Implementing a care bundle to reduce the incidence of severe intraventricular haemorrhages in a UK tertiary neonatal intensive care unit

This QI project aimed to reduce the incidence of all intraventricular haemorrhages in babies born at 30 weeks’ gestation or less by 30% over a three-year period.

Publication date: 12 October 2023


Dr Audrienne Sammut, Consultant Neonatologist, University College London Hospitals, NHS Foundation Trust


  • The issue that required improvement: Increasing rates of intraventricular haemorrhage (IVH) in our local preterm population leading to early re-direction of care and poor neurodevelopmental outcomes.
  • This was highlighted in clinical governance meetings as an ongoing risk, requiring urgent action.
  • We initially conducted a literature search and gathered information on similar care bundles. The points from this literature search were summarised in a presentation.
  • Stakeholders on the unit were identified: consultant lead for clinical governance with an interest in neurology, junior doctor, advanced neonatal nurse practitioner, practice development nurses, physiotherapist, speech and language therapist (NIDCAP trainer) and research nurse.


To reduce our incidence of all intraventricular haemorrhages in babies born at 30 weeks’ gestation or less, by 30% over three years.


  • Our Plan, Do, Study, Act (PDSA) cycle helped in organising the process, analysing ongoing performance once it was launched and making any necessary adjustments.
  • Key Performance Indicators (KPIs) were used for setting realistic targets such as aiming for a reduction of all IVHs by 30% in 3 years.
  • Clinical audit ensured ongoing data collection was used to assess practice and identify areas for improvement.
  • A Six sigma model was used to identify champions to help roll out the QI project and ensuring standards are maintained.

Our improvement plan

  • We designed and launched a care bundle in March 2021, which continues to be applied to all preterm babies born at 30 weeks’ gestation or less.
  • It includes perinatal optimisation and protective measures, to be applied at resuscitation and in the first 72 hours of life.
  • The main aim is to minimise handling and ensure cardiovascular stability is maintained throughout.
  • Stakeholders were presented with the care bundle and available evidence.
  • Regular meetings were held to adapt the care bundle to suit unit needs.
  • Posters and a guideline was created, and copies have been distributed in all intensive care rooms.
  • Regular lectures have been delivered to all medical and nursing staff at regular teaching/ study days.
  • The care bundle and relevant resources are included in junior doctors’ induction programme.
  • Practice development nurses and physiotherapists ensured all nurses received bedside teaching on moving and handling recommendations.
  • Email(s) have been sent to all staff with date of launch and copies of the poster and guideline.
  • For the first two weeks after the launch, it was mentioned daily at nursing and medical morning briefings prior to handover, to raise awareness.
  • Newsletter issued every 3 months and circulated to all staff via email. This includes audit data and highlights successes and areas requiring improvement.
  • The preterm care group collected 2 years of data retrospectively, to be able to compare with the cohort who were being enrolled in the IVH prevention bundle.
  • Prospective data was collected by members of the preterm care group.
  • Data analysis conducted on a 6-monthly basis and presented at unit audit meetings.
  • A preterm care guideline with delivery checklist has been written, to improve individual aspects of care, in line with the IVH prevention bundle.
  • There is a focus on ensuring normothermia owing to ongoing issues identified by the National Neonatal Audit Programme.


  • The IVH prevention bundle has been embedded as normal practice on our unit since March 2021.
  • We audited our IVH rates 2 years pre-intervention and 2 years post-intervention.
  • Thanks to our ongoing audit, we have been able to measure its impact and celebrate its success with the rest of the team. This has promoted enthusiasm and passion for the bundle amongst all the staff.
  • The results are as follows:
P value
Male Sex (%) 63 (59) 66 (52) 0.262
Gestational Age 27.14 (22.57-29.86) 27.43 (22.86-29.86) 0.568
Weight (g) 840 (446-1744) 859 (447-1661) 0.444
5 min APGAR 8 (1-10) 8 (2-10) 0.582
Antenatal Steroids (complete course) 88 99 0.354
IVH (%) 43 (40) 29 (23) 0.004
Grade 1-2 IVH (%) 27 (25) 16 (12.5) 0.012
Grade 3-4 IVH (%) 17 (16) 13 (10) 0.190
PHVD requiring surgical intervention (5) 5 (5) 2 (2) 0.162
  • There were no significant differences in characteristics between the pre intervention and post intervention cohorts. Our intervention was shown to reduce the rate of IVH in infants by almost half (40% vs 23%, p value = 0.004).

Challenges and learnings

  • Disbelief that the bundle would work in reducing our number of cases of IVH.
  • Resistance to change from some colleagues
  • Constant changeover of staff leading to the loss of members of the original multidisciplinary team that formed the initial preterm care group.
  • Tilting the head end to a 15-degree angle is sufficient (literature suggests 15-30 degrees but the incline was too steep at higher angles).

Top tips for implementation

  • Engage the right stakeholders early.
  • Be flexible – adapt the bundle to suit your unit’s needs.
  • Continuous data collection is key to improve shortfalls and celebrate success with the team.

Next steps

Currently UCLH is unable to submit IVH & cPVL data to the NNAP due to interface and data completeness issues. We are working hard to resolve this and aim to submit 2023 data.


Thank you to the UCLH preterm care team who have been instrumental in implementing the bundle, educating the team and collecting the data.

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