To assist with safe and appropriate admissions, transfers and discharges of neonates to and from Grampians Health Ballarat being a Level 4 Special Care Nursery.

The purpose of this document is to ensure all staff are aware of the admission, discharge and transfer criteria for the Grampians Health Ballarat Special Care Nursery and to enable optimal utilisation of cots and patient flow.

SCN: Special Care Nursery

GHB: Grampians Health Ballarat

NICU: Neonatal Intensive Care Unit

Neonate: Up to 28 days of age (if born at 40 weeks or later), or 44 weeks corrected age (if born at < 40 weeks).

HIE: Hypoxic Ischaemic Encephalopathy

TBG: True Blood Glucose

PIPER: Paediatric Infant Perinatal Emergency Retrieval service

PFC: Patient Flow Coordinator

REACH: Retrieval and Critical Health Website - Statewide bed state tool

CPU: Child Protection Unit

BOS: Birthing Outcomes System

M&CHN: Maternal and Child Health Nurse

Neonate admitted to SCN

Neonate in Maternity Unit

Neonate admitted to Paediatric & Adolescent unit

Neonate seen at home by Domiciliary staff

Neonate presenting to Emergency Department

Neonate being seen by any Outpatient Services Departments

Responsibility for decision making around neonates (admission, discharge and transfer) lies with: Paediatric Consultants, Paediatric Fellows, Paediatric Registrars, Nurse/Midwife in charge in SCN, Patient Flow Coordinator and in some circumstances PIPER medical staff, and indirectly in isolated cases, Department of Human Services, Child Protection workers.

• Admission and referral for care in SCN must follow consultation with the Paediatric team (registrar or consultant). 
• In an emergency situation, where a neonate requires immediate attention, initiating care in SCN is appropriate, with the Paediatric resident, registrar or consultant being notified as soon as possible.
• If a neonate presents to the Emergency Department (ED) and is assessed by a Paediatric Consultant, Fellow or Registrar as requiring admission to the hospital the Special Care Nursery should be the first option considered.
• If admission is determined to be necessary, and both staffing and cot available within SCN, transfer from ED to SCN can be expedited so that any procedures etc can be carried out in an environment fully staffed and equipped for this specialty.

Indications for admission to Special Care Nursery (from birth suite, theatre or post natal ward):

• Neonate requiring stabilization prior to transfer to a neonatal intensive care unit (Per below: Criteria for transfer to a NICU)

• Neonates less than 36 weeks gestation or birth weight less than 2.2kg

• Neonates that require significant resuscitation at birth for a period of observation as per paediatric team- usually 4 hours minimum

• Suspected, or known, meconium aspiration requiring observation/treatment

• Respiratory distress (tachypnoea, grunt, nasal flare, rib/sternal recession)

  • with significant distress or apnoeas, admission without delay

  • with subtle symptoms, admit if these persist beyond 1 hour of life

• Hypoglycaemia (TBG <1.5mmol for direct admission or x3 persistent hypoglycaemia despite following hypoglycaemia pathway, some babies may require NGT feeds for volumes to maintain TBG's or IV 10% glucose if not tolerating volumes)

• Presumed or confirmed sepsis (if unable to be managed on postnatal ward under paediatric care)

• Persistent temperature instability (< 36.5 or > 37.5 per axilla)

• Persistent tachycardia (HR > 160)

• Persistent tachypnoea (RR > 60)/ or other signs of respiratory distress

• Lethargy and/or poor feeding (if unable to be managed on postnatal ward under paediatric care)

• Poor colour or poor perfusion, eg. Capillary refill > 2 seconds

• Bilious or persistent vomiting

• Neonatal seizures

• Suspected or confirmed subgaleal Haematoma/Haemorrhage

• Early onset sepsis calculator indicates that IV antibiotics are required

• Physiological jaundice requiring phototherapy (if unable to be managed on postnatal ward under paediatric care) and all pathological jaundice

• Neonatal abstinence syndrome: admit neonates requiring closer observation, treatment for withdrawal, or neonates who cannot be appropriately managed rooming in with mother on post natal ward during a minimum 5 day (standard 7 day) observation/scoring period.

• Obvious congenital abnormality requiring assessment or intervention (at discretion of pediatrician)

• Suspected, or known, congenital cardiac abnormality

• Ongoing non-specific concerns, for observation (at the discretion of paediatric staff)

• Border babies (no medical indication for admission, but mother unable to care for baby; eg. mother admitted to ICU, baby for adoption, child protection/court order that baby be separated from care of mother).

Procedure (for SCN staff):

• Notify admissions office via fax (form in SCN or birth suite) of neonates admission to SCN (this may be done by maternity or SCN staff)

• Notify PFC

• Attend to admission observations and clinical requirements

• SCN staff to follow check list for all admission procedures on MR/390.7 Special Care Nursery Admission/Discharge plan.

Admissions from St. John of God (SJOG) to Grampians health Ballarat (GHB) Special Care Nursery:

• At the request of the consultant paediatrician

• Neonate assessed to be outside capability of Special Care Nursery at SJOG (due to acuity, staffing resources or bed state)

• Request made to SCN staff at Grampians Health Ballarat to accept transfer

• Discuss with neonatal consultant at PIPER the plan to transfer

• Grampians Health Ballarat SCN staff to discuss with PFC

• If possible senior staff member from GHB SCN can take transport cot and equipment necessary to SJOG SCN to retrieve infant.

Admission criteria for transfer from Level 5 or 6 hospital:

• Stable, not requiring respiratory support; low flow nasal prong oxygen acceptable.

• Tolerating partial or total enteral feeds (ie. not requiring parenteral nutrition)

• Transfer weight and gestational age (>/= 31 weeks) at discretion of duty paediatrician

• Transfer for palliative care will be considered at the discretion of the Paediatric team and nursing staff.

Admission criteria for transfer from a Level 1, 2 or 3 hospital:

• In utero transfers for obstetric or neonatal risk factors must be arranged through PIPER. PIPER staff should liaise with paediatric, obstetric and SCN staff at receiving hospital to confirm bed availability, in both the maternity unit and SCN, the on call Paediatrician and Obstetrician need to accept the patient medically.

• For transfer of a neonate, born in a Level 1,2 or 3 facility, where ongoing care is not possible due to the neonates condition, lack of space, or a lack of available nursing or medical staff, the referring hospital should liaise with PIPER and agree upon GHB as an appropriate destination for transfer and arrange suitable transport of the neonate.

In all cases, the decision to accept a transfer is to be made by the GHB rostered paediatrician, in consultation with SCN nursing staff (re. bed state in SCN and staff availability).  It is the responsibility of the nurse in charge of SCN to discuss any possible transfers with the PFC.

Procedure (for all admissions from an external source):

• Discuss potential admission with PFC to ensure it is appropriate to accept transfer

• Nursing staff or clerical staff in SCN to ensure admissions office are aware of babies admission to SCN.

• Parents may be required to present to the admissions office to complete relevant paperwork (if admission is from an external source)

• SCN staff to follow check list for all admission procedures on MR/390.7 Special Care Nursery Admission/Discharge plan.

Readmission from home (via Emergency Department or direct admits):

Most admissions of neonates to the hospital will be via the emergency department, but in some instances the admission may be directly from the community. Most commonly, these direct admissions will occur when the extended postnatal care midwives have seen the neonate at home or has been seen by lactation consultant in breast feeding clinic. In consultation with the on-call Paediatrician if it is then determined that admission is required, parents will be instructed to bring their baby to the hospital and present directly to SCN. If the baby is potentially very unwell/septic ensure paediatric doctors are present in SCN for the arrival of baby. The default unit to admit to for all neonates, requiring readmission from home, is the SCN. If the neonate is considered to be potentially infectious, then there needs to be a considered approach to which cot space in the SCN to admit the neonate to.  The options in this case are the isolation room (single room, fully equipped, but not a negative pressure isolation room), a single bay area and/or the option to nurse the baby in an incubator. Once results from septic screening are received the where, and how (use of PPE), the neonate is managed may be able to be modified. Support and advice regarding appropriate precautions to be implemented for the duration of a specific babies admission to be sort by way of referral to the infection prevention and control unit.

Common reasons for readmission from home will be for:

• Jaundice requiring phototherapy

• Poor feeding, weight loss

• Unwell, septic infants requiring observation +/- treatment

Neonates requiring increased care/observation, but managed on postnatal ward under paediatric care:

• Non-pathological jaundice: Coombs negative jaundice, requiring phototherapy (either in an incubator or in an open cot with the bili-blanket) could be cared for on the postnatal ward if the neonate is otherwise well and taking appropriate volumes of enteral feeds at 3-4/24 intervals.

• Neonatal Abstinence Syndrome (NAS): neonates who have been exposed to narcotics (including methadone, buprenorphine and heroin) in pregnancy require close observation for signs of neonatal abstinence/withdrawal. If appropriate, this should occur with the neonate rooming in with the mother on the postnatal ward. If NAS scores or behaviour indicates significant signs of withdrawal, the neonate should be transferred to SCN for ongoing observation, +/- commencement of treatment.

• Neonates with suspected sepsis, who are otherwise well/stable, may be managed on postnatal ward with an intravenous cannula insitu, this will require regular normal saline flushes, and may be used if intravenous antibiotics are required (this situation may arise when a cannula has been inserted, bloods taken to screen for sepsis, and treatment decisions will be dependant on results). It may be possible to continue to manage these neonates on postnatal ward with assistance from SCN staff, if required, in the administration of the antibiotics.

• Babies with hypoglycaemia, or at risk of hypoglycaemia and requiring increased monitoring of BGL's/TBG's, +/- intervention with additional feeds and/or oral glucose gel.

Criteria and procedure for transfer to a Neonatal Intensive Care Unit (NICU)

•  Neonates with a birth weight < 1500g (can be less at discretion of paediatric consultant)

•   Neonates with a gestational age < 32 weeks (can be 31 weeks at discretion of paediatric consultant)

•   Neonates requiring intubation/ventilation

•   Neonates with oxygen requirement > 60% (consult with PIPER to consider transfer to NICU for neonates requiring CPAP 8 and/or FiO2>45-50%)

•   Neonates having seizures, or at high risk of seizures

•   Neonates requiring cooling for management of HIE

•   Neonates with congenital abnormalities requiring tertiary care in the neonatal period

•   Neonates with known, or suspected, bowel obstruction

•   Neonates requiring parenteral nutrition

•   Neonates requiring exchange transfusion

• Neonates who require ongoing care of a chest drain

•   Neonates requiring ongoing care necessitating maintenance of an umbilical catheter >48 hours

The decision to transfer lies with the rostered paediatrician and there may be instances where exceptions to above criteria are made.

Procedure:

• Medical staff (consultant or registrar) to contact the PIPER emergency service on ph. 1300 137 650. Decision to retrieve, or not, will be made by the PIPER neonatal consultant after discussion with Grampians Health Ballarat paediatrician.

• Medical staff to complete a Medical e-discharge summary in Bossnet. If able to be completed in time the e-discharge summary should be printed and sent with babies paperwork.

• Grampians Health Ballarat nursing and medical staff continue to manage neonate while awaiting arrival of PIPER team. Once handover has been done to retrieval team, Grampians Health Ballarat staff continue to provide assistance as required.

• Transport/escort is provided by the retrieval team from PIPER.

• Copies should be made of medication chart, fluid charts, relevant progress notes, pathology results and most recent observation chart. "My Health and Development Record" should also be sent with the neonate, as well as any hard copies of X-rays. Nursing staff to complete BOS discharge for the neonate and send copies of relevant BOS printouts (eg. Birthing summary and Neonatal Discharge Summary).

• SCN staff to follow check list for all discharge procedures on MR/390.7 Special Care Nursery Admission/Discharge plan (note: not all aspects of discharge checklist will be able to be completed in a transfer situation)

• Update REACH website

DISCHARGE CRITERIA FROM SPECIAL CARE NURSERY

Discharge to home:

• Greater than or equal to 2.2kgs

• Greater than or equal to 36 weeks corrected age

• Medically stable

• Sucking all feeds (breast or bottle) for at least 48 hours and gaining an appropriate amount of weight (exception made for babies going home with a long-term nasogastric tube)

• If the Department of Health and Human Services (DHHS)/Child Protection Unit (CPU) are involved they need to be made aware of anticipated date of discharge with as much notice as possible, to allow appropriate planning and services to be put in place if required.  In cases where CPU are involved, discharge is not to occur over a weekend unless prior arrangements have been made and this is acceptable to all parties involved (family, CPU workers, paediatricians and SCN staff).

(Exceptions to first 2 criteria may be made, by the rostered paediatrician, if there are i.) no outstanding social issues, ii.) good support structures at home, iii.) ready access to follow up care as required, iv.) satisfactory weight gains, v.) established suck feeding, and, vi.) no outstanding medical issues).

Procedure:

• Medical staff to complete discharge scripts for medication; script can be sent to pharmacy via pneumatic chute and parents can pick up and pay for once ready (demonstration of medication dispensing to be done by SCN staff or paediatric pharmacist prior to discharge). If possible, this should be done prior to the day of discharge.

• Medical staff to complete e-discharge summary; once this is completed and baby is discharged, history is to go into SCN discharge tray and the ward clerks will pack up history and send to medical records

• Medical staff to inform SCN staff of medical follow up required, and complete relevant referrals and request forms (appointments, pathology and/or radiology) - all referrals/requests to go into the ward clerks tray and they will attend to this (if possible these appointments may be made prior the date of discharge).

• If home apnoea monitoring required (as determined by consultation between parents/caregivers and Paediatric Consultant) refer to APPENDIX 1 "Apnoea Monitor Hire Process Guide" for instructions

• If home oxygen required refer to APPENDIX 2 & APPENDIX 3 for Discharge Oxygen ordering process and Discharge Oxygen order forms.

• Medical staff to attend to Newborn Examination and enter into green book (My Health and Development Record) and BOS6

• Nursing staff to complete RIMS referral (electronic/encrypted) to the appropriate M&CHN service.

• Nursing staff to ensure any allied health services involved in care of baby are aware of discharge (eg. Social work, Lactation Consultant, Speech Therapy)

• Nursing staff to complete BOS and print off 2 x Neonatal Discharge summaries, explain the content to parents, and put these in the "My Health and Development Record" book (1 copy for GP/parents and 1 copy for M&CHN); the Newborn Examination and the Discharge Summary should be uploaded from BOS to Bossnet; the Home Visiting/Risk assessment should be completed on line - this is located in Bossnet under the babies medical record. The Domiciliary referral needs to be uploaded in BOS and this will automatically send it as a referral electronically (this is not to be done before the discharge date and time are entered).

• SCN staff to follow check list for all discharge procedures on MR/390.7 Special Care Nursery Admission/Discharge plan

• Discharge baby off IBAPAS

• Update REACH website

Transfer to postnatal ward:

• Medically stable

• > than or equal to 36 weeks gestation

• > than or equal to 2.2kgs

• Taking all feeds orally

• Maintaining temperature in an open cot

• Mother still an inpatient

Procedure:

• Have baby reviewed by paediatric team and be given approval for transfer out of SCN

• Notify Maternity ward coordinator

• Handover neonate to midwife caring for the mother on postnatal ward

• Notify admissions - "unqualified" baby if mother is still admitted (remains under paediatric medical team), "qualified" baby if mother not admitted

• Update BOS admission

• Complete discharge information in admission/discharge diary

• Update REACH website

Neonate managed on postnatal ward, but admitted under the paediatric team:

There may be circumstances where a neonate is well enough to be on the postnatal ward but not ready for discharge (as determined by a paediatrician) at the time that the mother is ready for discharge. In this instance the mother can be discharged and the baby is admitted under paediatrics. The baby becomes the admitted patient, the mother must be able to stay to continue to provide care to her baby, and the midwives will provide any nursing/midwifery care directed by the paediatricians. Babies can also be transferred from SCN to the postnatal ward and admitted there if the mother is discharged (the most likely circumstance where this may happen is if there is pressure on the beds in SCN, and the baby is considered safe to be able to be on postnatal ward for ongoing care, so the mother becomes a boarder on the ward and the baby becomes the admitted patient under paediatrics). There may also be occasions where neonates are readmitted from home directly to the postnatal ward (usually due to feeding issues/weight loss).

Common scenarios where this type of admission may occur are:

• Term, or near term neonates with feeding difficulties

• Neonates requiring a prolonged stay to be NAS scored, but not requiring treatment

• Growth restricted neonates, requiring extended stay, until appropriate weight gains evident

• Preterm, or ex preterm, neonates established onto full suck feeds and waiting to achieve appropriate weight gains on all suck feeds.

• Babies with jaundice requiring phototherapy (within paediatric medical team discretion)

TRANSFERS FROM SCN TO THE PAEDIATRIC AND ADOLESCENT UNIT (P&A UNIT)

There may be occasions where babies are transferred from SCN to the P&A unit for ongoing care. This will be done after consult between the paediatricians, nurses in charge on SCN and the P&A unit and the PFC. In these circumstances the SCN should complete the BOS/SCN admission, notify the extended postnatal care (Domiciliary) midwives of the transfer and notify admissions. It is suggested that the P&A unit staff follow the check list for all discharge procedures on MR/390.7 Special Care Nursery Admission/Discharge when the baby is ready for discharge (with the exception of completing the BOS paperwork, as this should have been done at the time of discharge from SCN), a referral should have been sent to Domiciliary at this point, so a phone call to notify of discharge from P&A is all that should be required to ensure that follow up visits are done (if considered necessary). Consideration needs to be given to which babies would be suitable for transfer to P&A unit (with preference given to term and post term babies).

TRANSFER CRITERIA FROM GRAMPIANS HEALTH BALLARAT SCN TO OTHER HOSPITALS WITHIN GRAMPIANS REGION

Grampians Heath Ballarat is the highest level SCN in the Grampians Region and therefore manages neonates from a large geographical area. Horsham and Maryborough, and to a lesser degree Stawell, Ararat and Daylesford, have the capacity to accept babies back for ongoing care. The ability of these hospitals to do this is dependent on bed and workforce availability. Transferring babies to these hospitals enables bed availability for higher acuity babies at Grampians Health Ballarat and also allows families to be closer to home while babies are still inpatients. There is no set criteria for these transfers. They are negotiated on an individual basis, as the hospitals have different capabilities.

Procedure:

• Discuss transfer with parents (they need to be aware that the usual requirement is for the mother to be admitted and the baby will be with her in a postnatal ward environment - this will not suit all families)

• Nursing staff to phone individual hospital and discuss possibility of transfer (usually speak to nurse/midwife in charge of maternity area)

• Medical staff at Grampians Health Ballarat to phone medical staff at receiving hospital and request transfer of care

• If transfer is to proceed, date/time agreed upon, parents informed and arrangements made.

• Transport can be arranged through a Non-urgent transport provider, for example: Ambulance Victoria. The chosen provider is usually determined by the hospital (transport and communications officer) and the choice is based on price and appropriateness of service. The contracts with these providers are re-negotiated periodically so there may be variation as to who is the preferred provider is from year to year. These transfers can usually be arranged the day before, or day of transfer with the provider.

• If transport is via PIPER returns service this needs to be arranged at least 24 hours prior to transport, ph. 1300 659 803 (transport mode will be at the discretion of rostered paediatrician). An appropriate escort will be provided by PIPER for these transfers.

• In addition to the usual discharge paperwork from BOS and BOSSnet (medical), a nursing handover letter should also be completed, with more detailed care plan that outlines: feeds, medications, parent involvement and any social issues. It is also recommended to outline goals for discharge (eg. greater than 36wks, greater than 2.2kgs, medically stable, sucking all feeds for 2 - 3 days and having satisfactory weight gains).

• Medical staff to complete discharge summary and copy of this to be printed and sent for receiving medical staff.

• Copy of medication chart, relevant progress notes and current feed chart should also be sent.

• Notify Extended Postnatal Care (Domiciliary midwifery staff) of transfer (for collation of statistics reasons and awareness of transfer, and to ensure subcontracting of home visits occurs)

• Details of transfer to be entered in SCN Admission/Discharge diary

• Time, date and destination to be completed on front sheet (of babies history)

• Discharge baby off IBAPAS

• Update REACH website

PUBLIC TO PRIVATE TRANSFERS

There are occasions when, due to a critical bed state in the Level 3 neonatal units in Melbourne, babies are admitted to St. John of God (SJOG) SCN who do not have private insurance. This funding is arranged through PIPER and the Department of Health. This funding is limited, so it is important that these babies are moved back into the public hospital system as soon as possible (ie. from SJOG to Grampians Health Ballarat SCN). Transport between SJOG and GHB can occur through the enclosed walkway on level 1 (GHB). These transfers will require a nurse escort from either SCN.

TRANSFER OF BABIES WITHIN THE HOSPITAL

If a mother is in the ICU, and baby is in SCN because of this (ie. no medical indication for admission to SCN), they may be escorted to and from the SCN by an appropriate family member. Babies should always be mobilised around the hospital in a cot or pram - not carried by staff, or a family member.

If a baby is being transferred back to their mother who is in theatre/recovery a midwife must be present to care for the baby at all times.

If a baby is admitted to SCN because it is medically indicated, they should be escorted by a SCN staff member if movement around the hospital is necessary (eg. to Radiology or to ICU if mother is there)