Analysis

Neonatal transitional care should become a 'must have' service

Draft British Association of Perinatal Medicine guidance sets out how transitional care should be provided in the future.
Premature

Draft British Association of Perinatal Medicine guidance sets out how transitional care should be provided in the future

Neonatal transitional care has been around for decades. The idea of providing half-way houses for mothers and babies who need support from expert neonatal staff was formed in the 1980s.

It is a type of care that can relieve pressure on neonatal units by reducing admissions, while avoiding unnecessary separation of mother and baby.

Neonatal transitional care can also ensure babies who no longer need continuous monitoring in a neonatal unit have smooth transitions home.

But with core neonatal services under financial pressure, provision of transitional services remains patchy and a recent audit by NHS England of 140 units found that, when informal arrangements are excluded, less than half of hospitals offer them.

46%

Neonatal units have a

...

Draft British Association of Perinatal Medicine guidance sets out how transitional care should be provided in the future

Premature
Picture: Alamy

Neonatal transitional care has been around for decades. The idea of providing half-way houses for mothers and babies who need support from expert neonatal staff was formed in the 1980s.

It is a type of care that can relieve pressure on neonatal units by reducing admissions, while avoiding unnecessary separation of mother and baby.

Neonatal transitional care can also ensure babies who no longer need continuous monitoring in a neonatal unit have smooth transitions home.

But with core neonatal services under financial pressure, provision of transitional services remains patchy and a recent audit by NHS England of 140 units found that, when informal arrangements are excluded, less than half of hospitals offer them.

46%

Neonatal units have a formal transitional care service

Neonatal Nurses Association executive member Róisín McKeon-Carter says it is clear that services are still too ‘inconsistent’.

‘Developing transitional care services is a challenge,’ she says, citing a lack of ‘clear guidance’ for commissioners and hospital trusts, as well as a ‘shortages of cots and staff’, as reasons for the lack of progress.

Nevertheless, she is ‘hopeful’ that the situation will change.

Term admissions

NHS Improvement and the British Association of Perinatal Medicine (BAPM) have embarked on programmes with the potential to transform how transitional care is organised, she says.

NHS Improvement has been running a system called avoiding term admissions into neonatal units (ATAIN), which involves experts working together to see how the admissions of full-term babies to neonatal units can be reduced.

There are nearly 55,000 admissions to neonatal units and over two-thirds of these are term babies, defined as those born after 37 weeks.

Advice has already been issued in the belief that one in five admissions can be avoided, while greater investment in transitional care is seen as vital.

For example, one study, published earlier this year, found that about two thirds of admissions for jaundice could be managed in transitional care settings.

Meanwhile, BAPM is attempting to establish a framework for running transitional services. Draft guidance was published this summer and consulted on, with a final document expected by the end of the year.

Real change

Ms McKeon-Carter, who is on the BAPM working group that is drawing up the framework, says the two pieces of work could ‘herald real change’, and create a situation in which transitional care is a ‘must have’.

She says this would be a ‘win-win situation’. ‘The rewards for the families and indeed the NHS will be great, with mother’s mental health and well-being being supported.

‘Newborn babies would be discharged home early and well from hospitals, which would prevent bed blocking of cots for babies who require intensive care.’

2 in 3

Admissions to neonatal units are term babies

Head of services for the charity Bliss Zoe Chivers is optimistic too. She believes a little extra investment, coupled with the re-designation of some special care cots as transitional care, could go a long way.

‘It’s going to take a few years to get to where we need to be, but I think there is a growing acknowledgement this is a core part of neonatal care,’ she adds.

Future services

Transitional care is usually provided in a postnatal ward or dedicated transitional care unit close to the neonatal service. At its best, multidisciplinary teams of staff are involved.

The draft guidance proposes that, for the first time, recommendations are made for the type of transitional care that is appropriate from birth, when additional needs develop and when a child ‘steps down’ from a neonatal unit.

Recommendations should also be made for the type of facilities that families should receive, including free parking, kitchens, family rooms and space for siblings.

Concerns have been raised, however, about the framework’s suggestions for nurse-staffing ratios.

It concurs with the National Institute for Health and Care Excellence’s guidelines on midwifery staffing, which state that there should be one midwife for every five to eight mothers, depending on complexity.

In terms of neonatal nursing it recommends a ratio of one to six babies.  

But RCN children and young people acute care forum committee member Doreen Crawford, who is also the consultant editor of Nursing Children and Young People, wants to see this ratio changed.

‘I think it is misguided. If you send your children to nursery, there is one nursery worker to three children. How can we then say one to six is fine for transitional care? These babies can crash quickly.’

Get this right, she says, and the benefits could be enormous.

‘Transitional care is absolutely fabulous – everywhere should have it. The only disadvantage of it is not having it.’

Good care

Derriford Hospital, Plymouth, offers the ‘full package’ of neonatal care. It has been praised by NHS Improvement for achieving above the national target for avoiding term admissions to neonatal units.

This achievement is attributed to the 18-bed transitional care facility in Plymouth Hospitals NHS Trust, which is supported by a seven-day outreach service. 

The unit is staffed by midwives, nursery nurses and maternity care assistants, along with neonatal nurses.

1:6

Ratio of neonatal nurse to babies recommended for transitional care in draft BAPM guidelines

Babies can be looked after alongside their mothers, who can gain confidence in caring for their babies even when they are small or sick, need to be kept warm in incubators or hot cots, or have tube feeds or treatment for jaundice with phototherapy lights. 

Partners are encouraged to come in at any time during the day, and there is a family and baby support team to offer help to all families with babies who need neonatal care in hospital.

Support includes emotional and practical help, advice with benefits and finances, and ongoing support through children’s centres on each child’s discharge home. 

The outreach team aims to discharge babies home safely and as early as possible to ease the transition out of hospital through providing expert neonatal care at home.

When is transitional care appropriate?

From birth, which means when:

  • The gestational age is 34 to 35 weeks.
  • The baby’s birth weight is under 1.6kg.
  • There is a predicted requirement for three-hourly nasogastric tube feeds.
  • There is a congenital anomaly likely to affect feeding.

When additional needs develop after birth, for example when:

  • A baby cannot maintain temperature.
  • A stable baby who has developed risk factors for sepsis, requiring intravenous antibiotics.
  • There is significant neonatal abstinence syndrome requiring oral medication or additional support.
  • There is excessive weight loss requiring additional support.
  • There is jaundice requiring phototherapy.

Babies ‘step down’, which means when:

  • Their gestational age is more than 33 weeks and they are clinically stable.
  • Their weight is more than 1.5kg and they can maintain temperature.
  • Monitoring of vital signs is required no more frequently than four-hourly.
  • Babies can tolerate three-hourly nasogastric tube feeds and maintain blood glucose.
  • Babies are stable but with sepsis requiring on-going intravenous antibiotics.
  • Babies have complex needs, such as home oxygen or nasogastric feeding, that require rooming in before discharge.

Source: BAPM draft guidance

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