In the event a reviewer indicates that there is sufficient information in the local review uploaded to the Each Baby Counts portal, they are advised to indicate whether, in their clinical opinion, different care might have made a difference to the outcome.
In the analysis, 74% (508) of the babies were identified as having an outcome where at least one reviewer was of the opinion that different care might have made a difference (Figure 11), with the other 26% (179) of the babies having an outcome where different care is unlikely to have made a difference to the outcome.
Figure 11: Proportion of babies for whom different care might have made a difference to the outcome (N = 687)
These proportions have seen relatively little variation across the previous Each Baby Counts reports (Figure 12). This is consistent with the 2017 perinatal confidential enquiry into intrapartum-related stillbirths and neonatal deaths which also reported 78–79% where different care might have made a difference to the outcome. There remains a question as to why this figure is so resistant to change. It may be a product of the Each Baby Counts methodology and that of other programmes that rely on the review of others’ practice from the position of hindsight. It is clear that even when the outcome is good, on review, improvements in care can still be found. Berglund et al. showed that even in controls (where Apgar score was 10), improvements in care were identified in 36% of cases, as compared with improvements in care being identified in 63% of cases where the Apgar score was less than 7.
The Each Baby Counts neonatology reviewers assessed the care of 319 babies whose reports were deemed to contain sufficient information to assess the neonatal care provided. In 123 (39%) of these, it was identified that different neonatal care might have made a difference to the outcome (Figure 13).
Figure 13: Proportion of babies for whom different neonatal care might have made a difference to the outcome (N = 319)
Similarly, this figure has not materially changed over the three reports for which it has been calculated.
This is substantially lower than the overall percentage but it should be borne in mind that by the time a neonatology review is requested, the baby may well be severely compromised and that, despite optimal care, the outcome may not change.
Where a reviewer considers that different care might have made a difference to the outcome, they are asked to indicate what they consider to be the critical contributory factors influencing the outcome. Each baby’s care can be reviewed by up to 5 multidisciplinary reviewers and they can each identify multiple critical contributory factors.
These contributory factors are shown in Figure 15 for all themes (excluding neonatal care), which is outlined separately in Figure 16.
These critical contributory factors (excluding neonatal care) are categorised into themes, with the 5 most common themes being cardiotocography (CTG) and blood sampling, risk recognition, team communication issues, individual human factors, and education/training (Figure 17). There were only 32 babies where reviewers did not identify any critical contributory factors falling under one of these themes.
Figure 17: Interrelation of the 5 most commonly identified themes; diagram produced using http://bioinformatics.psb.ugent.be/webtools/Venn/
These top 5 themes have not changed over previous reports, despite recommendations specifically designed to address them. The focus needs to move from ‘what’ needs to change to ‘how’ that change can be delivered.
The Each Baby Counts approach has consistently illustrated that there is seldom just one, single, factor that leads to an adverse outcome for a baby. This supports the understanding that care provision is rarely carried out by single individuals in isolation.
“Health care provision is rarely carried out by single individuals. Safe and effective patient care is, therefore, dependent not only on the knowledge, skills and behaviours of the front line workers, but also how the workers work together in the particular work environment, which itself is usually part of a larger organization. In other words, patients depend on many people doing the right thing at the right time for them: that is, they depend on a ‘system’ of care.”
World Health Organisation, "WHO Patient Safety: Curriculum Guide for Medical Schools" (PDF)
Through the lens of system thinking, one can think more widely than the prima facie causes of incidents and explore what the antecedents of the final behaviour were. For example, it is known that a sufficiently staffed workforce and availability of equipment are essential to create the conditions for excellent care to take place, but if they are not in place then risk of error on the part of the workforce and incorrect use of equipment increases. It is recognised that workforce is a complex phenomenon in its own right, and it is therefore necessary to be more sophisticated and move beyond talking about simple numbers to skill-mix (the different grades of staff present on the unit) and the preparation of these staff. Aligned to workforce, an increasing focus is being placed on culture and leadership; however, no amount of leadership training addresses not having enough staff present to deliver safe care.
It is also becoming increasingly obvious that training on its own is not a panacea to change behaviour. No amount of training can support someone to deliver care in a particular way if the resources to undertake the task are not present. Therefore, more sophisticated work on understanding systems and then on implementation is required, drawing from expertise within the implementation science community.