Neonatal care levels criteria: framework for practice

5.1 Definition of a Neonatal Intensive Care Unit (NICU)

5.1.1 Clinical Care Provision

A NICU should:

• Be co-located with specialist Obstetric and Fetal Medicine services.
• Be co-located with a Maternity service organised to accept criteria-appropriate in utero transfers from Maternity services attached to LNUs and SCUs. To ensure the smallest and sickest babies are delivered in the optimal centres, a NICU Maternity service should implement pathways to facilitate acceptance of these highest acuity in utero transfers. This will be supported by reciprocal pathways for criteria-appropriate in utero transfers from a NICU centre to a LNU/SCU centre.
• Usually provide the range of medical neonatal care to their local population, balancing available capacity with the ability to accept high acuity in-utero referrals as per agreed pathways.
• Meet optimal clinical activity demographics as recommended by BAPM:
  • Care for a minimum of 100 very low birth weight (VLBW) admissions per annum.
  • Provide a minimum of 2000 respiratory care days per annum.
    • Complex is defined as “support of more than one organ in addition to respiratory support with a endo-tracheal (ET) tube”.
• Accept babies of any gestational age for complex low-volume highly specialised care (HFOV, iNO, total body hypothermia, complex and/or prolonged ITU support) from LNUs and SCUs.
• Provide ITU care for babies and their families referred from LNUs and SCUs in line with the national referral criteria for NHS Scotland and with NHS England commissioning criteria:
  • Singletons < 27⁺0 weeks.
  • Birth weight < 800 grams.
  • Multiples < 28⁺0 weeks.
  • Complex and/or prolonged intensive care of more mature babies
    • Complex is defined as “support of more than one organ in addition to respiratory support with a endo-tracheal (ET) tube”.
    • Prolonged is defined as ITU support of more than 48 hours and not improving.
  • Therapeutic hypothermia in line with BAPM recommendations.

5.1.2. Staffing

• Be staffed in accordance with BAPM recommendations at each tier of medical staff:
  • Specifically NICUs must ensure on-site Consultant presence for a minimum of 12 hours per day.
  • For NICUs with > 4000 intensive care days per annum consensus recommends a Consultant presence 24 hours/day.
  • Medical Staff within a NICU must not have simultaneous clinical responsibilities outside the neonatal service.
• Be staffed with nursing staff and allied health professionals specifically trained to deliver NICU level care:

  (A) Nursing Staff

  • NICUs should have sufficient nursing staff to deliver care in accordance with the BAPM recommended Nurse: Patient ratios (1:1 Intensive Care, 1:2 High-Dependency Care and 1:4 Special Care).
  • Staff will exercise professional judgment supported by national capacity guidance to allow flexibility to accommodate further admissions where required.
  • A minimum of 80% of the nursing workforce establishment within a NICU should hold a current Nursing and Midwifery Council (NMC) registration.
  • A minimum of 70% of the registered Nursing workforce establishment within a NICU should hold an accredited post-registration qualification in specialised neonatal care (Qualified in Speciality (QIS)).
  • Babies requiring Intensive or High-Dependency Care should be cared for by staff who have completed accredited training in specialised neonatal care, or who while undertaking such training, are working under the supervision of a QIS-trained Registered Nurse.
    • A minimum of 1:1 or 1:2 staff: patient ratio should be provided at all times.
  • Babies requiring Special Care should be cared for with a minimum of 1:4 staff: patient ratio at all times, by either a Registered Nurse or a non-registered member of staff who has attained the appropriate competencies and skills, working under the supervision of a QIS-trained Registered Nurse.

  (B) Allied Health Professionals (AHPs):

  AHPs are fundamental to providing the best possible neonatal care for babies who are admitted to a neonatal unit and their families. AHP staffing should be provided in line with national recommendations and Scottish Neonatal AHP workforce development plans.

  • Dietetics:
    • Neonatal Dietetic provision Guidance
  • Physiotherapy:
    • Neonatal Physiotherapy recommendations are available at: Neonatal Staffing Recommendations | Association of Paediatric Chartered Physiotherapists (csp.org.uk).
  • Speech and Language Therapy (SALT):
    • SALT recommendations are available at: neonatal-speech-and-language-therapy-staffing-level-recommendations.pdf (rcslt.org).
  • Occupational Therapy (OT):
    • OT recommendations are available at: Microsoft Word - Occupational therapy staffing on neonatal units 22.08.18 (rcot.co.uk)
  • Psychological Support:

    NICUs should have access to specialised Neonatal Psychology services, provision within NHS Scotland is detailed in: Delivering Effective Services: Needs Assessment and Service Recommendations for Specialist and Universal Perinatal Mental Health Services (www.gov.scot)

  • Neonatal Pharmacy:

    Requirements are described in NPPG Neonatal – Pharmacist staffing recommendations published September 2022.

• A NICU requires to interface with other services to meet the care requirements of babies across a neonatal admission:
  • Support provision of Transitional Care (TC) in line with the BAPM 2017 Framework and ensure the clinical model utilises the clinical criteria detailed within the BAPM Framework. TC should link seamlessly to community care, facilitating early discharge and appropriate post-discharge support for families.
  • Provide a dedicated Community Liaison/Outreach Service to facilitate earlier supported discharge where clinically indicated. Local service delivery will require to be tailored to meet local geographical needs although the criteria and principles of such services should follow the recently launched national framework (describing principles of discharge planning, community liaison and follow up).
  • Provide a multi-disciplinary team trained in neuro-developmental assessment and therapy for high–risk infants that aligns with recommendations from NICE.
• Provide support and advice to Local Neonatal Units (LNUs) and Special Care Units (SCUs) within NHS Scotland.
• In line with BAPM standards provide support for parents and families with appropriate facilities and accommodation for those travelling to NICUs remote from their home but also for parents who might need accommodation close to the hospital for other reasons.
• Ensure all families experiencing neonatal care have access to financial support available via the Young Patients Family Fund.
• Repatriate babies as soon as their clinical condition stabilises to receive the appropriate level of care at a unit as close to home as possible.

5.2 Definition of a Local Neonatal Unit (LNU)

5.2.1. Care Provision

Local Neonatal Units should:

• Meet optimal activity levels as recommended by BAPM (2018):
  • Admit a minimum of 25 infants < 1500 grams.
  • Perform a minimum of 365 respiratory care days per annum.
    • For some LNUs this may be tailored to > 28⁺⁰ weeks of gestation based on activity, clinical expertise and/or facilities.
    • Dialogue should take place with the regional NICU team at 48 hours or sooner if clinically indicated and 24 hourly thereafter if intensive care support continues to be clinically indicated at the LNU. Dialogue should follow the agreed communication process between units and be recorded to allow audit.
• Provide all levels of clinical care (including transitional care and outreach support) for the majority of babies delivered at ≥ 27 weeks of gestation within their own local catchment area including:
  • Singletons ≥ 27 weeks
    • For some LNUs this may be tailored to > 28⁺⁰ weeks of gestation based on activity, clinical expertise and/or facilities.
  • Multiple births ≥ 28 weeks.
  • Birth weight ≥ 800 grams.
  • Babies requiring short periods of intubated ventilator support and intensive care in accordance with agreed pathways that are specific and tailored to each LNU.
    • Dialogue should take place with the regional NICU team at 48 hours or sooner if clinically indicated and 24 hourly thereafter if intensive care support continues to be clinically indicated at the LNU. Dialogue should follow the agreed communication process between units and be recorded to allow audit.
• Receive transfers from other services within NHS Scotland if these fall within the agreed framework for practice tailored to individual units, noting the priority of keeping families as near as possible to their unit of booking.
  • LNUs can receive babies from SCUs for continuing HDU or ITU care (of short anticipated duration) after initial stabilisation in SCUs.
  • Provide continuing care following repatriation from NICUs.

5.2.2. Staffing

• Meet national recommendations for staffing levels:
  • Medical staffing in accordance with BAPM 2018 recommendations for LNUs (Tier 1 to 3):
    • LNUs should have immediately available at least one resident Tier 1 practitioner (ST1 equivalent or ANP) dedicated to providing emergency care for the neonatal service 24/7.
    • LNUs should ensure the presence of a Tier 2 Practitioner dedicated solely to the neonatal service at a minimum during the busiest period for a co-located paediatric service i.e. 0900-2200 hrs.
    • LNUs undertaking either > 400 IC days annually or > 1000 RC days should consider providing a 24/7 resident Tier 2 dedicated to the neonatal unit and entirely separate from paediatrics.
    • LNUs delivering either > 600 Intensive Care (IC) days per annum or > 1500 Respiratory Care Days (RC) days per annum must ensure an immediately available dedicated resident Tier 2 practitioner 24/7.
    • LNUs providing > 2000 RC days or > 750 IC days per annum should provide a separate Tier 3 Consultant rota for the neonatal unit.
    • All LNUs should ensure that all Consultants on-call for the unit also have regular weekday commitments to the neonatal service. This is best delivered by a “Service week/Attending System” and no consultant should undertake < 4 service weeks per annum.
    • New appointments to cover LNUs at Consultant level/Tier 3 should have a CCT in Neonatal Medicine or be a General Paediatrician with a Special Interest in Neonatology or have equivalent neonatal experience and training.
  • Nursing staff numbers in accordance with BAPM guidance:
    • A minimum of 80% of the nursing workforce establishment within a LNU should hold a current Nursing and Midwifery Council (NMC) registration.
    • A minimum of 70% of the registered nursing workforce establishment within a LNU should hold an accredited post-registration qualification in specialised neonatal care (QIS).
    • Babies requiring intensive or high dependency care should be cared for by staff who have completed accredited training in specialised neonatal care or who, while undertaking this training, are working under the supervision of a registered nurse (QIS). A minimum of 1:1 or 1: 2 staff-to-baby ratios should be provided at all times.
    • Staff will exercise professional judgment supported by national capacity guidance to allow flexibility to accommodate further admissions where required.
    • Babies requiring special care should be cared for with a minimum of 1:4 staff-to-patient ratio at all times by either a registered nurse or a non-registered member of staff with the appropriate competencies and skills, working under the supervision of a registered nurse (QIS trained).
  • Allied Health Professionals
    • Provision of AHP service recommendations are provided within the following publications:
      • Dietetics: Neonatal Dietetic provision Guidance
      • Physiotherapy: Neonatal Staffing Recommendations | Association of Paediatric Chartered Physiotherapists (csp.org.uk).
      • SALT: neonatal-speech-and-language-therapy-staffing-level-recommendations.pdf (rcslt.org).
      • OT: Microsoft Word - Occupational therapy staffing on neonatal units 22.08.18 (rcot.co.uk)
      • Psychological Support: Perinatal Service Provision: The role of Perinatal Clinical Psychology - The British Psychological Society (bps.org.uk), recognising palliative care may be supported nearer to home and psychological support is important throughout the neonatal journey.
      • Neonatal Pharmacy Requirements are described at NPPG Neonatal – Pharmacist staffing recommendations published September 2022.
  • A LNU should interface with other services to meet the care requirements of babies across a neonatal admission:
    • Support the provision of Transitional Care (TC) in line with the BAPM Framework and ensure the clinical model utilises the clinical criteria detailed within the BAPM framework. TC should link seamlessly to community care, facilitating early discharge and appropriate post-discharge support for families.
    • Provide a dedicated community liaison/outreach service to facilitate earlier supported discharge. Whilst services must be tailored to local geographical needs the criteria and principles of such services should follow the agreed national framework.
    • Provide a multi-disciplinary team trained in neuro-developmental assessment and therapy for high–risk infants that aligns with recommendations from NICE.
  • LNUs should provide support for parents and families with appropriate facilities and accommodation in line with BAPM standards.
  • Ensure all families experiencing neonatal care have access to financial support available via the Young Patients Family Fund
  • Repatriate babies as soon as their clinical condition stabilises to receive the appropriate level of care at a unit as close to home as possible.

LNU care is not recommended for:

• Babies who require transfer to a NICU as per agreed national criteria and consistent with their unit-specific criteria:
  • Babies delivered at > 27 weeks of gestation who require complex and/or prolonged intensive care i.e. support of more than 48 hours without improvement.
  • Babies anticipated to deliver at < 27 weeks of gestation and/or at a birth weight of < 800 grams should aim to be transferred in-utero for delivery in a NICU (for some LNUs this will be agreed at < 28 weeks of gestation).

5.3 Definition of a Special Care Unit (SCU)

5.3.1 Care Provision

A Special Care Unit (SCU) should:

• Meet the BAPM 2018 recommendations for a SCU with respect to clinical activity and respiratory care days per annum:
  • Care for up to 25 VLBW babies per year.
  • Deliver up to 365 Respiratory care days /annum.
• Provide care for babies of 32⁺⁰ weeks gestation and upwards.
• Some SCUs may with prior agreement care for babies > 30⁺⁰ weeks of gestation, recognising that local geography is an important consideration in decisions within NHS Scotland. However this is dependent on appropriately trained staff and evidence of the SCU being able to demonstrate consistently good outcomes for such infants.
• Provide care for those babies with additional care needs who do not meet either Intensive Care or High Dependency care criteria.
• Provide Transitional Care, working in collaboration with postnatal services subject to the local integrated service model, ensuring this is in line with the BAPM TC Framework.
• TC should link seamlessly to community care, facilitating early discharge and appropriate post-discharge support for families.
• Provide a unit appropriate community liaison/outreach service recognising the service model will be dependent on geographical and personnel constraints. Liaison services should be aligned with the principles within the agreed National Framework for discharge planning and follow-up.
• Ensure all families experiencing neonatal care have access to financial support available via the Young Patients Family Fund.
• Provide developmental follow up services in line with NICE recommendations
• Provide on-going care for local babies following repatriation from a LNU or NICU in accordance with the agreed national framework.

5.3.2. Staffing

• Meet national recommendations for staffing levels within a SCU
  • Medical staffing (Tier 1 to 3) in accordance with the BAPM 2018 recommendations:
    • SCUs should provide a resident Tier 1 practitioner dedicated to the neonatal service in daytime hours on weekdays and a continuously immediately available resident Tier 1 practitioner to the unit 24 hours per day, seven days every week.
    • SCUs should provide a resident Tier 2 to support the Tier 1 in SCUs admitting babies requiring respiratory support.
    • In SCUs there should be a Lead Consultant for the neonatal service and all Consultants should undertake a continuing professional development (a minimum of 8 hours CPD in Neonatology) per annum.
  • Nursing staff numbers in accordance with BAPM guidance:
    • Babies requiring special care should be cared for with a minimum 1:4 staff-to-patient ratio at all times by either a registered nurse or a non-registered member of staff with the appropriate competencies and skills, working under the supervision of a registered nurse (QIS trained).
    • A minimum of 70% of the workforce establishment within a SCU should hold a current Nursing and midwifery Council registration.
    • A minimum of 70% of the registered nursing workforce establishment within a SCU should hold an accredited post-registration qualification (QIS).
  • Allied Health Professionals:
    • Meet national recommendations for AHP provision, recognising that AHP and Psychology support is important throughout the neonatal care journey. Pathways should exist for guidance and support from AHP services within the aligned NICU/LNUs to ensure continuity of care and consistency of advice to parents for repatriated babies.

SCU care is not recommended for:

• Babies anticipated to deliver below 32⁺0 weeks:
  • Such cases should be transferred in-utero to an appropriate LNU or NICU.
  • Some SCUs may with prior agreement care for babies > 30⁺⁰ weeks, recognising that local geography is an important consideration in decisions within NHS Scotland. However this is dependent on appropriately trained staff and evidence of the SCU being able to demonstrate consistently good outcomes for such infants.
• Any baby requiring Intensive Care or High Dependency care on an on-going basis:
  • Such cases should be transferred following initial stabilisation.
• Babies requiring anything other than short-term respiratory support e.g. for delayed transition:
  • Cases requiring a longer duration of respiratory support require direct communication with the linked LNU/NICU team to determine the most appropriate place of on-going care and whether transfer is indicated.

5.4 Definition of a Referring Hospital

A ‘Referring Hospital’ is defined either as the hospital from where the mother is being transferred out with her baby in–utero, or the local hospital where the ex-utero neonate was delivered.

5.5 Definition of a Receiving Hospital

A ‘Receiving Hospital’ is defined as either the destination hospital for maternal in-utero transfers, or the destination hospital for ex-utero transfers of a baby requiring specialist care or local care following repatriation.