Levels of neonatal care

Fetus and Newborn Committee, Canadian Paediatric Society (CPS)

Paediatr Child Health 2006;11(5):303-6
Reference No. FN06-02

Reaffirmed February 2011

Index of position statements from the Fetus and Newborn Committee

Content

• Objective
• Background
• Concept of regionalization
• Variation in classification systems among Canadian provinces
• Importance of the classification system
• Proposed classification of neonatal levels of care
  • Level 1: Basic neonatal care (normal newborn nursery)
  • Level 2: High-dependency neonatal care (special care newborn nursery)
  • Level 3: Intensive neonatal care (neonatal intensive care nursery)
• Standards for hospitals providing neonatal care
  • Multidisciplinary approach to neonatal care
  • Medical staff
  • Nursing staff
  • Respiratory therapy staff
  • Radiology
  • Subspecialties
  • Other staff
  • Transport
  • Parents
  • Clinical standards
• Continuing education and professional development
• References

OBJECTIVE

The objective of the present guideline is to establish a common classification system for neonatal-perinatal care facilities that can be used in all provinces and territories in Canada .

BACKGROUND

Canada has a highly regionalized neonatal-perinatal care system (1). In each region, hospitals are divided into three levels of care, and patients are referred to the facility with the appropriate level of care, depending on their condition: level 1 (normal newborn care), level 2 (high-dependency care) and level 3 (intensive care). However, because health care delivery is the responsibility of the provincial and territorial governments, the definitions for levels of care vary across jurisdictions. This has resulted in difficulties in the interpretation of resources and services available, access to care and costs of care.

CONCEPT OF REGIONALIZATION

In 1970, a Canadian neonatologist, Paul Swyer (2), first advocated regionalization of neonatal-perinatal care after observing that the neonatal mortality rate was higher in small hospitals delivering small numbers of infants than in larger hospitals with neonatal referral units and suggested that hospitals should be classified into three levels within each region: regional neonatal-perinatal centres (level 3) associated with university centres provide care for high-risk pregnancies and intensive care for severely ill infants; district hospitals (level 2) provide care for low-risk pregnancies and infants with less complicated neonatal problems; and community hospitals (level 1) provide care for normal births and healthy newborn infants. Level 1 and 2 hospitals were required to have the ability to resuscitate and stabilize ill newborn infants for transfer to an appropriate higher level facility using an integrated transport system. This system was implemented in Canada , which now has a regionalized system of perinatal care.

Following Swyer’s proposal, in 1976, the March of Dimes Committee on Perinatal Health in the United States issued a report that proposed three levels of increasing complexity of maternal and neonatal care within an integrated regional system (3). In 1997, the Committee expanded on these definitions and issued the Guidelines for Perinatal Care (4). The three levels of care were designated as basic, specialty and subspecialty. Level 1 (basic) units provide care for normal newborn infants but must have the personnel and equipment to perform neonatal resuscitation, evaluate healthy newborns and provide postnatal care, and stabilize newborn infants until transfer to an appropriate higher level facility. Level 2 (specialty) units can provide care to moderately ill infants with problems that are expected to resolve rapidly or who are convalescing after intensive care treatment. Level 3 (subspecialty) units provide comprehensive care for all critically ill newborn infants, including those who require surgical intervention.

VARIATION IN CLASSIFICATION SYSTEMS AMONG CANADIAN PROVINCES

Facilities are designated by the highest level of care provided. In 2002, Lee et al (5) reported significant variation in the classification of neonatal units among different jurisdictions in Canada . Neonatal units that provided similar services were classified as level 2 in some provinces and level 3 in others. Several provinces have also developed subclassifications within each level of care that further complicate interpretation of what the levels mean. In addition, some hospitals provide services of a higher level for which they have not been officially approved or funded. Consequently, their designated level of care may differ from the actual level of service provided. This has led to confusion about the relative capabilities and access to neonatal services among the provinces, and complicated decisions concerning planning and patient care (eg, appropriateness of patient transfer).

IMPORTANCE OF THE CLASSIFICATION SYSTEM

Standardization of the system of classification of neonatal units in Canada is important for several reasons. First, it permits articulation and examination of standards that must be met for provision of specified levels of care. Second, it facilitates orderly transfer of patients from one facility to another through common understanding of their relative capabilities and expectations. Third, it streamlines planning and allocation of resources, and facilitates examination of comparative regional resource use and outcomes. Finally, it can be used to ensure that appropriate funding is available for neonatal care facilities. Some studies (6-9), including one from Canada (6), have shown that centres designated at a higher level have lower mortality and morbidity rates for infants with comparable degrees of illness, showing that provision of care at the appropriate level through regionalization of care continues to be important.

PROPOSED CLASSIFICATION OF NEONATAL LEVELS OF CARE

Because newborn infants may be born with depressed respiration or circulatory impairment without warning, and unexpected deterioration of an initially healthy newborn may be rapid and catastrophic, all health care facilities providing care for newborn infants must be able to resuscitate and stabilize such infants until transfer to another appropriate facility, including the initiation of intravenous access and assisted respiration. Readiness to intervene for such infants must take into account the geographical location and the duration of time before assistance and transfer is likely. Some units providing lower levels of care must be capable of supporting infants for several hours while awaiting assistance.

Level 1: Basic neonatal care (normal newborn nursery)

Level 1a          

• Evaluation and postnatal care of healthy newborn infants; and
• Phototherapy

Level 1b

• Care for infants with corrected gestational age greater than 34 weeks or weight greater than 1800 g who have mild illness expected to resolve quickly or who are convalescing after intensive care;
• Ability to initiate and maintain intravenous access and medications;
• Gavage feeding; and
• Nasal oxygen with oxygen saturation monitoring (eg, for infants with chronic lung disease needing long-term oxygen and monitoring).

Level 2: High-dependency neonatal care (special care newborn nursery)

Level 2a

• Care of infants with a corrected gestational age of 32 weeks or greater or a weight of 1500 g or greater who are moderately ill with problems expected to resolve quickly or who are convalescing after intensive care;
• Peripheral intravenous infusions and possibly parenteral nutrition for a limited duration;
• Resuscitation and stabilization of ill infants before transfer to an appropriate care facility; and
• Nasal oxygen with oxygen saturation monitoring (eg, for infants with chronic lung disease needing long-term oxygen and monitoring).

Level 2b

• Mechanical ventilation for brief durations (less than 24 h) or continuous positive airway pressure; and
• Intravenous infusion, total parenteral nutrition, and possibly the use of umbilical central lines and percutaneous intraveneous central lines.

Level 3: Intensive neonatal care (neonatal intensive care nursery)

Level 3a

• Care of infants of all gestational ages and weights;
• Mechanical ventilation support, and possibly inhaled nitric oxide, for as long as required; and
• Immediate access to the full range of subspecialty consultants.

Level 3b

• Comprehensive on-site access to subspecialty consultants;
• Performance and interpretation of advanced imaging tests, including computed tomography, magnetic resonance imaging and cardiac echocardiography on an urgent basis; and
• Performance of major surgery on site but not extracorporeal membrane oxygenation, hemofiltration and hemodialysis, or surgical repair of serious congenital cardiac malformations that require cardiopulmonary bypass.

Level 3c

• Extracorporeal membrane oxygenation, hemofiltration and hemodialysis, or surgical repair of serious congenital cardiac malformations that require a cardiopulmonary bypass.

STANDARDS FOR HOSPITALS PROVIDING NEONATAL CARE

Multidisciplinary approach to neonatal care

Neonatal care has led to the development of a multidisciplinary approach to providing care for infants with complex health needs (10-24). Nurses, respiratory therapists, physiotherapists, occupational therapists, pharmacists, dietitians and others are integral members of the neonatal care team, and have evolved specialized and enhanced practice roles and responsibilities.

Medical staff

Level 1: A family physician or paediatrician should be available on call at all times.

Level 2: A paediatrician should be available on call at all times. When mechanical ventilation is in progress, the paediatrician should be available in-house or must assure that skilled staff, capable of immediately responding to potential emergency complications, are continually present. The medical staff of level 2b units should include a paediatrician with postresidency neonatal intensive care training.

Level 3: A qualified neonatologist should be available on call at all times. There should be 24 h in-house coverage by appropriately trained and supervised staff (eg, paediatrician, paediatric trainee or neonatal nurse practitioner) certified to perform the full range of resuscitation and intensive care roles (1).

Nursing staff

Units should provide patients with care from appropriately trained nursing staff. The number of nurses available should be sufficient to provide the following coverage:

Level 1: The unit should provide nursing care for both mothers and their babies. Each nurse may provide care for up to four mothers and their babies.

Level 2: The unit should provide a nurse to care for up to four babies, but this depends on the specific illnesses and circumstances. For sick babies, a nurse may be required to care for fewer than four babies.

Level 3: The unit should provide a nurse to care for one to two patients.

In addition, all units should have a designated nurse responsible for further education and training, including in-service experience. In collaboration with physicians, advanced practice nurses with specialized preparation, including clinical nurse specialists and neonatal nurse practitioners, may provide comprehensive care for patients (10-13).

Respiratory therapy staff

Respiratory therapy services should be available for units providing neonatal care at level 2b or higher. The role of respiratory therapists includes ventilation management, pulmonary function measurement and monitoring, newborn resuscitation and transport, and facilitation in the development of specialized aspects of care, such as the administration of nitric oxide during transport (14-16).

Level 2b: A registered respiratory therapist should be available in-house whenever an infant is receiving continuous positive airway pressure or mechanical ventilation support.

Level 3: The unit should have 24 h coverage by respiratory therapy services.

Radiology

Portable radiology services should be available for units providing neonatal care at level 2 or higher.

Level 2a: Portable x-rays should be available.

Level 2b: Portable x-rays should be available 24 h a day without delay. Head ultrasound should be available with radiology consultation.

Level 3: Portable x-rays should be available 24 h a day without delay. Ultrasound should be available seven days a week with rapid radiology consultation (17). Computed tomography, and preferably also magnetic resonance imaging, should be accessible.

Subspecialties

Units providing level 1b or higher care should have access to appropriate laboratory services, including clinical chemistry, microbiology and hematology.

Units providing level 2b or higher care should have access to radiology, ophthalmology and laboratory services (clinical chemistry, microbiology, hematology and transfusion, and pathology).

Units providing level 3 care should have defined lines of communication and access to obstetrics and perinatal medicine, neonatal surgery and anesthesia, paediatric cardiology, specialist consultations (eg, child developmental medicine; clinical genetics; paediatric infectious diseases; gastroenterology; endocrinology; neurology and neurophysiology; paediatric nephrology; and audiology), other surgical specialities (eg, ear, nose and throat; orthopedics; neurosurgery; plastic surgery; and urology), radiology, ophthalmology and laboratory services (eg, clinical chemistry; microbiology; hematology and transfusion; and pathology).

Other staff

Units providing level 3 care should have supporting staff that have appropriate training with respect to the care of newborn infants and their parents (10-25). They provide specialized neonatal assessments and treatments, and assist in the development of integrated treatment plans that optimize treatment efficacy and enhance patient safety. They include radiology and ultrasonography technologists, pharmacists, physiotherapists, occupational therapists, dietitians, infection control staff, administrative and clerical staff, phlebotomists, research assistants, pastoral caregivers, social workers, psychologists and community health workers.

Transport

An organized transport team trained in neonatal care, resuscitation and transport care with appropriate equipment must be available for the transfer of patients in each region. A system for managing transport requests around the clock must be clearly defined and easily accessible by medical teams at all regional units requesting transfer.

Parents

There should be appropriate facilities for parents, who should be encouraged to participate in the care of the infants. Facilities should include private breast pump rooms, refrigeration and storage facilities for breast milk, and parent rooms for overnight rooming in with the infant before discharge from hospital. A quiet room should be available for consultations and for families who may need privacy to deal with emergent circumstances.

Clinical standards

Clinical protocols: Written protocols should be available for key procedures and practices, including resuscitation and stabilization of babies, and should be reviewed and updated regularly.

Quality assurance: Units should longitudinally monitor mortality, morbidity, workload, resource use, practices and policies using a prospective database with well-defined items. These should be regularly reviewed and benchmarked against national standards. An audit program and critical incident reporting program should be in place.

Developmental follow-up assessment: Each unit should enrol high-risk infants in a developmental follow-up program that can longitudinally assess infants after discharge home.

Quality improvement: Each unit should have a multidisciplinary team trained to motivate, initiate and support quality improvement initiatives. Ideally, this team should work in coordination with similar teams in other hospitals.

Annual report: Each unit should produce an annual report summarizing their activity and performance in a standardized form. The report should also benchmark individual unit activity and performance against other units nationally, and against national criteria for service provision.

CONTINUING EDUCATION AND PROFESSIONAL DEVELOPMENT

Staff members of the unit should receive appropriate orientation and training before starting duties. Appropriate personnel should have training in neonatal resuscitation and stabilization. Unit staff members should attend regular continuing education activities, including conferences, clinical care rounds, journal clubs and other similar activities.  

REFERENCES

1. Mitchell-DiCenso A, Guyatt G, Marrin M, et al. A controlled trial of nurse practitioners in neonatal intensive care. Pediatrics 1996;98:1143-8.
2. Swyer PR. The regional organization of special care for the neonate. Pediatr Clin North Am 1970;17:761-76.
3. Committee on Perinatal Health. Toward Improving the Outcome of Pregnancy: Recommendations for the Regional Development of Maternal and Perinatal Health Services. White Plains: March of Dimes National Foundation, 1976.
4. American Academy of Pediatrics/American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, Fourth Edition. Elk Grove Village: American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, 1997.
5. Lee SK, Cardiff K, Stewart S, MacKenzie W. Report on Tertiary Neonatal Care in British Columbia. Vancouver: Centre for Healthcare Innovation and Improvement, 2002.
6. Chien LY, Whyte R, Aziz K, Thiessen P, Matthew D, Lee SK; Canadian Neonatal Network. Improved outcome of preterm infants when delivered in tertiary care centers. Obstet Gynecol 2001;98:247-52.
7. Phibbs CS, Bronstein JM, Buxton E, Phibbs RH. The effects of patient volume and level of care at the hospital of birth on neonatal mortality. JAMA 1996;276:1054-9.
8. Cifuentes J, Bronstein J, Phibbs CS, Phibbs RH, Schmitt SK, Carlo WA. Mortality in low birth weight infants according to level of neonatal care at hospital of birth. Pediatrics 2002;109:745-51.
9. Sanderson M, Sappenfield WM, Jespersen KM, Liu Q, Baker SL. Association between level of delivery hospital and neonatal outcomes among South Carolina Medicaid recipients. Am J Obstet Gynecol 2000;183:1504-11.
10. McMillan D, Perreault T, Watanabe M, Chance G, Fraser-Askin D, Hall J. Neonatal personnel in Canada. Paediatr Child Health 1997;2:193-7.
11. Clancy GT, Maguire D. Advanced practice nursing in the neonatal intensive care unit. Crit Care Nurs Clin North Am 1995;7:71-6.
12. Pickler RH, Reyna BA. Advanced practice nursing in the care of the high risk infant. J Perinat Neonatal Nurs 1996; 10:46 -53.
13. Mitchell A, Watts J, Whyte R, et al. Evaluation of graduating neonatal nurse practitioners. Pediatrics 1991;88:789-94.
14. Boucher SN, Singhal N. Development of a program for case room resuscitation by respiratory therapists. Can J Respir Ther 1992;28:167-71.
15. Duncan B, Thomson B, Akierman A. Evolution and analysis of a neonatal resuscitation program. Can J Respir Ther 1995;31:165-9.
16. Daya K, Bourcier L, Singhal N, McMillan DD. Administration of nitric oxide during neonatal transport. Can J Respir Ther 1997;33:93-7.
17. Canadian Paediatric Society, Fetus and Newborn Committee. Red blood cell transfusions in newborn infants: Revised guidelines. Paediatr Child Health 2002;7:553-8. http://www.cps.ca/english/statements/FN/fn02-02.pdf (Version current at April 17, 2005 ).
18. Lobas NH, Armistead JA, Ivey MF. Expanding staff pharmacists’ responsibilities to maintain pharmacy services in a neonatal intensive care unit. Am J Hosp Pharm 1991;48:1708-11.
19. Bryant BG. Clinical pharmacist: Emerging member of the NICU team. Neonatal Netw 1985; 3:40 -4.
20. Johnson CJ, Lobas NH, Ivey MF. Development of a pharmaceutical care system in a neonatal intensive care satellite pharmacy. Am J Hosp Pharm 1993;50:1158-63.
21. Mayfield SR, Albrecht J, Roberts L, Lair C. The role of the nutritional support team in neonatal intensive care. Semin Perinatol 1989;13:88-96.
22. Thompson M. Establishing and developing the position of neonatal nutritionist. In: Groh-Wargo S, Thompson M, Cox JH, eds. Nutritional Care for High Risk Newborns. Chicago: Precept Press Inc, 1994:396-401.
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24. Hunter J. Clinical interpretation of “education and training of occupational therapists for neonatal intensive care units”. Am J Occup Ther 1996;50:495-503.
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FETUS AND NEWBORN COMMITTEE (2005-2006)

Members: Drs Khalid Aziz, Department of Pediatrics (Neonatology), Janeway Children’s Health and Rehabilitation Centre, St John’s, Newfoundland and Labrador (board representative); Keith J Barrington, Royal Victoria Hospital, Montreal, Quebec (chair); Haresh Kirpalani, Children’s Hospital – Hamilton HSC, Hamilton, Ontario; Shoo K Lee, Northern Alberta Neonatal Intensive Care Program, Royal Alexandra Hospital, Edmonton, Alberta; Koravangattu Sankaran, Royal University Hospital, Saskatoon, Saskatchewan; Robin Whyte, IWK Health Centre, Halifax, Nova Scotia
Liaisons: Drs Dan Farine, Mount Sinai Hospital, Toronto, Ontario (Society of Obstetricians and Gynaecologists of Canada); David Keegan, London, Ontario (Maternity and Newborn Care Committee, College of Family Physicians of Canada); Catherine McCourt, Health Surveillance and Epidemiology, Public Health Agency of Canada, Ottawa, Ontario; Alfonso Solimano, BC’s Children’s Hospital, Vancouver, British Columbia (Neonatal-Perinatal Medicine Section, Canadian Paediatric Society); Ann Stark, Baylor College of Medicine, Houston, Texas, USA (Committee on Fetus and Newborn, American Academy of Pediatrics); Ms Amanda Symington, Hamilton Health Sciences Centre – McMaster Site, Hamilton, Ontario (Neonatal Nurses)
Principal author: Dr Shoo K Lee, Northern Alberta Neonatal Intensive Care Program, Royal Alexandra Hospital, Edmonton, Alberta

Posted June, 2006