Nottingham Neonatal Service - Clinical Guidelines Guideline A1

Title: Neonatal Admission and Cot Management Guideline

Version: v3 July 2009
Date: v1 April 2003. Revised v2 March 2007
Review date: July 2012
Approval: Neonatal Directorate / Clinical Guidelines Meeting
Author: Stephen Wardle, Cath Henson
Job title: Consultant Neonatologist, Matron Neonatal Services
Consultation:
Distribution: Neonatal Units
Risk managed: Inappropriate Refusals / Transfers

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. Caution is
advised when using guidelines after a review date. This guideline has been registered with the
Nottingham University Hospitals Trust.

Summary

Accepting Referrals
• Prioritise Nottingham admissions and network admissions particularly those requiring surgery
and babies below 26 weeks gestation (see priority list)

• Attempt to keep referrals within the network pool of cots using other network hospitals to move
babies within the network.

Bed Management
• Actively manage admissions and discharges to decrease length of stay and increase the
service’s ability to accept admissions

• Identify cot spaces that could be used if discharge if imminent

• Actively manage the nursing resource 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 (count as 0.5).

• Calculate admission status RED / AMBER / GREEN as follows

[Number of staff available (not including co-ordinator)] minus [(Number of Level 1 babies divided by
2) + (Number of Level 2 babies divided by 2) + (Number of Level 3 babies divided by 4)] = X

If X > 1 = GREEN, X < 0 = RED, X between 0 and 1 = AMBER

• Always transfer babies back to referring hospitals when appropriate and move to transitional
care when possible.

• Arrange the activity in the unit so that babies with low dependency needs are cared for in low
dependency bays

• Allocate staff to babies by skill mix and level of care to achieve the optimum configuration.

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1. Introduction

This guideline describes the process by which admissions are accepted as being suitable

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 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 duty 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.
3. Senior medical / surgical staff (SpR or Consultant) should discuss the referral directly with the
referring team and give advice for further management where appropriate.
4. Arrange transport with transport co-ordinator / team and plan most suitable members of the
transport team.

A.1 Categories of Admissions

Primary responsibility in order of importance of the neonatal intensive care units is to:-

City Campus QMC Campus Admission allowed if traffic light

1 Infants of women booked Infants of women booked in GREEN or AMBER
at in Nottingham (including Nottingham including (Discuss with co-ordinator if
intrauterine and post-natal intrauterine and post-natal AMBER - consider transferring
transfers from QMC transfers from City between units in Nottingham).
Campus). Campus. Discuss with consultant if RED.
2 Providing a regional Providing a regional GREEN
intensive care provision for intensive care provision for Discuss with consultant if RED or
other infants delivered at other infants delivered at AMBER.
City booked at other QMC booked at other Note if the IUT was accepted when
hospitals in the Trent hospitals in the Trent the unit was less busy or if care
Network (IUTs). Network (IUTs). 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 Providing a regional Providing a regional GREEN.
intensive care provision for intensive care provision for Discuss with consultant if RED or
infants with surgical infants with surgical AMBER.
conditions if QMC NICU conditions
on RED. Always check
that this is possible with
surgical team.
4 Providing a regional Providing a regional GREEN.
intensive care provision for intensive care provision for Discuss with consultant if RED or
newborns with medical newborns with medical AMBER.
problems delivered within problems particularly when
Trent Perinatal Network. City is on RED or AMBER.
5 Providing a supra-regional GREEN.
intensive care provision for Discuss with consultant if RED or
infants with certain AMBER.
problems such as
neurosurgical conditions

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6 Providing a supra-regional Providing a supra-regional GREEN.

intensive care provision for
infants needing medical
intensive care when cots
are unavailable in other
regions.
intensive care provision for
infants needing surgical or
medical intensive care
when cots are unavailable
in other regions.

A.2 Network Referrals

The Trent Perinatal Network is made up of Nottingham (Perinatal Centre), Derby (Local Neonatal
Unit), Mansfield (Special Care 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).

B. Cot Management Guideline

B.1 NICU at NUH City Campus

The unit consists of five rooms and four cubicles: - The level of care of babies that can be cared for
in each room is as follows: -

Room 1 - 3 Twelve Level 1 / 2 cots

Room 4 Two Level 2 / Two/Four Level 3 cots
Room 5 Four Level 3 cots
Cubicles Four Level 3 cots (other levels of isolated babies)

Realistically the number of babies of each level of care that can be cared for at any time is limited
by the number of nursing staff available and these designations just show in which areas babies of
each level can be cared for. Because of the walls between each bay cross cover between nurses
at times when there are less nurses present is more difficult and this can sometimes be a limiting
factor to admission of new babies.

B.2 NICU at NUH QMC Campus

The unit is distributed between five bays:-

Bays 1-3 Twelve cots

Bay 4 Six cots
Bay 5 Six cots

The unit’s current cot capacity is 20 cots which is made up of seven level 1, seven level 2 and six
level 3 cots. These can be organised in several different ways between the five bays depending
on the case mix at any particular time.

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The best available nurse to baby ratio should be achieved by allocating staff to babies according to
skill mix and level of care.

B.3 Nurse Allocation

1. Allocate staff to the low dependency area:
There should be a senior nurse in charge of the area to support the discharge process and co-
ordinate care in this area.

One nurse and a support worker can look after a maximum of 6 babies. One nurse and two
support workers can look after a maximum of 8 babies. If the number of level three babies rises or
if level two babies are in this area another nurse should be allocated to support the low
dependency team.

2. High dependency area allocation:-

The minimum standard is two level 1 babies per nurse and two level 2 babies per nurse - if
appropriate a support worker can be brought into the area to support the team particularly if there
are level 3 babies in the high dependency area but he / she would not have a workload of level 1 or
2 babies.

B.4 Occupancy
In general occupancy of the units should run on average at around 70-80%. For each unit this
means on average 14-16 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.

B5. Calculation of Admission status

Unit Status
When the best nurse to baby ratio has been achieved check the level of care required by the
babies then calculate as follows: -

[Number of staff available (not including co-ordinator)] minus [(Number of Level 1 babies divided by
2) + (Number of Level 2 babies divided by 2) + (Number of Level 3 babies divided by 4)] = X

Then the status of the unit is defined as follows: -

X Status
≥1 GREEN
0 - 0.99 AMBER
<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 14
level 1 and level 2 babies at each site.

B.6 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. Do not accept out of network admissions (Category 6)
when either unit is on RED unless X in the formula above is ≥ 3.

B.7 Definition of Status

GREEN
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.

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AMBER
Unit can accept categories of admissions 1-2 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
(Gestation < 32 weeks) during RED status negotiation should begin to transfer them to the other
hospital or have their delivery postponed.

During RED Status the Unit Coordinator should re-deploy staff to the clinical area from other non-
clinical activities. i.e. Off service, Office Days, Study Days
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 Unit Coordinator in the difficult decision making process
associated with RED status.

B.8 Communication
Good information is the foundation of good decision-making. Communication between nursing,
midwifery and medical staff (both neonatal and obstetric) is essential.

The decision to confer RED status should be taken by the on service / on call Consultant after
discussion with the Unit Coordinator 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.

B.9 Nurse to baby ratio

Establishment Figures
Ideally we aim to operate at recommendations from the BAPM 2001 standards of care, however,
neonatal intensive care is not currently funded to this level therefore this document set out a
minimum acceptable standard. This is that one nurse can be allocated two level 1 babies, three
level 2 or four level 3 babies or a mix as agreed by the nurse and unit coordinator.

BAPM 2001 New workforce document Minimum acceptable

draft recommendations standard
(2009)
Level 1 1 1 2
Level 2 2 2 2
Level 3 4 (not inc CSW) 3 (inc CSW) 4 (inc CSW)

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There are a number of occasions when nurse to baby ratio requires a one to one ratio. These
include: -
1. During admission until triaged
2. During transfer
3. Baby on nitric oxide
4. Baby requiring terminal care
5. Baby requiring exchange transfusion
6. Multiple system failure
7. Complex surgical need

Occasionally in order to facilitate transport for short periods of time, particularly if the transport will
reduce total workload and occupancy (e.g. back transfer or transfers out), it may be necessary for
nurses to take a slightly higher workload but this decision should always be made by the nurse co-
ordinator on duty for that shift.

B.10 Number of Staff Available

The number of nurses available should be calculated from the number of qualified staff not
including the co-ordinator on each shift as ideally the co-ordinator should not take a workload if
possible. There will be times when it is necessary for the co-ordinator to take a workload, even
though this is not ideal when on red or amber status.

B.11 Skill Mix

Ward Managers 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 and of that
70%, 60% are deemed competent to care for babies in intensive care and administer IV drugs).

The skill mix of the nursing staff is important in defining what sort of level of activity can be done
and what acuity of babies can be cared for. If the skill mix is poor then the unit status should be
downgraded by one level (i.e. GREEN becomes AMBER, AMBER becomes RED etc) for that shift.

Non-qualified staff (clinical support workers)

One qualified nurse and one clinical support worker can look after 6 level 3 babies. Therefore for
calculation of the number of nurses available clinical support workers should count as 0.5.

B.12 Bed Management Principles

Every attempt must be made to keep babies with their mothers; nursing intervention in labour suite
or postnatal ward may prevent admission to the NICU. If babies are admitted 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.

Planned admissions and planned transfers in should be taken into account including their urgency
and when AMBER 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.

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 should be reviewed and
amended if appropriate.

Babies who are receiving level 3 care should not remain in rooms / bays 1-3 when there is space
and staffing for them in rooms 4-5.

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).

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Babies who are stable enough for transfer back to referring hospitals should be transferred or have
their transfers planned.

Babies should be discharged in the morning were possible, with paperwork completed the day
before.

Babies should be discharged equally throughout the week including Friday Saturday and Sunday.
Weekend discharges can be given a 72 hour appointment for home follow up and advised to ring
the unit if needed.

References
1. 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–F103
2. Patient volume, staffing, and workload in relation to riskadjusted outcomes in a random
stratified sample of UK neonatal intensive care units: a prospective evaluation. Lancet 2002;
359: 99–107
3. 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;14:264–269