Context This project was performed in the Maternity and Neonatal unit of a tertiary hospital in Scotland. Involvement was from midwifery, quality improvement, e-health and neonatal staff

Problem Infants were not routinely screened for risk factors associated with acute deterioration in the postnatal period. There is a risk of serious harm which could be more quickly acted upon.

Assessment of problem and analysis of its causes The postnatal period is extremely busy for staff. Midwives are looking after many mothers and infants and need to prioritise cases. The neonatal unit noted that the risk assessment of infants in our centre was largely ad-hoc. A standardised approach has been suggested by the International Liaison Committee on Resuscitation (ILCOR). A tool for assessing every infant was needed for those carrying out the assessment.

Intervention Doctors created a checklist to be completed for each infant. Recognised risk factors trigger a Neonatal Early Warning Score Chart which creates a score based on observations over time. The risk assessment tool was initially a sheet of paper for completion before transfer from the labour ward to the postnatal wards. A simplified electronic version of the tool was then implemented and joined to an assessment performed on every infant within an hour of birth. The questions were made mandatory and required username and password input for completion.

Study design Not formal research. Snapshot audits performed and cycles of intervention and re-audit implemented.

Strategy for change The change was implemented over a 6 month period. Doctors, Midwives, E-health and quality improvement team members were all involved. The paper version of the tool was distributed to the wards and discussed at morning handovers and safety briefings. An e-learning module was created and posters presented throught the department. The results of "snap shot" audits were fed back to the "Safety Lead" Midwife for dissemination. An electronic version of the tool was created and the change in procedure was explained at the same daily meetings over several occasions

Measurement of improvement The acute effect of the interventions has been a measure of 'Risk assessment tool' use and completion rate. This was performed by analysis of 20 neonatal patient records in each snapshot looking for the presence of the risk assessment tool, whether it had been completed correctly and reasons why if this was not the case. Outcomes from the electronic version are under review currently showing improved completion rates and static quality.

Effects of changes Initially the tool had a poor implementation rate and was often incomplete. The worst performance was for the legal aspects of the document. This was improved with practical measures but lacked accountability. An electronic version of the assessment automatically generated all the legal documentation and identified the assessor. There are still occasions when time constraints delay the time of the assessment but these are far less common. One of the big challenge was creating an audit model that was sustainable and could evolve over time to ensure progress in other associated areas of postnatal care.

Lessons learnt The project was refined with key input from all departments which lead to a more sustainable project. Projects that combine jobs and reduce paperwork are the most likely to succeed. Everything takes longer than you think. Next time I would get all members together before the project to discuss challenges and feasibility of the planned changes.

Message for others The implementation of a universal newborn screening tool is achievable. Use of an electronic version is recommended. This should lead to earlier recognition of the unstable neonate.