Neonatal Implementation TRANSPORT PATHWAYS (Logistics) The plan is to transfer the longer term and complex neonatal intensive care to the Neonatal Intensive Care Unit (NICU) in Arrowe Park from January 2014. For the purpose of this paper a number of assumptions have been made:- 1. Both Ysbyty Glan Clwyd (YGC) and Wrexham Maelor Hospital (WMH) will operate as LNUs with a SCU at Ysbyty Gwynedd (YG) providing HDU. YG will retain 1 Intensive Care cot in order to resuscitate and stabilize babies prior to transfer to either the LNU or NICU. 2. Cheshire and Merseyside Neonatal Network Transport service will only provide a 24/7 retrieval service for the transfer of babies to the NICU and will not provide repatriations or uplifts within North Wales.. 3. It will be the responsibility of the North Wales Transfer team to provide a service to repatriate babies back to North Wales, uplifts, repatriation and transfers due to capacity / resource issues within North Wales. 4. South Wales is responsible for commissioning and organising the transfer of women and babies from Aberystwyth With all transfers and transport the following has been considered:- Commissioning responsibility What type of ambulance vehicle and crew is required What level/type/clinical competency of escort is required What is the target dispatch time Time taken to complete transfer Co-ordination of staff and equipment including return to their base Projected activity 1 Partner/family transport Any staff training issues will be picked up by the WOD workstream and contract negotiations will be addressed by the Finance & Contracts Workstream. The remainder of this paper will consider the range of scenarios requiring transfer of mother and/or baby. 1 For the purpose of this paper we have included the higher end of any estimates.
1. In-utero transfers from North Wales Obstetric Units to enable direct access to the Neonatal Intensive Care Unit YG, YGC, WMH Welsh Ambulance Services Trust () Collect mother and Midwife escort Arrowe Park Midwife to be transported back to referring unit by Taxi 40 mothers will require transfers per annum, with an estimated 50% delivering in Arrowe Park Transfers will be via Emergency Medical Service. (No other grade of ambulance crew are trained to assist the midwife if delivery occurs enroute). Dispatch time would depend upon the prioritisation of the 999, 2 response time target of 8 mins for a red call and 30 mins for a green call Midwife escort who will have clinical primacy (Will only need to carry drugs/medication as other equipment is standard on vehicles) Ambulance will be able to provide 1 seat for partner/relative (there are 3 seats and a stretcher in the saloon of all ambulances) Hand over and turnaround time in Arrowe Park estimate 60 mins Midwife will be transported back to referring unit by taxi allowing for the Ambulance and Crew to be deployed to any call once back in North Wales. BCU & WHSSC responsible for commissioning transport with 2 Red 1 calls are those where an immediate attendance is required to save life, e.g. Cardiac Arrest, Choking or exsanguinations haemorrhage including life threatening Ante Partum Haemorrhage or Post Partum Haemorrhage Red 2 calls are those where initial treatment and conveyance to a specialist facility is required to save life e.g. Heart attack or stroke Green 1 Calls where patients who require a face to face assessment to determine their needs. aim to attend these call within 30 mins.
2. Following transfer to Arrowe Park, if Mother does not deliver - discharged home or transferred back to local obstetric unit Arrowe Park Private Taxi or North West Ambulance Service (NWAS) Home, YG, YGC, WMH The vast majority of women will be discharged direct to their home and whenever possible use personal transport options. If this is not feasible, transport would be arranged via car e.g. hospital taxi (BCU funding responsibility) For those women requiring transfer back to the referring unit, a midwife escort will be required (not a paramedic crew). This will be a routine booking and be arranged by Arrowe Park with NWAS. Estimates that 20 mothers will not deliver (majority of these will be discharged from Arrowe Park, therefore not requiring ambulance/midwife). BCU will be responsible for commissioning any activity for transfer with NWAS.
3 Ex-utero Transfers to NICU North Wales Unit contacts Cheshire & Mersey Side Cot Bureau to agree transfer to NIC. Time scales for retrieval will be agreed at this point Cheshire & Merseyside Neonatal Network Transfer Team (Based at LWH) inform Proceed to LWHs to collect team and travel to referring unit CMNTT and arrive at referring hospital YG, YGC, WMH Transfer to Arrowe Park Transport team and equipment back to LWH Estimates that there will be 20 3 babies requiring per year (this would be in addition to the 11 babies per year who are already collected from North Wales requiring surgical intervention). There for it is estimated that 31 babies will require transfer by the CMNN Team Response time for the transport team will be dependent upon clinical need and agreed between the referring unit and the cot bureau based at LWH. The average time for dispatch, retrieval and return the transport team to LWH is estimated to be 8 hours. Alternative transport arrangements will be needed for mother/parent if no seat available in Ambulance. 4 WHSSC/BCU responsible for commissioning this service with LWH and NWAS 3 Estimated activity of 15 babies born at < 26+ weeks gestation and 10 > 26+6 weeks requiring long term and complex intensive care 4 Three seats are available in the Ambulance, if they are not taken by the transferring team, the remaining seat will be available for one of the parents
4. Repatriation from NICU to LNU/SCUs in North Wales (This also applies for babies transferring back from Alderhey etc following surgery, which already takes place) North Wales Transfer Team (Based at YGC) Collect and transport team and incubator/equipment Arrowe Park YG, YGC, WMH Return Team and kit back to YGC Repatriation of neonates back to North Wales are not time critical (24 hours notice) and can be safely conveyed by an Urgent Care Crew with medical/nursing escort Arrowe park handover time approximately 60 mins time at YG and WMH will take approximately 60 mins. Staff and kit would then need transport back to YGC. Activity will be approximately 40 babies Alternative transport arrangements will be needed for mother/parent if no seat available in Ambulance. 5 BCU will be responsible for commissioning this service with 5 Three seats are available in the Ambulance, if they are not taken by the transferring team, the remaining seat will be available for one of the parents
5. Ex-Utero up-lifts from YG to YGC LNU (This already happens) North Wales Transfer Team (Based at YGC) Collect and transport team and incubator/equipment Arrive at referring unit YG Transfer Baby and team to YGC These transfers would not be time critical that is dispatch time within 1 hour of accepting referral. Response time would be a clinical decision depending upon individual babies need and will only be required between 9am 9pm time at referring hospital estimated to be 2 hours Predicted activity will be 15 from YG. If there is no LNU cot available in YGC, baby will be transferred to WMH (This already happens) Alternative transport arrangements will be needed for mother/parent if no seat available in Ambulance. 6 BCU/WHSSC responsible for commissioning service with 6 Three seats are available in the Ambulance, if they are not taken by the transferring team, the remaining seat will be available for one of the parents
6. Internal repatriation of Neonates within North Wales North Wales Transfer Team (Based at YGC) or Nurse from receiving Neonatal Unit Collect baby, transport team and incubator Arrive at receiving unit YG Transfer team and kit back to YGC Transfer back is not time critical (24 hours notice) Transfers can be carried out by an Urgent Care Crew with appropriate nursing escort ideally from receiving unit time at receiving hospital, 60 mins Based on the number of in-utero 7 and ex-utero transfers from YG to YGC, the estimated activity will be 30 Alternative transport arrangements will be needed for mother/parent if no seat available in Ambulance. 8 BCU responsible for commissioning service with 7 Estimated that 50% of in-utero transfers will result in delivery 8 Three seats are available in the Ambulance, if they are not taken by the transferring team, the remaining seat will be available for one of the parents
7. Internal in-utero transfers for access to LNU (This already happens) YG Collect Patient and Midwife Escort Glan Clwyd Obstetric Unit Midwife to return to base by taxi EMS Crew. May be a BLS Technician crew. There is no need for a Paramedic as the escorting midwife will have clinical primacy. Dispatch time would depend upon the prioritisation of the 999, 9 response time target of 8 mins for a red call and 30 mins for a green call Midwife escort return to base could be undertaken by taxi in order to release the Ambulance crew at earliest opportunity Estimated handover time 30 mins Partner would be able to accompany the mother on transfer. In-utero transfers from YG to YGC is estimated at 15 per year BCU/WHSSC will be responsible for commissioning this service with If the woman does not deliver and is stable she would be discharged home and use own transport. If no transport available this would be provided by taxi. There may be a very small number of women who are transferred back to their local obstetric unit and they would require ambulance and midwife escort. This transfer would not be time critical and could be done by UCS, this would only happen infrequently (refer to scenario 2) 9 Red 1 calls are those where an immediate attendance is required to save life, e.g. Cardiac Arrest, Choking or exsanguinations haemorrhage including life threatening Ante Partum Haemorrhage or Post Partum Haemorrhage Red 2 calls are those where initial treatment and conveyance to a specialist facility is required to save life e.g. Heart attack or stroke Green 1 Calls where patients who require a face to face assessment to determine their needs. aim to attend these call within 30 mins.