Safety articles previously published in Infant have highlighted the importance of reporting incidents of actual harm or near misses to reduce the potential for future harm to others.^1-3 Trusts currently report over two million incidents every year via their local reporting systems that feed the information into the National Reporting and Learning System (NRLS). Clinicians in the Patient Safety team at NHS Improvement routinely review incidents to identify new or under-recognised issues that may need national action to highlight safety concerns to the relevant staff groups, suggest system-level changes, or address manufacturer design processes and thus improve patient safety.⁴

This safety article aims to outline the actions taken by the Patient Safety team at NHS Improvement in response to reported incidents from aspects of umbilical catheterisation, not previously covered by the British Association of Perinatal Medicine (BAPM) framework for practice,⁵ and to highlight potential for harm to babies.

Background

Central venous catheters (CVCs), including umbilical catheters, are used widely in neonatal care for the delivery of intravenous fluids and medications. Following the reporting of several fatal cases of extravasation in neonates, in 2014 the Patient Safety team asked BAPM to review their usage with the aim of reducing harm and improving safety. BAPM set up a working party to produce the 2015 framework for practice for the insertion and ongoing use and care of CVCs.⁵

Ongoing review of the NRLS has recently identified a small number of cases where adverse outcomes had been identified associated with cleaning of the umbilical site prior to catheter insertion and issues following removal of the catheter – neither of these issues were covered by the existing BAPM framework.

Cleaning of the umbilical site

The BAPM framework states: “Staff inserting central catheters have a responsibility to ensure they maintain their competence and should be familiar with the equipment and procedures used for catheter insertion in that setting.” This should include local protocols for cleansing prior to insertion of any invasive devices. The Medicines and Healthcare Products Regulatory Agency issued an alert in 2014,⁶ followed by a letter to the British Association of Paediatric Surgeons in 2015 about this very issue.⁷

Observation of the umbilical cord site after removal of devices should ensure haemostasis has occurred.

Removal of umbilical catheters

The original BAPM framework was developed in response to issues identified from the incorrect placement of lines leading to extravasation injuries – it therefore provided a framework for the insertion of devices but did not extend specific advice to removal of devices.

From our regular review of the serious incident reporting system (Strategic Executive Information System, StEIS) and the NRLS, we identified several incidents where harm had occurred from excessive bleeding following removal of umbilical devices. There were differences in management of removal processes and observation of the infant following removal. On discussion with several units it was apparent that there was no standard guidance for safely removing umbilical catheters.

To affect change within NHS services, the Patient Safety team works with many stakeholders in order to reach the most appropriate staff groups and areas needed to inform safety changes. We therefore approached BAPM and asked if the association would consider adding an addendum to the existing framework to support staff by providing guidance on best practice for removal of umbilical catheters.

BAPM has now published an additional practice point to its framework as follows:

“Following removal of umbilical venous catheters (UVCs) or umbilical artery catheters (UACs) ensure that the catheters are complete, haemostasis has been achieved and an adequate period of observation of the umbilicus is undertaken before placing the infant prone.”⁸