Unscheduled Acute Referrals to the Neonatal Team in Greater Glasgow and Clyde (GGC)

Criteria for referral back to neonatal team

Clinical documentation

Directing neonates to other teams

Neonatal transfers to RHCG NNU or booking hospital NNU from RHCG ED

Criteria for referral back to neonatal team

Referral for consideration of readmission, or acute review, to GGC Neonatal Services is only appropriate for neonates 10d of age, with a few exceptions as detailed below.   Babies that may be suitable for PNW or TC level care should be discussed with the neonatal team. Babies that may be unwell and not suitable for PNW/TC level care may be redirected to general paediatrics for discussion depending upon the clinical situation. Where there is concern about an infective cause for presentation, referral to neonatal services is not appropriate.

Neonates up to 14 days of age may be considered for acceptance back to GGC Neonatal Services if their presenting complaint is considered a perinatal problem. For example; ongoing need for breastfeeding support, phototherapy or slow postnatal weight gain. Need for ongoing feeding support, is regarded as an issue that has been present from first few days of life and not a baby whom was feeding well with a subsequent change in feeding behaviour. Medical reasons for poor feeding must always be considered.

In exceptional circumstances, an older baby that was discharged from the NNU within the previous 24-48h may be considered for readmission to the NNU if their presenting problem was felt to be directly related to issues already encountered during their NNU stay. This must be discussed with the neonatal consultant and may depend on availability of an appropriate cot space (preferably cubicle or family room).

Prolonged jaundice – see section on Jaundice below.

Cases where best location of care not yet determined

It is not possible to account for all clinical presentations and there will likely be neonatal patients that do not fit clearly into the pathway described in this document. In these circumstances a senior level discussion should occur between the referring team and the neonatal team, at least at Registrar or Consultant level. A conference call may be appropriate between referring team, general paediatric and neonatal teams. This can be arranged using the DECT phones or via Teams calls. It may be appropriate, in occasional circumstances, for the receiving team (neonatal or general paediatrics) to take the baby’s details from the referrer, coordinate discussions as to best place of care and contact the family directly with a plan. This is to avoid community based colleagues having to make multiple phonecalls between specialities when there is not a clear pathway agreed as to best location of care. Please ensure you take an accurate contact phone number for the referrer AND the family.

Documentation

It is recognised that the neonatal clinical notes located within Maternity and Neonatal Badger electronic patient notes are not currently available to clinical staff in ED, general paediatrics or GP to view directly. Discussions are underway, to address this issue. This guideline will be updated to reflect any subsequent changes.

Neonatal and Maternity teams documentation

Patient reviews by Neonatal and Maternity teams should be documented on Maternity Badger whilst the baby is still under CMW follow-up. Thereafter, electronic clinical notes should be documented on Clinical Portal. If the baby is admitted to the neonatal unit (NNU), then paper case notes should be used from point of admission. If a baby is being admitted to the PNW, the notes will remain on Maternity Badger.

Neonatal and Maternity Discharge letters and Badger notes

If a baby has been discharged from the postnatal ward (PNW), the NNU or transferred from CMW into health visitor (HV) care – the Neonatal Discharge Summary or Transfer of Care (TOC) document should be found uploaded on Clinical Portal. However there can occasionally be a time delay in these being uploaded. In these cases, the neonatal team can be contacted to look at the Badger electronic notes if required. Additionally, if a baby remains under CMW review and the referring team want to know what has been documented in the Maternity Badger notes about the baby, the neonatal team can be contacted to access this information and pass it on.

ED and general paediatric documentation

Outcomes of ED or general paediatric reviews should be found on Clinical Portal (clinical note, Immediate or Emergency Discharge Letter (IDL/EDL) and any charts/proformas uploaded). Additionally ED specific clinical notes and observations can be accessed on Trak care by selecting clinical record icon then clinical assessment tab. If a baby is seen in ED or CDU out of hours (OOH) and needs a CMW/neonatal review the next day e.g. for bilirubin or weight, a note on Clinical Portal is required in case of delay uploading the IDL. The follow-up required must also be discussed with the relevant team e.g. Neonatal team or CMW (phone numbers found later in this document).

Documentation for babies being admitted from ED or CDU to neonatal team

Babies that are to be admitted from ED or CDU to NNU or PNW should have all of their paper notes eg. Neonatal proforma, SBAR handover and nursing charts follow them to the NNU. These should be scanned on Portal first by the ED receptionist before the baby and their notes leave the department together.

Directing neonates to other teams

Patients being directed to ED

The ED at RHCG does not take referrals, however if direct ED attendance is required because the neonate is felt to be very unwell (see red box on page 4 for guidance) and needs urgent emergency attention they should be directed to the ED at the RHCG.

If a neonate is being directed straight to the RHCG ED, please also call to discuss the urgent situation with the RHCG ED team so the team are aware to expect this baby and what the urgent concerns are.

RHCG ED consultant 0141 452 4059 (84059) or ED co-ordinator 0141 452 4585 (84585).

Patients being directed to General Paediatrics

If a patient is being directed to general paediatrics/clinical decision unit (CDU), please discuss this with general paediatrics consultant on 0141 452 5735 (85735).

If a neonate has been accepted by the general paediatric team, the ‘ED expects’ list on Trak should be completed so they can be appropriately triaged and what the referring concerns are. The ED expects list will be completed by the accepting team (eg general paediatrics).

Click on the instructions below to complete ED expects list on Trak:

How to add a patient to the ED expects list - RHC ED.

Neonatal transfers to RHCG NNU or booking hospital NNU from RHCG ED

Patients being transferred from RHCG ED/CDU to booking hospital

In the case of a well neonate who requires readmission to the PNW/TC for phototherapy or breastfeeding support, these neonates should be referred to their booking hospital neonatal team and readmitted to their PNW. Transport is undertaken by the parents. Responsibility for the neonate lies with the referring team, until they have been admitted to the booking hospital. Further guidance in the referral pathway below.

If unsure about the suitability of the neonate to be transferred back to their booking hospital, out of RHC, then this must be discussed with a senior medic in the department who may then discuss with a senior neonatal medic at RHC. A senior medic would be regarded as Registrar or Consultant level.

Please refer to Appendix 3 – Transfer from RHCG ED/CDU offsite to booking hospital NNU (PRM or RAH) to ensure all criteria are complete.

Booking hospital vs birth hospital

For most neonates the booking and birth hospitals are the same. In a small number of cases, the neonate may be delivered at a different hospital than was intended at the pregnancy booking. In these circumstances, the neonate should still be referred back to the booking hospital as this is usually their geographically closest hospital and is how CMW and clinic follow-up usually align. There may be special circumstances when going back to birth hospital is preferable in that individualised circumstance but that needs discussion with the relevant neonatal teams on a case by case basis.

Babies transferring from RHCG ED/CDU to RHCG NNU

Please refer to checklist in Appendix 2: Transfer Checklist from RHCG ED/CDU to RHCG NNU 

Red = ED/999, orange = general paediatrics, yellow and green = neonatal team.

PNW admission criteria

Well baby, normal neonatal observations, alert, adequate oral feeding, normal blood glucose (if taken), maintaining temperature, weight loss <15% with acceptable UE, no sepsis concerns.

NNU admission Criteria

• Clinical issues as outlined in yellow box above. Baby ≤ 10d (unless exceptional circumstances at Neonatal Consultant discretion eg. Needs HDU/ICU level care and NNU can accommodate, ongoing breastfeeding/jaundice issues up to d14, older baby just discharged from NNU within last 48h and represents with same issue).
• SBAR handover between referring team and neonatal team, agreeing baby appropriate for transfer / admission to NNU. Observations acceptable for transfer to NNU, any changes in baby’s clinical status communicated to the Neonatal Consultant before leaving ED/CDU.
• Neonatal unit acuity, staffing and cot capacity (preferably cubicle) adequate for admission. This is a particular consideration if out of hours due to reduced level of medical neonatal staffing who are also committed to providing urgent medical cover to the NNU, ex utero transfers in from other NNUs, labour ward and PNWs.

Baby requiring period of observation to determine final outcome:

If a period of observation to determine need for admission or suitability for discharge home is required, this should be discussed with CDU and the general paediatric team. The neonatal team cannot provide a prolonged period of observation. Following observation, if admission to the neonatal services seems most appropriate because the clinical problem is felt to relate to perinatal issues, please discuss with the neonatal senior team.

Guidelines for management of neonatal jaundice can be found here Jaundice : neonatal guideline (scot.nhs.uk). Please see Appendix 1 – Quick reference guide for acute jaundice in the emergency department.

If baby requires admission for phototherapy, contact the booking hospital neonatal team on the numbers at the end of the referral pathway above. If baby currently in RHCG ED/CDU, consider need for d/w neonatal team at RHCG in first instance to ensure baby well enough to go back to birth hospital for phototherapy. Baby should be clinically well, looking for feeds, have normal neonatal observations and a normal blood gas and glucose if taken. Transport would be undertaken by the family. Responsibility for the baby remains with the referring team until they have been admitted to the booking hospital for treatment. Only in exceptional circumstances, can consideration be given to admitting the family to the RHC/QEUH campus rather than their booking hospital where the baby is well enough to have a parent led transfer to their booking hospital PNW. This will also be dependent upon PNW bed status.

If admission not required but baby needs a repeat bilirubin in 18-24h, then contact CMW team and leave message requesting date of repeat bilirubin, along with baby’s name, CHI and contact number. Document plan on Clinical Portal.

QEUH CMW = 0141 201 2256 externally or 62256  internally               

PRM CMW =   0141 201 3438 externally or 13438 internally                  

RAH CMW = 0141 314 7371 externally or 07371 internally

PROLONGED JAUNDICE

All prolonged jaundice (PJ) should be discussed same day with booking hospital neonatal team. Contact details as above. Guideline for managing prolonged jaundice Prolonged jaundice Neonates (NHSGGC) (scot.nhs.uk).

Red flags indicating need for urgent same day review - pale stools, dark urine, worsening jaundice, failure to thrive.

There is no neonatal referral age cut off provided it is not a new, late onset jaundice (e.g new jaundice developing after 4w of age) in a previously well baby  without any history of jaundice (those cases should be discussed with paediatrics).

For PJ in an older baby (e.g. ≥4w old) with red flags, it may be more appropriate, that they are seen same day via general paediatrics in CDU in case of underlying significant pathology such as biliary atresia and need for hospital admission. A discussion should happen at senior neonatal and general paediatric level.

PJ in well older baby without red flags should be seen as soon as possible at the neonatal clinic, within 1 week of referral.

Use in conjunction with full GGC neonatal guideline: Jaundice : neonatal guideline (scot.nhs.uk)

Who to assess?

All newborns are at risk of jaundice

Who to measure?

• Any baby with visible jaundice

Pay particular attention to:

• Babies with a family history of significant jaundice
• DCT positive babies (positive Coombs’s test due to haemolysis from maternal red cell antibodies)
• Breastfed babies
• Babies born at <38 weeks gestation

How to measure?

Use a transcutaneous bilimeter (Biliflash) if available OR serum bilirubin needed if no biliflash.

BILIFLASH CONTRAINDICATIONS

• <35 weeks gestation
• < 24 hours of age
• DCT (coombs) positive
• Has had previous phototherapy treatment

• This cohort will require a serum bilirubin (SBR)

If the biliflash reading is >250micromol/l or within 25micromol/l of the phototherapy treatment line an SBR should also be obtained and sent to the laboratory in a timely manner.

When to treat?

Tools and resources | Jaundice in newborn babies under 28 days | Guidance | NICE – click on gestation specific treatment threshold graphs.

All levels should be plotted on the appropriate gestation chart. Same gestation chart is used until D14 of life before moving up to next gestation chart.

Ensure the age (in hours) has been calculated accurately, treatment thresholds vary with gestation and age.

Treatment should commence once the SBR is above the treatment threshold, or if a previous SBR result is available and the rate of rise is clearly going to cross the treatment threshold within 6 hours.

If a baby is required to be admitted for phototherapy contact the booking hospital neonatal team to arrange admission to postnatal wards/NNU. Phone numbers at the end of the referral pathway. If the level plots within 50 micromol/l of the treatment line on the appropriate chart for gestational age this would need to be repeated within 18-24 hours and could be done by the community midwife, if the baby is well and fit for discharge. If this is the case, contact the community midwife, they will ensure this is allocated to the appropriate team.

QEUH CMW = 0141 201 2256 externally or 62256  internally               

PRM CMW =   0141 201 3438 externally or 13438 internally                 

RAH CMW = 0141 314 7371 externally or 07371 internally

Leave a voicemail providing:

• Name
• CHI
• Contact no for parent
• Reason for call; request for an SBR and date it is required

• Consultant Neonatologist must be involved in all discussions for Red and Amber category neonates. RHCG Neonatal consultant 82114. RHCG Neonatal Nurse in Charge 82111. RHCG Neonatal Registrar page 17690.
• SBAR Handover must have occurred between referring and accepting team.
• Consideration given to having a blood gas and blood glucose undertaken in babies being referred to a neonatal service.
• Accepting neonatal team aware of observations, available blood results and any changes in clinical condition following previous discussion.
• All babies should have a full set of observations in ED prior to leaving for the neonatal unit.  Any abnormal findings should be fully discussed with the accepting Neonatal consultant before the baby is transferred. 
• All babies accepted from ED or CDU for assessment on Level 2 neonatal service RHCG (even if then considered for PNW care) should have saturation monitoring in transit and until they have had a full set of observations and medical assessment on Level 2.
• All babies accepted for assessment on Level 1 should have full cardiorespiratory monitoring in transit and until medical assessment on Level 1.
• All original notes and observation charts accompany baby to NNU. Photocopies made in ED first to be scanned onto Clinical Portal.
• Consider need for retrieval by neonatal team with specialised equipment.

• In circumstances where transfer is to another booking hospital’s PNW, with the parents providing transport, the baby should be alert, active, feeding adequately and have normal a PEWs score on an appropriate chart before leaving. 
• No change in clinical condition and baby remains well, alert and feeding adequately.
• Any investigation results are known are acceptable for parent led transfer (including blood glucose if measured).
• Observations should be repeated prior to leaving the ED and must remain within normal limits.
• Parents must have reliable own transport (car) or have a hospital taxi organised
• SBAR handover to accepting neonatal team including patient’ CHI and accurate parental contact phone number.
• Parents should be advised exactly where to go and be given accepting neonatal units ward phone number in case of any issues on route.

            PRM Neonatal Unit 0141 451 5222

            RAH Neonatal Unit 0141 314 7035

• All notes and charts are photocopied and sent with parents and baby. Originals uploaded to Clinical Portal.

Refer to ED specific Neonatal documents and guidelines including neonatal proforma, hypothermia in ED SOP