Retinopathy of Prematurity (ROP) Screening Project

Authors

• Ann Mary Anthony, Neonatal Nurse and ROP Champion
• Mahmoud Eissa, Ophthalmology Resident Doctor
• Grace Whitehorn, Eye Secretary
• Louise Maund, Eye Secretary
• Roger Humphrey, Ophthalmology Consultant
• Mary Pedley-Duncalfe, Paediatric Consultant and Neonatal Lead

Salisbury NHS Foundation Trust

Background

Prior to receiving a National Neonatal Audit Programme (NNAP) outlier notification, the Neonatal team at Salisbury NHS Foundation Trust had already recognised that babies were not being screened within the appropriate ROP (Retinopathy of Prematurity) screening window. This was attributed to fixed clinical time given to the one Ophthalmologist skilled to undertake ROP screening alongside their other clinical and non-clinical commitments.

From March 2024, the neonatal leadership team reviewed all NNAP data, and this time raised concerns with regards to ROP screening time with the Ophthalmology team. Multidisciplinary team (MDT) meetings were held to better understand the ROP screening process from identification through to reporting. A clinical audit was registered via AMaT¹ in September 2024 and the Ophthalmology team kindly undertook an analysis of their ROP data. This showed only 34.78% of babies were receiving an ROP screen on time. During the MDT meetings it became apparent that the Ophthalmology booking team were not aware there was a window for screening. Babies were being booked in available slots for screening rather than within their own individual window.

The aim of this project was to achieve ROP screening within the NNAP developmental standard – 90% of eligible babies receive ROP screening within the recommended time windows for first screening.

The stakeholders were drawn from the multidisciplinary team and included the Ophthalmology ROP Lead Consultant, Ophthalmology Resident Doctor and eye secretaries, the Neonatal Clinical Lead and a neonatal nurse.

[1 – AMaT – Improve Together. Available at: https://www.amat.co.uk/]

Measures

Measurement for improvement was from BadgerNet data and the NNAP Restricted Access Dashboard (RAD) was used to look at quarterly trends. Improvement was considered if the percentage of babies being screened on time increased.

Improvement plan

The following improvement plan was implemented:

1. All referrals, made by the neonatal nurses, would include the screening window that each individual screening was required.
2. The screening window would be calculated using the Royal College of Paediatrics and Child Health (RCPCH) calculator² to ensure accuracy of dates.
3. A neonatal nurse became an ROP champion to support the roll out and use of the ROP calculator.
4. Progress would be monitored through NNAP data. This data is now available monthly through the Restricted Access Database (RAD) for closer monitoring.

Due to the multidisciplinary approach and with all team members wanting the project to be successful, no significant barriers were faced.

[2 – RCPCH. Screening of retinopathy of prematurity (ROP) – clinical guideline. Available at: https://www.rcpch.ac.uk/resources/screening-retinopathy-prematurity-rop-clinical-guideline]

Outcomes

The project has been a success with ROP screening times now at the NNAP developmental standard of 90% of patients receiving ROP screening on time for 2025 data. This is a significant improvement from the previous year when only 36.4% of babies received ROP screening on time.

Table One: NNAP Restricted Access Dashboard 2024 and 2025 ROP data.

The use of the RCPCH ROP calculator tool is now embedded in clinical practice with a change made to the paper form request card. Consideration will need to be given if requests become electronic in the future.

Unit data on the RAD will be reviewed regularly to ensure improvement is sustained and any deviation from the developmental standard is identified quickly and acted upon.

Challenges and learnings

The key to success was having the support of all the multidisciplinary team. We all met in person to discuss the problem and agreed on an improvement plan. The data improved quickly and so we were able to see early on that the plan was working.

Top tips for implementation

• A team approach with all team members invested in success