Maternity and neonatal services - neonatal intensive care plan: options appraisal

Options Appraisal Stage 2: Feasibility, Viability And Testing

Feasibility And Viability

22. In July 2018, representatives from the Perinatal Sub Group comprising Chair and Clinical leads met with senior representatives and clinicians from the Boards/Units which scored highest in the options appraisal (NHS GG&C, NHS Lothian and NHS Grampian). The purpose of the meeting was to discuss the outcomes of stage one of the options appraisal and to discuss practical aspects of implementation of the change to five and then to three neonatal intensive care units, including patient flows, staffing, capacity and timing. This was further informed by a series of bilateral meetings with each of the three Boards.

Testing

23. At the request of the then Cabinet Secretary for Health, in order to enable a better understanding of the processes required to implement the new model of care, it was rolled out first in two sites in Scotland to enable testing of the entire model ahead of wider roll out. The proposed test sites were Crosshouse and Queen Elizabeth University Hospital in the west, and the Victoria Hospital and Edinburgh Royal Infirmary in the east. This was announced in February 2019. Discussions with these early implementer sites began in late 2018 and they began to operationalise the new model in summer 2019. The Boards were asked to roll out a range of aspects of the new model of neonatal care, including the new model of neonatal intensive care, to enable better understanding of the implications for patient flow associated with other aspects of the new model. Planning Groups were established in the west and the east, which included representatives from the Perinatal Sub Group. These Early Implementer Boards reported progress with establishment and operation of the new model to the Perinatal Sub Group.

24. To inform roll out of the new model, the Perinatal Sub Group developed the following:

1. Criteria to Define Levels of Neonatal Care Including Repatriation Within NHS Scotland: a Framework

This document describes a clear framework across NHS Scotland for:

• The management of babies who require Intensive Care, High Dependency Care or Special Care.
• The safe and efficient transfer of babies to the most appropriate care facilities to receive care to meet their clinical requirements.
• The safe and effective repatriation of babies to the nearest appropriate care facility as soon as clinically indicated.

2. Neonatal Care: Information leaflet for women in Scotland

The leaflet provides information for families on the new model of care, different levels of care and where care is provided, and what to expect in the event of the need to transfer mother and/or baby.

25. Feedback on the Framework and the leaflet was sought from the early implementers as they tested the process.

Outcome Of Testing

26. Numbers of babies and women included in the early implementer testing phase was always predicted to be small therefore evaluation focused on testing system processes and communications. Clinical outcomes were not evaluated. In the first half of 2019 significant work was invested in identifying system and process changes required and agreeing new protocols and procedures between the two units in each axis and the Scottish Ambulance Service, specifically the in-utero co-ordination service within the established dispatcher team of the SAS. Key measures included whether the right mothers and babies were identified and transferred, the timeliness of transfer, whether facilities were in place to allow mother and baby to stay together, communication between units, with Scottish Ambulance Service and with families, and timely repatriation of babies.

27. From the start of the Early Implementer process in the summer of 2019 to the end of 2019 there were nine in-utero transfers and one ex-utero neonatal transfer from Fife to Lothian which met the Early Implementer criteria. Retrospective data was gathered following the onset of the pandemic for the period 1^st January 2020 to 31^st October 2022. In this time period there were fifteen in-utero transfers from Fife to Lothian which met the criteria, ten of which subsequently delivered at RIE, and five ex-utero neonatal transfers.

28. Between summer 2019 to end 2019 there were four in-utero transfers and no ex-utero neonatal transfers from Ayrshire to Glasgow which met the criteria. None of the in-utero transfers resulted in deliveries in Glasgow. Retrospective data was gathered following the onset of the pandemic from summer 2019 to 31st October 2022, during which time there were eight in-utero transfers and six ex-utero transfers from Ayrshire to Glasgow which met the criteria.

Findings and key learning points

29. Establishing systems and processes: Significant time had to be invested by clinicians and managers on all sites to establish delivery groups, to understand the criteria, to gather data, to develop agreed systems and protocols, to build awareness and achieve buy in from clinicians in both neonatal and obstetric services, and to develop communications processes. As a result the lead-in times for commencement were longer than expected. In particular Boards highlighted the importance of securing early obstetric engagement in planning the change.

30. Learning points: Once the agreed protocols and criteria were implemented, the Boards were asked to report against a set of quality measures and this identified the following themes:

• The communications systems that were established largely worked well and sites reported improved communications and a high level of staff awareness of the new system;
• Arrangements for transfer functioned smoothly between sites and with the Scottish Ambulance Service;
• Arrangements for repatriation worked, with a minor issue identified early on and addressed;
• Of the ten transfers which occurred, nine were in utero transfers, demonstrating systems for early identification of possible extreme pre-term labour were effective;
• Of note most women transferred in-utero during this process did not deliver and were discharged from the receiving Maternity Unit;
• A couple of minor process learning points were identified as the testing was underway and were acted upon promptly and communicated;
• Concerns about process for maternal transfer that came up during the process were dealt with. Guidance/support for in-utero transfers needs to be a priority focus for further roll out of the model, which has since been developed by the Scottish Perinatal Network’s Maternity Transport Group, with IUT guidance and pathway near finalised;
• Arrangements for continuity of bereavement care in relation to cross-Board transfer also requires to be considered. This is a learning point for all cross board transfer, not just for the families involved in the early implementer sites and is being addressed.

31. The Neonatal Care Information leaflet developed by the Perinatal Sub Group was available to women who required to be transferred. The transfers were discussed with all parents and clinicians reported that no concerns were raised, however due to the low numbers, only one parent provided formal written feedback early on in the process, which was positive. In moving forward with plans for implementation, Boards will be expected to use local mechanisms to continue to gather feedback on operation of the model.

32. In addition to the testing in relation to extreme preterm delivery, the units were asked to move forward with establishment of other aspects of the neonatal model of care. Three out of four of the units have now established Transitional Care Units, enabling babies with moderate additional care needs to be kept with their mothers on the postnatal ward, and the fourth unit (Royal Hospital for Children’s Neonatal Unit, QEUH, NHS GG&C) has phased planning in place to develop this service, primarily in the PRM, and then in QEUH. All units are also working towards delivery of neonatal community care, and Lothian are already seeing results with a reduced length of stay (an average reduction of 5 days) for babies that have been able to receive support from the community service.

33. Accommodation is currently available for families in both of the receiving intensive care units to enable them to stay with their babies, although GG&C highlighted building accommodation limitations in RHC/QEUH neonatal units which restrict expansion of physical capacity. When accommodation reaches capacity, the Young Patient's Family Fund, will provide reasonable reimbursement of accommodation costs for parents, where that has to be found outwith the hospital estate. All four units are now working towards Bliss Baby Charter accreditation, which will demonstrate that principles of family centred care are embedded within neonatal units. The The Royal Hospital for Children, Neonatal Unit at the QEUH has become the first Unit in Scotland to be awarded the Gold standard in family centred care.

34. In conclusion mothers at risk of extreme pre-term delivery and extremely pre-term babies were identified and transferred promptly, and appropriately discharged back to their local unit. Mothers and babies were kept together where appropriate. No significant patient safety concerns were raised. The Early Implementer Boards agree that the process is now operationalised following the testing period. Whilst acknowledging that clinical teams are discussing babies that fall into the sickest criteria in the framework, a start date needs to be agreed to formally implement this aspect of the criteria document. Units agree that reporting should now move to an exception basis. While no negative feedback was received from families about the process, small numbers have made it difficult to achieve the depth of parent feedback hoped for. Neonatal units have agreed to continue to seek parent feedback to ensure opportunities to improve the experiences of families are identified on an ongoing basis.