How quality improvement (QI) is keeping babies warm

All newborn babies are at risk of having an abnormally low body temperature (hypothermia) – especially those born premature or unwell. A low body temperature in babies can be dangerous and can lead to serious health complications or death. For many babies it will mean admission to the neonatal unit, leading to medical interventions (such as tubes or ventilators) and prolonged hospital stays. Keeping newborn babies warm is therefore a critical intervention that can improve a range of longer-term outcomes.

A core priority

Hypothermia in newborn babies is one of the most common causes of neonatal unit admissions in term babies – those born at 37 weeks or more. It is also important to avoid in premature babies. Reducing the incidence of admission due to hypothermia is therefore a core priority within the neonatal programme of the Maternity and Children Quality Improvement Collaborative (MCQIC).

Data submitted to the MCQIC team from neonatal units across Scotland shows that, currently, for babies born in Scottish hospitals:

  • Around 10 in every 1,000 births are cold on admission to the neonatal unit.
  • This equates to an average of 35 babies per month across Scotland.

The importance of working together

Frequently, the care given to mothers before, during and after birth (maternity care) and the additional care given to newborn babies (neonatal care) are separate services. To reduce the incidence of hypothermia, maternity and neonatal services need to work together to identify babies who are at risk of becoming cold, as well as identifying environmental factors that may increase the risk of hypothermia.

With this in mind, MCQIC set out to optimise collaborative working relationships between maternity and neonatal colleagues through:

  • Networking events focusing on team building and communication, clinical topics and adopting coaching approaches
  • Joint maternity and neonatal visits to provide support and share learning on collaborative working processes in other boards
  • Proactive social media activity to highlight key messages and learning
  • Dedicated discussions: both maternity and neonatal teams shared successes, challenges and ideas for improvement on themed WebEx sessions. They frequently discussed problems together and came away with ideas for improvement for testing, such as the use of woollen hats at birth and ways to optimise skin-to-skin care
  • Measuring progress with these interventions over time to identify what works and what doesn’t. This enables the teams to focus their quality improvement activity on the changes having the greatest impact.

A positive response

Staff working in maternity and neonatal services across Scotland have responded really positively to this work and a number of units have used quality improvement methodology to help reduce the number of hypothermic babies.

NHS Lanarkshire were particularly innovative in their approach, using a social media campaign to request donations of knitted hats from the community. The campaign was a success, with adult daycare centres in the local area forming knitting groups. These groups continue to provide a regular supply of knitted hats for babies.

Working closely with the infant feeding team, the maternity and neonatal team supported mums and particularly those whose babies were delivered by caesarean section, to increase the adoption of skin to skin - a technique of newborn care where babies are kept chest-to-chest and skin-to-skin with a parent. Other interventions have included bedside ‘hot cots’, which are specially adapted heated and covered cots. Coupled with these interventions, NHS Lanarkshire also:

  • Adopted a collaborative approach between maternity and neonates.
  • Used QI tools and techniques to identify, understand and improve upon current processes – this includes using process maps, Pareto charts and cause-and-effect diagrams.
  • Conducted small-scale, frequent tests of change – this enabled rapid feedback and learning on what did and didn’t work.
  • Used data to visualise their progress, allowing the team to see in real time what effect (if any) changes were having.
  • Conducted training to increase QI capability among staff, enabling more staff to understand and apply quality improvement methods.

This work has led to an 87% reduction in admission hypothermia to NHS Lanarkshire’s neonatal unit.

NHS Forth Valley placed ‘warm bundle’ posters in all labour and postnatal ward rooms to remind all staff and parents of the importance of keeping babies at an appropriate temperature. Other interventions included:

  • Information sheets on the use of hot cots and appropriate clothing/sheet complement when nursed in hot cot.
  • A teaching package on thermal management, which was made available to all staff.
  • Blanket warmers are now in the labour ward and maternity theatre.
  • Staff are encouraged to engage with displayed monthly run chart data in staff areas, which shows the progress they are making.

This work in NHS Forth Valley has led to a 64% reduction in admission hypothermia.

NHS Grampian have also seen impressive results with a 70% reduction in admission hypothermia. At a national level, the aggregated data for six units submitting data since May 2017 has shown a 23% reduction in the rate of babies who are hypothermic being admitted to neonatal units. That means eight fewer babies per month are being admitted with hypothermia.

Committed frontline staff

None of these results would have been possible without the enthusiasm and hard work of individuals involved in maternity and neonatal services across Scotland. To find out more about this important initiative, which is improving outcomes and experiences for babies and their families please see Maternity and Children Quality Improvement Collaborative.

MCQIC data shows that introducing knitted hats, as well as a focus on skin-to-skin, has seen NHS boards reduce the number of babies who are hypothermic admitted to neonatal units.