Optimal practice in neonatal parenteral nutrition: The role of quality improvement and risk management in providing high-quality parenteral nutrition

An interview with Professor Nicholas Embleton

In some infants, parenteral nutrition is the only way to provide the necessary nutrients for days or weeks. Being an invasive procedure, it also carries potential risks and therefore, requires certain infrastructure and thorough risk management paired with continuous quality assessment in order to ensure high quality of parenteral nutrition in daily practice. In this interview, Professor Nicholas Embleton from The Newcastle-upon-Tyne hospital & Newcastle University shares his view and experiences on means of quality improvement and how a blame-free culture can contribute to efficient risk management.

Question 1: Quality assessment and risk management rely on thorough and transparent reporting practices. Could you elaborate what in general makes the Briefing in a minute (BIM) an efficient method in Quality Improvement (QI) and Risk Management (RM)?

The great thing about BIM is that it is very quick to do, and you can do it repeatedly. We do every day after our morning teaching session, but you could do at every shift change i.e. twice per day. By the end of the week, you might have heard the same message 5 times, but then we have some fun, and we make a quiz “who can remember what the 4 items on BIM were this week?”. It allows us to communicate messages about QI or RM quickly.

Question 2: Concerning parenteral nutrition, which properties of the BIM are particularly advantageous in terms of quality improvement and risk management?

The ability to get a simple message communicated quickly – for example, we had an issue with placement of the filter in relation to the lipid infusion line. We realised some staff were placing the filter at the wrong location, which was leading to alarms. We were able to share that update really quickly. Although we meet as a whole team, shift handover happens separately for medical and nursing teams: the roles and responsibilities also differ. This means we have separate BIM for nursing and medical teams. The items discussed on BIM can be the same or different which allows us to ‘target’ different parts of a complex communication system.

Question 3: Can you say something about the implementation process of the BIM into daily work routines? Did it require training, for instance, to develop a routine in using simple, concise messages for the reporting?

We just started using it a few years ago, to be honest, I am not sure who had the original idea, but quite probably another hospital or department. It doesn’t require any training to use. You just need to give one person the responsibility of coordinating what will be the 3-4 items for that week. You can agree on those items at a departmental meeting, or you send an email to the senior team asking for specific items for BIM in that week. We write the items out and keep them in a folder – if you want you can look back at the last several weeks of BIM items. It is important that you don’t try and cover too much, so 3-4 items are about right. For more complex issues you need a different mechanism. So BIM cannot be used for teaching – it is not really an interactive event. But you could use BIM to say ‘we are using new filters for lipid; make sure you attend the training session before you start to use them’.

Question 4: To establish and to maintain a well-functioning risk management and reporting system, a blame-free culture is crucial. Yet, in healthcare, errors can range from minor mistakes to errors with tremendous consequences. How do you maintain and encourage open communication within your teams?

Establishing trust in the whole team is essential. Even when you know you didn’t mean to make the mistake, and even when it is not serious you can still feel bad. So developing a supportive team is crucial. We need to learn to look after our colleagues and stick together. That is all about being practical and recognising the real world: we are all human. It is not about ‘sticking together’ to hide mistakes away. At the end of the day, the motivation for working on a NICU is to make things better for the babies, so everyone wants to be involved in QI and RM. It is appropriate sometimes to maintain anonymity – if you made a ‘silly’ mistake, you don’t want to be ‘named and shamed’ at a large meeting, so we try hard to always maintain anonymity. It’s also important to recognise that as senior members of the team, we are much more confident in many respects – both in terms of knowledge and experience, but also more confident knowing that our colleagues will support us. More junior members may feel more worried and less confident. I might not perceive a small intravenous extravasation as being important, but the junior nurse responsible may feel really upset. Developing a friendly, supportive team and looking after each other is essential to good QI and RM. We are proud to have a ‘learning culture’ in our NICU. We accept that sometimes things will not go to plan. We deal with that by being honest and supportive. Parents appreciate honesty and deserve to be listened to. Parents appreciate it when a senior healthcare professional says “I am sorry this happened to your baby”. Saying sorry does not mean we made a mistake, it means we empathise and acknowledge that what happened to the baby has caused upset or harm. TEAM is the most important aspects of QI and RM.

We thank Professor Embleton for this insightful interview.

© N.Embleton

Professor Nicholas Embleton is Consultant Neonatal Paediatrician at the Newcastle-upon-Tyne hospital and a member of the expert panel for the topic of neonatal parenteral nutrition.