Guidance

Newborn and infant physical examination screening checks and audits

Updated 17 April 2019

1. NHS newborn and infant physical examination (NIPE) screening programme

The NHS newborn and infant physical examination (NIPE) screening programme offers a physical examination to every baby, within 72 hours of birth, and an infant examination at 6 to 8 weeks of age, with the objective of reducing morbidity and mortality. The programme aims to:

• identify and refer babies born with congenital abnormalities of the eyes, heart, hips, or testes, where these are detectable, within 72 hours of birth
• identify further abnormalities that may become detectable by 6 to 8 weeks of age, at the second physical examination

2. Screening pathways

NHS screening programme have defined pathways. The pathways show how the individual undergoing screening moves from one stage of the pathway to the next. Checks are needed at each stage to ensure the individual moves seamlessly and safely through the pathway, unless they choose not to.

If checks are not in place, there is a risk that an individual will not complete the pathway, or the pathway will be delayed unnecessarily. Quality assurance of screening programmes includes checking that failsafe procedures are in place and operating effectively.

3. Failsafe in screening programmes

Failsafe processes need to be in place in screening programmes. If something goes wrong, these processes help make sure it can be easily identified at the time and action can be taken to correct it before any harm occurs. To support the concept of failsafe being understood, an example is provided below.

3.1 Example of a screening failsafe process

Baby Russell was discharged home at 48 hours of age without a NIPE examination. The community midwife visited on day 3, but did not check that the NIPE examination had been completed.

As an individual practitioner, consider if:

• you are checking that all NIPE examinations for babies in your care are completed within 72 hours birth, as per national standards
• there is a systematic process to check that the NIPE examination has been completed for all eligible babies, within 72 hours of age
• there is a process to follow up those babies discharged home, or transferred into your care from another maternity service, who were not offered a NIPE newborn examination

Baby Russell was seen by 3 different community midwives on days 3, 5 and 10, and no one had identified that a NIPE newborn examination had not been completed. He was later examined by the GP for the 6 to 8 week examination and was found to have a dislocatated hip. If the NIPE examination had been completed in line with national guidance, this would have minimised a potential delay in treatment for baby Russell. For example, a hip ultrasound scan could have been undertaken within 2 weeks of age and treatment started. All healthcare professionals caring for baby Russell have a responsibility to check the NIPE screening status at each contact. There also needs to be a systematic and independent check of screening status for all newborn babies, via use of the national NIPE IT system; to identify babies who may have missed screening, and in time for corrective action.

There is evidence from screening safety incidents reported, that some providers are not checking the status of babies along the screening pathways, or, have unclear processes for:

• communicating the need for NIPE when discharged home and still requiring a NIPE examination
• follow up of screen positive cases to ensure the screening pathway is completed and outcomes known

Failsafe processes must be timely: they help to identify what is going wrong in real time (as it is happening).

4. Methodology

For each pathway we:

• mapped all the screening safety incidents, including serious incidents, reported
• applied findings from peer review quality assurance visits
• used queries received by the PHE screening helpdesk
• listened to a range of stakeholders’ views about risks

This process enabled us to focus on known weaknesses in the pathway.

5. How to use the template

The template outlines:

• what: this is what we recommend that you do
• why: the reasons why we are recommending this
• how: this is how you might do this
• when: this is how often we recommend you undertake the action/check

As you work through the document you may wish to check if:

• you already have local processes in place to regularly undertake these checks
• there are any gaps
• you are carrying out these checks often enough

If the answer is no to any of the above, you can use the last column (Trust response) to develop an action plan.

To benchmark services you can use:

• the completed checks and audits document
• any action plan developed
• the results of any audits

You can also use the above as evidence for quality assurance activities, including peer review visits.

6. Additional audits

We have also included some additional checks and audits that providers could undertake. These audits will help to determine if the whole system is working effectively.

7. Other important resources

This document should be used in conjunction with:

• service specifications
• standards
• handbook

8. Vignettes

We provide the following vignettes to demonstrate what can go wrong when failsafe checks are not in place or when checks are not robust or timely.

8.1 Delayed screening

On day 5, the midwife realised that NIPE was not offered or undertaken within the national standard timeframe of within 72 hours of birth. It was then completed and comments added regarding the reason for the delay. This breach of standard will be evidenced when the key performance indicators for NP1 are submitted. Regular use of nationally provided data reports and monitoring of coverage (by 72 hours) provides an opportunity to review all breaches in performance targets and address local process issues.

8.2 Incomplete screening

An audit of the neonatal intensive care unit identified that a baby who was discharged home had received incomplete screening. The eyes had not been examined before discharge. In babies who are too ill for screening, all elements of the examination should be completed as soon as the baby’s condition allows.

8.3 Delayed pathway for developmental dysplasia of the hip (DDH)

The NIPE newborn examination identified a suspected dislocated hip (screen positive for DDH) 48 hours after birth. A referral was made for a hip ultrasound scan. However, the appointment was not made in line with the national timescale of 2 weeks of age. The ultrasound was not carried out until the baby was 5 weeks of age and confirmed a diagnosis of DDH. An ultrasound completed at the correct time would have prevented a delay in treatment.

A baby was delivered by emergency caesarean section for breech presentation at term. The baby was discharged home on day 4 having had NIPE screening within 72 hours. However, no follow-up was arranged for a hip scan, (required due to risk factors – target timescale by 6 weeks of age). The GP identified the lack of hip scan at the 6 to 8 week infant examination. The baby had a hip scan a week later and DDH was diagnosed. The delayed diagnosis led to a delay in treatment.