Improving the care of babies at

risk of neonatal hypoglycaemia

Team GWH
25 March 2019
London
@MatNeoQI
improvement.nhs.uk
Our aims
1. Reduce NNU admission of babies with hypoglycaemia
2. Prevent brain injury associated with severe
hypoglycaemia
3. Improve patient satisfaction
Background
Main title for slide set
Previous practice on management of neonatal hypoglycaemia:
• Babies were having too many blood sugar checks,
Optional sub Post-
including title or
feed blood sugar name
• Confusion regarding maternal beta blocker use and blood sugar
monitoring – No consistency
• No clear guidelines for on-going management of babies admitted to
the neonatal unit with hypoglycaemia
• ATAIN – good rate therefore not an issue
Swindon ATAIN Trend
ATAIN and Hypoglycaemia
Benefits to mothers, babies and staff
New BAPM Guideline published in April 2017
• Reduced intervention – fewer heel blood tests
• Keeping mother and baby together – uplifting the concept of
transitional care
• Patient information leaflet – increasing family participation
• Clear pathway for staff – easier to know what to do when

Happy babies – happy mums – happy staff

 Improvement Approach

April 2017 August 2017 May 2018 June 2018

• BAPM guideline • Working group • Follow on • MatNeoQI
published • Discussion / meetings meeting
Consultation • Gave us
Process energy
• Team
interested
• Needed clear
pathway,
training & SOP
 Improvement Approach
July / Aug Sep / Oct Nov 2018 Dec 2018
2018 2018 • “Awareness
• Consultation • Guideline / SOP week” training
with other ready for launch (106-120 staff)
units (St
Michaels,
• Posters,
newsletter
• Live!
Exeter, Bath) • Survey on
current
knowledge
Driver Diagram
 Driver Diagram
AIM PRIMARY DRIVERS SECONDARY DRIVERS CHANGE IDEAS

Understand the culture and learning

Staff Survey on Knowledge
Culture of system in the department

1. Reduce NNU
admission
Safety and
continuous
improvement
Welco Develop and nurture the conditions that
enable a just and safety culture
Staff Training: Awareness
Week

2. Prevent brain Patient Satisfaction Survey

injury associated
with severe
Improve me
experience of
Work with mothers and families to
improve their experience of care
Reduce number of heel test
each babies receive
hypoglycaemia Patient and
3. Improve patient Staff Reduce NNU admission
Improve care processes to provide
satisfaction optimal thermo-regulation and
nutrition to all risk babies for Thermo-regulation measures
Implement hypoglycaemia
BAPM antenatal Patient pathway
Guideline Identify and mitigate risks of booklet
hypoglycaemia during antenatal and
postnatal period
Introduce Dextrose Gel
Measures
• Readmission rate
• Work Load
Balancing

Process

• Staff Knowledge
• Patient Satisfaction
Outcome

• Number of Heel
test / baby
• Reduce NNU
Admission
 Outcome measure 1
Number of Heel tests per baby
15
Number of babies

10

0
Before (Range = 3-7, mode = 3) After (Range = 2-5, mode = 2)
Heel tests : before and after QI launch

2 3 4 5 6 7
 Outcome measure 1
Number of Heel tests per baby
15
Number of babies

10

0
Before (Range = 3-7, mode = 3) After (Range = 2-5, mode = 2)
Heel tests : before and after QI launch

2 3 4 5 6 7
Outcome measure 2
Reduced admission of babies
(>35 weeks gestation) to NNU
Main title for slide set
Optional sub title or
name

There by uplifting the

concept of keeping babies
and mother together under
NTC framework
Process measure: 1 Staff Knowledge Survey

Respondents:
Round 1: 25

Round 2: 10
Process measure: 1 Staff Survey
Process measure 2 Patient Satisfaction
Survey
Carried out in January and February
• Did parent receive patient information leaflet? 80% Yes
• Did parent understand reason for baby is being monitored
for blood sugar? 80% Yes
• Experience with the care received by baby and mother
during this period? 82% Excellent
Balancing measure 1
Readmissions

0 for hypoglycaemia in December and January 

No increase in other areas like weight loss / feeding

difficulties..  
Balancing measure 2
Workload: Number of babies needing B S monitoring ?

Work load has increased from average 30 babies/month to 42 babies/month

PDSA cycle
PDSA Testing Ramps for dextrose gel

AP
SD

AP Cycle 1B: Clear pathway on administration

SD
Cycle 1A: Can midwife administer without being
prescribed?
PDSA Testing Ramps for dextrose gel

AP
SD

Cycle 1C: Training

AP Cycle 1B: Clear pathway on administration
SD
Cycle 1A: Can midwife administer without being
prescribed?
PDSA Testing Ramps for dextrose gel

1E: Collate information review

PDSA
AP
SD Cycle 1D: Where is it being stored?
Live – Dec 18
Cycle 1C: Training
AP Cycle 1B: Clear pathway on administration
SD
Cycle 1A: Can midwife administer without being
prescribed?
PDSA Testing Ramps Gas Analyser
7

1
AP
SD 0
Glucometer ISO15197:2003 Gas Analyser
1 2 3 4 5 6 7 8 9 10111213141516171819202122232425262728
Cycle 1A: Is Glucometer reliable at low reading
PDSA Testing Ramps Gas Analyser

Welco
me
Cycle 1B: Need for a separate Gas Analyser ?
AP
SD
Cycle 1A: Is Glucometer reliable at low reading
PDSA Testing Ramps Gas Analyser

Welco Final conclusion: No need for a

separate gas analyser on PNW

me
Cycle 1B: Do we need a separate Gas Analyzer ?
AP
SD
Cycle 1A: Is Glucometer (ISO 15197) reliable at low reading ?
Outcome / learning
• We have a clear pathway, structured and easy to understand.
• Patient participation is biggest thing – issuing leaflet in
antenatal clinic (as part of the diabetes booklet).
• We reduced NNU admission of term and late pre-term babies
- so more babies staying with mothers.

Happy babies – happy mums – happy staff

Key Messages – learning

Teamwork! Everyone contributed their bit

Collected good data to show impact

Positive feedback from staff and families

Everyone wants to improve patient care and without the

MatNeoQI collaborative we wouldn’t have had this impact at
short span of time
Key Messages – the future
• Applying same concept to other areas like NTC, Sepsis,
Discharge process etc…

• Share our experience and pathway/guideline with the local

learning system
Thank you
Presented by Dr K Girish Gowda and Christina Rattigan

Special thanks to
• Donna Johnson & Karin Jones, Midwives
• Julie Herring, Maternity Support Worker
• Dr Rebecca Webster Clinical Teaching Fellow and
• Heather, Ann and Nathalie from the MatNeoQI team
Neonatal Hypoglycaemia Protocol
as per BAPM guidelines

For infants at risk of neonatal

hypoglycaemia:
• Keep baby warm – hat and skin to
skin contact.
• Put in hot cot if ≤36 weeks.
• First feed within 1 hour.
• Breastfeeding support
• Do not allow more than 3 hours
between feeds. All babies commenced
• Assess and document feeding on the pathway must
cues and feeding effectiveness stay for 24 hours
with each
Please feed. of Cord Gas:
be aware post completion of
•pH Any colostrum
BE expressed
Think should blood glucose
be fed immediately to the baby. Please issue Patient
Hypoglycaemia
monitoring.
≤ 7.1 ≥ -12 Information leaflet :
Pathway
“Protecting Your Baby from
≤ 7 .0 ≥ -16 HIE pathway
Low Blood Glucose” to all
parents of risk babies as
soon as possible:
Patient Pathway : Starts in delivery suite on all babies with risk factors
Management of those at risk of neonatal hypoglycaemia Blood glucose 1.0-1.9mmol/l but asymptomatic
 For NNU babies Flow rate of 10% dextrose Infusion rate
(ml/kg/day) (mg/kg/min) How to make up any concentration of
glucose in any volume:
When blood glucose < 1.0mmol/l or 40 2.77
symptomatic , admit immediately to SCBU 60 4.16 Desired volume = V ml
Desired concentration of glucose = D %
80 5.55
Lower concentration of glucose = L%
100 6.94 Higher concentration of glucose = H%
Volume of higher concentration of glucose
120 8.33
to add = HV ml
130 9.03
Formula: HV = V (D - L) / (H - L)
140 9.72
LV = V - HV
150 10.42 Add HV ml and LV ml to get V ml of D%
Investigation for Hypoglycaemia in New-born infant
Indications:
• Two episodes of blood glucose <2.0 mmol/L in 48 hours
• Blood glucose <1.0mmol/l
• Blood glucose <2.5mmol/l and the baby has altered neurology
• If baby is requiring >8.0mg/kg/min dextrose to maintain sugars (think
hyperinsulinism)
Two EDTA
Please send
One Fluoride top sample for
hypoglycaemia
Two Lithium Heparin investigation

Four spots on Guthrie card