Trust Guideline for Admission of Newborn babies to the Neonatal Unit

A Clinical Guideline
For Use in: Neonatal Intensive Care Unit.
By: Paediatric Medical staff, Neonatal Nurses.
Newborn babies admitted from the labour ward,
For: post-natal ward, Children assessment unit or
Accident and Emergency department.
Division responsible for document:
Women’s and Children’s

Key words: Newborn, NICU, Admission,

Name of document author: Dr H O’Reilly,
Job title of document author: Consultant Neonatologist
Name and job title of document
Dr D Booth, Clinical Director for Paediatrics
author’s Line Manager:
Dr MP Dyke, Consultant Neonatologist
Dr P Clarke, Consultant Neonatologist
Supported by: Dr R Roy, Consultant Neonatologist
Dr F Walston, Consultant Neonatologist
Dr Priya Muthukumar, Consultant Neonatologist
Clinical Guidelines Assessment Panel
Assessed and approved by the:
(CGAP) - Chair’s Action
Date of approval: 02/10/2015
Ratified by or reported as approved Clinical Standards Group and Effectiveness
to (if applicable): Sub-Board
To be reviewed before:
This document remains current after this 02/10/2018
date but will be under review
Dr MP Dyke, Dr P Clarke, Dr D Booth, Dr R Roy,
To be reviewed by:
Dr O’Reilly, Dr Muthukumar, Dr Walston
Reference and / or Trust Docs ID No: CA4068 id 1317
Version No: 3
Description of changes: No clinical changes
Compliance links: (is there any NICE
None
related to guidance)
If Yes - does the strategy/policy
deviate from the recommendations of
NICE? If so why?
This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis
and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a
standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing
clinical circumstances, the diagnostic and treatment options available and the professional judgement,
knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant
guidance should be documented in the patient's case notes.
The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the
quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for
any misunderstanding or misapplication of this document.

Author/s: Dr Helen O’Reilly Date of issue: 02/10/ 2015

Valid until: 02/10/2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 1 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit

Quick reference guideline

Intensive care cot space should always be prepared and ready for use (see appendix1)
Transport incubator checked at start of every shift and ready for use (see appendix 2)

Antenatal counselling and visit to unit if possible

Anticipated or emergency admission

Disseminate information
Nursing staff immediately Medical staff

GOLDEN
Briefly explain to the parents the
Check baby’s identity HOUR
condition of the baby and reason
for admission to the neonatal unit
Temperature
control
Weigh
Respiratory Assist the nursing staff in
support transferring the baby to the
incubator, briefly assess baby
Assess the baby and transfer to Cardiovascular and adjust ventilator settings if
incubator & connect to ventilator support needed

Line insertion

Check ETT position & adjust Nutrition Prescribe

ventilator settings Vitamin K (if not already given)
Teamwork Antibiotics and infusions if
required.
Prepare for Lines insertion.
Connect to monitors & obtain
baseline admission observations

Insert lines/admission blood tests

Check blood glucose & blood gas Complete admission examination

X-ray to check ETT/lines position

Administer vitamin K, prepare
drugs and infusions
Admission documentation
Complete paperwork Update parents

Objective/s
Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015
Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 2 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit

To ensure safe, prompt and effective delivery of care to newborn babies admitted to the
Neonatal Intensive Care Unit (NICU) or Special Care Baby Unit (SCBU), through
organized and coordinated work of the medical and nursing staff.

Rationale
The first few hours after admission to the NICU are critical for the high risk new born
babies in general, and preterm low birth weight infants in particular. Careful adherence to
details in the delivery room and during the first few hours after birth is essential to help
avoid some of the immediate and long term complications. All staff should have a
consistent approach to the initial care of these fragile infants upon admission to the
neonatal unit.

Broad recommendations

Criteria for the admission of a sick newborn to NICU/SCBU

 Gestational age less than 34 weeks

 Birth weight less than 1.8 kg
 After prolonged resuscitation
 Severe congenital anomalies
 Any new born requiring surgery
 Newborn babies with cord pH less than 7.0 irrespective of gestation
 Hypoglycaemia (if persistent despite oral feeds or if <1mmol/L)
 Hyperbilirubinemia requiring intensive phototherapy or likely to need exchange
transfusion
 Unwell newborn e.g. respiratory distress, suspected sepsis, cardiac condition…etc.
 Infants with Neonatal Abstinence Syndrome requiring treatment
 Infants held in a place of safety as a result of Child Protection proceedings (SCBU)
 Any other concern where the baby can not be looked after on the post natal ward
safely
This is not intended to be an exhaustive list. Any newborn infant where close observation,
continuous monitoring or active management is needed and where the neonatal team feel
it can’t be provided safely on the postnatal ward or the transitional care area should be
admitted to NICU/SCBU as appropriate.

Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015

Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 3 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit
Transport arrangements for the movement of a sick newborn

Resuscitation and initial stabilisation of any sick newborn should be achieved prior to
moving the baby to the neonatal unit. The baby should be moved in a safe, controlled
manner with the appropriate staff as his/her condition dictates.

Transport from the home

For a neonatal emergency, a 999 ambulance, with paramedic support will be summoned
by the attending health professional.

Following initial resuscitation and stabilisation the neonate will be transferred by

ambulance to the consultant unit (Refer to guidelines on management of planned home
birth MID 2 and Transfer of care from midwives to other health professionals MID 5).

Transport from Delivery Suite

1. The transport incubator located on the NICU should be checked by a trained
neonatal nurse at the beginning of each shift to ensure it is ready for use (checklist
Appendix 2).
2. After delivery, resuscitation to be performed as appropriate for the condition of the
baby.
3. The baby can be moved once the team is comfortable that the baby is stable i.e.
has a patent airway, breathing (spontaneously or intubated & ventilated) and stable
circulatory status.
4. Adjust the portable ventilator settings, and ensure it is operating well.
5. Baby to be transferred to the portable incubator.
6. Re-assess the baby once in the transport incubator, particularly its colour, chest
movement, air entry and ETT position. Re-adjust ventilator settings if needed and
check that IV lines are properly secure ( if any lines inserted in the delivery suite
(DS))
7. Once team is happy that the baby is stable in the portable incubator they can move
to the NICU.

Transport from Post-Natal (PN) ward

1. Any sick baby on the PN ward should be assessed by the neonatal team prior to
transport to the neonatal unit.
2. If the baby’s condition is seen to be stable, with no need for immediate resuscitation
the baby can be moved to the neonatal unit in his/her cot accompanied by
midwife/nurse from the post-natal ward staff.
3. In case of unstable/sick baby the baby should have necessary resuscitation and
initial stabilisation while on the post-natal ward and then be transported in the
portable incubator as outlined above.

Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015

Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 4 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit
Duties of Staff involved in admission of sick newborn to NICU/SCBU

Nursing staff
1. Ensure an admission space always prepared and ready to use immediately

2. The cot will have been set up with the main equipments needed to provide
immediate care and monitoring (see appendix 1)

3. The Nurse in charge (coordinator) to decide which space the infants will be admitted
to, and who will be the admitting nurse.

4. Admitting nurse to make sure baby has two identity bands containing name, sex, date
and time of birth and hospital number and must verify details on them with the nurse
handing over the baby and the medical records. If possible the identity must also be
confirmed with accompanying parent. A cot card with the mother’s name and
registration number should also be attached to the incubator. As soon as babies
are permanently transferred to a cot, identity bands should be reproduced to
amalgamate these details. (see trust guideline ‘Policy for Identification of In-Patients
and Day Cases’)
5. If the baby is ventilated ensure that the ventilator settings match the current settings
on the transport ventilator before transferring the baby and enter weight. Attach the
sterile water and turn on the humidifier, set to 37C.
6. Weigh on transfer to incubator for baseline weight (to assist with drug and fluid
calculations). For accurate weight subtract estimated weight of equipment attached
to baby

7. Ensure that the endotracheal tube (ETT) is secure and that the level of the tube is
correct by noting that airy entry is equal. Record the size and the level of the ETT at
the fixing bar.

8. Place a saturation (SaO2) probe affixed to the best perfused limb (ideally right arm
for pre-ductal saturation) to gain reading of the baby’s oxygen levels. Record the
admission SaO2 (For saturation monitor alarm limits see Appendix 1)

9. Measure and record rectal temperature, heart rate and respiratory rate.

10. Attach temperature probe and cardiac monitor leads.

11. Measure and record blood pressure; report hypotension to the medical team.

12. Check blood sugar as soon as possible from heel prick and send Day 0 NNST
13. Infants less than 30 completed weeks should remain wrapped in the plastic bag until
all lines are secured, X-ray taken and humidity is ready for use.
14. Pass infant feeding tube (before CXR) and check for pH.

15. Measure and record the head circumference.

16. Arterial lines should be transduced to monitor mean arterial pressure.

Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015

Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 5 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit
17. Give vitamin K if not already given (check consent obtained).

18. Ensure that a photograph of the baby is taken and given to parents along with the
appropriate booklets. Show parents around the unit if appropriate.

19. Discuss method of feeding with parents; encourage early expression of breast milk.

20. Ensure that the medical team have updated the parents about the baby’s condition
and progress.

21. Ward clerk to register the baby, get hospital number and prepare folder (Night
receptionist on delivery suite for out of hours admissions).

22. Fill in admission book with baby’s and mother’s details.

23. Fill in “Admission management check list”, and file in the baby’s brown notes.
24. Place a completed cot card with the baby’s details on the incubator.
25. The ward clerk should ensure that the Health Visitor has been notified of the baby’s
admission within 24 hours or on next working day, as well as GP letter (completed
by SHO).

26. Check if baby qualifies for ROP screening. If yes, enter details in ROP folder.

Medical staff
1. Notify the nurse in charge immediately if you are informed by the Delivery suite
about any imminent delivery which might need NICU admission.

2. Consultant should always be informed of and should normally attend the delivery of
preterm infants < 26 weeks gestation. In addition the attending consultant should
be informed of any delivery in which there have been significant antenatal concerns.
In critical situations where ethical issues may arise, such as a decision whether or
not to continue resuscitation for an extremely preterm baby or a baby with a major
congenital abnormality, an experienced doctor (usually a consultant) should be
immediately available for discussion and in attendance as soon as possible

3. At delivery; help the nursing staff transferring the baby to the transport incubator and
connecting to the ventilator. Ensure the ETT (if intubated) is secure, and note the
level at the fixing bar. Ensure there is adequate chest movement and equal air
entry.

4. Once on the NICU; assist the nursing staff moving the baby to his/her incubator on
the unit, and connecting to the ventilator. Ensure the ETT still in correct place, by
observing chest movements and listening to air entry.

5. Adjust ventilator settings as needed, clinically.

6. Give time to the nursing staff (normally about 10-15 minutes) unless the baby is not
well, to check the weight, connect the baby to monitors, take the base line
observations, and check blood sugar and capillary blood gases if needed.

Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015

Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 6 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit
7. Prescribe vitamin k, antibiotics and infusions as appropriate, so the nursing team
can prepare while you are putting the lines.

8. Insert PVL first so fluids could be started, then umbilical lines if indicated (refer to
the NSC network guidelines on UAC/UVC insertion). Collect admission blood
samples, including day 0 NNST if not already done.

9. Document the procedure using the relevant label and stick in the notes (Same
apply for ETT)

10. Order X-rays to check ETT and lines position before starting the infusions,
document position and any adjustment made on the relevant sticker placed in the
notes.

11. Complete admission examination, as appropriate depending on baby’s condition.

12. Highlight areas not examined, so it can be checked at later time e.g. red reflex,
hips…

13. Obtain history from maternal notes, plus the parents if possible.

14. Fill admission booklet as well as SEND admission notes.

15. Speak to the parents as soon as possible and update them about condition of their
baby, reason for admission and current management and response.

16. Document discussions with the parents in the “Blue” communication sheet and
place in the baby’s brown notes.

17. Inform consultant of admission if not already present

18. Senior clinician to see parents within 24 hours of birth (date and time must be
recorded in notes so this can be documented on SEND).

All staff

If possible take time to debrief first hour care, look at what went well and consider whether
there are any learning points

Unit status and liaison with Delivery Suite (DS)

It is vital to keep up to date record of any pending deliveries where the baby might need
NICU admission, and to liaise closely with the DS.
1. Nurse in charge to call the delivery suite coordinator at the start and before the end of
every shift

a. To update the delivery suite team with the unit status (open/closed) and number
of cots available for admission.

b. Get latest information about delivery suite activity; and any anticipated/possible
admissions.
Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015
Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 7 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit
c. Record in the NICU daily report book, any expected admissions and delivery
suite activity.

2. Handover to nurse in charge on the next shift.

3. Any change in the unit status need to be communicated to the delivery suite as soon
as possible.

4. Delivery unit to inform NICU about any change in the DS status i.e. any deliveries in
progress where the newborn baby is like to need admission e.g. premature delivery.

5. Updated information about NICU and DS to be displayed on the board in intensive

care room 1 and updated regularly.

Reporting and learning the lessons from unanticipated admissions

For all cases of unanticipated admissions from home or wards (code ‘F5’ on CI trigger list)
a Trust incident reporting form should be completed. Such admissions and any other
admission where the neonatal team feel that it could have been avoided should be
discussed with the attending consultant and have an incident reporting form completed
(see below)

For relevant cases highlighted

1. The cases are discussed on the weekly grand round meeting attended by the medical
and nursing staff; a record of cases discussed is kept in the grand round folder
available on the neonatal seminar room.

2. Every week relevant cases would be noted to be presented and discussed in the
perinatal mortality and morbidity meeting held once per month with the obstetric
team.

3. Outcome of the case review in both meetings would be summarised with

recommendations formed into an action plan.

4. For Critical incident reporting refer to the Trust “Policy & Procedure for the Reporting
and Management of: incidents, near misses and serious untoward incident”

5. Incident to be graded according to the above policy and action followed as

appropriate.

Clinical audit standards

The following standards will be monitored by regular Audits, admission records review and
inspection of the admission space on the unit.

Audit standards (Monitoring the effectiveness of the Guideline)

Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015

Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 8 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit
1. Admission space should be ready at all times, with equipments as minimum meeting
the requirements set in the attached Appendix1.

2. Newborns admitted to the NICU will have the admission booklet and SEND
admission notes filled.

3. Admission management check list completed and filed in the notes.

4. Base line admission observations taken, including blood pressure and blood sugar,
and entered on the admission (Day 1) booklet

5. All procedures performed documented on appropriate fully completed label and stuck
in the notes.
Above standards to be monitored by regular Audits, admission records review and
inspection of the admission space on the unit.

Summary of development and consultation process undertaken before registration

and dissemination

The author drafted the guideline on behalf of the Neonatal Intensive Care Team. It has
been discussed with the neonatal nursing staff and circulated to the Neonatal Consultants.
This version has been endorsed by the Clinical Guidelines Assessment Panel.

Distribution list/ dissemination method

Trust intranet.

References/ source documents

1. British Association of Perinatal Medicine. (2010). Standards for hospitals providing

neonatal intensive and high dependency care. Third Edition

2. Department of Health. (2004). Maternity Standard, National Service Framework for

Children, Young People and Maternity Service. London: COI.

3. Confidential Enquiry into Stillbirths and Deaths in Infancy. (2003). Project 27/28.
http://www.cmace.org.uk/getattachment/e6ffafcf-acbd-4f22-ad8c-
4975b6cbee82/Project-27-28.aspx

4. Royal College of Anaesthetists, Royal college of Midwives, Royal College of

Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health.
(2007). Safer Childbirth: Minimum Standards for the Organisation and Delivery of
Care in labour. London: RCOG Press.

5. Avery’s diseases of the newborn. (2005) 8th edition. H. William Taeusch et al.

6. Toolkit for High Quality Neonatal Services. Department of Health (2009)

7. The Golden Hour: Resuscitation and early care of the extremely preterm infant.
www.yorkshireneonet.nhs.uk/training/Golden%20hour.pdf

8. Related Guidelines

Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015

Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 9 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit
a) Use of Polyethylene Skin Wrapping at the Delivery of the Very Preterm Infant
(NSC Practice guideline).

b) The Management of Thermoregulation In Neonates (Trust Guideline- NICU 1

Version 2)

c) The Management of Humidity for Infants Less than 30 weeks gestation (Trust
Guideline-NICU7 Version 1)

d) Management of Blood pressure monitoring in Neonates(Trust Guideline-NICU

5 Version 1)

e) Umbilical Venous Catheter (NSC Neonatal Network)

f) Umbilical Arterial Catheter (NSC Neonatal Network)

g) Intravascular Access Overview (NSC Neonatal Network Guidelines)

h) Policy for Identification of In-Patients and Day Cases (Trust Guideline - D5

Version 5)

Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015

Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 10 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit
Appendix 1

Equipments and Setting up for an admission to the neonatal unit

1. Pre-warmed incubator.
2. Incubator humidification pack.
3. Incubator Bedding-with suitable ‘Nesting’ and weighed nappy.
4. Ventilator with oxygen and air plugged in (should be checked once during every shift)
5. Bag of sterile water ready for the ventilator humidifier.
6. Oxygen flow meter.
7. Laerdal bag and face masks of different sizes/oxygen funnel.
8. Suction unit ready for use.
9. Monitor with attachments.
10. ECG leads with three electrodes attached.
11. Saturation lead and probe with Posey Wrap.
12. Drip stand.
13. Infusion pump/Burette set (1 Alaris)
14. Syringe pumps (at least 2 Omnifuse)
15. IV infusion filter.
16. Multi drawer Trolley; attached container for suction catheters (various sizes).
17. Plastic pot with:
 Infant feeding tube (pH paper)

 Swabs sticks. Take 4 swabs if admitting from DU (nose, ear & perineum for MRSA
and rectal swab for ESBL). If admitting from another NICU or from CAU also swab
any indwelling line or area of broken skin.
 BP cuffs; different sizes.
 Thermometer and sleeves ( to check rectal temperature)
 Temperatures skin probes and covers.
 Tape measure.
 Duoderm.
 Tape to secure NG tube.
 2.5 ml oral/enteral Syringe.
18. Saturation Monitor alarm limits

Birth gestation Lower limit Upper limit

Less than 37 weeks 91% 95%

More than 37 weeks 9188% 9894%

Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015

Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 11 of 12
 Trust Guideline for Admission of Newborn babies to the Neonatal Unit
Appendix 2
Transport incubator checklist for deliveries

 Ensure transport incubator is plugged in and charged.

 Check oxygen and air cylinders are at least full, replace if needed.
 Whilst switched on switch to ventilator mode to check circuit is working, and check
suction is working.
 Then switch off cylinders, also make sure that the suction unit is off.
 Put onto standby mode and check it is charging.

What should be on the transport incubator?

 Endotracheal tubes: two of each size.

 Two small, two medium and two large hats
 Endotracheal bars of three diff3rent sizes.
 Laryngoscope handle, ensure that it is working and two blades, small and large.
 Forceps for fixing bars.
 Curosurf bag: size 4 feeding tube and 2 ml syringe and needle, tape measure, scissors.
 Suction catheters two of each size, no more.
 Bag and small, medium and large face masks.
 Oxygen funnel and tubing.
 Bed make up with sheet, towel and plastic bag.
 One set of ECG leads and one oxygen saturation lead

Author/s: Dr Helen O’Reilly Date of issue: 02/10/2015

Valid until: 02/10/ 2018 Guideline Ref No CA4068 id 1317 v3
Document: Admission of Newborn babies to the Neonatal Intensive Care Unit
Copy of complete document available from: Trust Intranet Page 12 of 12