Deferred cord clamping was the most common reason for not achieving the ‘Big 5’ at all
unit levels.

• If DCC is not factored in compliance ranges from 0% to 100% with the mean being 47%.

By Q4 19/20 the data demonstrated that there have been improvements at NICU level but
that other unit types are not seeing such significant changes.

• In NICUs the range was from 19% (3/16) to 52% (14/27)

• In LNUs the range was from 0% (7 units) (0/9) to 22% (2/9)
• In SCUs all 4 units achieved 0% - they will never achieve 100% though as none of these
babies should be delivered in a SCU setting. However one unit did achieve all of the other
criteria for the 2 babies that they admitted. Previous quarters the unit has achieved 0%
and 50%.

DCC continues to be one of the main factors contributing to units not achieving the ‘Big 5’.
It is clear that there is still a considerable way to go before we see the Big 5 being achieved
for all babies.

It is hoped that continual monitoring along with the introduction of the DCC question in
the NNAP audit will help to improve this, both in terms of change in clinical practice and as
well as data recording.

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National Neonatal Audit Programme 2020 report on 2019 data

Further work will be focused on:

• Refining the reporting process and feeding back to maternity and obstetric colleagues
via the LMS
• Reviewing if type of delivery or location of delivery impacts on receipt of ‘Big 5’
• Reviewing final outcomes in relation to receiving the ‘Big 5’, specifically relating to BPD
& mortality
• Reviewing the impact of increased provision of DCC and its introduction into the NNAP
dataset

Sample of a unit level summary

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National Neonatal Audit Programme 2020 report on 2019 data

Case study 2: Prevention of Cerebral Palsy in Preterm

Labour (PReCePT): National implementation programme
and nested randomised controlled trial
Presented by

Karen Luyt (PReCePT Programme Clinical Lead and PReCEPT Study Chief Investigator), Ellie
Wetz (Programme Manager, West of England AHSN on behalf of the AHSN Network), Pippa
Craggs (PReCePT2 Project Manager, University Hospitals Bristol & Weston NHS Foundation
Trust)

Background

Being born preterm is the leading cause of Cerebral Palsy (CP), with lifelong impact on
children and families. Magnesium Sulphate (MgSO4) given intrapartum during preterm
labour reduces the relative risk of CP in very preterm infants by 30%1. The NNT (below 30
weeks’ gestation) to prevent one case of CP is 372, and yet UK use was inconsistent3, leading
to preventable health inequalities.

 In West-England we co-designed, with parents, obstetric, midwifery and neonatal clinical
teams, a scalable Quality Improvement (QI) initiative called PReCePT (Prevention of Cerebral
Palsy in Preterm Labour), which was piloted as PReCePT1 in five maternity units from 2015.
The uptake of MgSO4 increased from 21% to 88% within 6 months4. PReCePT1 influenced the
UK national preterm labour guideline, which recommends intrapartum MgSO4 in preterm
labour, < 30 weeks’ gestation6.

PReCePT1 achieved: a) scalable QI intervention ready for national adoption/spread

b) development of the national metric for MgSO4 uptake, in partnership with NNAP.

In 2018 the Health Foundation funded us to scale-up and research how best to support
teams to adopt PReCePT7. The national implementation of PReCePT was commissioned by
NHS England to be delivered by the Academic Health Science Network (AHSN) across
England8.

Measures

The primary measure is percentage uptake of MgSO4 per unit as reported by NNAP. The size
of the national adoption problem became evident in the 2017 NNAP report. Only 44% of
preterm babies received the benefit of MgSO4 neuroprotection, with large variability
(26-71%) between ODNs.

Our improvement plan


The Aim: for every maternity unit to adopt the NICE NG25 guidance and achieve 85% uptake
of administration of MgSO4 to eligible mothers in preterm labour in England by April 2020.

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National Neonatal Audit Programme 2020 report on 2019 data

A novel network QI delivery model:

• delivery by 15 AHSNs, aligned to Neonatal ODNs, in all 152 maternity/neonatal units

• regional QI and clinical leads, working with unit-level midwife champions (clinical time
funded)
• PReCePT obstetric and neonatal lead in each unit, enabling a perinatal team approach
• standardised QI resources (toolkit, implementation guide, training presentations and
promotional collateral)8
• nested randomised control research trial, in 40 maternity units, designed to assess the
effectiveness of two different QI implementation methods9

Outcomes

Mean average MgSO4 uptake achieved in England in 2019 was 84.9% Variability between
English ODNs was substantially reduced (Range in 2016: 26-71% vs. range in 2019 77.5-93.7%).
The likely impact will be a substantial ongoing reduction of avoidable cerebral palsy. PReCePT
enabled a national perinatal QI network and will provide best practice evidence for national
scaling up of perinatal QI initiatives.

Challenges and learnings

Lessons learnt to foster success:

• Place babies and families at the heart of the programme - parent advisers have strongly
advised that MgSO4 be offered to all eligible mothers to help improve the life chances of
preterm babies – video clips 10,11
• Funded support/time for front-line clinicians to deliver the project key to successful
delivery
• Fostering a perinatal team, joining together obstetric, midwifery and neonatal clinicians
– developing perinatal clinical leadership in every unit – video clip12
• National strategic alignment to the Maternity and Neonatal Safety Improvement
Programme and ODNs
• Positive use of social media to engage a truly national PReCePT community-@
PReCePT_MgSO4 @PReCePT_Study

Challenges:

• Designing a project that was responsive to differences in unit level culture and
microsystems
• High number of stakeholders to engage/coordinate with, challenged by regional
variation
• Access to real-time data to support the monitoring of MgSO4 uptake

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National Neonatal Audit Programme 2020 report on 2019 data

Top tips for implementation

• Engage and empower perinatal clinicians to lead at local and regional level
• Provide the QI skills, evidence and support to effect change
• Create a social media community of practice and communication plan
• Development a metric for national measurement of MgSO4 uptake, utilising routine
data
• Influence national policy; MgSO4 neuroprotection has become routine practice by
inclusion in the NHS Long-Term plan13, “Saving Babies’ Lives Care Bundle” 14 and NICE
guidance6, enabling sustainability of uptake.

References

1. Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D: Magnesium sulphate for women
at risk of preterm birth for neuroprotection of the fetus. The Cochrane database of
systematic reviews 2009(1): Cd004661.

2. Crowther CA, Middleton PF, Voysey M, Askie L, Duley L, Pryde PG, Marret S, Doyle LW;
AMICABLE Group. Assessing the neuroprotective benefits for babies of antenatal
magnesium sulphate: An individual participant data meta-analysis. PLoS Med. 2017 Oct
4;14(10):e1002398

3. Lea CL, Smith-Collins A, Luyt K. Protecting the preterm brain: Current evidence-based
strategies for minimising perinatal brain injury in preterm babies and improving
neurodevelopmental outcomes. Arch Dis Child Fetal and Neonatal. 2016 Dec 23. doi:
10.1136/archdischild-2016-311949.

4. Burhouse A, Lea C, Ray S, Bailey H, Davies R, Harding H, Howard R, Jordan S, Menzies N,

White, Luyt K.Preventing cerebral palsy in preterm labour: a multiorganizational quality
improvement approach to the adoption and spread of magnesium sulphate for
neuroprotection. BMJ Open Quality 2017;6:e000189.

5. NHS Scotland. The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care
in Scotland. 2017. https://www.gov.scot/publications/best-start-five-year-forward-plan-
maternity-neonatal-care-scotland-9781786527646/

6. National Institute for Health and Care Excellence (2015) Preterm labour and birth. NICE
guideline (NG25). 2015.

7. 
Health Foundation Scaling-up Improvement award. https://www.health.org.uk/
improvement-projects/precept2-reducing-brain-injury-through-improving-uptake-of-
magnesium-sulphate

8. 
h ttps://www.ahsnnetwork.com/about-academic-health-science-networks/national-
programmes-priorities/precept/

9. Finding the best way to scale up a perinatal Quality Improvement initiative: The PReCePT
study. https://arc-w.nihr.ac.uk/research/projects/preventing-cerebral-palsy-in-pre-term-
babies-the-precept-study/

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National Neonatal Audit Programme 2020 report on 2019 data

10. PReCePT: A mum’s perspective https://vimeo.com/301193950

11. PReCePT families https://www.youtube.com/watch?v=PMEjXrBGXpA

12. PReCePT Perinatal Teams https://www.youtube.com/

watch?v=QhJtKnZz8BY&feature=youtu.be

13. https://www.longtermplan.nhs.uk/online-version/chapter-3-further-progress-on-care-
quality-and-outcomes/a-strong-start-in-life-for-children-and-young-people/maternity-
National Neonatal Audit Programme 2020 report on 2019 data
and-neonatal-services/

14. Saving Babies Lives Care Bundle. Element 5, p38 https://www.england.nhs.uk/wp-content/

12. https://www.longtermplan.nhs.uk/online-version/chapter-3-further-progress-on-care-quality-and-
uploads/2019/07/saving-babies-lives-care-bundle-version-two-v5.pdf
outcomes/a-strong-start-in-life-for-children-and-young-people/maternity-and-neonatal-services/
13. Saving Babies Lives Care Bundle. Element 5, p38 https://www.england.nhs.uk/wp-
Acknowledgements
content/uploads/2019/07/saving-babies-lives-care-bundle-version-two-v5.pdf
• West of England Academic Health Science Network (WEAHSN)
• Acknowledgements
National Academic Health Science Network
• West of England Academic Health Science Network (WEAHSN)
• University Hospitals Bristol and Weston NHS Foundation Trust
• National Academic Health Science Network
• The
• Health Foundation
University Hospitals Bristol and Weston NHS Foundation Trust
• The Institute
• National Health Foundation
for Health Research Applied Health Collaboration West
• National
(NIHR Institute for Health Research Applied Health Collaboration West (NIHR ARC West)
ARC West)

SupportiveQuotes
Supportive Quotesfrom
from service
service users
users andand perinatal
perinatal teams
teams

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National Neonatal Audit Programme 2020 report on 2019 data

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National Neonatal Audit Programme 2020 report on 2019 data
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National Neonatal Audit Programme 2020 report on 2019 data

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National Neonatal Audit Programme 2020 report on 2019 data

Case study 3: Keeping mothers & babies

together: getting it right first time
Presented by

Shanthi Shanmugalingam, Lorraine Gallagher, Rose Villar. Royal Free London NHS
Foundation Trust

NNAP Measure: Minimising inappropriate separation of mother and term baby

Background:

The Atain (avoiding term admissions into neonatal units) programme aims to address rising
term (≥37+0 weeks) admissions by identifying the main reasons for admissions (respiratory
conditions, hypoglycaemia, jaundice, asphyxia). Observation of the clinical journey for infants
with risk factors for postnatal compromise (‘at-risk’ infants) highlights the complex pathways
our teams were navigating. Clinical guidelines differed according to the specific risk factor in
frequency and length of observations and support offered leading to variation in care
delivery. This extended to the management of late preterm (34+0-36+6 weeks) infants who
were often pre-emptively separated from their mothers. Parent diaries highlighted how
disempowered and vulnerable they felt in looking after their ‘at-risk’ baby. The need for
standardisation and simplification was clear.

Aim:

We extended the NNAP measure to include both term and late preterm infants and aimed
to reduce neonatal admissions to 6% by creating a single unified pathway of care for all ‘at
risk’ infants.

Our improvement plan:

The traditional approaches of focusing on individual risk factors fail to address the underlying
drivers of unwarranted variation in care delivery. The Royal Free Keeping mothers and babies
together (KMB2) pathway centres on standardising care through the introduction of a single,
simplified pathway focussing on the following key elements:

1. Standardised assessment of early respiratory distress

2. First hour care bundle
3. Orange ‘hat-risk’ nudge
4. Unified observation regime for all at-risk infants and revised Newborn Early Warning
Trigger Tool (NEWTT) chart
5. Written information for families.

We started by devising a unified observation regime. Each step was tested, revised using
rapid plan-do- study-act (PDSA) cycles and embedded before incremental introduction of
another facet of the pathway. Collaboration with families and staff has been central in
producing the pathway. The pathway team includes a father. Focus groups, one-to-one
interviews and video feedback were used to inform the development of the pathway
documents and continued to ensure rapid revision and retesting to hone the accessibility
and utility of the pathway.

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National Neonatal Audit Programme 2020 report on 2019 data

Measures & Outcomes:

The baseline admission rate for infants born after 34 completed weeks’ gestation was 8.3%.
We reduced this to 6.7% over a 2 year period (November 2017-November 2019). We continue
to work towards achieving our target of 6%. Each PDSA cycle was tested using both qualitative
(questionnaires, focus groups and interviews) and quantitative (e.g. number and quality of
NEWTT charts and first hour care bundles being completed and obstacles to this) process
measures. These measures were used to revise each step. Balancing measures included
length of stay of mothers on the postnatal wards and presentation or readmission through
accident & emergency departments within 7 days of birth. Both of these measures remained
unchanged indicating that these infants are being safely transitioned home.

Sustainability

Sustainability has been primarily achieved by involving frontline staff in designing, refining
and implementing the pathway and ensuring we achieved our brief of simplifying the
process. During the implementation phase, the Trust introduced electronic patient records
(EPR). We digitalised the pathway within the EPR to support sustainability and our midwifery
team have welcomed this introduction reporting it was “straight forward…makes sense.”.

Challenges and learning

We initially tried to implement the whole pathway at once, which resulted in staff rejecting
it as too complex. Implementing a single aspect of the pathway, with rapid revision and
refinement based on staff and parent feedback, proved more successful. Challenging
preconceptions was difficult. Taking the lead from Richard Thaler’s Nudge theory, we wanted
to introduce orange hats for ‘at risk’ infants so they can be easily identified on a busy postnatal
ward as requiring extra observations and feeding and temperature support. Staff were
concerned that families would feel stigmatised. Parents were overwhelmingly enthusiastic
citing increased confidence to ask for the extra support they needed. Hearing this directly
from parents led to rapid adoption.

Top tips for implementation

• It was important that the vision was clear and the name of the project was chosen to
reflect this. One parent commented, “the name of the pathway…really captured what it
was setting out to do”.
• Engagement with all members of the team was crucial. Using a variety of feedback
methods ensured a wide reach.
• The role of the parent voice cannot be underestimated.
• Communication within and across our teams has been important. Involving all the team
by actively seeking feedback and acting on it brought a whole team ethos to this work.
• Board level support was important in terms of support offered but also in recognising
and celebrating our successes.
• Spreading learning is important to ensure other teams were not reinventing the wheel.
We have presented the KMB2 pathway at national and international conferences,
through medical literature and shared widely through social media (our twitter handle
is @MumBaby2gether). The pathway (in whole or aspects) has been adopted by Trusts
across the UK and is available to all NHS Trusts via the NHS Improvement hub.

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Acknowledgements

The maternity and neonatal teams at both Barnet and Royal Free Hospitals have positively
embraced the KMB2 pathway. Their energy, drive and passion has been matched by the
families who have contributed to producing this pathway.
National Neonatal Audit Programme 2020 report on 2019 data
Measures (Run Charts)

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Case study 4: Improving Achievement and Documentation

of Parental Consultation Within 24 Hours of Admission
Presented by

Dr. Kristin Tanney (Clinical Lead), Dr. Sajit Nedungadi (NNAP Lead), Dr. Ngozi Edi-Osagie
(Clinical Head of Division, Newborn Services), Ms. Kath Eaton (Lead Nurse, Newborn Services),
Mr. Marc Hutchison-Saxon (Neonatal Critical Care Audit Facilitator), Mrs. Chris Ashworth
(Divisional Director, Newborn Services) Newborn Intensive Care Unit, St. Mary’s Hospital,
Manchester University NHS Foundation Trust

Background

We have struggled to achieve required standards in providing and documenting senior
clinician updates for parents in the first 24 hours of admission. In 2018, NNAP reported us at
81% vs NA of 95.9%. We deemed the problem to be multi-factorial, related to: high turnover of
babies and doctors; transition of babies from room to room; change in NNAP standard which
excluded Tier 1 ANNPs from communications; switchover to electronic patient records with
resultant documentation challenges. The aim of the project was to raise awareness of the
issue, improve quality of parental discussions and documentation, and to reach (and ideally
surpass) the NA success. Stakeholders involved: NNAP team as in author list above, Neonatal
Consultants, senior clinical fellows and trainees, senior nursing staff, and our NICU parents.

Measures

With our audit facilitator emailing daily any outstanding parental updates, and a monthly
visualisation of NNAP parameters on the NICU dashboard, we have been able to follow
improvements closely.

Our improvement plan

By discussing outstanding updates at handovers, making parents aware that they should have
a senior update soon after baby’s admission and involving the Room Lead nurse in the process,
there were frequent reminders and prompts. Circulating monthly data on individual consultants’
success has had a positive effect on communication and documentation, introducing an
important element of competition. Barriers to success included: nuances in our EPR leading to
suboptimal documentation, occasional language barriers, availability of senior doctors to give
updates out of hours, and keeping consultants engaged in the project. We have overcome
these barriers by making tweaks to our EPR communication tabs, increasing our use of
BigWord, targeted daily consultant emails, introduction of a “twilight” registrar shift, and the
publication of the Consultant Leader Board.

Outcomes

We were delighted to see that expected Q1 2020 NNAP data sees us at 95.1%, above the NA
of 94%, and in keeping with the expected 93% for 2019. We are confident that the results
reflect our commitment to providing timely, high-quality updates for parents of our NICU
babies. We will work to sustain the improvement, keeping all above measures in place.

Challenges, learnings and top tips for implementation

As this QI project has been very successful, we would not do anything differently were we to
do it again, and would be happy to share our story and interventions with other units facing
similar challenges.

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4. Methods

4.1. Audit measures and measure

development
The NNAP has developed the measures reported here with its partners and with input from
audit users, professional organisations, parent support organisations, neonatal networks,
national initiatives or members of the NNAP Methodology and Dataset Group and Project
Board.

Table 4.1 summarises the measures included in the 2019 data report.

The NNAP sets standards for measures included in the audit where it is appropriate to do so.
The developmental standard is a long-term goal to which units and networks should work.
Where standards do not already exist as part of national guidelines and guidance, the
standard is set by consensus with the NNAP Methodology and Dataset Group, Project Board,
and other key stakeholders.

The comparison standard is set at the national mean rate for the year of analysis. Outlier
analysis compares units and networks to this standard to determine whether there is enough
evidence to identify them as high or low outliers.

Table 4.1. NNAP audit questions, standards and associated guidelines

Start Measure Developmental Comparison Associated

NNAP question year type standard standard guidelines

Is a mother who delivers a baby

85% of mothers
between 23 and 33 weeks’ NICE guideline
should receive at National
gestational age inclusive given at 2008 Process [NG25], Preterm
least one dose of rate
least one dose of antenatal Labour and Birth
antenatal steroids.
steroids?

85% of mothers
Is a mother who delivers a baby be- should be given
NICE guideline
low 30 weeks’ gestational age given magnesium National
2016 Process [NG25], Preterm
magnesium sulphate in sulphate in the 24 rate
Labour and Birth
the 24 hours prior to delivery? hours prior to
delivery.

85% of babies born

at less than 27 NHS England, Ne-
Is an admitted baby born at less National
weeks GA should onatal
than 27 weeks’ gestational age de- rate
2017 Process be delivered in a Critical Care
livered in a maternity service on the (network
maternity service on Service
same site as a designated NICU? only)
the same site as a Specification
NICU.

The composite
Does an admitted baby born at National NHS England, Ne-
measure of
less than 32 weeks’ gestational rate (for onatal
timeliness and
age have its first measured 2013 Outcome timeliness Critical Care
normal temperature
temperature of 36.5–37.5°C and normal Service
should be met for at
within one hour of birth? temperature) Specification
least 90% of babies.

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Start Measure Developmental Comparison Associated

NNAP question year type standard standard guidelines

Scottish Gvt,
Neonatal Care
in Scotland:
A Quality
Framework NHS
Is there a documented A consultation
Wales. All Wales
consultation with parents by a sen- should take place
National Neonatal
ior member of the neonatal team 2013 Process within 24 hours of
rate Standards –
within 24 hours of a baby’s first first admission for
2nd Edition.
admission? every baby.
Department of
Health. Toolkit
for high quality
neonatal
services
Scottish Gvt,
Neonatal Care
in Scotland:
A Quality
For a baby admitted for more than
Not Framework NHS
24 hours, did at least one parent
None, applicable, Wales. All Wales
attend a consultant ward round at 2017 Process
benchmarking only no outlier Neonatal
any point during the baby’s admis-
analysis. Standards – 2nd
sion?
Edition. Bliss
Family Friendly
Accreditation
Scheme
Does an admitted baby born 100% of eligible
RCPCH, RCOphth,
weighing less than 1501g, or at ges- babies should
BAPM, BLISS.
tational age of less than 32 weeks, receive ROP
Guideline for the
undergo the first ROP screening in screening National
2009 Process Screening and
accordance with within the rate
Treatment of
the NNAP interpretation of recommended
Retinopathy of
the current guideline time windows
Prematurity.
recommendations? for first screening.

Does an admitted baby have one

Not
or more episodes of bloodstream
2014- None, applicable,
infection, characterised by one or Outcome
2016 benchmarking only. no outlier
more positive blood cultures
analysis.
taken, after 72 hours of age?
How many babies have a positive
Not
blood culture (any species) with a
2014- None, applicable,
central line present, after the first Outcome
2016 benchmarking only. no outlier
72 hours of life, per 1000 central
analysis.
line days?
Does an admitted baby born at less 2013- Treatment
Outcome None.
than 32 weeks develop BPD? 2015 effect of 0%.
Does an admitted baby born at
Not
less than 32 weeks’ gestational age
None, applicable,
meet the NNAP surveillance defini- 2017 Outcome
benchmarking only. no outlier
tion for NEC on one or
analysis.
more occasion?

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Start Measure Developmental Comparison Associated

NNAP question year type standard standard guidelines

For a baby born at gestational age

greater than or equal to 37 weeks,
who did not have any surgery or a Not
transfer during any admission, how None, applicable,
2017 Process
many special care(a) or benchmarking only. no outlier
normal care(b) days were analysis.
provided when oxygen was not
administered?

For a baby born at 34-36 weeks’

gestational age, who did not have
Not
any surgery or a transfer during
None, applicable,
any admission, how many special 2017 Process
benchmarking only. no outlier
care(a) or normal care(b) days were
analysis.
provided when oxygen was not
administered?

Does a baby born at less than Not

None,
32 weeks’ gestational age receive applicable,
2019 Outcome benchmarking
any of their own mother’s milk at no outlier
only
day 14 of life? analysis

Does a baby born at less than

Not
32 weeks’ gestational age receive
None, applicable,
any of their own mother’s milk at 2013 Outcome
benchmarking only. no outlier
discharge to home from a
analysis.
neonatal unit?

NICE guideline
Does a baby born at less than 30 [NG72],
weeks’ gestational age receive 90% of babies with Developmental
National
medical follow-up at two years 2012 Process two-year follow-up follow-up of
rate
corrected age (18-30 months data entered. children and
gestationally corrected age)? young people
born preterm.

NHS England.
1. What proportion of nursing shifts Neonatal Critical
are numerically staffed Care Service
according to guidelines and Specification
service specification? 100% of shifts Department of
Not
2. What proportion of shifts have compliant with Health. Toolkit for
applicable,
sufficient staff qualified in 2018 Structure guidelines and high quality
no outlier
speciality (QIS)? service neonatal services
analysis.
3. How many additional nursing specification. BAPM. Service
shifts are required to be worked Standards for
to meet guidelines and service Hospitals
specification? Providing
Neonatal Care

Does a baby born at less than 32

Not
weeks’ gestational age die be-
applicable,
fore discharge home, or 44 weeks’ 2018 Outcome None
no outlier
post-menstrual age (whichever
analysis.
occurs sooner)?

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4.2. Data flow
National Neonatal Audit Programme 2020 report on 2019 data

4.2. Data flow

Data for the NNAP analyses are extracted from the National Neonatal Research Database (NNRD)
held at the Data
 Neonatal Data
for the Analysis
NNAP Unitare
analyses (NDAU). Thefrom
extracted NNRDthe contains
National a predefined
Neonatal set of Database
Research variables
(the National Neonatal
(NNRD) heldDataset) obtained
at the Neonatal from
Data the electronic
Analysis neonatal
Unit (NDAU). The patient records of
NNRD contains each
a predefined
participating
setNHS trust or health
of variables board. Neonatal Dataset) obtained from the electronic neonatal
(the National
patient records of each participating NHS trust or health board.
Figure 28 describes this data flow and the feedback loop, which disseminates results and
 Figure 28
recommendations to describes this data
neonatal units, flow and
networks andthe
thefeedback loop, which
wider system disseminates
to inform results
and promote and
quality
recommendations to neonatal units, networks and the wider system to inform and
improvement.
promote quality improvement.

Figure 28. Simplified NNAP data flow diagram

Figure 28. Simplified NNAP data flow diagram

4.3. Case ascertainment and unit participation

In usual practice, every baby admitted to a participating neonatal unit is entered on the BadgerNet
patient record system is eligible for inclusion in NNAP. The audit therefore achieves 100% case
ascertainment in the participating organisations, unless a parent or carer has chosen to opt out of
having their baby’s information submitted to the audit. For the calendar year 2019, no babies were
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National Neonatal Audit Programme 2020 report on 2019 data

4.3. Case ascertainment and unit participation

In usual practice, every baby admitted to a participating neonatal unit is entered on the
BadgerNet patient record system is eligible for inclusion in NNAP. The audit therefore
achieves 100% case ascertainment in the participating organisations, unless a parent or carer
has chosen to opt out of having their baby’s information submitted to the audit. For the
calendar year 2019, no babies were opted out. Babies receiving special care alongside their
mother in transitional care areas or postnatal wards can also be entered, but it is known that
some units do not enter data for such babies. For this reason, NNAP’s measures do not
concentrate on care outside neonatal units.

All neonatal units in England, Wales and Scotland associated with a delivery unit are eligible
to take part, including special care units (SCUs), local neonatal units (LNUs) and neonatal
intensive care units (NICUs). All neonatal units in England, Scotland and Wales participated
in the audit in 2019.

Where there is a change in unit name, unit level or network configuration, the NNAP will
apply the status as at the end of the data reporting year. For example, if the configuration of
a network changes on 1 April 2019, 2019 data will be presented as per the network configuration
on 31 December 2019.

4.4. Data quality and completeness

The NNAP project team produces quarterly reports. These are sent to NNAP-participating
unit clinical leads and other unit staff involved in the audit, to provide regular updates on
their data completeness and measured adherence to the NNAP standards. The reports are
a prompt to review data accuracy and completeness. The final quarterly report serves as a
summary report of their annual data in January. Following that, there is a final period for
units to review and amend their data on the BadgerNet system up until 30 April. For the 2019
data report, this period was impacted by the measures to prepare for the COVID19 pandemic,
and the NNAP team understand that the loss of focus this led to may have had deleterious
effects on data checking processes. To mitigate this, NNAP extended the data checking
window by a further two weeks. However, it remains possible that some data will neither be
as complete, nor as accurate as it would have been had COVID19 not been occurring at the
time of the planned closure of the data validation window.

The final data download used in the report is extracted from BadgerNet after the review
period has closed. Units can also access and review their data in real- time using the
BadgerNet system reporting tools.

NDAU applies a data cleaning and validation process to the raw dataset before creating the
NNAP dataset used to produce the data included in this report.

Babies who were finally discharged, or have died, during the NNAP reporting period form
the NNAP dataset. The exceptions to this are the datasets used for Bronchopulmonary
dysplasia, Two-year follow-up and Mortality until discharge for very preterm babies.

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National Neonatal Audit Programme 2020 report on 2019 data

4.5. Outlier identification and management

Performance on audit measures is presented using descriptive statistics, and data are
available to review on NNAP Online. Outliers are identified by funnel plot analysis, using the
national rate as the standard. Table 4.1 describes the questions to which outlier identification
applies. The full NNAP statistical analysis plan for the 2019 data year is available on the
RCPCH website

The NNAP manages outlier status in line with the RCPCH policy Detection and Management
of Outlier Status for Clinical Indicators in National Clinical Audits, with the specific application
and timelines associated with NNAP reporting for the 2019 data year set out in the outlier
management plan. All neonatal services identified as outliers for one or more NNAP
measures were notified according to the policy prior to publication of this report.

4.6. Managing small numbers in the NNAP

The NNAP considers the risk of disclosure on a measure-by-measure basis from a variety of
methods resulting from the publication of results based on small numbers of cases. Given
the frequent occurrence of small numbers at the unit level, annualised reporting, applying
blanket masking to all cells would significantly reduce the utility of published NNAP results
for improvement purposes. To further minimise the risk, the NNAP does not publish
demographic data about the cohort of babies included in the audit, which would have the
potential to be used alongside published data for the audit measures to aid identification of
a baby.

4.7. D
 eveloping key findings and
recommendations
The NNAP brings together a multidisciplinary group, including parents, to identify key
findings and to translate the key findings and results of the audit into a set of recommendations
that can be acted upon to improve neonatal care. The recommendations are made to
support the existing goals and priorities of neonatal and perinatal services and are targeted
to the audience with the ability to action the recommendation.

Recommendations are designed to be specific to each audit measure. However, there are
several recommendations that relate to more than one audit measure.

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National Neonatal Audit Programme 2020 report on 2019 data

5. Driving improvements in neonatal

care

5.1. Recommendations and action plan

development
Recommendations are listed by measure in Chapter 2 and by audience in Appendix B.

What to do next:

1. Share your unit’s NNAP results with your multidisciplinary team, using NNAP Online and
the NNAP results presentation template.
2. With the multidisciplinary team, set goals and develop action plans where your unit
results require improvement and your unit is not meeting the audit recommendations.
3. Use the recommendations checklist to track your unit, trust/health board or network’s
status.
4. Monitor your unit’s performance through the year using NNAP quarterly reports and
real time data. Regularly revisit the recommendations checklist and your unit’s action
plan throughout the year.

5.2. Useful resources

• 
NNAP Online:www.nnap.rcpch.ac.uk/.NNAP results at unit, network and national level are
hosted on NNAP Online. We recommend that neonatal units and networks use NNAP
Online to view their results and compare themselves against other units of the same
designation. Use it to share results with the wider team, share best practice between units
and networks, and to stimulate quality improvement activities.

• 
NNAP results presentation template: www.rcpch.ac.uk/national-neonatal-audit-programme.
Use this template to help you communicate the main national and unit level audit
findings to your team.

• 
NNAP recommendations checklist: www.rcpch.ac.uk/national-neonatal-audit-programme.
Use this checklist to track your progress against this year’s NNAP recommendations.

• 
The NNAP quality improvement map:www.rcpch.ac.uk/national-neonatal-audit-programme.
Use this map to find national and international quality improvement resources, research,
policies, guidelines, quality assurance programmes, audits and registries by NNAP
measure area.

• 
British Association for Perinatal Medicine (BAPM) quality resources: www.bapm.org/
quality. BAPM’s repository of quality resources, alerts, safety and improvement stories.

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National Neonatal Audit Programme 2020 report on 2019 data

• 
RCPCH QI Central:www.qicentral.org.uk/. The RCPCH quality improvement sharing hub.
You can find this year’s NNAP case studies, as well as those from previous years, on QI
Central.

• 
Maternity and Children Quality Improvement Collaborative (MCQIC) resources:
www.ihub.scot/improvement-programmes/scottish-patient-safety-programme-spsp/
maternity-and-children-quality-improvement-collaborative-mcqic/. MCQIC is part of the
Scottish Patient Safety Programme. A number of QI resources are available on their
website.

• 
Maternal and neonatal health safety collaborative resources: www.improvement.nhs.
uk/resources/maternal-and-neonatal-safety-collaborative/#resources. The maternal and
neonatal health safety collaborative is a three-year programme to support improvement
in the quality and safety of maternity and neonatal units across England. Various resources
are available on their website.

5.3. Information for parents, carers and

families

Your baby’s care is a parent and carer’s guide to the NNAP and the audit results. Available in
English and Welsh, it tells families: what the audit is, what it aims to achieve, explains the
results for key audit measures, and what families can do in response to the results. We ask
units to make the booklet available to parents and carers in their unit. Your baby’s care is
available here: [new link to be added for 2020 leaflet] www.rcpch.ac.uk/resources/your-babys-
care-measuring-standards-improving-neonatal-care-2019

The NNAP fair processing and parent information leaflet Your baby’s information is available
here: www.rcpch.ac.uk/resources/national-neonatal-audit-programme-your-babys-information

The NNAP unit results posters summarise a selection of the unit’s NNAP results that are
most relevant to parents, families and wider members of the multidisciplinary team caring
for the baby. Neonatal units display the posters in a public area, and complete a second
poster, which explains the actions they are taking in response to their audit results. Designed
to be used alongside Your baby’s care, the posters help to communicate the meaning and
relevance of the audit results not only to parents, but to the wider team involved in caring for
the baby and mother.

NNAP unit results posters can be downloaded from NNAP Online www.nnap.rcpch.ac.uk.

All our information for parents, carers and families is developed in collaboration with our
parent, nurse and charity representatives.

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National Neonatal Audit Programme 2020 report on 2019 data

5.4. Future developments in the NNAP

As a well-established programme achieving high levels of engagement with the multi-
professional neonatal clinical community, the NNAP can respond quickly to changing quality
improvement priorities. The NNAP has made considerable positive impact since its launch
in 2006; achieving improvements across many areas of clinical practice, from antenatal
interventions, achieving normothermia on admission, to parental involvement in care and
clinical follow-up at two years of age. Variation remains, and the audit will continue to support
neonatal units and networks to achieve best practice in these areas.

Following feedback from audit users, the NNAP has introduced a measure of deferred cord
clamping in very preterm infants from 2020. There is evidence that the practice leads to a
large reduction in mortality. By reporting this measure the NNAP has an opportunity to
facilitate benchmarking and review of practise.

In 2021 the NNAP anticipates commencement of measurement of intraventricular

haemorrhage, post haemorrhagic ventricular dilatation and periventricular leukomalacia
according to consensus definitions.

The NNAP will continue to work closely with the wider neonatal community, through its
participants, stakeholder groups and national programmes of work. There are opportunities
to work with NHS Digital and the National Maternity and Perinatal Audit (NMPA) to improve
data linkage between the processes and outcomes of neonatal care and maternity care in
England.

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National Neonatal Audit Programme 2020 report on 2019 data

Index of appendices
Appendix A: Data completeness and unit participation

Appendix B: NNAP recommendations by audience

Appendix C: Glossary and abbreviations

Appendix D: NNAP governance

Appendix E: Pathogens in the NNAP

Appendix F: Neonatal care system and QI map

Appendix G: Methodology and Interpretation

Appendix H: Mortality vs NEC graph

Appendix I: Aims of the NNAP

 ppendices are available at: www.rcpch.ac.uk/resources/national-neonatal-audit-programme-annual-

A
report-2019-2018-data

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National Neonatal Audit Programme 2020 report on 2019 data

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infants. Archives of Disease in Childhood - Fetal and Neonatal Edition 2015;100: F553-F557. Available
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National Institute for Health and Care Excellence. Preterm labour and birth. NICE guideline (NG25)
ii

2015. Available from: https://www.nice.org.uk/guidance/NG25

NHS England. Neonatal Critical Care Service Specification. 2016. Available from
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https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-e/e08/.

iv
NHS England. Implementing Better Births: Integrating Neonatal Care into Local Maternity
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v
Scottish Government. Neonatal Care in Scotland: A Quality Framework. 2013. Available from
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vi
Welsh Health Specialised Services Committee, NHS Wales. All Wales Neonatal Standards -
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Department of Health. Toolkit for high quality neonatal services. 2009. Available from
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x
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xiii

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National Neonatal Audit Programme (NNAP) 2020
Annual report on 2019 data

©2019 Healthcare Quality Improvement Partnership.

Published by RCPCH November 2020

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Improvement Partnership (HQIP)
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London EC3N 2EX

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and Child Health
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