Neonatal care levels criteria: framework for practice

7. Criteria for Transfer and Repatriation between Neonatal Units

The transfer and repatriation of mother and babies is a normal component of neonatal care provision in Scotland, ensuring babies receive the most appropriate care at the correct time.

Transfer and repatriation decision will always be guided by the general principle of providing care as close to home as possible but it is important to recognise that in some cases timely access to the clinically most appropriate unit may require a transfer to a unit further afield.

7.1 Neonates Requiring Specialist Medical, Surgical, Sub-Speciality or Cardiac Assessment

Several National Services are only delivered at the Royal Hospital for Children (RHC), Glasgow. These national services include:

• National Cardiac services.
• National Airway service.
• Extra-Corporeal Life Support (ECLS) service.

Babies anticipated antenatally to require these specialist services should be planned for delivery at the RHC Glasgow, being transferred in-utero whenever possible, following liaison with the Fetal Medicine team.

For those deliveries where antenatal assessment has identified the likelihood of a requirement for specialist review after delivery, from either surgical or subspecialist teams, the optimal place of delivery should be determined before delivery. This should be clearly documented and communicated to the team. In some cases the optimal location to deliver care requirements will only become apparent following delivery; for such cases transfer should be arranged to the nearest appropriate NICU following birth as determined by the specific requirement for speciality review (e.g. ENT, Renal, Metabolic).

7.2 Neonates Requiring Transfer from an LNU to a NICU

Decisions about the best place of care and timing of transfers between units must be underpinned by regular structured and effective two-way communication between units. In line with the national framework, a Local Neonatal Unit (LNU) would not be expected to provide continuing care for the following categories of babies:

• Singletons delivered at < 27⁺⁰ weeks (for some LNUs this will be < 28⁺⁰)
  • where possible transfers should occur in-utero.
• Multiples births delivered at < 28⁺⁰ weeks
  • where possible transfers should occur in-utero.
• Birth weight below 800g
  • In-utero transfer should be considered when birth weight is anticipated to be below 800g.
  • Urgency of transfer ex-utero will be dependent on the clinical status and stability of the baby and it may be that a consensus decision between units is reached if the baby is marginally below this weight and clinically stable. This highlights the importance of discussion between units at senior clinical level.
• Neonates > 27 weeks of gestation in the following categories:
  • who receive ventilation for > 48 hours and/or whose condition is deteriorating:
    • Those who are unwell and anticipated to require ventilation for > 48 hours should be discussed with the relevant NICU regarding transfer on Day 1.
    • Ventilated babies whose clinical condition is stable and/or improving after 48 hours should be discussed on a daily basis with the relevant NICU.
  • Requiring complex and/or prolonged intensive care:
    • Complex is defined as “support of more than one organ in addition to respiratory support with an endo-tracheal (ET) tube” e.g. multiple inotropic support, respiratory support with HFOV/iNO.
    • Prolonged is defined as ITU support of more than 48 hours and not improving.
• Babies with cardiac and surgical conditions requiring specialist assessment and diagnosis where this is not available locally, including all babies requiring prostaglandin infusion.
  • When an antenatal diagnosis has been made an in-utero transfer for elective delivery within a NICU should occur in cases where time-critical surgical or specialised intervention is required postnatally.

Babies who should be discussed with a NICU but for whom care may continue in a LNU after discussion with the NICU Consultant, and if no other criteria for NICU care are present, include those:

• Expected to be ventilated for > 48 hours but stable/improving
• Ventilated but improving and requiring a single inotrope that is being weaned
• Neonates who require Therapeutic Hypothermia (TH) as long as those babies are otherwise stable, with minimal physiological instability and not meeting other criteria for transfer to a NICU.

7.3 Neonates Requiring Transfer from a SCU to an LNU or NICU

In line with the national framework, a Special Care Unit (SCU) will not be expected to provide:

• Care beyond the initial stabilisation to babies less than 32⁺⁰ weeks gestation, unless prior agreement.
• 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 the SCU having appropriately trained staff and being able to demonstrate consistently good outcomes for this category of infants.
• On-going Intensive Care or High Dependency Care for any baby apart from the period of initial stabilisation
• Babies requiring the following treatment and support:
  • Infusion of inotropes, insulin or prostaglandins
  • Inhaled Nitric Oxide, High Frequency Oscillatory Ventilation (HFOV)
  • Requirement for a chest drain
  • Exchange transfusion
  • Therapeutic Hypothermia.