Admission to the Neonatal Service - Guideline relating to

Publication: 01/07/2010  --
Last review: 09/07/2018  
Next review: 09/07/2021  
Clinical Guideline
CURRENT 
ID: 2215 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline relating to Admission to the Neonatal Service

1.0 Background Information
2.0 Duties of Staff involved in admission to the Neonatal Unit
3.0 Admission Criteria
4.0 Transport of babies between wards
5.0 Daily capacity and communication between Delivery Suite and the Neonatal Unit
6.0 Guidance when faced with limited capacity on the NNU
7.0 Clinical Governance activities in relation to admission to the Neonatal Unit

Appendix 1: Cot Management Policy

1.0 Background

Leeds Teaching Hospitals NHS Trust provides a Neonatal intensive care service (NICU) and regional Neonatal Intensive Care to the Yorkshire Neonatal Network. Specialist newborn surgery, cardiology, neurology, neurosurgery, hepatology and nephrology are also provided.

Delivery of Care
Neonatal Staff provide resuscitation and, where necessary, on going specialist clinical support for all babies born in the Leeds Teaching Hospitals NHS Trust. If required the neonatal staff provide ongoing specialist care for newborn babies admitted from other neonatal units and to babies born in the community immediately following birth.

The neonatal service is fully operational 24 hours 365 days a year.

As a Neonatal Intensive Care Service we provide for all newborn babies of all gestations in all levels of care as set out in the Neonatal Toolkit

Neonatal Intensive care (NIC),
High dependency care (HDC),
Special care (SC), and
Transitional Care.
Neonatal Unit (NNU)
Special care baby unit (SCBU)

Network and National Issues
Demand on the service and/or the clinical condition may require the baby to be transferred to another neonatal unit for ongoing care. Ideally this would be before the baby is born. Where care cannot be provided, the neonatal cot bureau via EMBRACE http://www.embrace.sch.nhs.uk, will aim to transfer the baby to an appropriate cot in the Yorkshire Neonatal Network. In the event that no cot is available in the YNN EMBRACE will source the nearest appropriate cot.

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2.0 Duties of staff involved in admission of babies to NNU/SCBU

The following staff are available to provide neonatal care. They will attend neonatal deliveries as required and be responsible for the admission of babies to the neonatal unit.

If required and if there is time prior to delivery the 2nd Responder, or if appropriate the Neonatal Consultant, will talk with parents about the potential problems their baby may have. Where admission to a neonatal unit is predicted, a pre-natal opportunity to visit the neonatal unit and meet key personnel is offered to the family.

Midwives
Communicate with the neonatal staff to provide as much advanced notice as possible of babies who may require admission to SCBU/NNU or involvement from the Neonatal team. Initiate immediate resuscitation in the absence of the neonatal staff and provide support to the neonatal staff during the resuscitation process as required.

Neonatal Nursing staff
Attend deliveries on delivery suite or any other area where resuscitation is given and stabilise prior to admission.
Neonatal nurses are responsible for the planning, implementation and assessment of specialist nursing care given to babies admitted to the neonatal unit.
Neonatal Nursery Nurses and Health care assistants will admit babies requiring special care under the supervision of registered nurses.

1st Responder (ST 2/3 Advanced Neonatal Nurse Practitioners [ANNP])
Attend deliveries as set out in the previously agreed guidance (Guidelines in Relation to the Care of the Newborn Immediately After Birth and Criteria for Paediatric Involvement on Delivery Suite, Guidance for Adult and Paediatric Resuscitation Training and Education Requirements
Congenital Diaphragmatic - Hernia Resuscitation & Stabilisation Guideline for deciding to institute intensive care and resuscitate infants of less than 26 weeks gestation
Guidance for Adult and Paediatric Resuscitation Training and Education Requirements
Management of Preterm Infants Born before 28 weeks

They make initial assessments and provide initial resuscitation if required. The babies may require further assessment by the middle grade doctor or consultant before the decision is made to admit the baby to SCBU. The ST2/3 /ANNP will then organise transfer and initiate any investigations, interventions, medication as appropriate under the guidance of the middle grade. They will also be responsible for obtaining the maternal history and clerking the baby.

2nd Responder (ST 3/4 - including some ANNPs)
Attend deliveries as per above protocols and guidelines, be responsible for informing Consultants as per Guidance for Informing Consultants of Impending deliveries (see below) and review the babies on the wards. They are responsible for initiating respiratory support if required and making decisions re further management. They will review all admissions and speak to the parents.

Neonatal Consultant
The neonatal consultant of the week may attend the delivery of the extremely preterm infant or infant requiring significant resuscitation. They will be responsible for leading the initial management of such babies. During the day 9pm-5pm and out of hours (on-call) the consultant expects to be informed by the 2nd Responder of deliveries as set out in the guidance below:

Guidance for informing Consultants on impending deliveries

Type of delivery:
The in service/on call consultant should be contacted if expecting the following deliveries imminently:

  • All babies < 26 weeks gestation
  • Multiple pregnancies < 28 weeks gestation
  • Any multiple pregnancy of triplets or more
  • Any baby for whom the need for advanced resuscitation can be predicted:
    • Hydrops foetalis
    • Diphragmatic hernia
    • Pulmonary hypoplasia
    • Life theatening congenital abnormalities
    • Severely abnormal CTG e.g. prolonged severe bradycardia, sinusoidal trace
    • Suspected fetal compromise

The consultant will make a decision as to whether it is appropriate to attend the delivery.

Appropriate timing:
Where possible, and especially at night, ensure that the consultant is given enough notice to attend the delivery if this is felt to be required.

In the event that a baby delivers and is unexpectedly requiring full resuscitation or where there has been insufficient notice prior to delivery, the consultant should be contacted as soon as is practically possible.

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3.0 Admission Criteria

Babies can only be admitted from:

  • Delivery Suite
  • Postnatal wards
  • Transitional Care wards
  • Another neonatal unit (this policy does not cover the clinical governance issues of transport from other units referred for tertiary care. That is covered by EMBRACE [the Yorkshire and Humber Paediatric and Infant Transport Service])
  • Newborn babies from community (within the first 24 hours of life)
  • The community for babies less than 3.5kgs admitted under the surgical team to the surgical newborn unit. There is a separate policy and guideline relating to this unique group of patients.

    All other babies should be admitted via Children’s services.
    • Criteria for admission to Postnatal Ward - please refer to the standard operating procedure- Postnatal Ward Admission Criteria
    • Criteria for admission to Transitional Care Ward
    1. Gestation 34 weeks and above,
    2. Birth weight between 1.8kg and 2.3kg
    3. Infant of diabetic mothers birth weight less than 2.3kg or greater than 4.5kg
    4. Cleft/lip palate or any other significant congenital abnormalities
    5. Suspected Down’s syndrome
    6. Requiring IV antibiotics for clinical signs of sepsis (after review by Neonatal team)
    7. Requiring significant phototherapy (more than one light/billiblanket)
    8. Infants requiring feeding support i.e. NG feeds
    9. History of maternal drug abuse in THIS pregnancy
  • Criteria for admission to the Neonatal Units
    All other babies that require intensive care, high dependency and special care should be admitted to the neonatal unit.
    For example:
  1. Respiratory distress
  2. Prolonged resuscitation
  3. Apnoeas/seizures
  4. Persistent hypothermia
  5. Clinical suspicion of sepsis or congenital heart disease
  6. Preterm deliveries; those 36+6 and below who did not fit the criteria for transitional care
  7. Antenatally diagnosed congenital conditions: such as cardiac, gastrointestinal and neurological conditions
  8. Babies who have been removed from their mothers at birth and require a temporary place of safety because of safeguarding concerns (see Child Protection Removal at Birth Interagency Procedures)
  9. Any baby assessed by the 2nd responder to be in need of a higher level of care.

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4.0 Transport of babies between wards

All babies must be transported safely and in such a way that their clinical condition and eventual outcome is not compromised. Transfer method will depend on their gestation and clinical condition. NO baby is to be carried in arms.

  • Transport within the hospital to the NNU
    For Preterm deliveries less than 28 weeks see guidance (Management of Preterm infants born before 28 weeks gestation).
    Babies from Transitional Care, Delivery Suite and postnatal wards that are stable and self ventilating in air may be transferred in a cot. Babies that are unwell, have respiratory distress, unstable temperature, suspected sepsis or suspected congenital heart disease must be accompanied by an appropriately trained professional with respect to Neonatal Resuscitation. If necessary babies should be stabilized by the neonatal team prior to transfer.

    Ventilated babies

Site

Location

Method of Transportation

LGI Delivery Suite
Obstetric Theatres
On resuscitaire
  Postnatal ward
Transitional Care ward
Any other area of the hospital
In Transport incubator
St James’s Obstetric Theatre
Transitional Care
On resuscitaire
  Delivery Suite
Postnatal Wards
Any other area of the hospital
In Transport incubator
  • Transport of babies from the community to the NNU
    For further guidance see Protocols relating to the transfer of women and babies by ambulance within the Maternity Service. As with the transfer of women into the hospital from the community the midwife attending will communicate with the delivery suite co-ordinator and in the case of a sick newborn baby Senior Neonatal Staff on the unit
    should be informed (bleep holder and 2nd responder) If Staff are unclear about the safest way to transport a baby they should contact the Neonatal Unit for guidance.

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5.0 Daily capacity and communication between Delivery Suite and the NNU

Capacity
Every effort will be made to provide care for babies born within the Leeds Teaching Hospitals NHS Trust. Attention is also given to cases that can only be managed in Leeds (or outside the YNN).

The Leeds Neonatal Intensive Care Unit Cot Management Policy covers the priority for admissions, predicting the need for a ICU cot and Intensive Care Capacity Escalation Policy. (Appendix 1).

Communication
Good communication must be maintained between the neonatal service and maternity service. The framework for this is set out in the Leeds Neonatal Intensive Care Unit Cot Management Policy (Appendix 1)

In summary

  • Cot status shall be determined by the Senior Nurse Coordinator in conjunction with the on-call consultant. It will be reviewed at 9am, 5pm and 9pm and documented in the “Co-ordinator daily communication book” and the Bed management Chart.
  • The Nurse Coordinator will liaise with delivery suite each morning to plan admissions and the Neonatal Consultant shall be available to plan admissions of complex or urgent cases with the Consultant Obstetrician.
  • The Neonatal Consultant of the week for each team should discuss pending admissions/deliveries each Monday morning with the Obstetrician of the week and daily with Delivery Suite/Obstetrician of the week.
  • The Delivery Suite Co-ordinator should communicate all new potential admissions to the Neonatal Nurse Co-ordinator and 2nd Responder at the earliest opportunity. The availability of cots on both transitional care and the neonatal unit is recorded on the shift handover sheet.

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6.0 Guidance when faced with limited capacity on the Neonatal Unit.

For full guidance see Leeds Neonatal Intensive Care Unit Cot Management Policy. (Appendix 1)

Reasons for closure of the unit are based on

  • Number of cots available
  • Dependency of the babies already on the unit
  • Skill mix of nursing and medical staff available
  • Potential availability of additional staffing resource.

Decisions to close the unit are made by the Neonatal Co-ordinator in consultation with the Neonatal Consultant of the week. Decisions to close the NNU must be escalated to the Neonatal Matron or Duty bed manager. The nurse Co-ordinator should refer to the Intensive Care Capacity Escalation Policy (part of the Leeds Neonatal Intensive Care Unit Cot Management Policy, Appendix 1).

Please refer to this for definitions and actions to be taken when Full and Critical/Over-capacity.

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7.0 Clinical Governance activities in relation to admission to the NNU

Refusals/closures

  • All refusals to the neonatal service in Leeds Teaching Hospitals will be monitored and recorded on the daily bed management Chart
  • The daily bed management Chart will than be inputted onto the data base and be discussed at the Operations Meetings and if needed an action plan will be formed
  • Some refusals will be audited via Embrace.

Where a baby has required transport to another neonatal unit for non-medical reasons a risk management form (IR1) should be completed.

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8.0 Process for reporting and learning from unanticipated admissions to NNU/SCBU

Unexpected and/or inappropriate admissions to NNU/SCBU will be identified through the maternity incident reporting system. Unanticipated admissions to the NNU/SCBU are on the maternity services trigger list and are reported via the Trust clinical incident reporting. All clinical incidents relating to unexpected admissions to the Neonatal Unit are reviewed by the Delivery Suite Risk Midwife and if necessary by the Maternity Risk Management  Team at the weekly risk management meeting. A report identifying any themes or identified learning issues will be presented every three months at the Perinatal Morbidity meeting Unanticipated admissions to NICU/SCBU are also monitored through the Maternity Services Forum and Maternity Services Clinical Governance and Risk Management Forum via the quarterly report. 

Transport
The following problems relating to the transport of babies should be monitored and reported through the Risk Management system (IR1)

  • Inappropriate transport used
  • Deterioration of babies condition related to transfer
  • Failure of transport equipment
  • Any other situation where a baby is considered to have been inappropriately transported.

The Lead Nurse, Transport Lead Nurse and Lead Consultant for Transport will be involved in auditing and reviewing the incidents and if necessary taking action to prevent reoccurrence.

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Provenance

Record: 2215
Objective:
Clinical condition:

All babies in need of Neonatal Care

Target patient group: Babies requiring admission to the Neonatal Service
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Midwives
Adapted from:

Evidence base

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix 1: Leeds Neonatal Intensive Care Unit Cot Management Protocol

Notes

  • Cot status shall be determined by the senior nurse coordinator in conjunction with the on-call consultant. It should be reviewed at 9am, 5pm and 9pm and documented in the coordinator diary.
  • The cot bureau should be informed of the cot status three times daily.
  • The nurse coordinator will liaise with delivery suite each morning to plan admissions and the neonatal consultant shall be available to plan admissions of complex or urgent cases with the consultant obstetrician.
  • The neonatal consultant of the week for each team should discuss pending admissions / deliveries each Monday morning with the obstetrician of the week and daily with delivery suite.

    Cot capacity
    Assuming fully staffed, capacity is as follows: Note that special care and high dependency cots are often used flexibly. If staffing is reduced the matron / lead nurse will determine the total ICU cot number for each day.
 

LGI

St James’s

Total

ICU Cots 9 6 15
High dependency and Special care 16 14 30
Surgical Newborn 10 - 10
TOTAL NNU 35 20 55
Transitional care 9 10 19


“Emergency ICU Cot”
An emergency ICU cot is an incubator/ platform and ventilator set up to receive an emergency unexpected admission. It is not a nursed cot space and should be over and above the number of ICU beds stated above. In the event that a baby is admitted into this space and all other cots are full then the unit becomes overcapacity (see action plan).

Priority for admissions
The relative priority of potential admissions must be assessed on an individual basis in discussion with the obstetrician. Once babies have been accepted they must be admitted unless an unexpected LTHT baby requires immediate stabilisation / intensive care.

In general priority should be as follows:

  1. Babies in LTHT who are born and require immediate admission.
  2. Unborn babies accepted for admission and in labour / induced (“booked beds”).
  3. Babies from YNN (including Leeds) with a disorder that can only be managed in Leeds*.
  4. Babies from YNN requiring intensive care, if Leeds is only bed in network.
  5. Unborn babies from Leeds requiring delivery
  6. Babies from YNN requiring high dependency or special care.
  7. Babies from outside YNN requiring intensive care#.

    * see definitions below
    #Note the catchment area for cardiac referrals is wider than the YNN

Cases that can only be managed in Leeds (or outside YNN)
These cases are particularly important to prioritise for admission to Leeds ICU as their care will otherwise have to be delivered outside the YNN. Priority should be given to facilitating the delivery / admission of these babies in Leeds and these must be discussed with the consultant neonatologist on call and the consultant specialist before they are refused.

Surgical, including:

  • Congenital Diaphragmatic hernia
  • Oesophageal atresia with fistula
  • Gastroschisis
  • Acute surgical emergency (e.g GI perforation / airway obstruction)
  • Urgent need for RoP treatment (may not require ICU bed)
  • Urgent neurosurgical case (may not require ICU bed)
    [consider whether can be referred to Hull for surgical management]

    Cardiac, including:
  • Duct dependent cyanotic congenital heart disease (Transposition, Pulmonary atresia)
  • Duct dependent obstructive lesions (Coarctation, Hypoplastic left heart)
  • Note: Newborns with cardiac disorders should normally receive their post-natal care on the neonatal unit. In some circumstances, term babies who have been stabilised may be safely transferred for specialist cardiac care on cardiac ICU / cardiology ward on the day of birth, but this should not be the routine and must be discussed at a senior level.

    Medical, including:
  • Extreme pre-term infants (23+0 to 24+6), born in Leeds, who may be too unwell to be safely transferred after birth.
  • Babies with expected significant pulmonary hypoplasia or hydrops fetalis or those born in Leeds who have PPHN requiring HFOV or Nitric oxide therapy.
  • Cooling for HIE (also available in Hull, Bradford or Calderdale)

Predicting the need for ICU cot
This is not always predictable, however an ICU cot should not be ‘reserved’ unless there it is likely to be needed. Genuinely unexpected need for intensive care can be managed in the emergency cot space pending transfer (see below). The following are likely to need an ICU cot to be available, at least initially.

  • Preterm ≤32 weeks
  • Known respiratory or airway problem (e.g. Diaphragmatic hernia, Neck mass)
  • Known life-threatening congenital malformation (e.g. Hypoplastic left heart, TGA, gastroschisis, exomphalos,)
  • Severe fetal compromise (e.g. anhydramnios, hydrops fetalis)
  • Likely need for exchange transfusion (significant titres / in-utero transfusions)

    Maternal diabetes, non-life threatening congenital abnormalities and likely sepsis or drug withdrawal are not indications for reserving an ICU space. Neither is gestational age 33-36 weeks. These babies may need a Transitional care, SCBU or HDU space. If they subsequently need ICU this will be managed as above.

Leeds Neonatal Unit Intensive Care Capacity Escalation Policy

Status

Definition

Action

OPEN

  • At least one empty ICU cot
  • No imminent admissions pending (confirm with delivery suite).
  • Nursing staff available
  • Open to local, YNN and out of
    network babies.
  • Ensure Cot bureau and delivery suite aware of open status so that delivery of pending cases can be planned

OPEN- DISCUSS

  • Only one empty ICU cot
  • Potential admissions on delivery suite or referred from YNN
  • Staffing problems reduce capacity
  • Can accept ICU referrals if no imminent ICU babies on delivery suite.
  • Inform delivery suite
  • Discuss staffing with matron

FULL

  • All staffed ICU cots occupied or
    reserved for imminent ICU
    admission (within 4 hours)
  • Unexpected staffing crisis during shift.
  • Inform consultant, surgical SpR and
    delivery suite.
  • Consultant, Coordinator and Matron to discuss staffing and form action plan.
  • Inform cot bureau and identify local ICU beds (including in adjacent networks)
  • Ensure emergency space is physically available.

CRITICAL
OVER-CAPACITY

  • All staffed ICU cots occupied AND baby unexpectedly requiring NICU is born / mother cannot be transferred out.
  • Baby with Leeds-dependent
    condition is born within YNN
  • Cot bureau to find nearest available
    ICU cots
  • Consultant, senior nurse and Matron
    to form emergency plan.
  • Patient(s) to be transferred to another hospital within next 12 hours to return to safe capacity.
  • Obstetrician to be informed to review pending women and feedback status.

Action planning

  • Review staffing allocation between areas and cross city- can ICU be maintained?
  • Review stable patients in ICU- can any be moved to HDU/SCBU?
  • Can any non-Leeds patient be returned to their base hospital?
  • Review patients in SCBU- can any be moved to transitional care?
  • Review planned deliveries over next 24-48 hours- is transfer out required?

Emergency planning

  • Duty manager to be informed.
  • Can emergency staff be made available (from home / other wards/ transport team)?
  • Review which patients should be transferred out- this is almost always the most recent admission, but sometimes a more stable baby may need to be transferred to a local
    hospital. This must be discussed at a senior level. Wherever possible Leeds patients should be kept within Leeds, but in exceptional circumstances may need to be transferred locally in YNN to allow Leeds-specific tertiary cases (defined above) to be admitted. Leeds patients should never be transferred out of network unless for a level of care that cannot be delivered in the YNN.
  • If all YNN units are all full senior nurse and consultant to coordinate transfer out of network to an appropriate level of care unit.

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