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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 Date: Jan 2011 Version: 0c Page: 3 of 30 Public Health Wales Neonatal services literature review 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 Date: Jan 2011 Version: 0c Page: 4 of 30 Public Health Wales 2 Neonatal services literature review 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 Date: Jan 2011 Version: 0c Page: 5 of 30 Public Health Wales Neonatal services literature review 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 Date: Jan 2011 Version: 0c Page: 6 of 30 Public Health Wales Neonatal services literature review 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: Date: Jan 2011 Version: 0c Page: 7 of 30 Public Health Wales Level 1 Level 2 Level 3 3 Neonatal services literature review 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. Date: Jan 2011 Version: 0c Page: 8 of 30 Public Health Wales Neonatal services literature review 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) Date: Jan 2011 Version: 0c Page: 9 of 30 Public Health Wales Neonatal services literature review 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 Date: Jan 2011 Version: 0c Page: 10 of 30 Public Health Wales Neonatal services literature review 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. Date: Jan 2011 Version: 0c Page: 11 of 30 Public Health Wales Neonatal services literature review 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) Date: Jan 2011 Version: 0c Page: 12 of 30 Public Health Wales Neonatal services literature review 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. Date: Jan 2011 Version: 0c Page: 13 of 30 Public Health Wales Neonatal services literature review 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) Date: Jan 2011 Version: 0c Page: 14 of 30 Public Health Wales Neonatal services literature review 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 Date: Jan 2011 Version: 0c Page: 15 of 30 Public Health Wales Neonatal services literature review 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. Date: Jan 2011 Version: 0c Page: 16 of 30 Public Health Wales Neonatal services literature review 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. Date: Jan 2011 Version: 0c Page: 17 of 30 Public Health Wales Neonatal services literature review 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, Date: Jan 2011 Version: 0c Page: 18 of 30 Public Health Wales Neonatal services literature review 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. Date: Jan 2011 Version: 0c Page: 19 of 30 Public Health Wales Neonatal services literature review 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 Date: Jan 2011 Version: 0c Page: 20 of 30 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 Public Health Wales Neonatal services literature review 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) Date: Jan 2011 Version: 0c Page: 22 of 30 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 Date: Jan 2011 Version: 0c Page: 24 of 30 Public Health Wales Neonatal services literature review 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) Date: Jan 2011 Version: 0c Page: 25 of 30 Public Health Wales Neonatal services literature review (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 Date: Jan 2011 Version: 0c Page: 26 of 30 Public Health Wales Neonatal services literature review (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 Date: Jan 2011 SUMsearch TRIP Version: 0c Page: 27 of 30 Public Health Wales Neonatal services literature review Reference List (1) Department of Health. Toolkit for High-quality Neonatal Services. London: DH; 2009. (2) All Wales Perinatal Survey. All Wales Perinatal Survey Annual Report 2008. Cardiff University; 2010. (3) Made S, Merialdo M, Keller M. Too little too late? Why Europe should do more for preterm infants. European Foundation for the Care of Newborn Infants; 2010. (4) Schmitt SK, Sneed L, Phibbs CS. Costs of newborn care in California: a population-based study. Paediatrics 2006;117(1):154-60. (5) Mistry H, Dowie R, Franklin RC, Jani BR. Costs of neonatal care for lowbirthweight babies in English hospitals. Acta Paediatrica 2009;98(7):1123-9. (6) Petrou S. Economic consequences of preterm birth and low birthweight . BJOG: an International Journal of Obstetrics and Gynaecology 2003;110:17-23. (7) Petrou S, Henderson J, Bracewell M, Hockley C, Wolke D, Marlow N, et al. Pushing the boundaries of viability: The economic impact of extreme preterm birth. Early Human Development 2006;82(2):77-84. (8) British Association of Perinatal Medicine. Standards for hospitals providing neonatal intensive and high dependency care (second edition) and categories of babies requiring neonatal care. London: BAPM; 2001. (9) National Assembly for Wales Health Wellbeing and Local Government Committee. Report on Inquiry into Neonatal Care in Wales. Cardiff: NAfW; 2010. (10) Bakewell-Sachs S, Blackburn S. State of the science: achievements and challenges across the spectrum of care for preterm infants. Journal of Obstetric, Gynecologic, & Neonatal Nursing 2003;32(5):683-95. (11) The Royal College of Obstetricians and Gynaecologists, The Royal College of Paediatrics and Child Health, National Workforce Projects. Children's and Maternity Services in 2009: Working Time Solutions. 2008. (12) BLISS. Special Delivery or Second Class: are we failing special care babies in the UK? BLISS; 2007. (13) UK Neonatal Staffing Study Group. 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(9301):99-107. Date: Jan 2011 Version: 0c Page: 28 of 30 Public Health Wales Neonatal services literature review (14) Hallsorth M, Farrands A, Oortwijn W, Atziandreu E, RAND Europe, National Audit Office. The provision of neonatal services: data for international comparisons. Cambridge: RAND Corporation; 2007. (15) BLISS. Bliss baby report 2008: Neonatal care in Wales. Bliss; 2008. (16) Woods L. Evaluating the clinical effectiveness of neonatal nurse practitioners: an exploratory study. Journal of Clinical Nursing 2006;15(1):35-44. (17) Hamilton K E StC, Redshaw ME, Tarnow-Mordi W. Nurse staffing in relation to risk-adjusted mortality in neonatal care. Archives of Disease in Childhood - Fetal and Neonatal Edition 2007;92:F99-F103. (18) Jallo N, Bray K, Padden M, Levin D. A nurse-driven quality improvement program to improve perinatal outcomes. Journal of Perinatal & Neonatal Nursing 2009;23(3):241-50. (19) Lee TWR, Skelton R, Skene C. Routine neonatal examination: effectiveness of trainee paediatrician compared with advanced neonatal nurse practitioner. Archives of Disease in Childhood - Fetal and Neonatal Edition 2000;85(2):F100-F104. (20) Mears M, Chalmers S. Neonatal pre-transport stabilisation – caring for infants the STABLE way. Infant 2005;1(1):34-7. (21) Welsh Assembly Government. All Wales Neonatal Standards for Children and Young People's Specialised Healthcare Services. Cardiff; 2008. (22) Teasdale D, Hamilton C. Baby on the move: issues in neonatal transport. Paediatric Nursing 2008;20(1):20-5. (23) POPPY Steering Group. Family-centred care in neonatal units: A summary of research results and recommendations from the POPPY project. London: NCT; 2009. (24) National Institute for Health and Clinical Excellence. Routine postnatal care of women and their babies . London: NICE; 2006. Report No.: NICE clinical guideline 37. (25) Renfrew M, Craig D, Dyson L, McCormick F, Rice S, King S, et al. Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis. NIHR; 2009. Report No.: 13. (26) Von Dolinger de Brito D, de Almeida Silva H, Oliveira EJ, Arantes A, Abdallah VOS. Effect of neonatal intensive care unit environment on the incidence of hospital-acquired infection in neonates. Journal of Hospital Infection 2010;65(4):314-8. (27) Philbin MK. Planning the acoustic environment of a neonatal intensive care unit. Clinics in Perinatology 2004;31(2):331-52. (28) Turrill S. Is access to a standardized neonatal intensive care possible? Journal of Nursing Management 2000;8(1):49-56. (29) Maternity Services Action Group (MSAG) Neonatal Services Sub Group. Review of Neonatal Services in Scotland. Scottish Government; 2008. Date: Jan 2011 Version: 0c Page: 29 of 30 Public Health Wales Neonatal services literature review (30) Vohr B, O'Shea M, Wright L. Longitudinal multicenter follow-up of highrisk infants: why, who, when, and what to assess. [Review] . Seminars in Perinatology 2003;27(4):333-42. (31) Thompson LA, Goodman DC, Little GA. Is more neonatal intensive care always better? Insights from a cross-national comparison of reproductive care. Paediatrics 2002;109(6):1036-43. (32) Langley D, Hollis S, Friede T, MacGregor D, Gatrell A. Impact of community neonatal services: a multicentre survey. Archives of Disease in Childhood Fetal & Neonatal Edition 2002;87(3):F204-F208. (33) Newborn Individualized Developmental Care and Assessment Program. Newborn Individualized Developmental Care and Assessment Program NIDCAP. Stockholm; 2006. (34) Conde AA, Belizán JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews: Reviews 2003;2(DOI.: 10.1002./14651858.CD00277-). (35) Department of Health. Implementation plan for reducing health inequalities in infant mortality: a good practice guide. Review of the health inequalities infant mortality PSA target . London: DoH; 2007. (36) National Institute for Health and Clinical Excellence. Specialist Neonatal Care Quality Standards. 2010. (37) Royal College of Obstetricians and Gynaecologists. Standards for Maternity Care: Report of a working party. London: RCOG Press; 2008. Date: Jan 2011 Version: 0c Page: 30 of 30