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Managing the neonatal transfer system

Some newborn infants will always need to be moved between hospitals and neonatal transport services need to well organised.
Births can occur in a variety of settings, including the home and local health care facilities. Wherever a baby is born, it is important that trained health care personnel with the right skills and equipment are available to provide basic life support.
To provide the highest quality of care for a preterm delivery or the new born baby, the pregnant mother or infant may need to be moved between the obstetric and the neonatal intensive care units within the hospital, or from home to hospital or between hospitals. To achieve this, each health system needs to develop and consider the most appropriate neonatal transfer system. In-utero transfers take place before birth. In-utero transfer is safer, easier, cheaper and associated with better outcomes for newborns than transfer after birth. There are a number of situations where an in-utero transfer to, or between hospitals, is needed to ensure specialist care for a high risk premature birth.
For example, a common situation is when the mother goes into early labour at a local health care facility which does not have the resources to provide care for preterm infants. A transfer system must be in place to safely move the mother to a specialist centre if staff are confident that birth will not occur during the transfer. In utero transfer is preferable whenever possible.
However, it does require: That the mother is willing to be transferred away from her environment, as it may be stressful, A fully-resourced means of transport, Transfers require a fully equipped ambulance irrespective of the distance to be covered, and, A good all-weather road network.
if in utero transfer is not possible, then an ex utero transfer, after birth, might be required. Ex utero transfers are more complicated, and require considerably more resources. They also need to be closely managed as they can result in poorer outcomes for newborns. Ex utero transfer within the hospital, between the obstetric unit and the NICU is preferable for both the baby and the mother. Transport incubators are required to move the baby through the hospital Ex utero transfer of the baby to or between hospitals is the most complex and costly type of neonatal transfer.
At the very least, ex utero transfer requires: an ambulance fully equipped with a neonatal transport incubator, and a skilled nurse and doctor who will care for the baby during the transfer, Again, the willingness of the mother for her baby to be transferred away, and a good, all-weather road network are required. As with in utero transfers, if the transfer is over a long distance, an air transport system is required This is even more complex and costly than a road transport system.
There are three cornerstones of a good neonatal transfer system: Anticipate the need for early transfer of the baby, This requires the obstetric and neonatal teams to initiate communication with the mother and family, Prepare for transfer, This may require stabilising the clinical condition of the baby before setting off on the journey, and Provide high quality care during the transfer. For example by maintaining the baby’s temperature during the journey. The transfer system has to be available at all times within the network.
Managing good communications is essential for a successful neonatal transfer system The health professionals on each side of the transfer must communicate with each other effectively, both verbally and through written documentation. They must also co-ordinate and manage communications with, and support for, the family throughout the transfer. Parental consent needs to be obtained for transfer. Specialised transport equipment is essential for neonatal transfer. An incubator is fixed to a trolley which must have integrated ventilators, monitors for heart and respiratory rates, blood pressure and temperature and a medical gas supply. This equipment needs a consistent power supply to function throughout the transfer. The baby is susceptible to potential trauma during transfer.
Comfort in the form of padding, noise reduction, warmth and even sedation may need to be considered. The best way to manage neonatal transfer between hospitals is to put in place a centralised neonatal transfer system that is fully equipped for newborn care and which has trained clinicians skilled in providing life support to newborn babies. How the transfer system is developed depends on the local health system and its available resources. The teams responsible for neonatal transport can be independent of the hospitals. This reduces staffing and equipment challenges for both the receiving and referring hospitals.
Developing a neonatal transfer system in the UK In 2001, in order to deliver the best quality care for new born babies, neonatal services were organised into clinical networks. Clinical networks are groups of hospitals that work together to provide safe and effective care for neonates and support and communicate decision making amongst health professionals and with patients and families. The UK’s neonatal clinical networks provide three levels of care for newborn babies. This has led to the parallel establishment of a neonatal transfer system to safely transport babies between the hospitals providing different levels of care. Each network is planned around the needs of a population of 1 million people, taking into account the local demography and geography, especially travelling distance.
The network has capacity to care for 95% of babies in their setting with less than 5% requiring transfer out of the area. Level 1 is the specialist care unit (SCU). This provides special care for babies in a local area. SCUs are equipped to provide some dependency services and to stabilise babies who may then need to be transferred to a level 2 or 3 unit. They have 4 nurses to 1 baby staffing. Level 2 is a local neonatal unit (LNU). The LNU provides care within its own agreed catchment area. They provide high dependency care and short periods of dependency care for babies before transfer to a level 3 unit, the neonatal intensive care unit or NICU.
Babies over 27 weeks in the LNU receive full care. These units assign 2 nurses per baby. Level 3 is care in a NICU for all babies in an agreed locality. NICUs also provide care for babies and families who have been referred to them from an LNU, SCU or other regions as agreed. Many NICUs are in the same place as neonatal surgical services and other specialties. Nursing in the NICU is based on one nurse per baby.
Each unit within the network must have access to 24-hour transfer service to ensure that babies receive care in the most appropriate setting to maximise clinical outcomes. In utero transfers are always considered to be the best option.
In summary: Transfer to appropriate neonatal care is essential for premature births, This can be to the NICU or local neonatal units according to the baby’s needs. In utero transfers, before the baby is born, are easier and less resource demanding, providing the mother can transferred safely and with her permission. Ex utero transfers are more complex. Ideally, the need for transfer is anticipated and the baby is stabilised and provided with a high level of care during transport.
When neonatal transfer systems are established, they need to be: Optimised for the local context, and services organisation, and properly equipped with the right personnel trained to undertake the work.

In this video we describe the different kinds of neonatal transfer in detail and the range of challenges in establishing and managing a neonatal transfer system. And we share the experience from the UK of setting up a national neonatal transfer system.

Categories of neonatal care

Across different health systems there are different categories of neonatal care. In the UK, three categories are used: special care, high dependency care and intensive care:

  • Special care is provided for all babies who cannot reasonably be looked after at home but do not need high dependency care or intensive care. Babies receiving special care may need to have their breathing and heart rate monitored, be fed through a tube, be supplied with extra oxygen or treated for jaundice. Special care which occurs alongside the mother outside the neonatal unit in a ward setting is often called transitional care.

  • High dependency care takes place in a neonatal unit and is provided to babies who need continuous monitoring but who do not fulfill any of the requirements for intensive care. Babies who weigh less than 1000g or are receiving help with their breathing via continuous positive airway pressure (CPAP) or are being given intravenous feeding may require high dependency care.

  • Intensive care is provided for babies with the most complex problems who require constant supervision and monitoring and, usually, mechanical ventilation. Due to the possibility of acute deterioration, a doctor must always be available. Extremely premature babies (< 28 weeks gestational age) all require intensive care and monitoring.

Adapted from the ‘Toolkit for High Quality Neonatal Services. NHS, 2009’

Moving the preterm infant

Some newborn infants may need to be moved between hospitals. Neonatal transport services need to be well organised. The service should be staffed by professionals trained in neonatal transport medicine and in using appropriate equipment.
With good preparation and stabilisation of the baby before setting off, minimal active intervention should be needed during the transfer. However, infants can deteriorate spontaneously, for example, because of a pneumothorax (when air leaks into the space between the lung and chest wall) or if equipment, such as endotracheal tubes or intravenous lines, become dislodged. Skills and equipment to deal with such eventualities must be available during the transfer. Care should be taken to maintain the infant’s temperature and, when possible, the environmental temperature of the vehicle should be raised.
Good verbal and written communication between health professionals throughout transport episodes is vital. Using clinical guidelines, operational policies, and checklists is helpful. Parents also need to know plans for their baby’s care, and the transport team should meet the parents when possible. In some settings informed consent is needed for transport and care. If parents are not travelling in the ambulance with their infant, they may need to know how to get to the destination hospital and what facilities will be available for them when they arrive. Helpful written information (for example, leaflets about the destination neonatal unit and maps) can be stored electronically and downloaded as needed.
Excerpt adapted from ‘ABC of preterm birth: Moving the preterm infant.’ BMJ 2004;329:1277

How is neonatal transfer managed in your setting and which key personnel are (or should be) involved?

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