Australia and New Zealand Neonatal
Network (ANZNN)Collaborative Network for Neonatal Care
Clinical Registry Special Interest Group
24 July 2015
Kenneth Tan, NeonatologistMonash Newborn, Monash Children’s HospitalDepartment of Paediatrics, Monash University
Objectives
• Overview of neonatal intensive care• Outcomes of NICU infants plus resource• Australia and New Zealand Neonatal Network• Role of ANZNN• Quality improvement
MONASH NEWBORN NICU
The NICU and the Australian Neonatal Network
Neonates needing intensive care at
Monash NICU
http://www.cuh.org.uk/rosie/services/neonatal/nicu/how_we_care/vital_needs.html
Premature infants
http://mimr-phi.org/infant-and-child-health
Figure 2. Changes over time in consumption of nursery resources (mean equivalent days of assisted ventilation) and survival rates to 2 years of age in each era, for infants of birth-weight 500–999 g, and in 250 g birth-weight subgroups. Redrawn from Doyle et a...
Doyle Evaluation of neonatal intensive care for extremely-low-birth-weight infants Seminars in Fetal and Neonatal Medicine, Volume 11, Issue 2, 2006, 139–145
Victorian NICU trend in ventilation
Cost of NICU care – preterms rates of
childhood disability
BMC Pediatr 2014. 14:93
Healthcare utilisation – preterm
infants
BMC Pediatr 2014. 14:93
Surgical and cardiac infants
Neonates needing surgery Congenital heart disease
Therapeutic hypothermia
A David Edwards et al. BMJ 2010;340:bmj.c363
Fig 2 Forest plot of the effect of therapeutic hypo thermia compared with standard care (normothermia) on survival with normal neurological function (“events”).
©2010 by British Medical Journal Publishing Group
Complications from neonatal intensive
care
History of oxygen use in preterm neonates
• early 1950searly 1950searly 1950searly 1950s: unrestricted, high O2, subsequent huge increase in RLF (severe ROP)
From: Wright K. Textbook of Ophthalmology 1997. Eds. Williams & Wilkins. Chapter 22
Retinopathy of prematurity –
worldwide cases
ANZNN
The Australian Neonatal Network
The establishment of the Australian and New
Zealand Neonatal Network
Journal of Paediatrics and Child HealthVolume 45, Issue 7‐8, pages 400-404, 20 JUL 2009 DOI: 10.1111/j.1440-1754.2009.01527.xhttp://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2009.01527.x/full#f1
Australia and New Zealand Neonatal
Network• In 1993 NHMRC Expert Panel on Perinatal Morbidity recommended that
“The Australian Institute of Health and Welfare National Perinatal Statistics Unit” – a national minimum data set and implement a data collection to monitor
mortality and morbidity of infants admitted to such [perinatal] units
• Data collection – Jan 1995 all level III NICUs in both Australia and New Zealand contributed to the audit– In 1998, all level II NICUs in NZ joined as did the one level II NICU from
Tasmania in 1999
• Until 2008 hosted by Centre for Perinatal Health Services Research at the University of Sydney
• In 2008, the Network moved to the Perinatal and Reproductive Epidemiology Research Unit (PRERU) at UNSW
Schematic flow of ANZNN
Management Group
Chairman Operations Manager
ANZNN Coordinator
ANZNN registration criteria
All babies admitted to a level III NICU at less than 28 days (during their first
admission) who:
• < 32 completed weeks’ gestation or
• < 1500 grams birthweight or
• receive assisted ventilation for 4 or more hrs. or
• receive major surgery
• Therapeutic hypothermia
The registration unit is the first level III nursery that the baby
remains in for 4 or more hours.
If retrieved, a baby is deemed to be in the care of the next hospital
when a specialist team arrives.
ANZNN Minimum dataset
• Large dataset required• Antenatal treatment• Maternal conditions• Delivery details• Care delivered (ventilation)• Mortality• Morbidity (intracranial haemorrhage, chronic
lung disease, retinopathy)
• 2 year outcomes (from 2012 report)
Purpose of ANZNN annual report
• Providing a core data
• Monitoring the clinical indicators for perinatal care
• Improving clinical practice while maintaining national standards
• Monitoring the use of new technologies
• Consistency in national data collections
• Follow-up data (2 year) available from 2012 report
• Available online
http://www.preru.unsw.edu.au/data-collection/australian-new-zealand-neonatal-network-anznn
Individual Unit Feedback
• Provided to medical directors of NICU• Confidential, password protected• Benchmarked against NICU network• Process of care, clinical outcomes, morbidity
etc.
• Non-risk adjusted data– Illness severity e.g.
CRIB-II and SNAPPE-II
ANZNN - Individual unit feedback for babies born in 2005
0
20
40
60
80
100
120
140
160
23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42Gestational age (weeks)
your unit
Days to go homeDays to go home
Inter quartile range
Median
Role of neonatal networks
• Randomised control trials• Observational studies• Quality improvement
• Advocacy
Thakkar 2006 Sem Fetal Neon Med 11:105-110
ANZNN Working groups
• Cranial ultrasounds• Common parenteral nutrition formulations• Chronic lung disease• Clinical Practice Improvement
BENCHMARKING
Quality Improvement
Institute of Medicine's six domains of quality.
C Lemer et al. Arch Dis Child Educ Pract Ed 2013;98 :175-180
Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.
The plan–do–study–act cycle.
C Lemer et al. Arch Dis Child Educ Pract Ed 2013;98 :175-180
Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.
Quality improvement and benchmarking
“So how do we set realistic targets for improvement? In health
care, as in many other fields, we often look around us to see
what others have achieved. The theory being that if they can do
it, so can we.”
Benchmarking for Improvement: Reducing Health Disparities
Blog Jacob Lippa MPH – www.ihi.org
Nosocomial infection
• Average length of stay – time to reach EDD + 2 weeks
• High risk of nosocomial infection or hospital acquired infection (HAI)
– Immature immune function– Permeability of skin barrier– Instrumentation (IV lines, blood tests, ventilation)
EPIC-I Results: Group A (NIT)
NIT(intervention group)
24.1%
17.1%
21.5%
12.5%
15.6% 16.4% 15.8% 15.5%13.1%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
baseline Oct03-Dec03
Jan04-Mar04
Apr04-Jun04
Jul04-Sept04
Oct04-Dec04
Jan05-Mar05
Apr05-Jun05
Jul05-Sept05
Quarter
Percentage of NI (ever infected)
NIT (control group)
32.7%
28.3%
38.0%
28.2% 28.3%
33.0%29.5% 29.5%
32.2%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
baseline Oct03-Dec03
Jan04-Mar04
Apr04-Jun04
Jul04-Sept04
Oct04-Dec04
Jan05-Mar05
Apr05-Jun05
Jul05-Sept05
Quarter
Percen
tage of CLD
Lee et al. CMAJ 2009 181:469-76
EPIC-I Results: Group B (CLD)C L D ( i n t e r v e n t i o n g r u o p )
3 1 . 5 %2 8 . 9 % 3 0 . 0 % 2 8 . 2 % 2 8 . 5 % 2 7 . 8 %
2 5 . 3 %2 7 . 4 %
2 1 . 7 %
0 . 0 %
5 . 0 %
1 0 . 0 %
1 5 . 0 %
2 0 . 0 %
2 5 . 0 %
3 0 . 0 %
3 5 . 0 %
4 0 . 0 %
b a s e l i n e O c t 0 3 -D e c 0 3
J a n 0 4 -M a r 0 4
A p r 0 4 -J u n 0 4
J u l 0 4 -S e p t 0 4
O c t 0 4 -D e c 0 4
J a n 0 5 -M a r 0 5
A p r 0 5 -J u n 0 5
J u l 0 5 -S e p t 0 5
Q u a r t e r
Per
cent
age
of C
LD
C L D ( c o n t r o l g r u p )
1 7 . 8 %
1 3 . 7 %1 5 . 0 %
1 0 . 0 %
1 2 . 4 % 1 2 . 8 %
1 0 . 1 %8 . 0 % 7 . 1 %
0 . 0 %
5 . 0 %
1 0 . 0 %
1 5 . 0 %
2 0 . 0 %
2 5 . 0 %
b a s e l i n e O c t 0 3 -D e c 0 3
J a n 0 4 -M a r 0 4
A p r 0 4 -J u n 0 4
J u l 0 4 -S e p t 0 4
O c t 0 4 -D e c 0 4
J a n 0 5 -M a r 0 5
A p r 0 5 -J u n 0 5
J u l 0 5 -S e p t 0 5
Q u a r t e r
Per
cent
age
of N
I (ev
er in
fect
ed)
Lee et al. CMAJ 2009 181:469-76
International Networks
ANZNN and other networks
http://www.canadianneonatalnetork.org/portal
International Neonatal Network
comparisons
Summary
• Overview of the NICU clinical environment• Organisation and aims of ANZNN• Benchmarking activities in Australian NICU• Future directions in ANZNN
Acknowledgements
• Assoc Prof Ross Haslam, Chairman ANZNN• Assoc Prof Kei Lui, Operations Manager
ANZNN
• Sharon Chow, Coordinator ANZNN
