# Transfer to neonatal care services

`````{admonition} Executive summary
:class: info

**Outcome:** Admission to neonatal care services (transitional, special, high dependency or intensive care)

**Specific to HIE?**
* No - NHS statistics on reason for admission indicates 2.5% admissions to any care services, and 5% admissions to intensive care, are due to suspected HIE

**Which infants with HIE?**
* Depends on type of service - intensive care will be the most unwell/unstable - whilst any care service reflects any infants requiring additional support
* Haven't identified the percentage of infants with HIE who are admitted to neonatal care

**Any other benefits or caveats not already mentioned?**
* Outcome of interest since admission is costly
* Doesn't necessarily mean poor long-term outcomes

**Conclusion:** Potentially recommended. Alone, this is not suitable as 95%+ of admitted infants will not have HIE. However, in combination with other indicators of HIE, it could support identifying more unwell infants with HIE (most unwell, if focussed on NICU).
`````

## Neonatal care services

**Neonatal care services** 'provide care for all babies less than 44 weeks post menstrual age that require on-going medical care'. Each year, around 10% of all births 'will receive some type of neonatal care'.

Types of **neonatal unit**:
* **Neonatal Intensive Care Unit (NICU)**
* **Local Neonatal Unit (LNU)**
* **Special Care Unit (SCU)**

Types of care:
* **Intensive Care** - 'for babies who are the most unwell or unstable and have the greatest needs in relation to staff skills and staff to patient ratios'
* **High Dependency Care** - 'for babies who require skilled staff but where the ratio of nurse to patient is less than intensive care'
* **Special Care** - 'for babies who require additional care delivered by the neonatal service but do not require either intensive or high dependency care'
* **Transitional care** - also known as 'Special Care with Primary Carer Resident'. Either delivered by a dedicated transitional care unit or on a postnatal ward. This is when more care is needed than normal, and this is provided by the parent with support from a midwife/healthcare professional trained in 'elements of special care but does not require a specifialist neonatal qualitfication'

[[Source (NHS England Neonatal Critical Care Service Specification)]](https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/01/e08-serv-spec-neonatal-critical.pdf)

## Statistics

### Reason for admission to NICU

**South West England** 2017 report on **term** admissions to **NICUs**:
* Respiratory syndromes (44%)
* Other (26%)
* Hypoglycaemia (9%)
* Suspected HIE (7%)
* Monitoring (7%)
* Infection (7%)

[[source]](https://www.swneonatalnetwork.co.uk/media/101820/sw-term-admissions-2017-main-report.pdf)

### Reason for admission to any neonatal care services

NHS England 2017 report looked at **term** admissions at neonatal units (**all types**). They focussed on and reported the percentage of admissions due to:
* Respiratory conditions (25%)
* Hypoglycaemia (12%)
* Jaundice (6%)
* HIE (2.5%)

[[source]](https://www.bliss.org.uk/research-campaigns/neonatal-care-statistics/statistics-for-babies-admitted-to-neonatal-units-at-full-term) and [[source]](https://www.england.nhs.uk/wp-content/uploads/2021/03/reducing-harm-leading-to-avoidable-admission-of-full-term-babies-into-neonatal-units.pdf)

**South West England** 2017 report on **term** admissions at neonatal units (**all types**)found slightly different stats:
* Respiratory syndromes (36%)
* Suspected infection (23%)
* Hypoglycaemia (9%)
* Monitoring (6%)
* Suspected HIE (5%)

[[source]](https://www.swneonatalnetwork.co.uk/media/101820/sw-term-admissions-2017-main-report.pdf)

### Differences over time and between places

In the 2017 NHS England report, suspected HIE was the fifth most common reason for term admission to neonatal care services (n=138 infants) - equating to 2.4 admission per 1000 births - and this was a **substantial increase** from 2012 where only one baby was admitted for suspected HIE in the region.

* 2012 - 1
* 2013 - 3
* 2014 - 5
* 2015 - 128
* 2016 - 138

[[source]](https://www.swneonatalnetwork.co.uk/media/101820/sw-term-admissions-2017-main-report.pdf)

In the latest data (2020-21), South West had suspected HIE as cause of 5.8% admissions (n=121) - whilst it was 2.2% (n=55) for Thames Valley and Wessex, and 2.6% (n=50) for Kent Surrey Sussex.

## Other considerations

Admission is an important outcome due to **cost** - admission is expensive, and transfer to neonatal care services can be important for cost-benefit analyses.

**Availability of data** is uncertain - e.g. anecdotally, some datasets won't state the type of admission.

Whilst this reflects a poor short-outcome outcome, I haven't yet identified data on **long-term outcomes** - but we know it's likely that milder HIE cases won't be admitted, whilst moderate to severe are more likely - and there is data on outcomes of moderate to severe HIE. Anecdotally, many of the babies will only need a short period of care and will not have poor long-term outcome.