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PIPER

Paediatric Infant Perinatal Emergency Retrieval

Defined transfer (Time Critical Newborn)

Review date: June 2018

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Defined transfer (Time Critical Newborn)

Retrieval System

Paediatric Infant Perinatal Emergency Retrieval (PIPER) works collaboratively with health services as part of the critical care service system to ensure that women, newborns, infants and children have access to the most appropriate level of care for their individual needs. PIPER is responsible for negotiating bed/cot access to services and in consultation with the Royal Children’s Hospital executive1 is responsible for leading statewide escalation processes for time critical perinatal and newborn transfers when service system capacity is approaching critical levels. PIPER and level 6 services share the responsibility to ensure that patients requiring time critical access to level 6 services are exposed to minimum risk, particularly those associated with delayed transfer. The retrieval process commences when the decision to transfer is made and ‘bed finding’ occurs in parallel with this process.

Defined transfer

A time critical newborn transfer occurs when newborn access to level 6 services is essential and it is deemed safe by the PIPER consultant(s) to initiate and achieve transfer. The term ‘time critical’, encompasses both the severity of a newborn’s condition and the likelihood of deterioration as identified in Attachment 1.

A defined transfer (Time Critical Newborn) recognises that the needs of time critical infants are best met by stabilisation and immediate transfer to a level 6 nursery2. Demand for critical care services is often high and there can be periods when demand for level 6 cots exceeds the immediate supply. However at these times, to safeguard patient care, PIPER is authorised to nominate a level 6 service to receive a time critical newborn. This is called a ‘defined transfer’ and

reflects the appropriate system response to the needs of critically ill patients3.

Level 6 neonatal services must establish systems, tools and processes to support a consistent approach to implementing Defined Transfer (Time Critical Newborn) once activation occurs. This includes establishing well developed internal escalation processes, documented lines of accountability and clear business continuity strategies, particularly in relation to staffing arrangements during the activation period.

Auspiced by the Department of Health and Human Services, the Defined Transfer (Time Critical Newborn) activation procedure is outlined below with a corresponding decision flow chart provided in Attachment 2.

Defined Transfer (Time Critical Newborn) Activation Procedure

Assessment Prior to activating the Defined Transfer (Time Critical Newborn) process, the PIPER consultant(s) must undertake an assessment process, including relevant consultation to determine the most appropriate receiving level 6 neonatal service based on standard assessment criteria that include:

Capability and capacity of the referring health service

Specific needs of the newborn for specialised level (6A or 6B) services, particularly where there are clinical characteristics which may restrict the choice of receiving service (e.g. need for surgery, extreme prematurity, suspected or known cardiac, metabolic or other complex medical conditions)

Degree of clinical urgency

Known or anticipated critical care system demands

Normal referral and historical clinical relationship patterns

Geographical proximity

Needs and consideration of the patient’s family.

If the identified level 6 service has available level 6 cot capacity, then the transfer must be accepted by the health service. A health service is considered to have available level 6 cot capacity when the number of occupied level 6 cots is less than the minimum number of level 6 cots that must be made available for operation, as agreed

1 PIPER operates under the governance of the Royal Children’s Hospital. 2 Defining levels of care for Victorian newborn services (2015). 3 Adult Retrieval Victoria published the Time critical defined transfer guideline in 2011. In 2013, two separate specific defined transfer guidelines were published for time critical cardiac and neurosurgical patients. These guidelines are now well established and accepted by the Victorian public critical care sector (for more information http://www.ambulance.vic.gov.au/Main-Home/Arv/Resources.html).

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between the Department of Health and Human Services and individual hospitals; and as recorded on the REACH4 Neonatal website. Assessment of a unit’s available Level 6 cot capacity includes the number of babies in level 6 cots that no longer require level 6 care (waiting transfer to ward/back transfer or discharge5) as this is considered level 6 capacity that could be released in the short term.

While it is acknowledged that babies with high dependency may be appropriately cared for within a level 6 nursery, health services must prioritise agreed level 6 cot capacity for newborns identified as meeting criteria for level 6 newborn care as defined in Attachment 3.

Activation Activation of a Defined Transfer (Time Critical Newborn) is taken only after an assessment has taken place as outlined in step 1 above. If the identified level 6 service does not have available cot capacity and declines the transfer, then a decision to initiate a Defined Transfer (Time Critical Newborn) will be authorised by the Director PIPER (or delegate) as follows:

1. The Director PIPER (or delegate) allocates the receiving health services on the basis of agreed distribution (Table 1: level 6A; or Table 2: level 6B)

2. The Director PIPER (or delegate) notifies the receiving level 6 service bed manager or delegate (in accordance with internal health service policy) that a defined transfer to their service will occur . The receiving service bed manager will then communicate and operationalise the local health service response and actions

3. The Director PIPER (or delegate) will notify the Assistant Director Perinatal Services and Child Health, Policy and Planning, Department of Health and Human Services, of the defined transfer.

Time Critical (6A) newborns Time Critical (6A) newborns are allocated to level 6 services on a geographic basis as follows6 (Table 1). A map is also provided in Attachment 4:

Table 1 Mercy Hospital for Women

Metro Services

Knox Private Hospital Mitcham Private Hospital Waverley Private Hospital Mercy Hospital for Women

Regional Services

Bendigo Health Castlemaine Health Cohuna District Hospital Echuca Regional Health Kerang District Health Kyneton District Health Service Maryborough District Health Service St John of God Hospital Bendigo Swan Hill District Hospital Benalla & District Memorial Hospital Goulburn Valley Health Yarrawonga District Health Service Albury Wodonga Health Northeast Health Wangaratta Mansfield District Hospital The Kilmore & District Hospital

4 Statewide system level information on capacity within level 6 neonatal services is reported using the Retrieval And Critical Health (REACH) Neonatal website. 5 Babies waiting discharge/transfers are identified on the REACH Neonatal website. 6 The proportion of cots at each level 6 newborn service in relation to the total number of cots available in the state has been used to determine the

catchment for each level 6 service (e.g. Monash Medical Centre utilises 29% of Victoria’s level 6 cots, therefore the number of statewide maternal

birth episodes proportionally allocated to those cots is approximately 29%). Modelling was based on VAED maternal episode data for 2014-15.

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Monash Medical Centre

Metro Services

Cabrini Malvern Jessie McPherson Private Hospital Casey Hospital Dandenong Hospital Frankston Hospital Peninsula Private Hospital St John of God Hospital Berwick The Bays Hospital Box Hill Hospital Angliss Hospital Monash Medical Centre Clayton

Regional Services

Bairnsdale Regional Health Service Bass Coast Health Central Gippsland Health Service Gippsland Southern Health Service Latrobe Regional Hospital Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group

Royal Women's Hospital Metro Services

Epworth Freemasons Frances Perry Private Hospital Royal Women's Hospital Women’s Sandringham Werribee Mercy Hospital

Regional Services

Colac Area Health Portland District Health St John of God Hospital Geelong SW Healthcare Camperdown SW Healthcare Warrnambool Terang & Mortlake Health Service Geelong Hospital Western District Health Service East Grampians Health Service

Royal Children's Hospital * *Where Defined Transfer (Time Critical Newborn) has been activated and RCH identified as the

designated health service, in the absence of a specific RCH indication, infants born < 27 weeks

should be directed to the Royal Women’s Hospital. 7

Metro Services

Northpark Private Hospital St Vincent's Private Hospital Sunshine Hospital The Northern Hospital

Regional Services

Ballarat Health Service Djerriwarrh Health Service St John of God Hospital Ballarat Wimmera Health Care Group Mildura Base Hospital

7 Defined transfer of outborn extremely preterm babies with gestational age <27 weeks should not be directed to RCH unless there is a specific surgical or complex medical indication for management at a level 6B hospital.

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Time Critical (6B) newborns Newborns requiring management at a level 6B service will only be allocated through Time Critical (6B) defined transfer after a thorough assessment has taken place as outlined in step 1 above; and where level 6B health service on-call executive (after internal advice) have not reached a consensus about where the baby should be placed. Time Critical (6B) newborns are allocated to level 6B services on the following geographic basis (Table 2). A map is also provided in Attachment 5.

Table 2

Royal Children's Hospital Metro Services

St Vincent's Private Hospital Sunshine Hospital The Northern Hospital Northpark Private Hospital Epworth Freemasons Frances Perry Private Hospital Royal Women's Hospital Mercy Hospital for Women Mercy Werribee Public Hospital

Regional Services

St John of God Hospital Geelong Geelong Hospital Colac Area Health East Grampians Health Service Portland District Health South West Healthcare Warrnambool South West Healthcare Camperdown Terang & Mortlake Health Service St John of God Ballarat Djerriwarrh Health Services Ballarat Health Service Western District Health Service Maryborough District Health Service Castlemaine Health Wimmera Healthcare Group Mildura Base Hospital Swan Hill District Hospital Kerang District Health Cohuna District Hospital Echuca Regional Health Yarrawonga District Health Service Goulburn Valley Health Benalla District Health Bendigo Health St John of God Health Care Bendigo The Kilmore and District Hospital Kyneton District Health Service Mansfield District Hospital Northeast Health Wangaratta Albury Wodonga Health

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Monash Medical Centre

Metro Services

Women’s Sandringham Monash Medical Centre Clayton Jessie McPherson Private Hospital Cabrini Malvern Mitcham Private Hospital Waverley Private Hospital Knox Private Hospital Box Hill Hospital Angliss Hospital St John of God Berwick Dandenong Hospital Casey Hospital Frankston Hospital Peninsula Private Hospital The Bays Hospital

Regional Services

Central Gippsland Health Service Gippsland Southern Health Service Bairnsdale Regional Health Service Bass Coast Health Latrobe Regional Hospital Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group

Defined Transfer (Time Critical Newborn) review and monitoring

All defined transfer decisions will be retrospectively reviewed by PIPER to ensure the agreed process and assessment has occurred.

PIPER will provide a quarterly report of all Defined Transfer (Time Critical Newborn) occurring in the period (including referring hospital, receiving hospital and trend analysis) to the Manager, Maternity and Newborn Program, Department of Health and Human Services.

A summary report of all transfers will be provided to the CEO of the level 6 services quarterly by PIPER.

Level 6 services may request a post hoc review of a PIPER decision to activate a defined transfer in writing to the Director of PIPER.

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Attachment 1

PIPER Neonatal: Time Critical Retrieval Classification

Time Critical - Depart within 15 minutes

1. Ongoing resuscitation a. Collapse or shock b. Severe asphyxia c. Cyanosis or bradycardia

2. Extreme Prematurity a. < 32 weeks in a hospital with level 1,2 or 3 neonatal capability b. ≤ 28 weeks in a hospital with level 4 or 5 neonatal capability

3. Ventilated in a. Any nursery without mechanical ventilator b. A hospital with neonatal capability level 1-3 c. Greater than 60% oxygen

4. Infant in hospital without staff or equipment to deal with clinical situation

5. Bile stained vomiting – rule out malrotation

6. Other

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Attachment 2: Defined Transfer (Time Critical Newborn)

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Attachment 3

Definition of a level 6 newborn

Babies meeting the following criteria should be managed in a level 6 A or level 6 B service as identified in Defining levels

of care for Victorian newborn services (2015).

Criterion

1 Mechanical ventilation via:

1. endotracheal tube 2. tracheostomy

2 Extreme Prematurity:

1. current weight < 1000g 2. corrected gestation < 28 weeks

3 Neonatal surgery involving opening of a body cavity – on the day of surgery

4 Specific diagnoses

1. seizures (frequent) 2. unstable upper airway obstruction

5 Non-invasive respiratory support PLUS one or more of:

1. an intercostal catheter* 2. parenteral nutrition* 3. prostaglandin E1 4. nasal positive pressure ventilation (NIPPV)

6 Vascular access

1. arterial line 2. femoral venous line 3. umbilical venous line*

7 Interventions and Therapeutics

1. insulin 2. inotropes 3. dialysis 4. therapeutic hypothermia 5. exchange transfusion

8 1:1 nursing care#

1. clinical acuity 2. expected death within 24 hours for level 6 inpatients

* Denotes ‘limited intensive care’- suitable for care in level 5 newborn service.

# Watson SI et al. The effects of a one-to-one nurse-to-patient ration on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population based study. Arch Dis Child Fetal Neonatal Ed 2016; 0: F1-F6. Doi:10.1136/archdischild-2015-309435.

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Attachment 4:

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Attachment 5: