Table 1

Summary of the five PDSA cycles

INTERVENTIONS/IDEAS TO TEST

  1. The issue was discussed in the local quality improvement (QI) meeting to raise awareness among staff members of all grades.

  2. Improve radiology reporting to increase the timely identification of poorly placed lines.

  3. Posters were designed to promote improvement actions. A CVC traffic light guide was created, along with illustrative reminders on the correct securing method of the catheter.

  4. A new multidisciplinary radiology project was implemented to support the correct positioning of the limbs4 5 and body of the baby before an X-ray was taken to check line positioning.

  5. An education pack was brought together to support trainees of all levels of expertise.

 PDSA Plan Do Study Act
PDSA 1.1
Raise awareness
(December 2021 to January 2022)		Awareness raised of the issue within the team26 lines were reviewed. Colour coding showed 4/26 ‘red’ lines (15.4%)Improvement in ‘red lines’—reduced by 12.1%
However, concerns remained regarding timely review of radiology reports and time of releasing		 ADOPT
Ward round proforma adjustments
IDEAS

  1. Check reports again retrospectively (ABANDON)

  2. Improve interteam communication (Radiologists and Neonatologists—Later project)

  3. Speed up radiology reporting (PDSA 2)

PDSA 1.2
Raise awareness
(December 2021 to January 2022)		Ward round proforma changed to include ‘review of the line tip’
PDSA 2
Improve radiology reporting
(December 2021 to January 2022)		Neonatal team invited to implement some changes of their ownSenior team reviewed reports for short period of time—not sustainable.
Some conversations took place with radiology. No detectable impact		Ideas not easily actionable and sustainable ABANDON
PDSA 3.1
Increased use of CVC traffic light system
(January 2022- February 2022)		Posters to raise awareness of line positioning during X-ray (figure 2)38 lines reviewed. Colour coding showed 3/38 ‘red lines’ (7.8%)Another significant improvement. Cumulative reduction in ‘red lines’ 19.7%. ADOPT
Illustrative posters
IDEAS

  1. Make Posters more widely available by uploading them on Neonatal Education website (Padlet)

  2. Incorporate into unit’s guidelines

  3. Print and laminate posters. Place next to the main computers in all clinical areas (PDSA 3.3)

PDSA 3.2
Increased use of ‘stepwise approach of PICC securing method’		Detailed illustration of the correct securing/dressing method of the catheter (figure 3)Illustrative method of catheter tip securing and dressing was well received.
PDSA 3.3
Make posters more widely available
(February 2022 to March 2022)

  • Place posters next to the main computers in all clinical areas

  • Add into unit guidelines

  • Add to the trust’s electronic neonatal education website

27 lines reviewed. Colour coding showed 4/27 ‘red lines’ (14.8%)A reduction in performance was subsequently noted (7% increase in ‘red lines’). Rota gaps and new staff rotating were considered likely contributors ADOPT
IDEAS
More ideas needed to reduce variation during rota changeovers

  1. Optimise quality of X-rays as adversely affecting decision making (PDSA 4)

  2. Education package (PDSA 5)

PDSA 4
Improved preparation and management of babies for X-ray
(deficit ID during baseline data collection—March 2022 to April 2022)		Preparation optimised towards correct alignment of body and limbs. New ‘Am I X-Ray ready’ poster designed42 lines reviewed. Colour coding showed 3/42 red lines (7.1%)Percentage of red lines stabilised at 7%.
Another reduction by approximately 8%		 ADOPT
Radiology department incorporated our work into their local education material.
PDSA 5
New education package created and distributed to new rotation of doctors
(April to May 2022)		Education package which included (1) vascular anatomical landmarks, (2) tips and hints of correct CVC insertion and monitoring of the line tip, (3) potential complications44 lines reviewed. Colour coding showed 3/44 ‘red lines’ (6.8%)This change was found to be effective. However, feedback revealed that the CVC guide was quite long and not comprehensive ADOPT
Guide to be distributed in every new rotation of doctors. Future PDSA cycle planned to review effectiveness of planned changes
IDEA

  1. New team to create short explanatory videos

Further actions undertaken to support sustainability

  • Results presented locally, regionally and internationally to raise awareness

  • Main author became member of the working group of the regional neonatal CVC guidelines

  • Main author applied to BAPM to review national CVC guidelines and share local experience and QI work

  • Project handed over to subsequent teams and focused on improving the education package

  • Explore use of cyanoacrylate glue to secure lines more effectively

  • Feasibility of implementing point-of-care ultrasound

  • BAPM, British Association of Perinatal Medicine; CVC, central venous catheter; PICC, percutaneously inserted central catheter.