Download Neonatal services literature

Neonatal services
literature review
Author: Sarah Andrews, Principal in Public Health, Jo Charles, Associate
Specialist Public Health, Rob Atenstaedt, Consultant in Public Health,
Siobhan Jones, Consultant in Public Health, Gill Richardson, Executive
Director of Public Health, Aneurin Bevan LHB, Andrew Jones, Executive
Director of Public Health, BCU HB
Date: July 2011
Version: 1 (Final)
Publication/ Distribution:

Internet
Review Date:
Purpose and Summary of Document:
To answer the question:
What is the current evidence base on best practice in relation to the
delivery of safe and sustainable neonatal services?
Work Plan reference:
NEONATAL SERVICES LITERATURE REVIEW ................................. 1
1
SUMMARY OF KEY MESSAGES ................................................. 3
2
BACKGROUND ......................................................................... 5
2.1 Methodology ........................................................................ 5
2.2 The importance of neonatal health .......................................... 6
2.3 Factors impacting on neonatal health ...................................... 6
2.4 Definitions of levels of service provision ................................... 7
3
WORKLOAD AND DEMAND ...................................................... 8
3.1 Rising birth rate .................................................................... 8
3.2 Rising risk factors in mothers ................................................. 8
3.3 Medical advances .................................................................. 9
3.4 Working time rationalisation ................................................... 9
3.5 Staffing levels and structures ................................................. 9
4
FURTHER CHALLENGES ......................................................... 10
4.1 Transport ............................................................................ 10
4.2 Support to families............................................................... 11
4.3 Infant feeding ..................................................................... 11
4.4 Capacity ............................................................................. 12
4.5 Neonatal Unit environment ................................................... 12
4.6 Data collection and analysis .................................................. 12
5
MODELS OF SERVICE CONFIGURATION ................................ 13
5.1 International comparisons on prematurity rates ....................... 13
5.2 International comparisons on service structure ........................ 13
5.3 Innovations in service structures ........................................... 13
6
PREVENTING NEONATAL ILL-HEALTH ................................... 14
7
RECOMMENDATIONS FROM THE LITERATURE ....................... 15
7.1 All Wales Neonatal Standards (21) ......................................... 15
7.2 National Institute of Health and Clinical Excellence (NICE) quality
standard on specialist neonatal care ...................................... 16
7.3 British Association of Perinatal Medicine (BAPM) recommendations
(8) .................................................................................... 16
7.4 Inquiry into Neonatal Care in Wales (9) .................................. 17
7.5 Royal College of Obstetricians and Gynaecologists Standards for
Maternity Care (37) ............................................................. 19
8
CONCLUSIONS ...................................................................... 20
9
APPENDICES ......................................................................... 20
Public Health Wales
1
Neonatal services literature review
Summary of key messages
Prevention and early intervention
 Neonatal ill-health is associated with many preventable risk factors,
including maternal smoking and obesity
 Preventing premature/Low Birth Weight births (mainly by
preconceptual and prenatal care and education) can bring huge
savings. These account for a high proportion of maternity/obstetric
care costs
 Socioeconomic factors are the biggest predictors of LBW and
prematurity
 Failure to address avoidable maternal ill-health is both expensive
and leads to worse neonatal outcomes.
Mortality and outcomes
 Systematically identifying and managing risky pregnancies reduces
Neonatal Intensive Care Unit (NICU) admissions.
 Low birth-weight babies have better outcomes if delivered at
hospitals with regional NICUs
 Transport and transfers are often poorly organised: dedicated
services improve outcomes
 Long-term outcomes are improved by meeting parents’ needs: for
psycho-social support, information about the baby’s condition,
breastfeeding support, support at home
 Tentative evidence supports new community services to shorten
hospital stays, including videoconferencing links with the home and
support at home from specialist staff. Community neonatal services
reduce length of stay without increased readmissions but costings
are not yet robust
 There are promising examples of new care practices but they still
lack robust evidence
Data and governance
 Data and data collection systems need improvement: there are still
some apparent statistical differences which arise as a result of
variance in definitions
 Managed clinical networks result in improved services and outcomes
Design of NICUs
 Planned capacity for NICUs should not exceed eighty per cent.
 Layout and design can significantly reduce healthcare associated
infections
 Accommodation and facilities for parents can shorten length of stay,
including play areas for siblings and comfortable sitting areas
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Evidence supports Unit layout which allows for maximum family
involvement and provides babies with reduced noise and light levels
Costs
 Economies of scale can be achieved but at the price of reduced
access
 Some capacity issues can be addressed by looking at staff roles and
skill mix, as long as sufficient competency based specialist training is
offered
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2
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Background
The purpose of this report is to provide information to support the North
Wales Review of Maternity, Neonatal, and Gynaecology and Child Health
services. The aim of the review is to describe the optimum service delivery
model that will ensure safe, sustainable and efficient maternity, neonatal
and paediatric health services are provided for the population of North
Wales. The future model of service delivery will seek to improve
population health and optimise health and well-being outcomes for women
and children.
In order to ensure that discussion and debate are as well-informed as
possible, this paper seeks to provide:

An understanding of the background to the current situation

A summary of key guidance and recommendations made by national
bodies and authorities

Findings from a targeted review of key sources

An indication of the key aspects of safety, quality and sustainability
against which proposed options generated within the review process
may be viewed.
2.1
Methodology
Due to the short timescales involved in undertaking this review, a method
drawn from an approach known as Rapid Appraisal has been used.
Searches were undertaken of core databases, topic specific databases and
meta search engines for recently-published (since 2000) evidenceinformed material. Here the phrase “evidence-informed” is used
purposefully to distinguish it from the more familiar term “evidencebased”. Use of the term evidence-based would imply
1. a systematic review approach to ensuring all relevant literature is
identified;
2. reference to a “hierarchy of evidence”; and
3. structured critical appraisal of the individual pieces of literature.
This review has used a structured approach to identify relevant reports
and papers, many of which are summaries of available evidence with
recommendations for good practice. The most important sets of
recommendations are reproduced in full in the penultimate section. The
initial searches were undertaken by the Public Health Wales Library and
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Knowledge Management Services Team, and their full search strategy is
listed as an Appendix.
2.2
The importance of neonatal health
Neonatal services provide care to babies born prematurely or with an
illness or condition requiring specialist care. Sixty per cent of infant deaths
occur during the neonatal period.(1)
Infant mortality rates have been falling in developed countries, however
there is significant variation between developed countries. In Wales there
is variation in rates between different economic groups, with the risk of
preterm birth (and associated mortality) highest amongst those who live
in deprived areas. (2)
Preterm infants who survive birth are at greater risk of developing both
short and long-term health complications including cerebral palsy,
sensorial and motor disabilities, respiratory illnesses and learning and
behavioural disorders. The earlier a baby is born the less developed its
organs will be and the higher the risk of medical complications later in life.
This causes major personal impact on the child and its family,
psychologically, financially and socially, and also wider cost implications
for health and other public services and the child’s contribution to society.
Other neonatal health problems can have a similar impact, and treatment
and care by neonatal services aim to minimise or prevent this.(3)
Relevant to this review is the significant cost of neonatal services: some
studies have shown that 5% of the babies generate 75% of the costs of
neonatal care, and that prematurity is responsible for more than 50% of
costs.(4) One recent (2009) study calculated average costs per baby at
between around £12,000 and £18,000 depending on the level of the unit,
excluding ambulance costs. The average cost per baby of ambulance
transport, if required, was around the same amount again in addition. (5)
Successful neonatal treatment and care can save future healthcare costs
in many cases but also enables the survival of babies who will need
ongoing care.
Thousands of infant deaths, chronic disabilities and health conditions
linked to preterm birth and other neonatal health problems, and their
related costs, could be prevented through improved neonatal prevention,
treatment and care. (6;7)
2.3
Factors impacting on neonatal health
Preterm birth was the cause of 31.1% of deaths after live birth in 2008 in
Wales, and remains the major cause of infant mortality. Other main
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causes of death were congenital anomaly (24.3%), sudden unexplained
death in infancy (10.8%), infection (14.9%) and intrapartum events
(6.8%). (2)
The main risk factors for prematurity (3) are multiple pregnancy, previous
preterm birth, and maternal uterine or cervical abnormalities and
infections. Other risk factors are listed below. The impact of multiple births
as a result of fertility treatment on the service needs to be further
investigated.
Table 1: risk factors for neonatal ill-health, beyond prematurity
and previous preterm birth
Maternal
and familial
lifestyle
factors
Maternal
medical
conditions
Familial
demographic
factors

Smoking

Alcohol consumption

Drug use

High stress levels/long working hours

Late or absent prenatal care

Lack of social support

Infections (urinary
sexually transmitted)

Uterine or cervical abnormalities

High blood pressure

Diabetes

Clotting disorders

Underweight

Obesity

Mother aged under 17 or over 35

Low socio-economic status/deprivation

Ethnicity
tract,
vaginal,
(3)
2.4
Definitions of levels of service provision
According to the British Association of Perinatal Medicine Standards (8)
neonatal care services can be categorised as follows:
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Level 1
Level 2
Level 3
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Units provide Special Care but do not aim to provide any
continuing High Dependency or Intensive Care.
Units provide High Dependency Care and some short-term
Intensive Care.
Units provide the whole range of medical neonatal care,
including Intensive Care, but not necessarily all specialist
services such as neonatal surgery.
Workload and demand
Of the 33,000 babies born in Wales each year approximately 3,800 are
admitted to neonatal units. (9) Several factors have combined to increase
the demand and workload for neonatal services, including the rising birth
rate, rising risk factors for prematurity, medical advances in fertility
treatment and in the survival of premature and sick babies, and
restrictions on working hours which limit availability of staff. These have
caused capacity issues for most services.
3.1
Rising birth rate
There has been a rise of more than 20% in the birth rate in Wales since
2001/2. This followed a period of falling birth rate. There have been
increases in the rate for all age groups, particularly for women aged over
40 and under 20. (2) Both of these groups include women who are at
higher risk for problem pregnancies and whose babies may have more
need of neonatal care.
3.2
Rising risk factors in mothers
Both deprivation and obesity are recognised risk factors for prematurity.
(3)
North Wales contains some areas of high deprivation, and 12% of its
Lower Super Output areas are in the most deprived fifth of the Welsh
population. These pockets of deprivation are mainly found in urban areas
such as Bangor, Rhyl, Blaenau Ffestiniog and Wrexham, however
scattered areas of rural deprivation are also present, can be more extreme
and are less well mapped.
In North Wales 54% of adults were overweight or obese in 2008, and the
trend is clearly rising with high levels of overweight and obesity already
apparent in children and teenagers.
Both of these factors, along with others particularly smoking, are
contributing to a rise in the numbers of babies admitted to neonatal units.
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A population profile has also been produced to inform this review, which
gives detailed information on the status of maternal and child health in
North Wales.
3.3
Medical advances
The availability of assisted conception has produced more multiple
pregnancies, which are more likely to be under weight and or premature;
and many more vulnerable babies are surviving after being admitted for
neonatal care as treatments improve, however this raises the numbers
being treated. (9) (10)
Medical intervention is now routinely available for extreme prematurity,
which has dramatically reduced the age at which survival can be expected.
The WAG Inquiry into Neonatal Care in Wales highlighted the huge
technical advances in neonatal care both in terms of babies surviving at
much lower gestational ages and the successful management of conditions
such as gastroschisis, where babies would once not have been expected to
survive (9)
3.4
Working time rationalisation
Changes in the expectations around working hours of medical staff – both
trainees and consultants - have had major impact in the delivery of
services both in the UK and in other parts of the world. In the UK this has
been the result of the phased implementation of the European Working
Time Directive (EWTD), but even without such requirements, similar
changes have been witnessed elsewhere. Under EWTD, Doctors should
work a maximum 48 hour week.
One outcome of the changes to working hours and redesign of the way in
which doctors are trained has been a move towards consultant-delivered
services in some areas. (11)
These changes have resulted in intense pressures on service capacity as
currently structured.
3.5
Staffing levels and structures
Staffing levels required to support the different levels of care are generally
agreed: for example nursing levels should be one to one in intensive care,
one nurse to two babies in high dependency care and one nurse to four in
special care, although it is claimed that only 3.8% of UK neonatal units
achieve this. (12) One evaluation found that mortality was raised with
increasing workload in all types of Neonatal Intensive care Units. (13)
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Staffing levels in Wales, for both medical and nursing staff, were described
in a 2007 international comparison report as critically low (14).
There are shortages of staff at all levels in Wales. Shortfalls are being
addressed by attempting to improve recruitment and retention of staff.
The situation is also being addressed by training, again at all levels, but
aspects of present configurations make this difficult to sustain, for
example nursing staff cannot be released to attend training when staff
numbers are low. (15)
Models of care involving Advanced Neonatal Nurse Practitioners have been
assessed very positively by a number of studies, (16) (17) (18) (19) which
generally find that nurses can undertake many tasks safely as long as
they have sufficient specialist training.
4
Further challenges
4.1
Transport
Neonatal services depend on the availability of reliable transport services
to bring babies and their mothers to the most appropriate care setting to
meet their needs. Ideally the level of care required can be anticipated and
transport can be in utero, which is safest, however many problems only
become apparent at delivery or later, and this may necessitate
stabilisation and transport to a higher level unit from the place of delivery
or in some cases from home. (20)
Some transfers, identified as “inappropriate” as they are for non-clinical
reasons, are caused by lack of capacity in a service which would otherwise
provide an appropriate level of care. Capacity issues can cause knock-on
inappropriate transfers as units are in turn affected by incoming cases and
have to refuse or move admissions.
Problem issues identified over transport include:

Staff having to leave units to accompany babies in transit

Availability and response times from the Ambulance Service

Journey times affecting outcomes
In the UK, only Scotland has designated neonatal transport teams and a
centralised transport network. (14) The All-Wales Neonatal Standards call
for the commissioning of transport teams, which may vary in model
according to local need. (21)
The RAND technical report, 2007, noted that in comparison to other
countries, Wales had poor provision for neonatal transfers, with a lack of
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an integrated transport network, dedicated transport staff and dedicated
vehicles (14):
Neonatal transport in the UK has also been criticised for its lack of
standardisation, a lack of understanding of the effect of transport on
neonatal physiology, and for potential legal implications which could
provide challenges. (22) The Welsh Assembly Government has now
approved funding for a neonatal transfer service starting in January 2011.
4.2
Support to families
It is recognised that outcomes for babies are improved by providing
appropriate support for parents and families.
The Poppy project found that although neonatal units usually provide
outstanding clinical care, less consistent attention has been paid to nonclinical issues and how these affect a family’s journey through neonatal
care and the transfer from hospital to home. Staff are invited to consider
the ingredients of family-centred care and how it feels to be in the
parents’ shoes. (23)
Parents require accommodation to be able to stay close to their babies,
and reviews have repeatedly set out minimum standards for what should
be provided for them, including access to a telephone, kitchen facilities, a
sitting area and playing areas for siblings. Despite this many units have no
accommodation provided for parents, and what there is may be only
funded through the efforts of the voluntary sector. (23)
Parents also require information about their child’s condition, both verbal
and written, and emotional and psychological support. Particular help is
needed over transitional care as parents prepare to take babies home,
some still requiring high levels of additional care.
4.3
Infant feeding
Babies receiving neonatal care benefit greatly from receiving breast milk,
given their vulnerability, and all available standards highlight the
importance of using the available framework of the UNICEF Baby Friendly
Award levels for hospital and community services. NICE guidance states
that breastfeeding support should be made available regardless of the
location of care. (24) Providing breast milk for babies receiving neonatal
care services can be challenging and services have a responsibility for
making it as easy as possible for mothers to express and store milk for
their babies, including providing electric breast pumps and space and
encouragement to use them. In some cases donated milk from breast milk
banks may be required.
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The UNICEF standards are exacting and all staff must be aware of how
their actions can reinforce or undermine achievement of the award. Coordination of clinical, training and strategic aspects is required. (25)
4.4
Capacity
Planned capacity of neonatal units should not exceed 80%, as it has been
suggested that the increase in mortality becomes statistically significantly
worse above that level. (6)
Other sources have recommended planning to aim for 70% capacity as
safer. The Bliss survey in 2008 found that 38% of the neonatal units in
Wales say they exceeded 100% capacity at some point during 2007.
When units become full then even planned admissions may have to
transfer elsewhere, usually long distances at short notice and sometimes
outside Wales, putting great strain on families and involving safety risks
for babies. Multiple births may be accommodated in different hospitals,
and the inevitable reduced contact with parents causes poorer outcomes
and impossible demands on families. (12)
4.5
Neonatal Unit environment
The physical layout of neonatal units, in particular the cot to sink ratio,
has been found to have an impact on the rates of Healthcare Associated
Infections. (26) The acoustic environment also requires planning, taking
into account that there are some clinical advantages in crowding (keeping
a maximum number of babies in view at one time).(27)
4.6
Data collection and analysis
One study found that there was confusion in neonatal services and a lack
of definition over criteria for service review, recommending better
standards of national and regional data collection and analysis to allow for
better service planning and audit. (28)
Other papers have also supported the requirement for improvements in
data collection (14) (29) (1)(reference).
Research is called for over a range of issues, for example longitudinal
follow up studies of outcomes in high risk infants to assess the benefits of
interventions. (30)
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5
Models of service configuration
5.1
International comparisons on prematurity rates
The rates of premature births in developed countries can be compared as
one of the indicators of maternal and child health, but also as part of an
exercise in comparing neonatal care systems. (See Appendix 1) Rates
range between the United States of America at one end, and Sweden at
the other with less than half rate of the USA. Wales has similar rates to
many other European countries, and is a little lower than England. (14)
(3)
5.2
International comparisons on service structure
Direct comparisons between countries are difficult as most have different
health care structures and are affected by population distribution patterns.
Statistics are collected differently and varying definitions may be used, for
example of prematurity and levels of service.
A key aspect of the debate is around the level at which centralisation of
services is essential to enable specialist excellence and how to retain
equity of access. The highest spend (in the USA) does not produce the
best outcomes. There is general consensus about the benefits of managed
networks, however Sweden, with best results, does not use them as they
have nationally centralised control of services. A major review of neonatal
services in Scotland recommends the use of regional networks alongside
regional planning and implementation of the guidance documents listed
here. (29)
The United States commits greater resources to neonatal intensive care
than other developed nations but its infants do not have proportionately
better survival, even taking into account its higher levels of low birth
weight. It has been suggested that this is because it offers less extensive
preconception and prenatal services. (31)
Sweden has the lowest rate of preterm births, attributed to high levels of
prenatal care and restrictions of in vitro fertilisation to single eggs to avoid
multiple pregnancies. (3)
5.3
Innovations in service structures
There are promising reports in the literature about methods of newborn
care and treatment, and about community-based care succeeding in
shortening hospital stays. The evidence for all these is not yet conclusive
but is promising. Here are some examples of these.
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One study (32) looked at the impact of community neonatal services and
found that they shortened hospital stays without increasing risk of
readmission, but costs were not assessed.
The Newborn Individualised Developmental Care and Assessment
Programme (NIDCAP) has been developed to stimulate preterm infants at
levels adapted to the child’s degree of neurological maturity. (33)
Kangaroo care, providing skin to skin contact for preterm babies, has a
growing body of evidence for good outcomes. (34)
6
Preventing neonatal ill-health
The Department of Health Implementation Plan for Reduced Health
Inequalities in Infant Mortality in 2007 identified a number of actions
which would reduce neonatal and infant mortality and morbidity.
The document focused on the wide health gap between economic groups,
and in particular the consistently poorer infant mortality in families from
routine and manual occupations (R&M), as illustrated in figures for
England and Wales in 2002-4, even as overall infant mortality is going
down. Detailed statistical modelling has been able to quantify the
projected impact on the infant mortality gap should each of the remedial
actions be taken.
All of the identified actions or interventions in the table below would
reduce infant and child mortality and/or ill-health, and most would help to
reduce demand for neonatal services. Prevention actions must be planned
for alongside service reconfiguration, as failure to address avoidable illhealth is both expensive and leads to worse neonatal outcomes. (35)
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Table 2: Actions to prevent inequalities in neonatal ill-health
(35)
7
Recommendations from the literature
These evidence-informed recommendations are drawn from the most
substantive current Wales or UK documents, and focus on how services
should be shaped.
7.1
All Wales Neonatal Standards (21)
These standards, produced in 2008, are a highly detailed set of
recommendations which need to read as a whole and cannot be
reproduced here. They describe the current crisis in neonatal services,
how under-resourced and inefficient they are, and how the current
configuration is unsustainable. These standards should be implemented as
a priority.
They include Standards covering:

Access to neonatal Care
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
Staffing of neonatal Services

Facilities for Neonatal Services ,including Equipment

Care of the baby and family/Patent Experience

Transportation

Clinical pathways, Protocols and Guidelines/Clinical Governance

Education and Training/Clinical Governance
7.2
National Institute of Health and Clinical Excellence
(NICE) quality standard on specialist neonatal care
This set of standards has just been published (October 2010) (36) and
covers:
7.3

Neonatal care

Care pathways and guidelines

Annual needs assessments

Skilled and multidisciplinary staff

Neonatal transfer services

Encouraging parental involvement in care

Breastfeeding

Co-ordinated transition to community care

Data, audit and research

Health outcomes
British Association of Perinatal Medicine (BAPM)
recommendations (8)
1. The Categories of Babies Requiring Neonatal Care have been revised to
reflect the significant changes that have taken place in the care of sick
newborn babies during the last decade. This document describes revised
Standards for Neonatal Intensive and High Dependency Care which should
only be undertaken in hospitals with appropriate resources and staff with
specialist experience.
2 All maternity hospitals, including those that do not provide intensive or
high dependency care, must have staff and facilities for resuscitation and
stabilisation for the unexpectedly sick newborn infant. Procedures must be
agreed with the local hospital(s) with a neonatal unit for the transfer of
high-risk obstetric cases and the post-natal transfer of sick babies.
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3 Hospitals providing neonatal intensive and high dependency care must
have continuous availability of qualified medical and nursing staff and
resources to meet the needs of all babies.
4 Hospitals must be able to demonstrate the necessary professional and
technical infrastructure, together with protocols to access specialist
services provided elsewhere.
5 Standards for the expected levels of equipment have been established
and should be adhered to. Local systems for purchasing, quality assurance
and replacement of equipment are necessary.
6 There must be suitable facilities for parents to stay near to their baby.
7 Each unit providing Neonatal Intensive and High Dependency Care
should comply fully with:
• Clinical guidelines
• Quality Assurance
• Follow up of high risk survivors
• Monitoring service provision and access
• Training and continuing education.
8 Units should produce an annual report summarising their activity in a
standardised form.
9 All units providing neonatal care should be appraised against national
criteria of service provision.
10 The introduction of Managed Clinical Networks should improve the
quality of care for mother and baby and facilitate achievement of these
Standards.
7.4
Inquiry into Neonatal Care in Wales (9)
Recommendation 1. We recommend that the Welsh Government should
ensure that a review of capacity be undertaken by the All Wales Neonatal
Network, to include current staffing and activity levels.
Recommendation 2. We recommend that the Welsh Government, in
assessing future requirements of the service, should pay particular
attention to the increasing birth rate in Wales.
Recommendation 3. We recommend that the Welsh Government should
ensure that there is capacity across all services to meet future demand.
Recommendation 4. We recommend that the Welsh Government should
ensure that staffing ratio guidelines, in compliance with BAPM 2001
minimum standards and as set out in the All Wales Neonatal Standards,
are met, but not through a reduction in cot numbers.
Recommendation 5. We recommend that the Welsh Government should
put in place measures to ensure that neonatal units achieve occupancy
levels that are capable of meeting the fluctuations in demand.
Recommendation 6. We recommend that the Welsh Government should
require the All Wales Neonatal Network to develop a plan to deliver the All
Wales Neonatal Standards within a clear set of timescales, and to make
public the action it will take to ensure the standards are met.
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Recommendation 7. We recommend that the Welsh Government should
ensure that rigorous procedures are in place to monitor the
implementation of the All Wales Neonatal Standards.
Recommendation 8. We recommend that the Welsh Government should
establish a Cot Locator system, to ensure that cots are allocated on an
efficient basis and to reduce unnecessary transfers between units. The
system should be compatible with systems in England.
Recommendation 9. We recommend that the Welsh Government should
ensure that the clinical network and database is working effectively as
soon as possible.
Recommendation 10. We recommend that the Welsh Government
should ensure that the 12-hour transport service is in place and
operational as soon as possible.
Recommendation 11. We recommend that the Welsh Government
should keep under review the effectiveness of the 12-hour transport
service, in particular in relation to meeting demands on the service and
patients' needs. Further to this, we recommend that, at an appropriate
time, consideration should be given to whether a 24-hour transport
service would better meet patients' needs.
Recommendation 12. We recommend that the Welsh Government
should ensure that the All Wales Neonatal Network regularly reviews
arrangements for cross-border transfers of patients, to ensure that they
are effective.
Recommendation 13. We recommend that the Welsh Government, in
conjunction with the Health Boards, puts in place measures, as a matter of
urgency, to address the shortfall in medical and nursing staff to ensure
services are safe.
Recommendation 14. We recommend that the Welsh Government
should ensure that procedures are put in place to ensure that neonatal
nurses can access education and training.
Recommendation 15. We recommend that the Welsh Government
should explore with relevant professional bodies, including the Royal
College of Nursing and Royal College of Midwives, the development of a
neonatology specialty.
Recommendation 16. We recommend that the Government should
ensure better integration of, and joint working between, neonatal and
maternity services.
Recommendation 17. We recommend that the Welsh Government
should ensure that Health Boards review their current arrangements for
supporting parents of special care babies, to address in particular:
practical guidance for health professionals on identifying parents’ needs;
helping parents to be involved in their baby’s care; and providing support
to parents as they gradually become the main carers.
Recommendation 18. We recommend that the Welsh Government
should ensure that sufficient accommodation is provided for parents,
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particularly in the lead centres. As part of this, we recommend that the
use of transitional care units should be considered.
7.5
Royal College of Obstetricians and Gynaecologists
Standards for Maternity Care (37)
From Standard 16: Care of babies requiring additional support
Some babies may have or can develop problems, for which timely and
appropriate treatment is essential. The effective use of networks will
ensure the best possible outcome.
16.8 Maternity services should have agreed arrangements for the transfer
of a recently delivered mother and her newborn baby to a linked
secondary or tertiary unit should problems arise.
16.9 Parents of babies with identifiable medical or physical problems
should receive timely and appropriate care and support in an appropriate
environment.
From Standard 17: Care of babies born prematurely
17.1 Formal arrangements must exist for women and their babies to
access a network of specialist services; commissioners and providers
should collaborate to establish a strategy to ensure appropriate capacity.
17.2 Managed maternity and neonatal care networks should include
effective arrangements for managing the prompt transfer and treatment of
women and their babies experiencing problems or complications.
17.3 Because extremely premature births may take place rapidly when no
senior members of the team are available, advance liaison should take
place whenever possible between the consultant obstetrician, consultant
paediatrician and senior midwife to ensure that there is prospective
understanding on the management and on who will try to be present at
the delivery.
17.4 Special care baby unit facilities should be available on site in all level
II and level III consultant-led units and there should be a defined rapid
access route to neonatal intensive care in all level II and level III
consultant-led units.
17.5 All maternity services must have systems in place for identifying
high-risk women, informing plans of care for women admitted with
threatened preterm delivery, and for transporting preterm babies in a
warmed transport incubator.
17.6 Prompt referral to an obstetrician with appropriate expertise should
be made in all cases of threatened preterm labour to assess the need for a
tocolytic and to avoid delay in the administration of corticosteroids.
17.7 Recommendations for the care of babies born at the threshold of
viability, such as those produced by the British Association of Perinatal
Medicine, should inform local guidelines.
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From Standard 27 Maternity and neonatal networks
27.1 Commissioners and providers must develop maternity and neonatal
care networks. This is achieved through a multidisciplinary and multiagency approach requiring agreement with all those likely to be involved
in providing care, including service managers and all relevant health and
social care professionals and service user representatives.
27.5 Maternity services should agree arrangements for both in utero
transfer and the transfer of a recently delivered mother and/or her
newborn baby to a linked secondary or tertiary unit.
From Standard 30: Staffing
30.30 All consultant-led obstetric units should have a named consultant
paediatrician who has responsibility and a special interest in neonatology.
30.31 There must be 24-hour availability in obstetric units within 30
minutes of a consultant paediatrician (or equivalent staff and associate
specialist grade) trained and assessed as competent in neonatal advanced
life support.
8
Conclusions
Prevention of neonatal ill-health, especially prematurity, is an essential
part of improving outcomes and reducing costs.
There is an urgent need to address capacity in neonatal care in Wales, and
face the sustainability issues generated by rising demands on the service.
Transport issues have started to be addressed.
Detailed standards and recommendations are available and should be
applied.
Acknowledgments
The authors would like to acknowledge the invaluable contribution from
Dinah Roberts and Ken Jones from the Public Health Wales’ Library
Knowledge and Management Service in the development of this report
9
Appendices
Appendix 1: International comparisons on prematurity and
neonatal service patterns
Appendix 2: Search Strategy
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Appendix 1: International comparisons on prematurity and neonatal service patterns
Country
Total live births/year
Organisation of neonatal care, with numbers of units if available
% preterm (<37 wks)
USA
4.25 million
in 2008
12.3%
Variable structures of care, mostly private.
Austria
77,752 in 2008
11.1%
Centralised in largely populated areas
Belgium
120,663 in 2007
8.3%
106 maternity units, 19 NICUs. Each neonatal unit decides its level of care
Czech
Republic
114,632 in 2007
7.6%
117 basic centres, 6 intermediary centres and 12 perinatology centres (with
NICUs)
Denmark
67,400 in 2008
6.8%
33 maternity units, 17 with dedicated neonatal units; 4 nominated hospitals
care for extremely preterm infants
France
828,309 in 2008
6.8%
Between 270 and 300 NICUs. Three categories of care: Type 1 obstetric
care only; Type 2: Neonatal care unit; Type 3: intensive neonatal care
service and reanimation unit.
Germany
684,862 in 2007
Italy
517,135 in 2006
6.5%
Operational neonatal units in 198 hospitals, NICUs in 116
Netherla
nds
172,281 in 2007
7.6%
3 levels of care: Level 1: neonatal care by midwives and GPs; Level 2: by
obstetricians (98 hospitals) and paediatricians (67 hospitals); Level 3:
7.1%
4 categories of care: Perinatal centres levels 1(highest level) and 2; clinics
with a perinatal focus, and birth clinics for normal deliveries
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specialised services in perinatal centres with NICUs (10 hospitals)
Poland
414,000 in 2008
6.8%
3 levels of care: Hospital care level 1 – no pathology (286 hospitals);
Hospital care level 2 – limited/medium pathology (96 hospitals); Hospital
care level 3 –most severe pathology (39 hospitals). NICUs are mainly linked
to 3rd and sometimes 2nd level care.
Portugal
102,567 in 2007
9.3%
40 neonatology units, 19 of which provide differentiated perinatal support.
There are 22 NICUs
Spain
492,527 in 2007
6.7%
5 main categories of care: resuscitation-stabilisation; intermediate basic
care; intermediate special care; high dependency intermediate care;
intensive care; followed by hospital assistance at home. These categories
are distributed according to historical factors.
Sweden
107,648 in 2008
5.9%
37 neonatal units, of which 19 deliver high quality specialised care.
Specialised intensive care is centralised in 6 university hospitals.
England
690,013 in 2006/7 8.3%
Scotland
60,041 in 2008
Wales
35,748 in 2008
162 neonatal units and 46 NICUs, in 24 neonatal clinical networks
7.9% 16 large neonatal units
(in 2005)
7.1% 13 neonatal units
(in 2005)
Northern
Ireland
25,361 in 2008
c. 6%
7 neonatal units
(3) (14)
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Appendix 2: Search Strategy
Topic: Neonatal services
Search question: What is the current evidence base on best practice in relation to the
delivery of safe and sustainable neonatal services?
By:
Helen Wright
Date : 13 August 2010
1.Methodology
Newborn babies
Pre-term babies
Preterm babies
Low birth weight babies
Small babies
Underweight babies
Sick babies
birthweight
ANNP
Advanced Neonatal Nurse Practitioners
NICU
MESH
HMIC BNI
Models of service
Service models
Service delivery
Service provision
Service redesign
Service reconfiguration
Service rationalisation
Models of care
Access to services
Provision of services
Intensive care units/neonatal og, man
Neonatology
Maternal- child nursing
Infants, very low birth weight
Infant, premature
Transportation of patients/og
Neonatal care
Infant care BT
Neonatal intensive care
Neonatal intensive care units
Premature baby units
Special care baby units
Neonatal services
Neonatal services
Neonatal nursing
Public Health Wales
Neonatal services literature review
Neonatal units
Neonates
Perinatal care
Well baby clinics
Change management
Health provision
Health service development
Health service delivery
Health service evaluation
Health service management
Health service organisation
Health service planning
Health service utilisation
"hospital planning and design"
Models
Nursing models
Organisational change
Organisational structure
Patient safety
Risk factors
Risk management
Service delivery
Service demand
Service development
Service needs
Service planning
Service relocation
Service standards
Service utilisation
Staffing levels
Standards
Unit management
Ward organisation
Workforce
Workforce planning
Publication types
Database searches filter =
Systematic reviews, RCTs, Meta analysis , reviews
Limitations
 Language

Dates covered/period of
publication
English only
2000-
Filters used
Exclude
Include
Developing countries
Screening for specific conditions
Congenital anomalies
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2. Sources
(i.)Core databases/
sources
BNI
CINAHL
Clinical Evidence

Cochrane Library

EMBASE

HMIC

MEDLINE

NICE

Library catalogue & knowledge base

PsycINFO
x
(ii.) Topic specific
databases, sources
Databases
Child data
MIDIRS
X
POPLINE
Map of medicine
Department of Health (inc:
Children, Young People &
Services)
NSF for
Maternity

Department for Health & Children [Ireland]
Department of Health, Social Services &
Public Safety [NI]
NHS
Institute
Improvement
for
Innovation
and
NHS Quality Improvement Scotland (inc.
Findings – CH & Maternity Services &
Reproductive health)
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
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(ii.) Topic specific
databases, sources
NHS Scotland
NHS Quality Improvement

Scottish
Government
(for
Services Action Group reports)
Maternity
Welsh Assembly Government (inc: NSF for
Children, Young People & Maternity
Services)

CMACE (Centre for Maternal and Child
Enquiries)

NPSA
NIHR-SDO
Health select Committee
Welsh Audit Office

National Audit Office
National Perinatal Epidemiology Unit
Maternity
Evidence
Birmingham]
[University
of

King’s Fund – maternity topic

National Collaborating Centre for Women's
and Children's Health

NHS Evidence (specialist collections)
- health management – Maternity
services

Royal College of Midwives

Royal College of Paediatrics & Child Health
Royal
College
Gynaecologists
of
Obstetricians
&

Royal College of Surgeons
AIMS (Association for Improvements in the
Maternity Services)
European Foundation
Newborn Infants
for
the
Care
of
MARCH (Centre for Maternal Reproductive
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(ii.) Topic specific
databases, sources
and Child Health)
Maternity Action

National Childbirth Trust
National Maternity Support Foundation
Independent Midwives Association
Warwick Infant and Family Wellbeing Unit
ChiMat Child and Maternity Observatory

British Association of Perinatal Medicine
(BAPM)

Expert Group on Neonatal Services
National Specialised Advisory Group
Obstetrics and Gynaecology
on

BLISS
Neonatal Nurses Association
British Association of Perinatal Medicine
(iii) Meta search engines

Google/Google Scholar
Intute
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SUMsearch

TRIP

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