NEONATAL INTENSIVE CARE UNIT. Author: Divisional Manager and Divisional Nurse, Children & Women

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1 AGENDA ITEM 4.4 NEONATAL INTENSIVE CARE UNIT Executive Lead: Deputy Chief Executive/Director of Planning Author: Divisional Manager and Divisional Nurse, Children & Women Contact Details for further information: Jessica Castle or Bernie Steer ext SITUATION The purpose of this paper is to provide the Board with an update on the current position of the Neonatal Intensive Care Unit (NICU) at the University Hospital of Wales, the clinical risks associated with capacity and environmental issues and to recommend a way forward to mitigate the current identified risks. BACKGROUND Across South Wales, there are three designated level III tertiary units, Cardiff, Singleton and Royal Gwent. These are the only units that are capable of taking the most critically ill and premature babies. Intensive care facilities are provided in the other units (Nevill Hall, Royal Glamorgan, Prince Charles, Princess of Wales, and Carmarthen) but cannot provide the same level of specialist care and prolonged periods of critical care that may be required. The neonatal units in Cardiff and Cwm Taf form the South Central part of the neonatal network to provide intensive care, high dependency and special care services for the local populations of Cardiff and the Vale and Cwm Taf, with Cardiff as the main provider of intensive care level facilities. In addition, Cardiff is the sole unit in Wales supporting neonatal surgery and a quarter of all admissions are from other units in Wales. Activity In the financial year to date, NICU activity increased above 2011/12 levels for the comparable period for intensive care, high dependency and special care. The figures in the table below do not include the number of babies transferred out due to lack of neonatal capacity. Bed Days Level of Care 2011/12 (full year) 2011/12 (to Dec) 2012/13 (to Dec) % Occupancy % Increase ITU (Level 3) HDU (Level 2) SCBU (Level 1) Neonatal Capacity Page 1 of 6 Board Meeting

2 Capacity There are 30 cot spaces available on the NICU: 8 intensive care 10 high dependency 12 special care The British Association of Perinatal Medicine (BAPM) recommends that neonatal units should operate at around 70% occupancy to achieve optimal care and it is recognised that at occupancy levels above this clinical outcomes deteriorate. Neonatal activity is almost entirely emergency driven and so is subject to marked fluctuation in demand over time; these fluctuations determine the requirement for mean critical care occupancy levels no higher than 70% to allow peaks of demand to be safely managed. Demand Demand for neonatal services in the future is expected to increase. The main factors impacting on demand are as follows: Increasing birth rate; over the last 4 financial years the birth rate in Cardiff and Vale has steadily increased, 6151 in 2008/9, 6240 in 2009/10, 6437 in 2010/11 and 6477 in 2011/12, together with increased levels of prematurity and increased survival of premature infants, Strategic service developments; due to workforce pressures, work is currently underway to reconfigure Obstetrics, Neonatal and Paediatric services in South Wales. This is likely to result in centralisation of services and a further increase in demand/activity required in Cardiff, Increasing neonatal refusals; Cardiff should already be providing intensive care facilities for Cwm Taf babies as part of the South Central Network and is currently unable to respond reliably to this demand, Increasing maternal transfers; in the last 6 months, 14 women have been transferred out to another unit to deliver (18 babies) and there is a need to repatriate this activity, not least for patient safety reasons. ASSESSMENT In 2005, following amalgamation the neonatal unit at UHW had 34 cots; 10 ITU, 12 HDU and 12 special care. In 2009, 4 critical care (2 ITU and 2 HDU) cots were closed due to a shortage of medical staffing. Although the acute staffing shortage has been resolved through work with the Wales Deanery; the cots have remained closed due to concerns regarding infection related to overcrowding on the unit. The UHB has undertaken a three phase environmental improvement programme in the current unit that has gone some way to address storage issues, improved space within the overall footprint of the Unit and replacement of taps and sinks to minimise the risk of Pseudomonas infection. This work has now been completed but does not address the underlying problem of a Unit that is functionally inadequate. The existing space does not meet minimum clinical recommendations even with these cot closures and infection control continues to be a major concern. As a result of these cot closures and increased demand for care across the South Central area, there are daily capacity problems at UHW. Since December 2011, the unit has been at or over capacity for approximately 32% of the time, with the greatest Neonatal Capacity Page 2 of 6 Board Meeting

3 pressure being at critical care level. This has an impact on both neonatal and obstetric service delivery and results in mothers and babies being transferred out of Cardiff to other units in Wales or to England for neonatal care. The neonatal network has undertaken a review of neonatal capacity across South Wales and its most recent report was provided to the Children and Young People Committee at Welsh Government on 7 March This most recent assessment demonstrates that despite an overall birth-rate that now appears to be falling in South Wales, the extremely preterm birth-rate (defined here as infants <31weeks gestation) has continued to rise over recent years, apart from 2011,which was an unusually low year. The South Central and South East Communities have experienced large increases in the extremely preterm birth-rate between 2011 and 2012 while there has been a modest fall in the South West, in the same period. The increase in activity experienced by units in South Wales appears to be attributable to the significant rise in the extremely preterm birth-rate. These infants have a disproportionally high impact on a Units workload both in terms of length of stay and acuity of care. Increased numbers of babies have been cared for outside their own Health Community in South Wales. Cwm Taf units have continued to provide some ongoing neonatal intensive care outside the context of a NICU, and without this, the need to transfer babies out of Wales would have been even higher. It is evident that there is inadequate critical care capacity in the South Central Health Community to support locality based care, which is causing unnecessary clinical risk There are additional concerns with the existing neonatal unit which all relate to lack of physical space: Insufficient storage Inadequate family facilities No staff changing facilities Inadequate toilet provision for staff and visitors The configuration of the unit is poor with insufficient space, storage and an undesirable layout of clinical and supporting rooms. Existing recommendations for the design of a neonatal intensive care unit recommend between 12 and 20m 2 per critical care cot and 9.5m 2 per special care cot. A recent review of the unit in respect of current recommendations showed that the unit had approximately 50% of the minimum recommended space level per cot at all intensity levels and lacked a number of facilities considered essential for a leading neonatal unit. South Central Capacity Issues The All Wales neonatal network has recently carried out a capacity review across Wales which shows that occupancy rates in the South Central region regularly operate at levels well in excess of those recommended at around %. The pressure is greatest at high dependency and special care levels, with babies often occupying intensive care cots to receive high dependency care because of a shortage of high dependency cots. The network has identified a shortfall of 12 cots in Neonatal Capacity Page 3 of 6 Board Meeting

4 the south central region of the network and has asked organisations to address this shortfall in capacity. In addition the birth-rate in Wales continues to rise and it is anticipated that there will be a further increase in demand for neonatal critical care cots in the future. Special Care (SC) An additional 9 SC cots are needed within the South Central Community to meet the 80% average occupancy standard, if no further improvements can be made to reduce current SC occupancy levels. Cwm Taf Health Board continues to have relatively high SC occupancy rates, which suggests further improvements could be made. High Dependency (HD) An additional HD cot is required to meet the minimum average occupancy standard of 70%. Implementation of the current business case to increase HD capacity by 2 cots in Cwm Taf would be welcomed. This would allow: IC cots to be used more effectively and would to a degree compensate for the substantial IC cot deficit within this Community Fewer mothers and babies receiving unplanned care outside South Wales. The two Health Boards will need to work closely together to ensure the benefits of the additional capacity are realised for the local population. Intensive Care (IC) An additional 4 IC cots are required to meet the substantial deficit in provision that is evident in the South Central Health Community. It is apparent that the current configuration of IC cots is inadequate for the provision of locality based care and is leading to a disproportionate number of mothers and babies being displaced outside of the Health Community for care. This leads to increased clinical risk and results in a poorer service to families. A volume of IC continue to be delivered in the IC cot in Royal Glamorgan Hospital, Cwm Taf, and as with previous recommendations, this should be relocated to Cardiff and Vale as soon as practicably possible. Infection Rates Infection rates on the neonatal unit at UHW have in the past been found to be at unacceptably high levels as benchmarked against the Vermont-Oxford network (an international network of neonatal units allowing benchmarking with units of similar activity levels and workload). A phased quality improvement programme has been implemented on the unit which has reduced infection rates over the last few years, and there are regular audits undertaken to monitor and manage the situation to ensure the ongoing reduction in the level of infection rates. There has also been a programme of minor remodelling of the existing neonatal unit along with environmental improvements in relation to infection concerns and also to improve patient flow. However, there are still ongoing concerns, especially around the presence of pseudomonas, and the next recommended phase of the programme is to increase the amount of space between cots through the development of a capital solution. Neonatal Capacity Page 4 of 6 Board Meeting

5 Storage There are inadequate storage facilities on the neonatal unit resulting in storage of large pieces of equipment in clinical spaces or in corridors creating risk and contributing to over-crowding. This problem has been highlighted at visits to the neonatal unit by the CHC and the executive board. There have been repeated attempts to address this issue with applications to the accommodation and decluttering committees and a site for storage of equipment off the unit has been identified, however to date a solution has not yet been identified.. Family Facilities It has been highlighted at previous CHC visits that the facilities for families on the neonatal unit are poor due to the lack of space. There is no waiting room or facility for parents to make themselves refreshments. In addition there is only one rooming-in room, which is in almost constant use for either bereavement care or to facilitate breast-feeding/family support prior to discharge home. The Neonatal Taskforce set up by the Department of Health has recommended that a unit should have as many rooming-in rooms as intensive care cots to support breast feeding. Staffing There have been concerns that staffing with in the Unit has not been adequate and the UHB committed to improve the situation with the recruitment of additional staff to address the 7 wte gap. Action has been taken and now the South Central Health Community are the closest to achieving full compliance with the Standards based on nursing establishments, with 97.8%compliance.. It has been agreed between the UHB and Cwm Taf that a programme of staff rotation between the Units should be established so that staffretain their skills, are able to support demand across both sites and better understand the pathway of care across the South Central area. Actions As a result of the ongoing clinical, capacity, infection control and environmental risks, the Division has raised concerns that there needs to be a solution for the neonatal unit despite the potential impact of the outcome of the South Wales Programme consultation. The risks are clearly documented and scored as the key risk for the Children & Women s Division and feature as one of the top risks on the UHB risk register. The solution to provide a greater amount of space between each of the cots and to enable the provision of additional cots in relation to capacity issues will entail a significant capital solution. The Director of Planning has now established a Neonatal Services Project Board and Project Team to consider and develop a Business Case setting out the options for developing an appropriate infrastructure that meets the current and future needs of the Neonatal Service. The first meeting of the Project Board took place on 13 March and will meet bi-monthly to progress this work. One of the options for consideration is likely to include the retention of the existing neonatal accommodation and the development of the second floor of the Tertiary Tower. This would locate the new unit adjacent to both the existing neonatal accommodation and the delivery suite in line with current recommendations. The Assistant Director of Planning, Capital and Estate Management, has undertaken a detailed feasibility study to determine the number of cots that could be accommodated both in the existing unit and in the Tertiary Tower accommodation, and the results indicate space for a maximum of 40 cots. Neonatal Capacity Page 5 of 6 Board Meeting

6 The capital cost of the development has been estimated at circa 6m which includes the work to be undertaken in the Tertiary Tower, refurbishment of the existing neonatal unit and also a number of enabling schemes to relocate some existing services from Tertiary Tower accommodation. As this development will require major capital investment it will be necessary to follow the three stages of the business case process i.e. Strategic Outline Case, Outline Business Case and Full Business Case which will dictate the timescale for the implementation of the solution. RECOMMENDATION The Board is asked to: NOTE the contents of this report and the actions taken to minimise risk and make short term improvement CONFIRM support for the Division and Planning Department to progress with an option appraisal and business case development Financial Impact Quality, Safety and Experience Standards for Health Services Risks and Assurance Equality and Diversity The financial impact of any future proposals will be considered in depth through the option appraisal and modelling process integral to the development of a Business Case as appropriate. The development of a Business Case and the consequent service changes will be consistent with the delivery of best clinical practice and All Wales Neonatal Standards. The Report provides assurances against the following Healthcare Standards: Standard 7- Safe and Clinically Effective Care Standard 13 Infection Prevention and Control (IPC) It is intended that the development of a Business Case and implementation of a solution, will mitigate the risks identified on the corporate risk register: UHB16/12 Ability to provide required level of care to Neonates. Furthermore, it provides assurance against Board Assurance Framework Objective 2: Patient Safety. An Equality Impact Assessment will be required and will be completed as part of the development of the Business Case. Neonatal Capacity Page 6 of 6 Board Meeting

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