Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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waiting list for neonatal intensive care
- Richard Nicholl (27 September 2000)
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Perinatal Crisis-care: demands on supply
- Rani Pal (28 September 2000)
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Resourcing neonatal intensive care
- Alan C Fenton (28 September 2000)
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National census of availability of neonatal intensive care
- P Toozs-Hobson (28 October 2000)
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National census of availability of neonatal intensive care
- Michael Hall (28 October 2000)
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Richard Nicholl, Consultant Neonatologist NorthWest London Hospitals NHS Trust
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Dear Sir, We audited the requests received by our own Neonatal Unit to accept transfers (mostly in-utero) from other Maternity Units over a 3 and a half year period ( Jan 1996- June 1999).This audit was presented as a poster at the annual BAPM meeting, London, September, 1999. Our Maternity Unit is medium sized, around 3,500 deliveries per year and our Neonatal Unit is Level II ,i.e. NOT a tertiary centre. 471 requests were received from 51 hospitals , that is, one request every 3 days. 3 fairly local hospitals accounted for 35% of the requests. However, requests were received from throughought London, the South East and beyond (Oxford, Norwich and Kent are examples). Of direct relevance to the article by Parmanum et al, 83 requests (18%) were from Level III (teriary units), reflecting the lack of capacity by these units. 84 requests (18%) for transfer were for multiple pregnancies, of whom only 28 (33%) were accepted, whereas 50% of singleton pregnancies were accepted. As the paper states "these findings are probably part of a wider problem affecting all delivery units". Richard Nicholl
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Rani Pal, Consultant Paediatrician UK
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Are our perinatal centres aiming to give a first class service or are we all in a knee-jerk crisis-care spiral? The equation involves obstetricians too. Uncalculated workload of multiple births appearing at 24 weeks gestation and high-risk deliveries (cardiac and surgical) who present themselves unannounced and inevitably their chronic morbidity leads to bed stasis in tertiary perinatal centres. Demand exceeds supply: 90% bed occupancy for efficiency, bed turnover slows with chronic morbidity, and naturally the transfers out of region for local babies causes disgruntlement. Nurses morale and goodwill will inevitably diminish in this high demand, low return senario. Limitations of low staffing ratio is common to all units. Why is it difficult to recruit, retain and expand ? Reluctance to share nursing manpower within a region curbs optimization of bed availability. Poor incentives: appreciation and renumeration for this high demand speciality is presently miniscure. Why carry on in an emotionally and physically exhausting speciality? Nursing task relief: Transitional wards where mother's play a greater role with supervision of nursing support, have been developed in some centres; technicians for equipment maintenance and auxillaries for cleaning and preparing incubators may deploy work-load, releasing nurses for better use of their specialised skills. To improve the equation of neonatal intensive care bed needs: we need to calculate the obstetric supply for that region, improve interaction of a mobile regional nursing force, provide extra incentives and look to deviating non-nursing duties and sharing care. The local population will receive its local service when there is an easier route than transfering out. |
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Alan C Fenton
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The paper by Parmanum et al 1 is welcome and has highlighted a major problem facing clinicians providing specialised perinatal care. There are however important related issues that warrant further consideration. Perinatal transfer is a complex process that begins with a clinical decision to transfer a patient and ends with the safe arrival of that patient at the receiving hospital. Parmanum et al did not address whether the indications for transfer were similar in the perinatal centres studied and whether there was any morbidity or mortality associated with transfer. Outcome data, particularly with regard to in utero transfers are important as it is well recognised that 15-40% of women remain undelivered up to one week following transfer 2, 3 and not all infants who subsequently deliver will require neonatal intensive care facilities. The ability to predict both imminent delivery (for example the presence of fibronectin in cervicovaginal secretions 4) or the likelihood that an individual baby will need intensive care would clearly influence the decision to transfer. The definition of what constitutes an "inappropriate" transfer will vary depending on local geography and the organisational characteristics of perinatal services within a given region. Neonatal intensive care in the former Northern region is organised on a collaborative basis. The arrangement ensures that any newborn baby born to a mother resident in the region is guaranteed access to intensive care facilities in one of four provider units on 98% of occasions. Whenever possible transfer is to the unit nearest the mother's place of residence. When this is not possible transfer is to the next nearest unit and so on. Central coordination minimises time spent locating an available cot. This arrangement has been shown to maximise resource utilisation 5 but makes some perinatal transfers between tertiary centres inevitable. Failure to achieve "best practice" in our service is defined as the need to transfer a baby or mother to a unit outside the region. A collaborative model may not be appropriate for all regions but might be suited to areas where distances between tertiary centres are relatively short. We agree with Parmanum et al's view that lack of nursing staff as a reason for transfer was underestimated; in our experience this is the single largest reason for transfer out of one of our perinatal centres. It is essential that additional resourcing is directed towards the staffing of any existing or new cots if a safe and effective service is to be provided. We believe that data pertaining to the numbers of and outcome following perinatal transfer should be routinely collected and audited. These data will be essential in determining the additional resources required to improve provision for perinatal services. Alan C. Fenton David Milligan
Stephen Sturgiss
Sean Ainsworth
References 1. Parmanum J, Field D, Rennie J, Steer P. National census of availability of neonatal intensive care. Br Med J 2000; 321: 727-729. 2. Behrenz KM, Mastrobattista JM, Monga M. Maternal-fetal transfers: indications, appropriateness, and cost. Am J Perinatol 1998; 15 (10): 557- 9. 3. Ryan TDR, Kidd G Mervyn. Maternal morbidity associated with in utero transfer. Br Med J 1989; 299: 1383-1385. 4. Peaceman AM, Andrews WW, Thorp JM, Cliver SP, Lukes A, Iams JD, Coultrip L, Eriksen N, Holbrook RH, Elliott J, Ingardia C, Pietrantoni M. Fetal fibronectin as a predictor of preterm birth in patients with symptoms: a multicenter trial. Am J Obstet Gynecol 1997; 177: 13-18. 5. Northern Neonatal Network. Requirements for neonatal cots. Arch Dis Child 1993; 68: 544-549. |
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P Toozs-Hobson
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Editor - We applaud the efforts of Parmanum et el in their attempts to assess the problems with neonatal intensive care in the UK. In particular it was interesting that they indicated whether a lack of staff was mentioned as a specific factor resulting in the unavailability of cots for postnatal transfers, though unfortunately this information was not available for in utero transfers. However what was not clear from the paper was whether staff shortages were viewed as an acute problem or a chronic problem. We are aware of units that have re-developed neonatal intensive care cots that have never been opened due to lack of funds to recruit neonatal nurses. The implications of the 2 different course of reduction in the cots are clearly different. If there are cots that are permanently closed because of lack of staff then the issue is one of training and retaining good quality neonatal nurses however the implications of cots not existing is much wider. This would require capital investment as well as identification of adequate space within limited resources, in addition to the staffing problems. Where cots do exist but yet there are insufficient staff also raises questions about the planning of service development. Capital investment may be obtained from charities with no guarantee of running costs (as with the national lottery funding radiotherapy equipment) which ultimately represents wasted funding with no benefit to patients. These separate issues have completely different implications for resourcing and planning the future service and perhaps the results of this paper have much wider ramifications on future service development throughout medicine. Mr P Toozs-Hobson
Mr PJ Thompson
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Michael Hall
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Editor - The paper by Parmanum et al has documented the number of maternal and neonatal transfers occurring from referral centres in the UK during a specified three-month period (1). However, in attempting to give some epidemiological perspective to the observed numbers the denominator used by the authors to calculate the rate per 1000 deliveries, at least in the case of Wessex, is that of the total number of deliveries in the whole region, rather than the number of deliveries occurring in Southampton, which was the centre involved in the study. While Southampton is a University hospital which provides a number of tertiary services relating to neonates, the neonatal Medical Unit is not funded as a regional referral centre. Most of the neonatal intensive care within Wessex takes place in the nine district general hospitals in the region, all of which offer level 1 neonatal intensive care. A more representative denominator, therefore, would be the number of deliveries taking place within Southampton - 4837 during the year of the study. The rate of transfers out then becomes 11.6 per 1000 deliveries, rather than 1.4 per 1000. It then perhaps becomes more apparent that this rate of transfers represents a substantial proportion of the district's at -risk delivery population. M Hall
R Ironton
A O'Donnell
M Ashton
E Donovan
R Thwaites
Melanie J Gompels
1. Parmanum J, Field D, Rennie J, Steer P. National census of availability of neonatal intensive care. BMJ 2000; 321:727-729. (23 September) |
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