Nottingham Neonatal Service - Clinical Guidelines

Transcription

1 Full Title of Guideline: Author: Directorate & Speciality: Patient group to which the guideline applies: Version: Neonatal Admission and Cot Management Guideline Stephen Wardle / Barbara Linley Directorate: Family Health - Children Specialty: Neonates Newborn Infants admitted to the Neonatal Units If this guideline supersedes V3 Stephen Wardle / Cath Henson another clinical guideline please be explicit about which guideline it replaces including version number: Date of submission: November 2017 Consultation Process: Ratified by: V4 Neonatal guideline meeting and senior neonatal staff. Neonatal Guideline Meeting Date: November 2017 Review Date: November 2022 Summary of evidence base this guideline has been created from: References to guidelines / studies used in the preparation of this guideline are detailed at its end This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. 1

2 Summary ing Referrals This guideline follows the principles set out in Neonatal Toolkit [1], NICE Quality Standard for Neonatal Care [2] and Neonatal Intensive Care Service Specification [3]. Prioritise Nottingham and Network admissions particularly those requiring surgery and babies below 26 weeks gestation (see priority list) Plan to keep referrals within the network pool of cots using other network hospitals to move babies within the network. Bed Management To be assessed, discussed and planned by Consultant Neonatologist / Service registrar and nurse in charge / ward sister on a shift by shift basis. Actively manage admissions and discharges to decrease length of stay and increase the service s ability to accept admissions Nursing shift proforma to be completed by 08:30 and Trust staffing App completed by 09:00 via the ipad. City Campus Neonatal Unit contact Kings Mill Neonatal Unit for cot and staff numbers after 09:30 Daily face time consultation by Consultant and nurse in charge from both campuses around bed management and nursing / medical staff numbers. Nurse in charge to liaise daily with the Children s Hospital site matron to provide unit status, number of cots occupied and staffing for the following 24 hours. On Fridays/ public holidays they require staffing numbers for the weekend. Identify cot spaces that could be used if discharge is imminent Actively manage the nursing resources to reduce the variation in nursing numbers between shifts Nursing Allocation should be as described in this document. The nurse in charge should calculate number of staff available including clinical support workers Calculate admission status / as follows Number of nurses available _ No. of L1 babies No. of L2 babies No. of L3 babies 4 = X Unit Status If X > 1 If X between 0 and 1 If X < 0 RED Always transfer babies back to referring hospitals when appropriate and move to transitional care when possible. QMC: Arrange the activity in the unit so that babies with special care needs are cared for in low dependency bays. Arrange activity to utilise bays 1-4 as intensive care / high dependency and bay 5 as low dependency. There should be no more than 2 babies in bay 1 and no more than 3 babies in bays 1-4. Bay 5 should have no more than 6 babies. City: Arrange activity in the unit so that babies with special care needs are cared for in low dependency bays. Arrange activity to utilise bays 1-3 as intensive care / high dependency and bays 4 and 5 as low dependency. There should be no more than 4 babies in each of bays 1-3. Bays 4 and 5 should have no more than 6 babies. 2

3 Allocate staff to babies by skill mix and level of care to achieve the optimum configuration. 1. Introduction This guideline describes the process by which admissions are accepted as being suitable. These evaluations should occur at the start of each shift and be discussed by senior nursing and medical staff on both campuses. However further discussions may be required during each shift when referrals for admission are made. Decisions with regard to the suitability of outside admissions are made by the clinical team involving neonatal medical staff, obstetric staff (when considering IUTs) and surgical teams (when appropriate). In general, outside admissions will usually be communicated by telephone to one of these teams. For surgical admissions the appropriate surgical consultant should be informed and for all admissions the Neonatal Consultant on service should be informed. Once the suitability of the referral for admission is established the following should occur: 1. Establish whether the service is in a position to accept, based on the bed management guideline (traffic light assessment - see below). 2. Determine the most appropriate location for the new referral, based on type of referral and capacity considerations. If consideration is being given to reorientation of the neonatal unit to accommodate an admission and balance staffing, then the consultant on duty/call should be involved in this discussion with a senior nurse before any movement is made. For some referrals consider would they be most appropriately placed on a paediatric ward or PCCU or neurosurgery ward? 3. When required, senior medical / surgical staff (SpR or Consultant) should discuss the referral directly with the referring team and transport team. Advice for further management should be given where appropriate. A.1 Categories of Admissions Primary responsibility in order of importance of the neonatal intensive care units is to:- Cat City Campus QMC Campus Admission allowed if traffic light 1 Infants of women booked in Nottingham including intrauterine Infants of women booked at Nottingham including intrauterine Discuss with nurse in charge, and post-natal and post-natal transfers consider transferring transfers from QMC Campus. from City Campus. between units in Nottingham. 2 Providing a regional intensive care provision for other infants delivered at City booked at other hospitals in the Trent Network (IUTs). Providing a regional intensive care provision for other infants delivered at QMC booked at other hospitals in the Trent Network (IUTs). 3 Providing a regional intensive care provision for infants with surgical conditions RED. Note if the IUT was accepted when the unit was less busy or if care was transferred to Nottingham during pregnancy for other reasons and is now threatening to deliver then these infants should be regarded as category 1. 3

4 4 Providing a regional intensive care provision for newborns with medical problems delivered within Trent Perinatal Network. Providing a regional intensive care provision for newborns with medical problems particularly when City is on RED or. 5 Providing a supraregional intensive care provision for infants with problems such as neurosurgical conditions / renal etc 6 Providing a supraregional intensive care provision for infants needing medical intensive care when cots are unavailable in other regions. Providing a supraregional intensive care provision for infants needing surgical or medical intensive care when cots are unavailable in other regions. if occupancy is acceptable (X 3) A.2 Network Referrals The Trent Perinatal Network is made up of Nottingham (Perinatal Centre), Derby (Local Neonatal Unit), Kings Mill (Local Neonatal Unit), Lincoln (Local Neonatal Unit) and Boston (Special Care Unit). As the lead centre for the network we have a commitment to try to provide intensive care for babies born in Trent particularly those below 26 weeks gestation and those with surgical conditions. This should be taken into consideration when these referrals are being considered. If we are unable to take a network referral try to keep referrals within the network pool of cots using other network hospitals to move babies within the network but ensure that babies below 26 weeks are transferred to a Perinatal Centre (Leicester or Sheffield are the closest). Consider some other options: a. Can the referral be delayed for 12 or 24 hours particularly if IUT? b. Could the referring unit take back a baby for convalescence in exchange for the acute baby? c. Could the baby s problem be dealt with consultant-to-consultant advice to avoid a transfer altogether? d. If the baby is not extremely preterm (<= 26 weeks) or surgical could it be referred to one of the Local Neonatal Units (Derby / Lincoln / KMH). B. Cot Management B.1 Occupancy In general occupancy of the units should run on average at around 70-80%. This means on average City Campus 19 babies/ QMC Campus 14 babies. Persistently high occupancy rates may be associated with increased risks of morbidity and mortality [1-3] and should therefore be avoided. However the most important factor is the number of nurses available to look after babies and this document emphasises the need to assess this in a uniform manner. By prospectively managing admission and refusal numbers, in a uniform and objective way, we aim to sustain the standard of care offered to the babies already in the NICU and improve staff morale. B.2 Calculation of Admission status Unit Status The nurse in charge needs to make a daily assessment of the level of care required using the classification of dependency from the BAPM / NNA system 2001, by the babies, this will allow the best nurse to baby ratio to be achieved. Then calculate as follows:- 4

5 Number of nurses available _ No. of L1 babies No. of L2 babies No. of L3 babies 4 = X Unit Status If X > 1 If X between 0 and 1 If X < 0 RED In the rare event that there are sufficient nurses but no spaces in bays 1-3 after correct allocation, then this may also need to be taken into account. This will only occur if there are more than 12 level 1 and level 2 babies at each site. If there is no cot availability at NUH, discussion will take place between sites with consultant and nurse in charge around bed management and potential transfers out. B.3 Nottingham Admission Status In addition to calculating the admission status for each unit it is important to consider the overall status of the Nottingham Neonatal Service, to be discussed on morning consultation between both units (nurses in charge and consultants). Face time via the ipad may be available to facilitate this. Consider any subspeciality, surgical, neuro and renal babies who are or may be able to move to appropriate wards. Do not accept out of network admissions (Category 6) when either unit is on RED unless X in the formula above is 3. B.4 Definition of Status Unit can accept all categories of admissions but if other unit is on red or amber consider carefully before accepting admissions from outside the network. Unit can accept admissions of categories 1 or 2 i.e. Inborn babies but not transfers in. Category 6 admissions should be refused. Category 3-5 admissions should be fully discussed with the attending consultant on an individual basis before a decision about refusal. In particular referrals for surgical care from within the Trent network should always be discussed with the on service / on call Consultant. RED Unit cannot accept any further admissions routinely. However where transfer of a woman booked at City or QMC is unsafe, labour or delivery is precipitous or a newborn baby becomes unexpectedly unwell the baby may require admission, stabilisation and transfer. Where there are booked women who may deliver and their infants are certain to require admission during RED status, negotiation should take place with the obstetric team to transfer them in utero to another appropriate hospital or have their delivery postponed if condition allows. If these are extremely preterm or surgical babies the possibility of transferring other babies to create space should be considered. During RED Status, if the allocation does not meet the cot management guideline, the Ward Sister should re-deploy staff to the clinical area from other non-clinical activities. i.e. Off service, Office Days, Study Days. The Ward Sister liaises with the nurse in charge on the alternate campus regarding staffing levels and acuity. 5

6 The Childrens hospital site matron should be contacted to see if any staff from the paediatric wards can be deployed to work on the neonatal unit. Note: If staff required for the City campus a Paediatric staff member can work on the QMC neonatal unit and a neonatal staff member can be sent to work at the City campus. Details of these activities will be made available. Housekeepers, Receptionists and senior members of the Nursing and Medical team should proactively prioritise workloads to support the clinical floor when informed of RED Status, Non clinical meetings will be held daily to inform such staff of the each unit s status. In RED Status the following support is invaluable, ensuring adequate supplies are available, cover for breaks, ensure hygiene and nutrition needs are met and supporting the needs of families. Senior staff should also support the nurse in charge in the difficult decision making process associated with RED status. B.5 Communication Good information is the foundation of good decision-making. Communication between nursing, midwifery and medical staff (both neonatal, obstetric and paediatric) is essential. The decision to confer RED status should be taken by the on service / on call Consultant after discussion with the Ward Sister / or nurse in charge and the following should be informed: - Both Neonatal Intensive Care Units Obstetricians at the hospital on RED and the Obstetric team at the other hospital, Delivery suite at the hospital on RED and the Delivery suite at the other hospital, PAC / MASFU. Childrens hospital site matron. B.6 Nurse Allocation 1. Allocate staff to the low dependency area: There should be a senior registered nurse in charge of the area to support the discharge process and co-ordinate care. The Family care and family support sister are available to help support the discharge process Monday to Friday if there is no low dependency coordinator. Babies requiring special care are looked after with a minimum of 1:4 staff-to-baby ratio at all times by either a registered nurse / midwife (QIS) or non-registered staff (e.g. an assistant practitioner or nursery nurse who has undertaken accredited training to a minimum of National Vocational Qualification (NVQ) 3 / Foundation Degree), working under the supervision of a registered nurse / midwife (QIS). [Refs toolkit 2, 3, 78] Support Workers There are two limiting factors to the allocation of babies in low dependency: a.) because of the geography of the neonatal units there are often 6 babies in low dependency. These can be cared for by a Registered nurse and a support worker i.e. 2 staff to 6 babies. b.) Support workers are not able to look after babies in oxygen or with intravenous fluids therefore if there are a large proportion of babies in oxygen or with intravenous fluids this limits the allocation. When there are more low dependency babies the ratios become easier to manage and we can deliver the toolkit ratio of 1:4. 2. High dependency area allocation:- Babies requiring high dependency care are cared for by staff who have completed accredited training in specialised neonatal care or who have undertaken the neonatal foundation programme and are working with the support of a registered nurse / midwife (QIS). A minimum of a 1:2 staff- 6

7 to-baby ratio is provided at all times (some babies may require a higher staff-to-baby ratio for a period of time). [ref toolkit ] Babies requiring intensive care are 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 / midwife (QIS). A minimum of a 1:2 staff-to-baby ratio is provided at all times (some babies may require a higher staff-to-baby ratio for a period of time). B.7 Nurse to baby ratio Establishment Figures Ideally we aim to operate at recommendations from the Neonatal Toolkit [1] and National Service Specification [3], however, this is not currently possible and difficulties with recruitment leave us short of the optimum number of neonatal nurses therefore this document set out a minimum acceptable standard. This is that one nurse can be allocated two level 1 babies, two level 2 or four level 3 babies Neonatal Toolkit [ref] and National Service Specification [ref] Minimum acceptable standard Level Level Level 3 4 (inc CSW) 4 There are a number of occasions where nurse-to-baby ratio needs to be 1:1 because babies need more care / intervention / monitoring. This ratio needs to be re-assessed daily by the nurse in charge / consultant. These include: - 1. Baby requiring end of life care 2. Baby requiring exchange transfusion 3. Unstable / acutely unwell baby on nitric oxide (if stable or non-acute then may not be required) 4. During transfer to radiology or theatre 5. Baby on dialysis 6. Pre-operative, unwell CDH. 7. Oesophageal atresia with repolgle and washouts B.8 Number of Staff Available The number of nurses available should be calculated from the number of qualified staff not including the nurse in charge on each shift as ideally the nurse in charge should not have a clinical allocation. If the nurse in charge does need to take a clinical allocation in an emergency the unit is on red and action should be taken to try to reduce the activity level or find additional staff from other areas. B.9 Skill Mix Ward Sisters should ensure that the off duty rota has the correct amount of staff that are needed each day. They should ensure that 70% of the team are Registered nurses. Non-registered staff (clinical support workers) In general there will be at least 1 clinical support worker on duty on each shift. These individuals will generally be deployed in low dependency but can also help out in high dependency, however cannot take a clinical workload of intensive care or high dependency babies. Dependant on allocation, the CSW are responsible for supporting and providing general housekeeping and equipment cleaning when required alongside the housekeeping/procurement team. B.10 Bed Management Principles Every attempt must be made to keep babies with their mothers; medical / nursing intervention in labour suite or postnatal ward may prevent admission to the NICU. If babies are admitted 7

8 unnecessarily when care could be provided in labour suite or a postnatal ward, or when there are delays in the diagnosis, treatment or discharge of babies valuable resources are wasted and cot shortages occur. Recognition of Social care status and concerns around the mother and her mental state should be considered before transfer of care is made. Planned admissions and planned transfers in, should be taken into account including their urgency and when or RED these should be deferred following Consultant to Consultant discussion. Potential admissions e.g. women being assessed on delivery suite should only be considered if women are actually in labour or if obstetric intervention is planned. Babies who are preterm but >34 weeks, have an expected weight of > 1.8kg and no anomalies should not be factored in as potential admissions. Consultant ward rounds should occur daily for all babies in the unit and the predicted length of stay and preparation for discharge should be discussed and the care pathway reviewed and amended if appropriate. Nasogastric tube feeding at home should be considered for the baby with the parents Babies who are receiving level 3 care should not remain in rooms / bays 1-3 City/ Bays 1-4 QMC when there is space and staffing for them in rooms / bays 4-5 City or Bay 5 QMC. Babies who are well / stable enough should be moved to the post-natal ward, transitional care and from rooms 1-3 to rooms 4-5 (if appropriate for nurse staffing). Babies who are stable enough for transfer back to referring hospitals should be transferred or have their transfers planned. Babies who no longer require neonatal care and fulfil the criteria for paediatrics ie 44 weeks/ potential for LTV or long term surgical care, need to be referred, by the service consultant to the appropriate paediatric teams. The nurse in charge should discuss bed availability on a daily basis with the children s hospital site matron. (Please refer to Gastroschisis, integrated surgical conditions, hernia, LTV pathways as point of reference) Also see discharging babies on home oxygen guideline (Neonatal Guideline B3). Babies should be discharged in the morning were possible, with paperwork completed the day before. Transfers out for Capacity Whilst we try to avoid transfers out for capacity they may sometimes need to occur. The baby being transferred should be determined by the consultant and nurse in charge and the parents should always be informed by a senior doctor (consultant or registrar) or experienced ANNP. Transfers out should be within Nottingham where possible but also consider the dependency of the baby being transferred and the level of unit they could go to based on their level of care / gestation. References 1. Toolkit for High Quality Neonatal Services. Report of the Neonatal Intensive Care Services Review DOH Oct Quality Standard for Neonatal Care. NICE 2010 ( carequalitystandard.jsp)

9 4. Nurse staffing in relation to risk-adjusted mortality in neonatal Care. Karen E StC Hamilton, Margaret E Redshaw, William Tarnow-Mordi. Arch Dis Child Fetal Neonatal Ed 2007;92:F99 F10 5. Patient volume, staffing, and workload in relation to risk adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation. Lancet 2002; 359: Relationship between probable nosocomial bacteraemia and organisational and structural factors in UK neonatal intensive care units. The UK Neonatal Staffing Study Group*. Qual Saf Health Care 2005;14: