The PERIPrem story so far
Sarah Bates is the National Quality Lead for BAPM and has worked alongside Karen and the team as the operational clinical lead for PERIPrem across the South West for the last four years. Sarah’s day job is as a neonatologist in Swindon. Sarah told the story of PERIPrem so far…
Back in 2018 both Karen and I were concerned about the high brain injury rates in the South West of England. Our mortality rates were also not where we would like them to be and we were not on track to meet the ambitious targets in the NHS long-term plan.
Karen and I were both working on similar projects in our respective areas around the interventions that had the strongest evidence base to push down those mortality and brain injury rates. We combined these together and, with the fantastic support from our regional academic health science networks (now health innovation networks) and the neonatal network for our region, PERIPrem was born.
But how do we close that ‘lost in translation’ gap to make sure that the evidence is used for every baby every single time? None of these interventions are particularly new and the compelling evidence has been out for a while. That is where we are struggling. We can see from the data that in some regions only between five and 10, or even maximally 15%, of babies are getting the simple evidence-based interventions that they need.
If you don’t know about PERIPrem, here’s a very simple animation that explains the bundle in about five minutes.
This is a snapshot of the PERIPrem bundle with its 11 different elements. We have a huge range of free, open-access resources to support these, which are all on the PERIPrem website, and all endorsed by the Neonatal Nurses Association. Access the resources here. We’ve also worked with BAPM and the British Intrapartum Care Society over the last 18 months to support further national resources inspired by these.
One of the things that we are so proud about is that families and parents with lived experience of preterm birth were part of our team from the very start. They helped us design the programme as part of the steering group and they are still a very powerful vocal and influential part of this work. Developing and delivering this in partnership with parents has been such a fantastic privilege.
We began planning PERIPrem around 2019 and we launched in the South West in April 2020, around the same time as the start of the Covid pandemic, which created huge challenges. To have achieved the kind of success with the impact on outcomes for babies and families despite a global pandemic is just fantastic.
Core to PERIPrem is the unit-level pre-term birth lead team that’s now referenced very strongly in Saving Babies Lives. We funded time for the neonatal nurse and the midwife – not for years, just a short implementation period – but as the operational lead for PERIPrem, I can tell you that I still spend a lot of time with those colleagues, because they are very much still there leading and implementing the project.
Another really core element of PERIPrem is the quality improvement (QI) coaching model at unit level; having those critical, supportive friends to help you with QI methodology and data but also just to listen and to continue to support and inspire. That dynamic was absolutely key.
Creating a common language
Also important was how we’ve shared success at unit and regional level, building community and momentum. When we embarked on this project, I didn’t know how much the branding the identity would really matter but it’s become a common language across our region and to use ‘PERIPrem’ almost as a verb to describe optimisation of a preterm journey. I absolutely see that as hugely impactful on teams but also on parents who move around the region and hear this common language.
One of the ways in which we do that is with the PERIPrem passport. Families and babies move around units across the region, and we have a fantastic story of one family that moved from one of our special care baby units to one of our neonatal intensive care units to one of our local neonatal units for delivery. They talk so powerfully about how it gave them such a sense of trust in the whole region and their care by having the same language used throughout.
But of course, it’s not just the South West now because many women may go to Wales and there they’re now hearing the same language with the PERIPrem Cymru programme.
The PERIPrem parent passport is one of the brilliant examples of the impact of having parents as partners on your improvement journey, which we have translated into lots of languages.
Preterm birth is not what anybody plans when they become pregnant. It’s not what the pregnancy magazines tell you to expect. It can feel very disempowering and terrifying. Parents we’ve worked with have told us how important it is to them to understand the journey and how the parent passport can play a small part.
One of the core ingredients for improvement has been the data. There’s lots of different sources of data out there. We have of course our Badgernet data which informs all our all our ODN dashboards as well as the NNAP data. We recognised the need early on to do much more detailed data collection to drive improvement through the optimisation tool. Data is undoubtedly a core element for improvement.
The wider spread of PERIPrem
I hope will be aware of the great BAPM toolkits. They’re a fantastic resource, particularly the most recently published Building Successful Perinatal Teams. If we are talking about core ingredients for success here, then a strong perinatal team has to be on that list.
Many of you who work in England will have been part of the NHS Getting It Right First Time (GIRFT) neonatology review led by Eleri Adams. She comments in the report that we are not on target to reach the NHS long-term plan and that she supports the approach PERIPrem is taking as we’ve shown what can be done with this structured collaborative approach with parent empowerment at the heart of this.
In 2022 we started looking at the high neonatal mortality and brain injury rates across Wales. The Welsh Health Minister announced a programme for maternity and neonatal safety support with a vision for Wales but we recognised that one of the quickest ways to drive that change was to implement a PERIPrem programme across Wales.
We received Welsh Government funding in January 2023, and launched PERIPrem Cymru the following February with a fantastic neonatal lead team and that preterm birth lead team concept in every health board in Wales. Their vision for Wales is something I really admire and support: Pob Babi Bob Tro, every baby every time. So it doesn’t matter where you’re born and it shouldn’t matter what your ethnic background is, you are entitled to receive all of the optimal perinatal evidence-based care no matter what.
Nearly 2,500 babies have been cared for to date using the PERIPrem bundle, and I want to share a couple of examples of the impact this is having. This is data recently released by the National Neonatal Audit Programme (NNAP).
One of the process measures, which I know teams around the country are working on, is achieving at least 60 seconds of delayed cord clamping for preterm babies. We know this has an enormous impact on mortality but it’s not being done frequently enough.
We can see that over two-thirds of babies are receiving this now but there’s huge variation with some regions’ rates at less than 50%. But the South West has remained a very positive outlier for this intervention. One of the reasons, is this isn’t just implemented in one or two of our big units. This is implemented in every single unit, local neonatal units, small special care baby units and neonatal intensive care units, working in partnership.
One of the other newer metrics reported by NNAP is early breast milk. By that we mean any maternal breast milk being received by babies by day two of life and this includes some very well 32- and 33-week babies.
Shockingly only 50% of babies are receiving this across England Wales and Scotland. We’ve got so much work to do. You can see Wales is performing well but again there is staggering variation. In the South West, 82% of babies are getting this.
One of the most recently published resources that references PERIPrem came out in late 2023 – a review of maternity initiatives in the English NHS was published by Mary Dixon-Woods in BMJ Quality and Safety. This review looked back over 10 years of large-scale maternity improvement programmes, and of those PERIPrem and PReCePT (and obviously PERIPrem was very inspired by PReCePT methodology) ranked in the top 10% on the quality metrics. Only two of the programmes included service user support right from the start and again that was PERIPrem and PReCePT.