Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Wednesday, March 02, 2011.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Guidelines for Admissions to NICU, and Discharges and Transfers from NICU

Admissions

Guidelines for Admission to Level 3

1. Birthweight less than 1250g.
2. Gestation less than 30 weeks.  Some infants born at 30-32 weeks may be admitted to Level 3 because of staffing acuity.
3. Requirement for intermittent positive pressure ventilation.
4. Requirement for an exchange transfusion.
5. Any other baby whose clinical condition is such that they cannot be appropriately cared for in Level 2.

Guidelines for Admission to Level 2

1. Low Birthweight - under 2500g.
   Some babies between 2000 and 2500g may be able to go directly to the postnatal ward.
   This will depend upon the clinical assessment of the baby and whether the postnatal ward is deemed likely to provide an appropriate level of care or not.
2. Prematurity - 36 weeks gestation or less.
   For babies between 35 and 36 weeks gestation, criteria as in (1) apply.
3. Infection - suspicion of infection together with clinical concern.
4. Respiratory problems
   (a) Apnoea or cyanotic episodes.
   (b) Any respiratory distress causing concern.
   (c) Persisting signs of respiratory distress for more than one hour.
5. Gastrointestinal problems
   (a) Feeding problems severe enough to cause clinical concern.
   (b) Bile stained vomiting, or other signs suggesting bowel obstruction.
6. Metabolic problems
   Inability to maintain a serum glucose concentration greater than or equal to 2.6mmol/L despite adequate feeding.
7. CNS problems
   (a) Convulsion.
   (b) Moderate birth asphyxia, which may require monitoring for an initial period to ensure problems do not ensue.
8. Malformations
   Congenital anomalies that may require intervention unavailable on the postnatal wards, or an initial period of observation, eg Pierre Robin Syndrome.
9. Cardiovascular
   Problems requiring monitoring or intervention unavailable on the postnatal wards.
10. Miscellaneous
    Any baby that is causing concern to such a degree that the attending doctor or NS-ANP feels that the baby requires observation or treatment in Level 2. It is better for a baby to be admitted unnecessarily than for a baby requiring admission to be left on the ward.
11. Social issues/terminal care
    Such babies ideally be nursed on the ward with parents, or at home. On occasions (after multidisciplinary consultation) circumstances dictate that these babies require a period of care on Level 2.

Infants that have been born at very low birthweight or low birthweight, represent an at risk group of children. Increasingly they are being discharged home at a weight less than 2.5kg. The following guidelines are suggested when considering discharge of such infants.

1. The baby has to be gaining weight - it doesn't have to have reached any particular weight, however, as long as there is weight gain.
2. The baby has to be sucking all feeds.
   If breast feeding is being established, it is not a prerequisite that the baby is on full breast feeding prior to discharge, provided we are happy that the baby is able to suck strongly.
   However we must be sure that the mothers are aware of the need to continue to monitor progress once further feeding changes are made at home, i.e. a switch from complementing to fully breast feeding etc.
3. The baby must be able to maintain his or her temperature in a cot in a normal household environmental temperature.
   This is particularly important when discharging low birthweight babies home in the winter.
4. Parents must be willing and happy to take the baby home and to have demonstrated that they have adequate parenting skills.
   This may be self-evident, particularly when there have been other children in the family, although not always.
5. Some basic information should be known about the home environment and the community to which the infant is going, i.e. if they are living in a remote area in a caravan, then one would be less likely to effect a discharge home at a low birthweight.
6. There should be adequate community follow up services available.
   It may be appropriate to contact the general practitioner by telephone to discuss follow up.
   In remote areas details should be known about the availability of a Well Child Service visiting.
   The neonatal home care nurses will be able to provide some initial support and follow up and to provide liaison for ongoing community follow up.

Transfers & Discharges from NICU and PIN

Transfers from Level 3

• For transfers from Level 3 to Level 2 or PIN a formal transfer should occur between Level 3 Registrar or NS-ANP and the appropriate registrar or NS-ANP.
• Ideally the parents would have been told a few days in advance to accustom to the transfer and possibly have looked around Level 2 or PIN.
• A transfer letter should be in the notes (and should also be sent to the LMC/GP).
• The problem list should be up-to-date (as should happen when a discharge/transfer summary is prepared)

For infants discharged from Level 2

• Babies transferred to PIN need a formal letter if they have had a  complicated course whilst in Level 2.  If they have had a recent transfer summary from Level 3 to Level 2, this may not be necessary.
  • Babies who are transferred to PIN should have an up-to-date problem summary in the notes.
• Babies transferred to other hospitals must not go without a registrar or NS-ANP letter.
• Babies being transferred to towns outside the Auckland area should have a formal letter prior to discharge.

Discharge Documentation

All patients discharged from hospital must have:

• A full examination record on the appropriate form (include age in days, weight, length, head circumference).
• A plan for follow up clearly documented in the case notes.
• A record of any prescribed therapy.

Discharge Letters

• No baby is to be discharged from Level 3, Level 2, or PIN without a letter.
• For babies who are being discharged to the postnatal wards and where there are going to be delays in generating a discharge letter, the baby can be discharged with out a letter being available.  However, it is the responsibility of the resident team (registrar or NS-ANP) to ensure that a letter is completed as soon as possible and is filed in the notes of the baby.
• PLEASE ENSURE that the discharge letter contains the correct information.
  • The database can only use the information available within it.
  • It provides a structure for the letter, and makes an attempt at providing a letter that is nearly complete.  You need to check the letter you have produced and edit it in Word.
• The quality of the letters you sign your name to reflects on your abilities as well as the quality of the care that the baby has received in NICU.  PLEASE CHECK AND EDIT THE LETTERS BEFORE YOU SIGN THEM AND SEND THEM OFF.