Study setting: WA has approximately 34,000 live births annually [11],1100–1200 [12, 13] infants are transferred by NETS WA to one of two tertiary NICUs in the state capital, Perth. The furthest trip is 2200 km and may take ~24 h to complete[12,13,14]. Each NETS WA retrieval team consists of doctors (senior registrar and/or neonatal consultant), a nurse (neonatal and transport trained) and an ambulance transport officer.

NETS WA team operates with support from St John’s Ambulance services for Perth metropolitan urban area that sprawls over 175 kms (road only). Approximately ~70% of the NETS WA retrievals are within the Perth metropolitan area. NETS WA is supported by the Royal Flying Doctor Services Western Operations (RFDS) for transfers outside the metropolitan area ( ~ 30%) that require rotary and fixed wing aircraft for retrievals (road and air) [12,13,14]. The referral and transport process of NETS WA retrievals is like other standard neonatal retrieval teams (Appendix 1).

Ethics approval

Institutional approval (Governance Evidence Knowledge Outcomes, GEKO WA project number 50894) was obtained to conduct a quality improvement (QI) study to quicken launch times. This study was approved by the Safety and Quality Framework of the Child and Adolescent Health Service of Western Australia (Governance Evidence Knowledge Outcomes, GEKO WA project no 50894). The study was conducted using routinely collected data for service improvement and received a waiver of ethics for the inclusion of this de-identified data. Informed consent was not required. All methods were performed in accordance with the relevant institutional ethics committee guidelines and regulations.

The study followed the standard SQUIRE 2.0 guidelines [15].

Design

Single service centre QI study undertaken by NETS WA.

Definitions

Launch time is the “Time the team departed base” (ANZNRN data dictionary, (2022)) [7]. The dictionary defines the “urgent” retrievals as those that should have launch times of less than 15 min ie priority 1 (p1) retrievals. The “serious” retrievals are classified as those requiring launch times between 30 and 60 min (p2 retrievals) and those classified as “Not time critical” could be more than 60 min (p3 retrievals) [7]. The other metrics evaluated were “first look time” and “total retrieval time”. “First look time” is defined as “time the NETS team first saw the patient” and the “total retrieval time” is the “total time taken from the initial referral call till the retrieval was completed” (ANZNRN 2022) [7].

Aims and goals

The primary aim was to quicken the launch times of the NETS WA teams for urgent transfers. The SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goal was to decrease the launch times of the NETS WA teams for urgent retrievals to ≤15 min (recommended by ANZNRN 2022) over two years [7]. The secondary aim was to evaluate the impact of quicker team launch times on the “first look time” and “total retrieval time”.

Study period: The study was conducted over two years (January 2022–December 2023).

Data collection: A complete list of study variables is described in Appendix 2. These variables are routinely captured by the NETS WA team members in REDCap web application during each retrieval. Data were collected before, during and after the PDSA cycles in the study period.

Quality Improvement (QI) team

A core NETS WA QI team consisted of the NETS WA medical director, a lead retrieval consultant, neonatal senior registrars (2 to 5 years’ experience), clinical nurse consultant and senior neonatal nurses.

Baseline period (January–May 2022)

Focus group discussions (FGD) were conducted to review local audits and existing literature at baseline prior to the introduction of the QI interventions. The data collected in this period determined the time-centric metrics of NETS WA teams on urgent priority retrievals at baseline.

An online poll was conducted to explore factors impacting the current launch times. This delineated the root cause analysis and modifiable risk factors as described in the driver diagram (Fig. 1). Consensus-based QI initiatives were introduced as Plan-Do-Study-Action (PDSA) cycles in timely intervals to address these factors. PDSA cycles are a central component of QI initiatives and are impactful in neonatal care [16, 17]. Four PDSA cycles were introduced during the study period. FGD were organized at the beginning of each PDSA cycle and after the last PDSA cycle to ensure long term impact.

Fig. 1

PDSA cycles and their timeline are detailed below:

PDSA cycle 1 (June 2022)

Equipment: Transport incubators (portable cot, ventilator, monitors, syringe pumps and transport fixation device) were moved and stored in a secure room next to the parked NETS ambulances. Prior to this the transport incubators were stored in the NETS WA office three floors above the ambulance departure area. The mobilization of NETS WA cots from level 3 to the ambulance for loading would take approximately 3–4 min. Decreasing this time was a key component of the first PDSA cycle.

Education: Weekly sessions to educate staff about NETS specific processes. Regular education sessions were conducted to orientate the new rotating staff about the definitions and expected standards for departure as per the ANZNRN data dictionary [7] (Appendix 2).

PDSA cycle 2 (October 2022)

Personnel: NETS WA referral calls were (until October 2022) led by the NICU consultants for management, in addition to their existing ward responsibilities. The newly recruited NETS WA only consultants were responsible for leading retrieval calls, management, and accompanying retrieval teams without any ward responsibilities. The QI team consolidated the NETS processes and education for time-centric quality metrics with this core group of dedicated neonatal retrieval consultants [7].

PDSA cycle 3 (February 2023)

Triage uniformity: A set of conditions (medical and surgical) were designated as automatic activation for P1 retrieval tasking of NETS WA teams from February 2023 (Appendix 3). This led to uniformity in tasking for P1 retrievals. Before this, P1 tasking was done at the discretion of the retrieval consultant.

Ongoing Education: Weekly sessions to educate new staff about NETS specific processes and time-centric quality metrics, as elaborated in PDSA cycle 1 (Appendix 2).

PDSA cycle 4 (April 2023)

Verbal Communication effectiveness: The need for urgent transfers were stated clearly by the retrieval consultant and then documented in the call conference notes. The team were also instructed to leave the call-conference and depart base within 15 min of this instruction.

Ongoing Education: Weekly sessions to educate new and rotating staff about NETS processes and time-centric quality metrics, as elaborated in PDSA cycle 1 (Appendix 2).

After PDSA period (May–December 2023)

Data were collected for another 8 months to ensure improvement was sustained beyond the last PDSA cycle.

The study flow chart with PDSA cycle timeline and data collection is depicted in Fig. 2.

Fig. 2Statistical analysis

Data were compared for three epochs ie baseline: Jan–May 2022, PDSA period: June 2022–April 2023, after PDSA period May–December 2023.

Categorical variables were expressed using frequency, percentage and compared using the Fisher’s exact test. Continuous variables were expressed as median and inter-quartile ranges (IQR). Groups were compared using Kruskal-Wallis test with Dunn’s correction for multiple comparisons between the 3 epochs. A p value of <0.05 was considered statistically significant. Analysis was performed using GraphPad Prism (MA, USA).

The study period (January 2022–December 2023) was divided into monthly blocks for the run chart analysis. These describe median times of the time-centric quality metrics over the study period (Figs. 3.1–3.3). Common signals such as shift ( ≥ 6 consecutive points above or below the median line), trend ( ≥ 5 consecutive points increasing or decreasing) and astronomical data points (clear outliers due to extreme variation) were followed to interpret the run charts [18].

Fig. 3

1: Run chart for launch time (all retrievals). 2: Run chart for first look time (all retrievals). 3: Run chart for total transport time (all retrievals).