A REVIEW OF NEW ZEALAND NEWBORN INTENSIVE CARE...

A REVIEW OFNEW ZEALAND NEWBORN

INTENSIVE CARE SERVICES1992

Caroline Maskill

Department of HealthTETARI ORA

HEALTH RESEARCH SERVICES - 1992

0

A REVIEW OFNEW ZEALAND NEWBORN

INTENSIVE CARE SERVICES1992

Caroline Maskill

A report for the Health of Women and Younger People Policy SectionPrepared by Health Research Services,

DEPARTMENT OF HEALTH, P0 BOX 5013, WELLINGTON

April 1992

Copyright

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in anyform or by any means, electronic, photocopying, recording or otherwise, without the priorwritten permission of the Department of Health.

Disclaimer

This report has been prepared by Caroline Maskill of Health Research Services, Department ofHealth. Its purpose is to inform discussion and assist in future policy development. The opin-ions expressed in the report do not necessarily reflect the official views of the Department ofHealth.

Client

This project was commissioned by the Health of Women and Younger People Policy Section,Department of Health.

It is an internal report, primarily intended for distribution within the Department of Health. Ithas not been reviewed outside the Department.

Contents

Summary ....................................................................................................................... 1

Section 1Introduction ................................................................................................8

1.1Newborn care services.................................................................................8

1.2Aims of the review......................................................................................8

1.3Methods ......................................................................................................9

1.4Definition of 'neonatal .............................................................................. 101.5 Definitions of low birthweight, prematurity and intrauterine

growthretardation.....................................................................................10

1.6Definitions of 'intensive' and 'special' newborn care...............................11

1.7'Levels' of newborn care...........................................................................12

1.8Structure of the report...............................................................................15

Section 2 Geographic distribution of services, unit size and levels of care ................16

2.1Regionalisation .........................................................................................162.2 Geographic distribution of newborn services in New Zealand...................18

2.3Size and levels of care of units visited.......................................................21

2.4Geographical access to services.................................................................22

Section 3 Profile of newborns and outcomes of intensive care..................................27

3.1Risk of needing newborn intensive care ....................................................27

3.2Admissions to New Zealand newborn units...............................................31

3.3Health outcomes........................................................................................37

Section 4Transfers and transport..............................................................................41

4.1Transfers/transport and regionalisation......................................................41

4.2When to transfer newborns........................................................................41

4.3Organising transfers ..................................................................................44

4.4Transport/transfer co-ordinators................................................................45

4.5Transport methods and problems ................................................................ 46

4.6'Back transport' ........................................................................................46

Section 5Facilities and staffing................................................................................48

5.1Equipment.................................................................................................51

5.2Design of newborn units ............................................................................ 52

5.3Diagnostic and transfusion services...........................................................53

5.4New technology ........................................................................................ 55

5.5Staff resources...........................................................................................58

5.6Home care services ...................................................................................59

(iii]

Section 6Quality assurance and information requirements .61

6.1What is quality assurance? ........................................................................61

6.2New Zealand legislation on newborn care.................................................62

6.3Quality assurance in New Zealand newborn units......................................62

6.4Research ....................................................................................................

6.5Information requirements..........................................................................66

Section 7Financial issues.........................................................................................68

7.1Costs of newborn care in New Zealand .....................................................687.2 Cross boundary charging and diagnosis-related groups (DRGs) ................69

7.3Other funding issues in New Zealand........................................................73

7.4Overseas economic analyses......................................................................74

Section 8 Newborn services and the new health system............................................75

8.1Regional health authorities (RHAs)...........................................................75

8.2Core services.............................................................................................76

8.3Interim charging........................................................................................78

8.4Gaining contracts ......................................................................................79

Section 9Recommendations.....................................................................................80

9.1Data collection..........................................................................................80

9.2Research and monitoring...........................................................................819.3 Geographic distribution of newborn services/regionalisation.....................82

9.4Core services.............................................................................................84

9.5Cross boundary charging...........................................................................85

9.6Replacing equipment .................................................................................86

9.7Nurse training, conferences and research...................................................86

9.8New technology ........................................................................................86

Appendix...................................................................................................................... 88Bibliography.............................................................................................................108

[iv)

Tables

Low birthweight categories.....................................................................11Definition of neonatal intensive care.......................................................11Definition of neonatal special care..........................................................12Department of Health definition of levels of neonatal care......................13Auckland Area Health Board's classification of levels ofneonatalcare ........................................................................................... 14

Table 1.1Table 1.2Table 1.3Table 1.4Table 1.5

Table 2.1Number of cots in the eight New Zealand hospitals visited .....................21Table 3.1 Numbers of infants reported to have been discharged from

New Zealand 'neonatal intensive care units', 1990..................................32Table 3.2 Comparison of national discharge data and hospitals' own

admissionsdata.......................................................................................33Table 3.3 Primary reason for admission to intermediate nursery:

inborn infants, Christchurch Women's Hospital......................................35Table 3.4 Reasons for admission to Taranaki Base Hospital Neonatal Unit,

1991........................................................................................................35Table 3.5

TPN treatment in Dunedin, 1989-91 .......................................................37Table 5.1 Interviewees' comments on newborn unit equipment and

itsmaintenance.......................................................................................51• Table 5.2Comments on the physical design of newborn units................................53

Table 5.3Staff resources of newborn intensive/special care units........................... 58Table 7.1Costs of treating infants in newborn units in New Zealand......................68Table 7.2 DRGs used by Auckland Area Health Board for costing treatment

of out-of-board infants, 1990 ..................................................................71Table 7.3

AppendixAppendix

Appendix

Appendix

Appendix

Appendix

Number of discharges, total days stay and total costs of treatingout-of-board infants, 1990.......................................................................72Table 1 Definitions of levels of neonatal care ........................................88Table 2 New Zealand hospitals with neonatal units by unit leveland area health board, 1991 - as stated by area health boards ..................92Table 3 Indications for transfer of infants for special care inNew Zealand (guidelines accompanying Obstetric Regulations 1975).....93Table 4 Numbers of liveborn infants by area health boards andbirthweight, 1990 (provisional data) .......................................................95Table 5 Percentage of liveborn infants in birthweight categoriesby area health boards, 1990 (provisional data) ........................................95Table 6 Numbers and percentages of live birthweight groups forNewZealand, 1973-1990........................................................................96

(vi

Appendix Table 7 Numbers of neonatal deaths of livebom infants 1978-88,by birthweight categories........................................................................97

Appendix Table 8 Percentage of survivors of liveborn infants 1978-88,by birthweight categories........................................................................97

Appendix Table 9 Quality assurance measures in visited newborn units..................98Appendix Table 10 National Working Party's recommendations for

'management' data relating to infants ...................................................106

Figures

Figure 2.1a North Island hospitals with levels H-ffl newborn units, 1991(highest level of care as stated by area health boards)...............................19

Figure 2.1b South Island hospitals with levels il-ifi newborn units, 1991(highest level of care as stated by area health boards) ............................... 20

Figure 2.2a 300km boundaries of level III newborn units in New Zealand -NorthIsland............................................................................................24

Figure 2.2b 300km boundaries of level ifi newborn units in New Zealand -SouthIsland............................................................................................ 25

Figure 3.1 Percentage of low birthweight live births by area health boardof domicile and categories of low birthweight, 1990...............................29

Figure 3.2 Trends in the rates of low birthweight in New Zealand, 1973-90 ............30Figure 3.3 Trends in the numbers of low birthweight births in New Zealand,

1973-90 ..................................................................................................30Figure 3.4 Trends in the percentage of survivors of liveborn infants 1978-88,

by birthweight categories........................................................................38Figure 3.5 Trends in survival of very low birthweight infants (without lethal

abnormalities) born in National Women's Hospital. 9181-88 .................. 38Figure 3.6 Survival rates of very low birthweight infants admitted to Dunedin

Newborn Intensive Care Unit 1980-85 and 1986-91................................39

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SummarySection 1: Introduction and definitions

Newborn intensive and special care services have played a role in decreasinginfant mortality rates.

Newborn intensive care is expensive because of the equipment and technologyused.

New issues in newborn care include: the increasing proportion of low birthweightbirths, prevention programmes, new technology, ethical and economicconsiderations and reorganisation of New Zealand health services.

There is a variety of definitions of 'intensive' and 'special' care and of levels ofcare (for example, levels II and III).

Section 2: Geographic distribution of services, unit size and levels of care

Overseas, regionalisation of services is an accepted method of distributingnewborn intensive care resources and is believed to optimise outcomes.

Regionalisation of newborn services has been developing in New Zealand overthe past two decades. There are five officially recognised level ifi units, althougha number of level II units provide some level ifi care. The safety of the latterpractice is subject to considerable debate.

Some hospitals regularly use more cots for intensive and special care than theyare funded for. Most are flexible in the way they use cots for intensive andspecial care.

Area health board staff interviewed differed on the ideal size and minimumthroughput of newborn intensive care units.

•The geographic distribution of intensive care services has developed on thegrounds of distance as well as on the size of the population served.

• Geographic distance is a significant stressor for out-of-town families in terms ofseparation and the financial costs of accommodation and travel. Area healthpolicies on subsidising these costs are inconsistent throughout the country.

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2A REVIEW OF NEW ZEALAND NEWBORN INTENSIVE CARE SERVICES 1992

Section 3: Profile of newborns and outcomes of intensive care

Conditions that put newborn infants at risk of needing intensive or special careinclude: prematurity, low birthweight, respiratory distress, jaundice, a diabeticmother, congenital anomalies and other medical problems.

About 2-3% of newborn infants need intensive care.

Six percent of New Zealand liveborn infants are of low birthweight (<2,500g).About 1% have very low birthweight (<1,500g) and 0.4% are of extremely lowbiithweight (<1,000g).

The proportion of infants with low birthweight in New Zealand has increasedover the past two decades, with a significant increase in the rate of extremely lowbirthweight.

Locally collected data on admissions to newborn units are kept in inconsistentways. Nationally collected discharge and (transfer) data are not consistent withlocal data and are too unreliable for analysis. A difference in the definition of'neonatal intensive care' is likely to be one of the causes of the poor data quality.

Data on reasons for admission to newborn intensive care, treatment received, andmortality and morbidity are collected comprehensively by some newborn units,but not at all by others.

•Survival rates of extremely low birthweight infants have improved dramatically•over the last decade.

•Newborn infants who need intensive care have a higher rate of long termmorbidity than other infants, although permanent disability is still uncommon.

Section 4: Transfers and transport

•Effective transport systems are essential for regionalised newborn care.

•Antenatal transfer of mothers is preferable to transporting infants at high-risk,although high-risk situations are often not predictable.

•Transfers between level ifi centres because of a lack of cots has become lesscommon recently because of the increase in cots in Auckland.

SUMMARY 3

•

Transport systems in New Zealand are adequate, apart from in Christchurchwhich will soon lose its access to fixed-wing aircraft with the closure of Wigram.

•

Transport equipment needs replacing in Wellington, and Taranaki Base has notransport equipment.

Section 5: Facilities and staffing

• The standard of equipment varies throughout the country. Some units such asNational Women's, Christchurch and Wellington have old equipment whichneeds replacing. Most newborn unit budgets do not have the resources for aplanned equipment replacement programme. Equipment maintenance servicesare very good in most newborn units.

• The physical design of the newer, purpose-built newborn units generally workswell. Older units such as Taranaki Base and Christchurch have inadequatedesigns (they are currently being replaced or redesigned).

•

Surfactant replacement treatment was available in all the visited newborn units,although special funding arrangements have been necessary.

•

There is very little support for introducing extracorporeal membrane oxygenation(ECMO) into New Zealand in the near future.

• Diagnostic and transfusion services for newborn units are generally satisfactory.Exceptions are Christchurch, where communication between the newborn unitand off-site laboratory could be improved, and Hastings, where out-of-hours testsare sometimes hard to arrange.

•

Medical and nursing staff shortages exist in some newborn units, particularlyChristchurch and Wellington.

•

Home care services are being provided to some extent in all of the level ificentres except Christchurch.


Section 6: Quality assurance and information requirements

• Quality assurance measures are becoming well established in some New Zealandnewborn units, whereas others have only limited resources to carry out qualityassurance.

• The lack of computerised databases, personnel for data entry and data analysis,national comparative data and long term follow-up services are major barriers tomonitoring local outcomes.

•The previously recommended national perinatal database and epidemiology unitwere strongly supported.

• Most level ifi hospitals have special in-house training for newborn intensive andspecial care nurses. However, their opportunities to attend outside conferencesand training are limited.

•All the visited newborn units had their own protocols and/or guidelines fortreatment and procedures, but there are no nationally agreed standards for these.

Several newborn units have carried out consumer feedback surveys.

Level ifi units are conducting neonatal medical research, however very littlenursing research is being done.

Section 7: Financial issues

Information on the costs of newborn intensive care is limited in New Zealand,although financial information systems are being introduced.

Cross boundary charging is used to transfer funds to area health boards whichtreat out-of-board infants in their intensive or special care newborn units.

Systems of cross boundary charging have changed several times in recent years.Considerable confusion about the current system exists, particularly amongmedical and nursing staff.

• Interviewees were generally not satisfied with the current use of diagnosis-relatedgroups (DRGs) for cross boundary charging. Overseas studies have confirmedthe inadequacy of using DRGs in costing newborn care.

• Interviewees thought that newborn units should have received an increase infunding because of the recent increase in the number and survival of very andextremely low birthweight infants.

SUMMARY 5

• Interviewees thought that financial support (subsidies) for out-of-town parents,funding for staff training, home care and follow-up and preventive services wereimportant.

• Overseas studies have shown that the costs of intensive and special care ofnewborns increase with decreasing birthweight. Cost-benefits are less favourablewith decreasing birthweight.

Section 8: Newborn services and the new health system

• The establishment of regional health authorities could potentially have positive ornegative effects on newborn care. Regionalisation could be strengthened becauseof the reduced numbers of RHAs compared with area health boards. However,competition between providers could deregionalise services, as has been reportedin the United States.

•

Most interviewees thought that all currently available newborn intensive careservices should be core services in the future.

• Most interviewees did not support core services excluding treatment of infants ofcertain birthweights or gestational ages. The lack of support was for clinical,practical and ethical reasons.

•

Some interviewees thought that core services should be guidelines only, ratherthan absolute rules for service provision.

• Interviewees generally did not support interim charging for infants in intensiveand special care. There was some indication that this charging may discouragefollow-up checks.

•

Interviewees saw marketing, quality of care and adequate equipment as importantin gaining contracts to provide newborn services in the future.

Section 9: Recommendations

Recommendation 1: Comprehensive data on newborns should be collected in aconsistent way by all obstetric and newborn unitsthroughout the country.

Recommendation 2:

These data should be brought together in a national database.

Recommendation 3: Nationally agreed definitions of newborn special andintensive (and/or level H and level ifi) care should bedeveloped.


Recommendation 4: Research and monitoring on infants needing special andintensive care services (and other infants) should beundertaken at a national level.

Recommendation 5: Research and policy development should be undertaken toinvestigate the increasing incidence of very lowbirthweight infants and identify means of reducing the ratesof low birthweight infants.

Recommendation 6:Regionalisation of newborn services should continue to beencouraged.

Recommendation 7:Until accurate comparisons on local outcomes can be made,the current distribution of level ifi services should remain.

Recommendation 8: The current practices of some level H units in providingadvanced level ffi care should be more widely documentedand debated, and a national consensus sought.

Recommendation 9:Consideration should be given to increasing the number ofnewborn intensive and special care cots.

Recommendation 10: Because of the rapidly changing nature of newbornintensive care services and improvements in outcomes, thedefinition of core services should be able to be updated atregular intervals.

Recommendation 11:

Recommendation 12:

Recommendation 13:

Recommendation 14:

Quality measures should be specified as integral to corenewborn services, and therefore could be included incontracts.

Facilities, accommodation and travel for families should beconsidered as essential aspects of core newborn services.

Retrieval and back-transport services should be specified ascore newborn services.

Consideration should be given to include long term follow-up and home care as core services.

Recommendation 15: Serious consideration should be given to changing thecurrent diagnosis-related groups-based cross boundarycharging system.

SUMMARY 7

Recommendation 16: Resources to replace outdated equipment should be apriority for crown health enterprises and regional healthauthorities.

Recommendation 17:

Nursing staff should have improved access to outsidetraining, conferences and research opportunities.

Recommendation 18: Adequate funding should be provided for new technologythat is proved to be effective in newborn intensive andspecial care.

Section 1 Introduction

1.1 Newborn care services

Newborn special and intensive care services are considered to have contributedsignificantly to decreased infant mortality rates (Budetti and McManus 1982; Cormanand Grossman 1985). A previous review of New Zealand neonatal intensive careservices concluded that 'newborn special care services, because of their potential forsaving life and preventing handicap, should be regarded as an important national healthpriority' (Maternity Services Committee 1982:5). The 1982 review also recommendedthat 'special care services for the newborn should be reviewed again after a suitableinterval, as part of a review of all services for reproductive health' (ibid.:45).

However, the financial cost of intensive care is high. Equipment is expensive and staffneed an advanced level of training (Australian Health Ministers' Advisory Council1991). As resources for neonatal intensive care services are limited, many countries(including New Zealand) have allocated these services on a restricted, regional basis.

Since the 1982 review, some issues in neonatal intensive care have changed. Forexample, the proportion of low birth weight births has increased slightly over the lastdecade (Morrell 1990), and the proportion of very low birthweight births (under 1500g)has increased markedly (Howie 1990). Prevention programmes have been testedoverseas (ibid.) and new technology, such as replacement surfactant and ECMO, hasbeen developed (Australian Health Ministers' Advisory Council 1991). There has alsobeen wide debate on the ethical and economic issues of providing intensive care to verylow birth weight infants and those with severe health problems (Clarkson 1983; Kuhse etal. 1988). New Zealand health services have also been reorganised into area healthboards, and further reorganisation is planned (Upton 1991).

This review was commissioned by the Health of Women and Younger People PolicySection of the Department of Health. Because of the recent advances in newborn careand the 1982 recommendation for further review, the Section considered it timely for aformal review to develop national policy on newborn intensive care services.

1.2 Aims of the review

The aims of this review are to:

•identify current issues and problems of neonatal intensive care services inNew Zealand; and

•suggest improvements in services and solutions to the identified problems.

[81

INTRODUCTION 9

The focus of the review is on the provision of level ifi (intensive) care, in the context ofother newborn and obstetric services. Level 11 (special) care is investigated to a lesserextent.

1.3 Methods

A literature review, a review of admission and discharge statistics and interviews withhospital staff were used in this review.

Literature review

A literature review was carried out on newborn intensive care services. The literaturewas found through a computer based search from the Department of Health library. Thesearch covered New Zealand and overseas literature from 1985 onwards. In addition,some literature was provided by the Health of Women and Younger People PolicySection. The most relevant literature has been summarised in this report and supportscomments made by interviewees and the results of the statistical analysis.

Statistical review

Some information has already been published on outcomes of neonatal intensive careand was incorporated into the review. For example, issues such as the survival of lowbirth weight babies and national infant mortality rates have been examined previously(Darlow 1991; Department of Health 1990; Maternity Services Committee 1982).

Relevant data from Health Statistical Services were analysed. However, the availabledata were limited to information on infant mortality and birthweight.

Some area health boards keep their own data on newborn admissions to intensive andspecial care. However, because of the inconsistency of these data, and the lack ofaccessibility to it within the timeframe for this review, a detailed analysis of these datawas beyond the scope of this review.

Information from area health boards and other agencies

Neonatal intensive care issues were discussed with key people in Auckland, Hamilton,Wellington, Christchurch, Dunedin, Hastings and New Plymouth. Forty-two people

10 A REVIEW OF NEW ZEALAND NEWBORN INTENSIVE CARE SERVICES 1992

were interviewed, some in groups, and others individually. At least three staff wereinterviewed in each centre. They included:

paediatricians and nursing staff in level ifi (and some level II) units, communitynurses;

newborn unit managers;

area health board service planners, an ethicist; and

parent support group (National Women's Hospital).

The review also looked at some area health board and newborn unit reports, for example,service statements and operational/strategic plans.

Before presenting the detailed results of the review, it is worth clarifying some of the keyterms used. While various definitions exist, the ones adopted by this report are decribedbelow.

1.4 Definition of 'neonatal'The 'neonatal' period is defined for statistical purposes as being within the first 28 daysafter birth (National Health Statistics Centre 1990). The 'early' neonatal period is frombirth to before the seventh day of life, and the 'late' neonatal period is from seven days, tobefore 28 days. However, 'neonatal' services are not restricted to looking after infants ofless than 28 days old. Many infants who are admitted remain in neonatal care units wellpast the official 'neonatal' period.

Therefore, services which care for neonates and some 'post-neonatal' infants (aged up toone year) will be referred to as 'newborn' services in this report.

1.5 Definitions of low birthweight, prematurity and intrauterinegrowth retardationOne of the main reasons for admission to newborn units is low birthweight. This iscommonly, but not always, associated with early gestational age i.e., prematurity orpreterm delivery (the latter defined as less than 37 weeks gestation). The World HealthOrganization (1977) defined low birthweight as being less than 2,500g. More detailedcategories are shown in Table 1.1.

INTRODUCTION 11

Table 1.1: Low birthweight categories

Low birthweight Less than 2,500gVery low birthweightLess than 1,500gExtremely low birthweightLess than 1,000g

Source: Adapted from Australian Health Ministers' Advisory Council (1990).

Low birthweight occurs because of prematurity (preterm birth) or intrauterine growthretardation, or a combination of both. Preterm birth is 'usually defined as birth occurringbefore the thirty-seventh week of gestation' or 'less than 37 weeks from the lastmenstrual period'. Intrauterine growth retardation is low birthweight, but over 37 weeksof gestation. Preterm infants usually require more intensive care than full-term infantswho have low birthweights (Morrell 1990).

1.6 Definitions of 'intensive' and 'special' newborn care

'Intensive' care is the highest level of newborn care, and is usually provided in level ifi(or above) units. Neonatal intensive care units generally look after critically ill infants,those who are very premature or very low birthweight and those who have undergonemajor surgery (see Section 3).

The Royal College of Physicians (1988:41) summarised neonatal intensive care asfollows:

Table 1.2: Definition of neonatal intensive care

Neonatal intensive care

1. Babies receiving assisted ventilation (intermittent positive ventilation(IPPV), intermittent mandatory ventilation (IMV), constant positiveairway pressure (CPAP)), and in the first 24 hours following itswithdrawal.

2. Babies receiving total parenteral nutrition.3. Cardiorespiratory disease which is unstable, including recurrent apnoea

requiring constant attention.4. Babies who have had major surgery, particularly in the first 24 post-

operative hours.5. Babies of less than 30 weeks' gestation during the first 48 hours after

birth.6. Babies who are having convulsions.7. Babies transported by the staff of the unit concerned. This would

usually be between hospitals, or for special investigations or treatment.8. Babies undergoing major medical procedures, such as arterial

catheterisation, peritoneal dialysis or exchange transfusion.

Source: Royal College of Physicians (1988)


'Special' care is a less intensive form of neonatal care, usually provided in level II units.It involves non-routine care of infants who need medical intervention.

The Royal College of Physicians (1988:41) summarised neonatal special care as follows:

Table 1.3: Definition of neonatal special care

Neonatal special care

1. Babies who require continuous monitoring of respiration or heart rate, orby transcutaneous transducers.

2. Babies who are receiving additional oxygen.3. Babies who are receiving intravenous glucose and electrolyte solutions.4. Babies who are being tube fed.5. Babies who have had minor surgery in the previous 24 hours.6. Babies with a tracheostomy.7. Dying babies.8. Babies who are being barrier nursed.9. Babies receiving phototherapy.10. Babies who receive special monitoring (for example frequent glucose or

bilirubin estimations).11. Other babies receiving constant supervision (for example babies whose

mothers are drug addicts).12. Babies receiving antibiotics.13. Babies with conditions requiring radiological examination or other

methods of imaging.

Source: Royal College of Physicians (1988)

1.7 'Levels' of newborn care

Defining newborn care by the levels or types of care required helps to allocate unitswithin regions or countries, and determine the number of staff needed to look afterinfants. Different definitions of the various levels of newborn care exist.

INTRODUCTION 13

The New Zealand Department of Health's (1991) most recent definitions of the levels ofchildbirth and newborn services are as follows:

Table 1.4: Department of Health definition of levels of neonatal care

Level 0Care provided by general practitioner(s) and midwives foruncomplicated deliveries and well baby care.

Level IService provides care for uncomplicated deliveries and wellbaby care. Facilities, including a blood bank, are provided foremergency caesarean section and emergency care whennecessitated by geographical distance. Level I lacks acombined obstetric/paediatric service and is not a referralcentre.

Level IIService provides specialist and paediatric care, which includes alimited obstetric and newborn referral centre with limited facilitiesfor newborn intensive care. To be provided by all area healthboards.

Level IllA regional specialty service which includes a full range ofobstetric and paediatric care, including newborn intensive care,that acts as a major obstetric and newborn referral centre forparticular regions and operates a newborn transport service.Level Ill services should be co-ordinated and planned jointly byvarious regions to provide a nationally unified service for thewhole of New Zealand. Should be provided by Auckland,Waikato, Wellington, Canterbury and Otago Area Health Boards.

[Level lviNational neonatal surgical and intensive care services forpremature infants and serious newborn conditions. Surgical andintensive care facilities should be on the same hospital site andco-ordinated with newborn paediatric medical services. Theseservices are provided by Auckland and Wellington Area HealthBoards.

Source: Department of Health (1991)

These definitions were adopted after extensive consultation with area health boards.

Some other recent definitions are provided in Appendix Table 1.

Because definitions of levels of newborn units are not always the most useful forplanning and staff-mg purposes, some services have developed definitions based oninfants' dependency levels. The Auckland Area Health Board (1991:79), in a review oftheir local neonatal services, proposed a continuous scale of neonatal intensive andspecial care. This was because they believed 'a clear differentiation between level ifiand level II is often unrealistic in practical situations where there are skilled staff'.

14 A REVIEW OFNEWZEALAND NEWBORN INTENSIVE CARE SERVICES 1992

Table 1.5: Auckland Area Health Board's classification of levels of.neonatal care

Examples ufIki1Lh Pro Nursing SLafT

and Care Needs, Implications

Nurses : Babies

preterre neonate requiring fullventilation,

paralysed

pre or post-surgery

continuous infusion of medication

monitoring of vita] functionsevery 15 minutes

Exchange transfusion

planned full ventilation forspecific time e.g. for 24 hrs

post surgery

Fully ventilated - stable

Endotzncbial CPAP

Nasopbaxyngeal CPAP

Hourly feeds, regular monitoring

Self respiration some of thetime - switch as required

preparing for home withrespiration assistance1V treatmentPhototherapyl-2hourlyfeedsbirth asphyxiajust off ventilationlCPAP

2-3 or 4 hourly feedsfeeders and growcrs

close monitoring of temperatureantibioticspreparing for home

0

4)

Leveifli I:4)

U

C

4)-n0

U

UC4)

C

pC -=

C

-tn. c -Q.>

4)-nC

0-n0

mothercra.ft

1: 1

1:1.5

1 :1.2

1 :2.3

1:3 or 4

1:4

1: 5 in Wards

Source: Auckland Area Health Board (1991:79)

INTRODUCTION 15

As Table 1.5 shows, categorising neonates by the levels of care they need allows neonatalunits to allocate the approprate staff using staff:infant ratios.

1.8 Structure of the report

The report begins by defining levels of neonatal care and discussing the type of infantswho require intensive and special care (Section 1). Sections 2-8 provide the results ofthe review under the following headings:

geographical distribution of neonatal services, unit size and levels of care(Section 2);

newborn profile and outcomes of intensive care (Section 3);

transfers and transport (Section 4);

facilities and staff (Section 5);

quality assurance and information requirements (Section 6);

financial issues (Section 7); and

new born services and the new health system (Section 8).

The report concludes with a discussion of the main findings and makes some policyrecommendations (Section 9).

Section 2 Geographic distribution of services,unit size and levels of care

2.1 RegionalisationThe costs and the number of technological advances in the past two to three decades havemeant that resources have had to be rationed to efficiently distribute skilled staff andequipment (Darlow et al. 1989). This has been achieved in most western countries byregionalising neonatal intensive and special care.

Regionalisation of perinatal health services was considered advantageous in the 1970s.The New Zealand Maternity Services Committee (1982:22) cited the United StatesCommittee on Perinatal Health (1976) definition of regionalisation and the perceivedadvantages:

the development, within a geographic area, of a co-ordinated, co-operative system of maternal and perinatal health care in which, by mutualagreements by hospitals and physicians and based upon population needs,the degree of complexity of maternal and perinatal care each hospital iscapable of providing is identified so as to accomplish the followingobjectives: quality care to all pregnant women and newborns, maximalutilisation of highly trained personnel and intensive care facilities, andassurance of reasonable cost-effectiveness.

McCormick (1981) stated that regional networks were important so that medicalproblems, in mothers and babies from a defined population, could be identified as earlyas possible. Transfers could then be undertaken to larger centres where 'the mostsophisticated of intensive techniques' were available.

Overseas, decreased infant mortality rates have been, at least partially, attributed toregionalisation of services. For example, Stahlman (1991) described regionalisation inthe United States as being cost effective and responsible for significantly lower perinatalmorbidity and mortality levels. Stahiman stated that a regional system was 'medicallysound and fiscally responsible as it served to provide the most highly skilled individualswith the most sophisticated (and expensive) technology for high-risk patient care'.

McCormick et al. (1985) evaluated a specific programme of regionalised neonatal care inthe United States (funded by the Robert Wood Johnson Foundation [RWJFJ) bycomparing regions with and without the programme from 1970-79. They found thatneonatal mortality rates decreased dramatically in all the regions studied. However, therewas no significant difference in the outcomes of the areas with the RWJF programme andthose without. The authors attributed this result to the fact that regionalised neonatal care

[16]

GEOGRAPHIC DISTRIBUTION OF SERVICES, UNIT SIZES AND LEVELS OF CARE 17

had been operating in all the regions during the evaluation period. McCormick et al.found that there were changes in the hospital of delivery so that higher risk deliveriesmore frequently occurred in regional centres. This suggested that regionalisation hadencouraged antenatal risk identification and subsequent transfer of medical managementto the higher level perinatal centres.

In a cost-benefit analysis of care of very low birthweight infants in Rhode Island, Walkeret al. (1985) examined outcomes before and after regionalisation (1974-5 and 1979-80).The study found that mortality rates for 501-1, 500g infants decreased significantly afterregionalisation. Neuro-developmental morbidity rates remained the same. Economicbenefits were greater than the costs both before and after regionalisation, but the increasein the number of survivors in the second time period produced higher economic benefits.The study showed that the economic benefits were greatest for infants weighing 1,001-1500g. and that there was an economic loss for 501-1,000g infants. Since the time ofthis study, outcomes for extremely low birthweight infants have improved (see Section3).

In a prospective study, Field et al. (1991) investigated short term outcomes of infantsadmitted in one year to newborn special and intensive care units in the Trent region ofthe United Kingdom. They concluded that for infants of less than or equal to 28 weeksgestation, the recognised large intensive care units' provided significantly better survivaloutcomes than smaller units. They also stated that, for infants of more than 28 weeksgestation, there was no difference in mortality rates between the two types of care.

However, Mugford (1991) questioned the interpretation of these results because of thepossibility that all medical conditions were not controlled for in the study. For example,infants who were considered too sick for transfer to the regional unit and who stayed inthe smaller units to die could have increased the mortality rates of the smaller units.Conversely, the mortality rates in the larger units could have been elevated because ofinfants having more serious, life threatening conditions than those in smaller units. Also,Field et al. did not study long term morbidity levels.

Similar criticisms have been made of the study by Rosenblatt et al. (1985) which lookedat perinatal mortality rates in levels 1-ifi obstetric hospitals in New Zealand. Mortalityrates in small, rural hospitals were found to be lower than in the larger centres, except forinfants of very low birthweight. Apart from low birthweight, medical conditions such asserious malformations which could have affected the infants' survival were not taken intoaccount. In utero transfers were also not taken into account (Lancet 1985).

Newborn intensive care units which carried out >500 days of ventilated care per year.


Rosenblatt et al. concluded that the outcome of the study:

probably reflects the cautious antenatal practices of general practitionersand the effective regionalisation of perinatal services in New Zealand...There is no evidence that a satisfactory outcome depends on a minimumnumber of deliveries (Rosenblatt et al. 1985:429).

2.2 Geographic distribution of newborn services in New Zealand

Regionalisation of newborn services has been developing in New Zealand over the pasttwo decades. Figure 2.1 shows the geographic distribution of levels H and ifi newbornservices in New Zealand in 1991. The information provided by area health boards to theDepartment of Health relates to the highest level of care offered in each board. Thedistribution of level ifi services, as stated by area health boards, differs to some extentfrom that specified by the Department of Health's (1991) service statement and thatrecommended by the Maternal Services Committee (1982). In addition to newbornintensive care units in the country's five main population centres, several units which areusually regarded as being level II units were described as providing level ifi care.Taranaki Area Health Board stated that it did some level ifi work (long term assistedventilation) and Hawkes Bay Area Health Board defmed Hastings Hospital as a level Incentre. Middlemore was also decnbed as doing level 111 work, although it is not yet afull level ifi unit (a decision has been made that it will be). In addition to the eighthospitals which offer level ifi care, 15 hospitals were stated to offer level H care, and 11offer level I care.

For this review, all level ifi units and the two level H units which were reported ascarrying out level ifi work were visited. Staff (paediatricians, nurses and planners) wereinterviewed about their work and the surrounding issues.

I


Figure 2.1a: North Island hospitals with levels Il-Ill newborn units, 1991(highest level of care as stated by area health boards)

____ RA bod.aj•iuA-4ab4A t0 o.re

* k vo dL&t I1IaL.64..A.U. 6ø..4

Source: Figure by author from Department of Health data (see AppendixTable 2)


Figure 2.1b: South Island hospitals with levels li-Ill newborn units, 1991(highest level of care as stated by area health boards)

F'Source: Figure by author from Department of Health data (see AppendixTable 2)


2.3 Size and levels of care of units visited

The sizes of the units as reported by those interviewed in the present review are shown inTable 2.1. There is a considerable amount of flexibility in the use of cots in mostcentres. Level III cots can be used for level II infants and vice versa. The number ofventilated cots, the amount of physical space and the number of staff available are themain constraints on the maximum number of infants which can be cared for, rather thanthe 'official' allocation of cots.

The number of special care cots depends on the organisation of perinatal services. Somehospitals have separate nurseries or intermediate care where infants go once they arerelatively independent. These cots are not counted as intensive or special care. Otherhospitals have rooms within their neonatal units for mothers and infants who are almostready to go home. The level of care that ordinary post-natal wards provide is alsovariable. For instance, in Dunedin, the post-natal ward routinely cares for infants whoneed phototherapy or tube feeding up to three times a day.

Table 2.1: Number of cots in the eight New Zealand hospitals visited

Number of intensive care Number of (additional)(level Ill) cotsspecial care cots

National Women's16 48Middlemore4 (maximum ventilated)14Waikato 11 intensive care14 special care, 11 intermediate careNew Plymouth3 ventilated 5 (maximum 13)Hastings 2 ventilated 9-20Wellington 14 (up to 18) 11Christchurch Women's 6 14 special, 10 intermediateDunedin 4-6 10-12

The figures presented in Table 2.1 are similar to those collected by a meeting ofpaediatric and area health board staff (Special and Intensive Care Services for theNewborn in New Zealand 1991). In addition, the meeting stated that there is oneintensive care cot each in Palmerston North and Invercargill.

Staff in several of the newborn units such as Wellington and Christchurch stated thatthere were insufficient cots for the demand. Extra cots (over the official allocation) areused by many units when demand is high. Peak occupancy rates of up to 150% werereported by interviewees. However, there are staff, equipment and space constraints tousing extra cots. Transfers to other centres and refusing admissions from other areahealth boards are sometimes necessary.

Interviewed staff stated that some level ifi work such as long term ventilation is carriedout in Hastings, Taranaki Base and Invercargill (and probably in some other level II

A REVIEW OF NEW ZEALAND NEWBORN INTENSIVE CARE SER VICES 1992

centres). There was some concern, mainly among staff in level ifi centres, that thispractice may not produce the best outcomes for infants. Other level H and III staffthought that long term ventilation was acceptable and safe in level H units because of theparticular paediatricians who were working there, and the fact that higher birthweightand less ill infants are usually kept in level H units. Hastings neonatal unit has a policyof transfering all infants of less than 1000g birthweight. Taranaki Base keeps all infants,regardless of weight, unless they need surgery or other specialised treatment which thelocal hospital cannot provide.

Staff in one of the smaller level III units pointed out that, if level H units in their regiondo not transfer infants to the regional centre, the regional centre has fewer admissionsoverall. This situation could mean that staff in small regional centres get inadequateneonatal experience. A neonatal consultant from a larger level III centre also commentedthat level ifi work by lower level units could be taking away resources from the regionalcentres.

There was considerable debate about the ideal size of level III units. Six to 10 cots wassuggested by one interviewee as the minimum viable size of a neonatal intensive careunit, based on outcomes from overseas studies. However, staff in one of the smallerlevel III units asserted that small units tend to have advantages over larger ones, such as:

•more opportunities for parents to be involved in infant care, for example, skin toskin contact; -

•more opportunities for families to be involved in medical decisions;

siblings are able to visit more easily; and

•better continuity of care.

It is possible that larger units would also be able to offer these advantages with differentmanagement practices. It is also probable that the experience of staff and clinicalpractice influence outcomes, rather than the size of units themselves.

2.4 Geographical access to services

Overseas studies on the regional allocation of neonatal care usually focus on the numberof intensive or special care cot numbers needed per 1,000 population or per 1,000 births.Very few have investigated the extent to which geographic distance from neonatal careaffects outcomes (mortality and morbidity).


Mugford (1991:411) points out that:

Although it may be the case that care in a regional referral unit canimprove the chance of survival for babies of gestations of 28 weeks orless, the problem still remains for those providing the service of how toensure that all the babies have access to appropriate services, especially inrural areas with dispersed populations.

Rosenblatt et al. (1985) suggested that regionalisation has the potential to lead to aconcentration of services in large urban areas, with the loss of some small rural obstetrichospitals. In rural areas, this would reduce the availability of lower level services whichare essential for the referral of high risk pregnancies to regional centres.

In a South Australian study, Davies et al. (1982) examined mortality rates of 389 infantswho were transported to an Adelaide neonatal intensive care unit from 1978 to 1980.Infants who were transferred from more than 300km away had significantly highermortality rates than those from closer locations. The authors suggested that colder coretemperatures of the infants and possible difficulties in transferring mothers antenatallyfrom such distances result in this poor outcome.

Davies et al. (1982:70) stated that 'the transport of babies over distances greater than300km is peculiar to Australia'. Large distances to level in centres are also involved inthe New Zealand situation, although there may be closer access to a lower level centre.Figure 2.2 shows areas within 300km of level ifi centres. Note that road distances can beconsiderably greater. Additionally, the presence of Cook Strait is a major barrier totransporting infants. However, apart from the extreme north of Northland, all theinhabited areas of New Zealand are within 300km of existing level ifi neonatal centres.

Staff from several of the smaller centres visited for the present review stated thatisolation was the major factor in them keeping infants who needed level ifi care.

A few of those interviewed for the current review suggested that only one level III unitmay be necessary for the South Island. As there will only be one regional healthauthority covering this area, the possibility of one South Island level ifi unit is likely tobe considered in the future. If there were only one unit, interviewees expected that thiswould be in Christchurch. This suggestion was on the basis of the population served, thenumber of deliveries and/or the relatively low number of admissions to the Dunedin unit.

In terms of distance, however, the loss of the Dunedin unit would leave Dunedin itself,over half of Otago and all of Southland more than 300km away from the nearest level ifiunit in Christchurch. Many of those interviewed believed that this scenario would beunacceptable to families for social reasons. Likewise, the loss of the Christchurch unitwould leave some of Canterbury and a considerable area of the West Coast further than300km from a level III unit. Christchurch itself would be on the outer edge of a 300kmradius of Wellington.

//

I

I

/I

I

I4/

tII,I

'II,'I

1<,F

/F

I

I/


Figure 2.2a: 300km boundaries of level .111 newborn units in New Zealand -North Island

Source: Figure by author


Figure 2.2b: 300km boundaries of level Ill newborn units in New Zealand-South Island

/

'S

SS.

Source: Figure by author


Even within a 300km radius, transport can be difficult in New Zealand (see Section 6).Isolation was cited by Taranaki Base unit staff as the reason for carrying out long termassisted ventilation. Neonatal staff in Hastings also said that isolation was the reasonthey tried to keep as many neonates in Hastings as possible.

With the current distribution of neonatal intensive care units, families from out of townwere reported by those interviewed to find the situation difficult. For example, the reportof the Dunedin Newborn Intensive Care Unit (1992) stated:

The financial burden for some families can be severe. Also if parentshave left siblings behind in the care of families or friends they usuallyworry about the separation and feel obliged to leave their sick neonate andreturn home. ... Fathers' jobs are often disrupted though most employerswill give holiday time or leave of absence.

Staff in Dunedin reported that, at times, Invercargill families with infants in the Dunedinneonatal care unit have resorted to sleeping in cars because of the cost ofaccommodation.

Parents from the Parent Care support group at National Women's Hospital confirmedthat stress is high for parents from out of town. Transport costs are high and jobs andincome are disrupted. Out-of-town mothers were perceived to be solo parents, in effect,because their partners often have to stay at home to work. Even families who live withinthe main centres may have access problems if they do not own a car and they have to relyon family and friends to help. The interviewed parents pointed out that those at risk ofhaving a low birthweight infant - the young, Maori and solo mothers - often have lessaccess to the resources they need.

Area health board accommodation policies vary. Most provide rooms for mothers (forexample in ex-nurses homes) at a cost of around $20 per night. Fathers are often notcatered for. Some hospitals provide rooms in the neonatal unit for mothers to look aftertheir babies a few days before going home.

Section 3 Profile of newborns and outcomes ofintensive care

This section describes the factors that put infants at risk of needing intensive care and thenumbers and types of infants who are admitted to newborn intensive care units. It alsosummarises short and long term outcomes in terms of mortality and morbidity. Theinformation is based on limited national statistics, previous studies and, where available,local data. Comments On the quality of specific data are made in the relevant sections.

3.1 Risk of needing newborn intensive care

A number of factors have been identified that put the infant at high risk of needingintensive care after birth (Babson et al. 1980, World Health Organization 1972). Thesefactors, which may be identified during pregnancy or delivery or by the condition of theinfant, include infants who:

are very immature, weighing less than 1,500gm (about 1% of infants born);

remain depressed after resuscitation (about 0.5%);

show increasing signs of respiratory distress (about 1%);

have surgically correctable defects or who may have congenital heart disease(about 0.5% for both combined) (Babson etal. 1980:101).

In addition, Babson et al. (ibid: 107) identified those who need medium-risk care as beingthose with:

birth asphyxia (Apgar score usually below 6 at 1 minute) requiringresuscitation but stable at 30 minutes;

birth trauma, for example, excessive bruising, paralyses;

abnormal behaviour, for example, lethargy, irritability, poor feeding;

early appearance of jaundice (<24hr) and use of phototherapy;

anemia (Hct <35%) and polycythemia (Hct >65%);

increased respiratory rate without cyanosis or distress, for example, tachypnea ofnewborn;

[271


multiple births;

prolonged ruptured membranes;

major congenital anomalies not requiring immediate surgery or critical care;

preterm infant 33 to 36 weeks gestation;

dysmature or malnourished infant;

small-for-date and undergrown infant; and

large-for-date and infant of a diabetic mother.

About 15% of infants born in tertiary centres, which is equivalent to about 10% of birthsin each region, need some degree of special care. Approximately 2-3% of infants overallneed intensive care (Darlow 1991).

The Maternity Services Committee (1982:55) summarised conditions of infants whichrequire them to be transferred to a unit providing special care (Appendix Table 3). TheCommittee advised that 'in cases of doubt, most neonatal paediatricians would prefer ababy to be transferred unnecessarily than too late with damage that could have beenprevented'.

Rates of low birthweight in New Zealand

As noted above, low birthweight, usually associated with prematurity, is one of the mainrisks for needing intensive care in the newborn period.

For New Zealand as a whole in 1990, 3,595 infants (6% of the total number of livebirths) weighed less than 2500g. Extremely low birthweight (<1000g) accounted for0.45% of births (273 infants). Three hundred and thirty-nine infants (0.56%) hadbirthweights from 1000-1499g; and 4.96% (2,983) weighed 1500-2499g. There is ahigher incidence of low birthweight among Maori - 8.6% compared with 5.6% amongnon-Maori (calculated by author from provisional data supplied by Health StatisticalServices).

Figure 3.1 shows the percentage of live births which were low birthweight (<2,500g) in1990 for babies living in each area health board. Taranaki and West Coast Area HealthBoards had more than a 7% low birthweight incidence. In addition, Otago, Wellington,Tairawhiti, Bay of Plenty and Auckland had above average proportions of lowbirthweight.

Northland

Waikato

Talrawhiti

Taranaki

Wellington

West Coast

Otago

NEW ZEALAND

• 1500-2499

[1 1000-1499

• <1000

PROFILE OF NEWBORNS AND OUTCOMES OF INTENSIVE CARE29

Figure 31: Percentage of low birthweight live births by area health boardof domicile and categories of low birthweight, 1990

0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00Percentage of live births

Note: Some of these percentages are based on small numbers (see AppendixTable 4).

Source: Figure by author from provisional data supplied by Health StatisticalServices (see Appendix Tables 4 and 5).

Trends in low birthweight rates from 1973-90 are shown in Figure 3.2. Overall, therehas been a slight increase in rates since 1973. The rate of low birthweight has fluctuated,with higher rates in the early 1970s and the late 1980s, and relatively low rates inbetween. A more pronounced 'U shaped' pattern has occurred in the numbers of verylow birthweight infants (Figure 3.3). Both the numbers and rates of extremely lowbirthweight infants (<1000g) have increased markedly since 1973 (Figures 3.2 and 3.3).This is likely to have had a significant impact on level 111 workload.

6

5

4Percentage of

live births

2

1

0

• 1500-2499

[1 1000-1499

• <1000


Figure 3.2: Trends in the rates of low birthweight in New Zealand, 1973-90

7747576fl7879808182838485 8687888990

Year

Source: Figure by author from Howie 1990 and data supplied by HealthStatistical Services (see Appendix Table 6).

Figure 3.3: Trends in the numbers of low birthweight births in NewZealand, 1973-90

350

300

250

Numbers of 200live births 150

100

50

01IIIIiIiII73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90

Year

Source: Figure by author from Howie 1990 and data supplied by HealthStatistical Services (see Appendix Table 6).


3.2 Admissions to New Zealand newborn unitsData on admissions to newborn intensive or special care units are not collected at anational level. Limited data were available locally from some units for the presentreview, and some of these have been analysed. Some other units keep their own data, butthese were often not available in an accessible form. Moreover, as local data arecollected in different ways, valid comparisons cannot always be made.

National statistics are collected on 'discharges' (which include discharges, transfers anddeaths) from 'neonatal intensive care units'. However, these do not reflect the truenumber of infants who are treated in newborn units for a number of reasons:

There is an apparent lack of a consistent definition of 'neonatal intensive careunit' - infants who have undergone level II and/or level I care are probablyincluded in data provided by hospitals (see below). Additionally, some hospitals,for example, Dunedin, have newborn units which include level ifi and level IIcare treatment. This could result in an overenumeration of infants of a very largemagnitude (up to the total number of births in the hospital). (See Section 2 forfurther discussion on definition problems).

Discharge data should refer to the service in which the infant is last treated beforedischarge out of the hospital. Therefore, those who recuperate in lower levelunits or wards after intensive care (the usual procedure) theoretically will not becounted as a discharge from 'neonatal intensive care' 2. This could result in alarge underenumeration of infants.

Additionally, nationally collected data were not available on length of stay or occupancyrates. These are essential for planning purposes.

Because of these problems, only limited data on discharges were analysed for the presentreview. The main purpose of collecting these data was to check on the quality ofnationally collected data through a comparison with local data.

Numbers of admissions

Discharge data obtained for a data quality analysis of New Zealand 'neonatal intensivecare units' are shown in Table 3.1. These data were provided by area health boards toHealth Statistical Services. Note that many of the hospitals included in the data do nothave level ifi units (see Section 2). Over 2,000 'neonatal intensive care discharges' wereactually from units providing only level H care. They are therefore unlikely to havecarried out a significant amount of 'intensive' care, as it is usually defmed. Data

2 For example, of 147 infants of birthweight 1.8-2.5kg born in Christchurch Women's Hospital in1983, about half went to the neonatal unit. Of these 74 infants, only 7 were discharged straighthome; 59 went to the intermediate care nursery; 4 went to the post-natal ward 3 died and 1 wastransferred to another hospital (Darlow 1984).


provided for the national data base are obviously based on different definitions than dataused locally for managing newborn units.

Table 3.1: Numbers of infants reported to have been discharged from NewZealand 'neonatal intensive care units', 1990

Hospital Level of unit 'Discharges'(maximum

level ofcare)3

National Women's 3 2613Middlemore 3 732Waitakere 0 1St. Helens now dosed683Gisbome 2 178Hastings 3 265Nelson 2 69Christchurch Women's 3 493Northland Base 2 86Dunedin 3 314Palmerston North 2 382Timaru 2 37Southland 2 43Taranaki Base 2 217Tauranga 2 406Waikato 3 1208Rotorua 2 354Wanganui 2 105Wellington 3 285Hull 2 223Grey 1 116

Source: From data supplied by Health Statistical Services

Table 3.2 further analyses the quality of the discharge data. It compares nationaldischarge data with selected hospitals' own admissions data. It is likely that the latter aremore valid as they are generally collected in the newborn units themselves and are usedfor managing the unit.

As stated by area health boards (see Appendix Table 2).


Table 3.2 Comparison of national discharge data and hospitals' ownadmissions dataHospitalNumber of NICUYear(s)Number ofYear(s)Source of information

discharges (HSS 'admissions'data)

Christchurch2301986 297 1986Dadow (1986)

Women's3071987 302 1987Darlow (1987)

4961988

3611989

4931990

Dunedin 407198636219875031988 316averageReport of Dunedin Newborn

1987-91Intensive Care Unit (1992)

2731989(range 285-380)

3141990

National Women's2391986'Neonatal unit' 11091986Knight (1987)

3131987

18071988NICU341

11671989SCBU 1176 }1990Auckland Area Health Board(1991)

26131990total l5l7}

Mkldiemore 6661986

1541987

4861988

8881989

7321990 730 1990Auckland Area Health Board(1991)

Hastings 16319862011987

3221988

2481989

2651990 266 1990Interview

284 1991Interview

Taranaki Base841986 173 1986

1481987 222 1987

3471988 227 1988} Personal Communication

1881989 208 1989

2171990 234 1990

168 1991

Wellington 63519866161987

16371988

6771989Department of HealthN/AInterviewtarger

2851990approx. 620

Walkato 6811986approx 2601986

8131987approx 2801987} Department of Health

23331988approx3001988}(1990)

13171989approx 3251989

12081990


Most of the national discharge data are likely to be significant overenumerations of thenumbers of newborns who actually received intensive care. Even within hospitals, itappears that most or all discharges from level ifi and level H units have been counted asbeing from 'neonatal intensive care'. Additionally, from Table 3.2, it can be seen thatfor some hospitals, for example National Women's and Taranaki Base, the reportednumbers of discharges fluctuated dramatically over time. The hospitals' own data didnot do so. Similar inconsistencies were reported in the national discharge data for otherhospitals and for the data on transfers which were obtained for the current review. Thelatter were analysed but were considered too unreliable to present in this report.Discharge data were obtained on the numbers of preterm infants but have not beenincluded for similar reasons.

Administrative changes, such as the closure of St. Helen's and the separation of intensiveand special care units, could contribute to some extent to the reported fluctuations. It isalso possible that hospital's procedures for coding discharges may have been inconsistentover time.

Reasons for admission

There have been a few published New Zealand studies which have examined reasons foradmission to newborn units.

One study looked at admissions to the intermediate care nursery at ChristchurchWomen's Hospital (Darlow 1984). The intermediate care nursery was set up because ofthe growing pressure on nursing time in the neonatal unit for the care of infants whowere either well (but small) or who had only minor health problems. The primaryreasons for admission are shown in Table 3.3.

Of just over 300 admissions to the Christchurch Women's neonatal unit in 1987, 18%weighed less than 1500g at birth, 30% weighed 1500-2499g, and the remaining 52%weighed 2500g or more (Darlow 1987).


Table 3.3: Primary reason for admission to intermediate nursery: inborninfants, Christchurch Women's Hospital 1983

Diagnosis fl*%*Healthy premature 8235Intrauterine growth retardation 2410Mothercrafting/recovery from intensive care5022Infant of diabetic mother 63Hypothermia 63Accompanying twin 115Mild birth asphyxia 94Phototherapy 83Respiratory distress 94Malformations 42Feeding problems 42For adoption 42Miscellaneous 156Total 232

* Approximately as many infants had more than one diagnosis and the primarydiagnosis was considered to be 'somewhat arbitrary'

Source: Darlow (1984)

Data provided by Taranaki Base Neonatal Unit (a level 11+ unit) summarised the reasonsfor admissions of 169 infants in 1991 (Table 3.4).

Table 3.4: Reasons for admission to Taranaki Base Hospital Neonatal Unit,1991

Source: Personal communication

Information CentreMinistry of HealthWellington

36 A REVIEW OF NEW ZEALAND NEWBORN INTENSIVECARE SERVICES 1992

Darlow (c.1987) reported that the average length of stay in the neonatal unit atChristchurch Women's Hospital in 1987 was 18.0 days. This was longer than in 1984,when an average of 8.7 days was spent in the neonatal unit, followed by 6.3 days in theintermediate nursery (a total of 15 days) (Darlow 1984).

Ventilation

Ventilated level ifi infants at National Women's Hospital have an average ofapproximately 14.6 days on ventilation (3800 ventilated days for 260 infants).Ventilated level ifi infants at Middlemore have a lower average of about 3.3 days (200ventilated days for 60 infants) (calculated from Auckland Area Health Board 1991).This difference is likely to be because the more seriously ill infants are treated atNational Women's.

Several interviewees from level ifi units believed that level H units should not ventilateinfants for more than two or three days. Seven infants were ventilated at Taranaki BaseHospital in 1991. One infant was ventilated for 40 days, and the others were ventilatedfor an average of 4.5 days. A larger number of infants had been ventilated in previousyears (19 in 1990 and 18 inl989) (pers. comm.).

In Hastings in 1991, 21 infants were ventilated for a total of 56 days. The maximumventilated time was one month. Usually the maximum ventilation time in Hastings isaround three days (information from interview).

In 1987, 73 infants (24% of admissions) were ventilated in Christchurch Women'sHospital for an average of 10.2 days each. Very low birthweight infants were ventilatedfor an average of 14.0 days and other infants for 4.9 days (Darlow c.1987).

Total parenteral nutrition (TPN)

Fifty-seven newborns (19% of admissions) treated in Christchurch Women's Hospitalneonatal unit in 1987 had total parenteral nutrition (TPN). Very low birthweight infantshad TPN for an average of 15.3 days each, whereas the average for other infants was 8.5days. Darlow commented that this had been a considerable. increase compared with theprevious year (Darlow 1987).

TPN was given to eight babies at Taranaki Base Hospital in 1991. The length of TPNtreatment ranged from 2-31 days (pers. comm.).

Table 3.5 shows TPN treatment given in Dunedin over the past three years.


Table 3.5: TPN treatment in Dunedin, 1989-91

YearNumber of infantsTotal days TPNAverage days perinfant

1989 28 316 11.31990 34 417 12.31991 34 357 10.5

Source: Report of the Dunedin Newborn Intensive Care Unit 1992

3.3 Health outcomes

The health outcomes of infants who require intensive or special care help determinewhether active treatment is worthwhile. A large number of previous studies andavailable statistics relate to outcomes of low birthweight infants, particularly theirmortality rates. There have also been some morbidity studies. This section will focus onNew Zealand data.

Survival and Mortality Rates

Howie (1990) stated that there has recently been a striking fall in death rates particularlyin very small infants. This can be seen in Figure 3.4, which shows trends in the survivalrates of liveborn infants by birthweight. From 1978-88, survival rates for infants withbirthweights of 500-999g have improved more than threefold, from 17.7% to 59.1%.There has been a less dramatic, but still very significant, improvement for infants withbirthweights of 1000-1499g.

Some data on local survival rates also exist. The survival of infants in ChristchurchWomen's neonatal unit for 1986-87 was reported by Darlow (1987). Of the 37 infantsweighing 500-999g (extremely low birthweight) without lethal congenital malformations,22 (59%) survived. Three of the six of those born outside the hospital died, whereas 19of the 31 born in the hospital survived. Of the 72 infants weighing 1000-1499g, 61(85%) survived. Fifty-four (86%) of 63 born in the hospital survived, as did seven of thenine born outside the hospital.

For low birthweight infants admitted to Christchurch Women's Hospital in 1990,survival rates were 14 of 21 infants (67%) for 500-999g infants and 38 of 40 infants(95%) for 1000-1499g infants (Darlow 1991). This is equivalent to an extra 32 infantssurviving compared with a decade ago.


Figure 3.4.: Trends in the percentage of -survivors of liveborn infants 1978-88, by birthweight categories

100

90

8070

Percentage of 60neonatal 50survivors

30

20

10

0CDN.

0) 0 i-C)U) (0 N. (0N. (0 (0 (0 (0 (0 00 00 (0 co

Year (1978-88)

Source: Figure by author from Howie (1990) and data supplied by HealthStatistical Services (see Appendix Table 8)

Data for low birthweight infants born at National Women's show a similar dramaticimprovement for extremely low birthweight infants (Figure 3.5).

Figure 3.5: Trends in survival of very low birthweight infants (withoutlethal abnormalities) born in National Women's Hospital, 1981-88

Green Lane - National Women's HospitalSURVIVAL OF VERY LOW BIRTHWEIGHT INFANTS

INBORN AT N.W.H. WITHOUT LETHAL ABNORMALrnES. 1981-1988

10

LI)8 1000-124 9

IC-)Cl)

750-999gm

U)

500-749gm

1981-21983-41985-61987-8YEAR

Source: Auckland Area Health Board (1991)


The Dunedin Newborn Intensive Care Unit reviewed the survival rates of infantsadmitted to the unit (Figure 3.6). The unit stated that Dunedin neonatal survival rates of85.5% of infants with birthweights <1500g were similar to Auckland (89%), Hamilton(93%), Wellington and Christchurch (both 83%). The survival rates were also similar tooutcomes in three Australian centres (82%, 76%, and 8 1%).

Figure 3.6: Survival rates of very low birthweight infants admitted toDunedin Newborn Intensive Care Unit 1980-85 and 1986-91

Dunedin NICUSurvival by birth weight

100go80706050403020100 I-

Dunedin 80-85 Dunedin 86-91 USA 1986/87n=5 23 9831 32 116

501 —750 gms751 - 1000 gms M 1001 - 1500 gms

Source: Report of the Dunedin Newborn Intensive Care Unit (1992)

Longer term mortality rates were reviewed by Bourchier and Weston (1991) and byHarding and Howie (1987). The former study was of a cohort of very low birthweight(<1500g) infants who had been in the Waikato newborn unit from 1984-88. The post-neonatal mortality rate of the cohort was 68.2 per 1,000 live births (29 infants). Themost common causes of death were complications of prematurity and sudden infant deathsyndrome.

In contrast, the second study, a one-year follow-up study of surviving infants born atNational Women's Hospital in 1980, found that no infants surviving neonatal intensivecare died from cot death. Infant mortality rates among the intensive care survivors wereno different from other Auckland children. Congenital anomalies were the main cause ofdeath of normal birthweight survivors of neonatal care.

C0)

0

U

-D

0

0)C>>I-

CCUC0.


Morbidity

Hurt (1984) listed a variety of common problems of high-risk surviving infants. Theseinclude abnormal growth patterns, neurological impairment and developmental delay,decisions on the timing of immunisations, anaemia, impaired hearing, retinopathy ofprematurity, seizures, congenital heart disease, respiratory problems and parentingproblems.

Harding and Howie (1987) found that subsequent hospitalisation rates and average daysstay for neonatal unit survivors in their first year were higher than for other infants.Hospitalisation was more frequent in very low birthweight intensive care survivors(15.5% in very low birthweight survivors, 11.7% for low birthweight survivors and11.6% for normal birthweight survivors). The main reasons for the hospitalisation ofintensive care survivors were respiratory infections and surgery.

Disabilities such as retinopathy, neurodevelopmental disorders and respiratory diseasesare complications of prematurity.

Retinopathy of prematurity is an eye disease of premature infants which can causeblindness in its most serious form (Stages 3 and 4). Darlow reported that in 1986-87, ahigh proportion of premature infants born in Christchurch before 29 weeks' gestation,and with birthweights of less than 1000g, had retinopathy of prematurity. Thirteen of 14infants born at 24-26 weeks gestation and 13 of 27 infants born at 27-29 weeks gestationhad some degree of retinopathy of prematurity. Only 3 of 44 infants born after 29 weekshad the disease. All four infants of less than 750g birthweight, 16 of 18 infants of 750-999g birthweight, 6 of 22 infants of 1000-1499g birthweight and only 3 of 41 infants of1250-1499g birthweight had retinopathy of prematurity.

Chronic lung disease was defined by Darlow (1987) as being 'in oxygen at 28 days andrequiring oxygen for most of the first month of life. In 1986, of 43 infants withbirthweights less than 1500g. 18 (42%) had chronic lung disease. In 1987, thecorresponding figure was 35% (15 of 43 infants).

Section 4 Transfers and transport

4.1 Transfers/transport and regionalisationAn effective transport and transfer system is essential for regionalised neonatal care(Fletcher and Paris 1990; Reid 1986). Reid (1986:478) stated:

The service region must be carefully evaluated for size, usual weatherconditions, distances, and geographic obstacles (such as mountains orlarge bodies of water). These factors will, in turn, play a part in decisionsabout which mode of transportations and equipment will best service theregion.

The Australian Health Ministers' Advisory Council (1990) emphasised the importance ofa fast regional system so that equal access to level ifi is provided. The council describedthe elements of a regional retrieval system as being:

24 hour availability of consultation and retrieval;

specially trained neonatal intensive care nurses on a 24 hour roster nominated forthis service;

equipment especially designed for transport;

co-ordination between level ifi neonatal intensive care units;

education-in-service and for peripheral hospitals;

data collection and evaluation of service;

full-time director; and

full-time clerical staff (ibid. :32-3)

4.2 When to transfer newbornsIdeally, mothers should be transferred antenatally if it is known that a highrisk infant willbe delivered (Darlow et al. 1989). This is because 'the uterus is the ideal "transportincubator" (Fanaroff and Klaus 1979:383). Predicting the delivery of a high risk infantis not always possible, and therefore moving neonates between hospitals is sometimesnecessary. Stabilisation of the infant before transport, transporting as early as possible

[411


and having skilled staff available are important (Barr et al. 1981, Fanaroff and Klaus1979, Reid 1986).

Generally, newborns will need transporting if they require a higher level of care than isavailable at their place of birth (usually a hospital). For example, a preterm neonaterequiring full ventilation who is born in a level I unit will need to be transported (seeSection 2 for definitions of levels of care).

Fletcher and Paris (1990) explored ethical issues regarding the transport of neonates.They suggested that all obstetric hospitals should have specific policies for decidingwhich babies they should transport. The authors provided the following guidelines:

1. ACUTE (Acute, Critical, Unexpected, Treatable and Easily diagnosed)

These infants need transport to and treatment in a hospital with the appropriatelevel of care. This group includes newborn infants who:

are premature and have hyaline membrane disease;

have sepsis, pneumonia or meningitis; or

have surgically correctable malformations.

2. UNSURE (Unknown disease, Suspected Response)

These infants should be fully treated and transported if necessary until a diagnosisis made or the response is obvious. This group includes infants who have:

•a birthweight less than 800g;

•severe birth asphyxia; or

•unexplained disease or syndrome which has not been fully diagnosed.

3. KNOT (Known, Not Treatable)

These infants should be kept in the hospital of birth if possible. The groupincludes infants who have:

•anencephaly (unless a transplant donor);

•trispomy 13 or 15;

•birthweight <600g and have not been resuscitated; or

•severe asphyxia (Apgar scores 0,0) with no response to resuscitation.

TRANSFERS AND TRANSPORT 43

Fletcher and Paris stated that it is better to treat an infant before it is weighted than todelay treatment. Hospital policies which ease the decisions regarding neonatal transportshould consider:

delivery-room policies regarding resuscitation;

policies on prenatal and post natal communication with parents;

criteria for maternal transport;criteria for infant transport;

easy availability of consultation with appropriate personnel at a tertiary-careinstitution; and

criteria for not transferring infants (Fletcher and Paris 1990:51).

Darlow et al. (1989) examined the frequency and nature of neonatal transfer data for allvery low birthweight (<1500g) infants in New Zealand in 1986. They found that, of the413 livebom infants, 42% were transported within 48 hours of birth from home or from alower to a higher level neonatal unit. Twenty five (6%) of infants were transferred out oftheir region because of lack of cots. Twelve of these were in utero transfers. Most ofthese infants were from Northland or Auckland. Darlow et al. points out that there is anincreased risk with long distance transport and the lives of already-stressed families arefurther disrupted.

Harding and Cull (1988) reviewed 599 journeys made by the Waikato newborn transportservice from 1980-86. A total of 554 infants were transported over the time studied, with52% of journeys being emergency retrievals from other hospitals. Assisted ventilationwas used for 55% of emergency retrievals. Most of the journeys were by roadambulance, and 23% of the journeys were by fixed-wing aircraft. Fifty-eight percent ofthe retrieved infants were of low birthweight (<2500g) with 26% of very low birthweight(<1500g). The median gestation was 34 weeks.

The most common reasons for emergency retrievals were respiratory distress (47%),congenital abnormality (9%), preterm, not otherwise specified (9%), birth asphyxia(8%), meconium aspiration (7%), sepsis (6%) and apnoea (4%). Fourteen infants diedbefore they could be transported, and 31 (10%) died after transport. The authorsconsidered that only one of these infants would have survived if they had beentransported earlier.

The Department of Health (1990) obtained information on transfers of infants from levelifi centres and their regions to other level ifi centres. Transfers from Auckland to othercentres because of a lack of cot space were becoming less frequent over time.


4.3 Organising transfers

The British Association of Permatal Medicine Working Group (1989) surveyed 3,734neonatal referral requests in the United Kingdom for one year (1986-87). Both antenataland post-natal referrals were included in the survey. The Working Group found that 9%of attempts to transfer were not successful, that is, no cot was found. There was also asignificant proportion of successful transfers which were difficult and time consuming toarrange. The authors concluded that there were still not enough cots available to meetthe demand.

In Southern California, a co-ordinating regional 'Infant Medical Dispatch Centre'(IMDC) was set up in 1979 to overcome some of the problems in arranging transfers. Inparticular, the availability of cots in participating hospitals was recorded everyday, andan automatic telephone dialling system was installed. The IMDC was evaluated by Vogtet al. (1981) who found that, after the IMDC was introduced, there was a six-foldimprovement in the mortality rates of infants weighing 701-2000g born in hospitalscovered by IMDC. This included an improvement in low birthweight infants withhyaline membrane disease.

In New Zealand, the following procedures occur if a neonate needs to be transferred to alevel III neonatal unit. This information was provided by staff interviewed for thepresent review.

1. Medical staff from the referring centre contact medical staff from the regionallevel III centre about the availability of cots.

2. If cots are available, either the referring centre will arrange transport or the levelIII centre will come to retrieve the infant (depending on the availability ofequipment and staff and the condition of the infant). -

3. If cots are not available in the regional centre, it is their responsibility to arrange atransfer to another centre.

4. Once the infant has been treated, the level ifi centre arranges back-transport.

There is some flexibility in which regional centre is chosen to be contacted first. Thereare some generally agreed geographic areas which are served by the level ifi centres.These areas do not always coincide with area health board boundaries.


Timaru apparently sends neonates to either Christchurch Women's or Dunedin; and NewPlymouth usually sends infants to National Women's rather than Waikato. The reasonsfor this deviation from a purely regional system include:

• regional centres do not provide exactly the same services. For instance, there isonly one paediatric surgeon in Wellington and the paediatrician is not alwaysavailable, and cardiac surgery is only available in Auckland;

• transport availability. For example, there are no commercial flights between NewPlymouth and Hamilton although it is the closest regional centre (it is a roadjourney of 242km, about 4 hours). Therefore infants are generally transferred byplane to Auckland or Wellington;

•

families' wishes. For example, if families have relatives to stay with in oneregional centre, this is sometimes taken into account; and

personal contacts between medical staff.

There was some criticism from level III staff that transfers from lower level units andprivate hospitals are not always arranged soon enough. Ante-natal transfer may bepossible more often than is the current practice.

4.4 Transport/transfer co-ordinatorsIn general, interviewees stated that there were no major problems in arranging transfers.Some said that cots were occasionally unavailable, although this situation has becomeless common. When cots are not available in the regional centre, arranging a transfer toan alternative level III can be time consuming.

In 1982, the Maternity Services Committee recommended that regional co-ordinatorsshould be appointed to facilitate neonatal transfers. This has not occurred. It wassuggested by only, one person interviewed. Many interviewees commented that peaknumbers of admissions occur throughout the country at the same time. The recentdecrease in overflow problems may explain why interviewees did not suggest co-ordinators. Also, interviewees were not specifically asked for their opinions on theintroduction of co-ordinators. Darlow et al. (1989) and the ad hoc national meeting inAuckland (Special and Intensive Care Services for the Newborn in New Zealand 1991)continued to recommend co-ordinators as a way of improving the regional transfersystem.

A transport co-ordinator is employed in Hastings hospital during normal working hoursduring the week. At other times in Hastings and in the other centres, nursing staffarrange the practical aspects of the transfer, such as transport, once medical staff havedecided that a transfer should take place.


4.5 Transport methods and problems

Chartered fixed-wing aircraft are used as the main method of air transport to Hastings,Taranaki Base and Dunedin hospitals. National Women's Hospital use fixed-wingaircraft and helicopters, and Waikato and Wellington hospitals mainly use helicopters.Scheduled Air New Zealand flights are occasionally used by Hastings, New Plymouthand Dunedin - mainly for returning infants once they are well.

Christchurch Women's Hospital does not have an air retrieval system, but relies on AirForce Orion planes from Wigram for emergency transport. Neonatal transport inChristchurch is currently being reviewed as Wigram is due to close soon. Funding forestablishing a transport system in this region will need to be found. Christchurch staffwere also concerned at the lack of personal injury insurance for staff on retrievals.

Wellington staff commented that their transport incubators are about 11 years old andneed urgent replacement. Due to a change in civil aviation regulations, helicopters arenow unable to land at Wellington Hospital unless they have a patient onboard. Thisaffects the use of helicopters to transport retrieval teams directly from Wellingtonhospital to the infant who needs retrieving.

Taranaki Base Hospital does not have a transport ventilator and therefore infants have tobe retrieved by the hospital of destination if they are going to another level III unit.

The costs of helicopter transport or scheduled flights are usually greater than charteredlight aircraft.

Interviewees mentioned that poor weather conditions at New Plymouth and Waikatoairports caused transport problems.

4.6 'Back-transport'

Infants who have been treated in level ifi neonatal units can be 'back-transported' tolower level units for convalescence.

Bose et al. (1985) studied the cost-effectiveness of back-transporting infants in a Utahneonatal intensive care unit in 1980. They found that infants who were transferred backto community hospitals cost, on average, $320 less than those who remained in theintensive care unit until discharge. Overall, savings in daily bed charges, laboratory testsand medications outweighted the transport costs.

In the New Zealand study by Darlow et al. (1989), 45% of infants born in 1986 withbirthweight <1500g were transferred back to a lower level centre nearer home followingrecovery. The authors stated that back-transport is an 'efficient means of decreasingpressure on the level III units' (ibid.:276).


Staff at one of the level H hospitals stated that level ifi units could send infants back forrecuperation earlier than is currently the practice. This was based on their belief thatlevel H hospitals could safely dare for 'iMants after they needed level ifi care. However,other level II staff thought that infants were sometimes transferred back to them tooquickly.

Section 5 Facilities and staffing

Neonatal intensive care units require sophisticated medical technology. As previouslystated (see Section 3), this has meant rationing these resources to a relatively smallnumber of level ifi centres. Diagnostic services are required to back up medicaltreatment in the units. Long term follow-up services are discussed in Section 6.

This section explores recent advances in neonatal care, new technology, staffingresources and home care services. It describes the equipment and diagnostic servicesavailable to neonatal intensive care units which were visited and reviews the physicaldesign of these units.

5.1 Equipment

The equipment required by neonatal intensive care units is rapidly developing and-advancing. Bajo (1983:176) described recent advances as follow:

Care provided [to] the newborn has passed through many phases and nowinvolves the use of highly technological diagnostic and therapeutictechniques and sophisticated life support systems... Intravenoushyperalimentation, advanced thermoregulatory apparatuses and cardiaccatheterisation are all associated with expensive, sophisticated machinery.Computerised ventilatory systems may further refine mechanicalventilation in the future.

From a review of equipment in 60 neonatal intensive care units in the United States in1982, Bajo lists major pieces of equipment:

ventilators and hoods;

humidifiers and blenders;

infusion pumps;

cardiac, blood pressure and Po 2 monitors;

incubators;

lights; and

computer terminals.

[4

FACILITIES AND STAFFING 49

A statement by the British Paediatric Association and the British Association forPerinatal Paediatrics recommends that the following equipment should be available foreach newborn in intensive care:

•1 intensive care incubator, or unit with overhead heating;

•1 respiratory, or apnoea, monitor;

•1 heart rate monitor;

•1 intravascular blood pressure transducer or surface blood pressure recorder;

•1 transcutaneous Po 2 monitor or intravascular oxygen transducer;

•1 transcutaneous Po 2 monitor;

•2 syringe pumps;

•2 infusion pumps;

•1 ventilator; - -

•1 continuous temperature monitor;

•1 phototherapy unit; and

•1 ambient oxygen monitor (cited in Working Group of the National MedicalConsultative Committee 1990).

The United States found that the neonatal intensive care equipment had a life of aboutfive years. Respiratory 'paraphernalia' (blenders, bags and flow meters) had the highestturnover and lights had the lowest turnover. Monitors changed most rapidly in theirsophistication and additional monitors were obtained frequently. This was because ofadvances in technology, rather than because of technical difficulty or depreciation (Bajo1983).

Bajo points out that the cost of running equipment is not solely the cost of the equipmentitself. The cost also depends upon:

•pre-purchase evaluation opportunities;

•repair capabilities;

•breakdown frequency;

•self monitoring systems of the equipment;


staff education on use of the equipment;

-•other services offered by the company which sells the equipment;

•possibility of trading-in equipment;

•reliability of the company selling the equipment; and

•restrictions established by the Hospital's Standardization Committee.

Previous reviews, both overseas Working Group of the National Medical ConsultativeCommittee 1990) and in New Zealand (Maternity Services Committee 1982) have foundthat the equipment being used in neonatal intensive care units was inadequate. Loss offunction, inavailabiity of servicing and lack of spare parts and supplies were criticisms.

A detailed inventory of equipment held by New Zealand neonatal intensive care unitswas beyond the scope of the present review. However, hospital staff were asked if theythought their unit's equipment and its maintenance were adequate.

Table 5.1 summarises the responses. Generally, the maintenance of equipment wasadequate (with the exception of Middlemore). The adequacy of the equipment itself wasvariable - possibly reflecting the financial situation of the area health boards.


Table 5.1: Interviewees' comments on newborn unit equipment and itsmaintenance

Hospital Comments on equipment Comments on equipmentmaintenance

National Women'sReplacement value of equipment =Maintenance is good/very good.$2.5m. Undercapitailsed to replacethis - would take 32 years at currentbudget allowance. Some equipmentis over 15 years old -'approachingobsolescence'.

Middlemore Equipment has improved over last 2Only one technician and an assistantyears. Well equipped for a level IIfor whole hospital - 'far fromunit, but will need more equipment tosatisfactory'. Ideally should share abecome a level Ill unit. technician with adult intensive care

unit. Hospital is beginning to contractout maintenance work.

Waikato Would like more equipment to ensure Equipment is well maintained - haveavailability during peak times. Notown technician.enough equipment to carry out routinemaintenance programme - no back upequipment. Equipment new in 1980 isnow getting dated

Taranaki BaseEquipment adequate. Two ventilators Have just started a regularwill need replacing soon. maintenance programme - has not

been going long enough to assess,but should be an improvement.

Hastings 'Quite well equipped'. Equipment maintained by biomedicalengineers dept at Napier Hospital.

Wellington Most equipment over 10 years old.Good - have to make the most out ofShort of most things e.g., monitors,the equipment.ventilators, over-head warmers,syringe pumps etc. Often noequipment available for anemergency.

ChristchurchA lot of equipment is 'antiquated' andGood services from a sharedbreaks down frequently. Havetechnician. Could do with ownapplied to AHB for a grant to get new technician.equipment. Have to move babiesaround the unit so that the sickerones get the new equipment. Nocapital grants for 6 years. Is high onAHB's list of priorities - there will be agrant this year (1992).

Dunedin Equipment inventory in report of theGood maintenance, excellent back upDunedin Newborn Intensive Care Unit staff. No technical assistance for(1992). Will need new transportventilation equipment.incubator in 2-3 years. Otherwiseequipment is adequate.

Source: Table by author from information from interviewees


5.2 Design of newborn units

'The physical surroundings of the neonatal intensive care unit affect the abilities of itsprofessional staff to organize and provide patient care', (Sheridan 1983:37).Recommended design features include:

proximity of newborn units to delivery suites (preferably on the same floor);

adequate space for each infant position;

•adequate support space of approximately the same floor area as the patient carespace;

•adequate oxygen, air, vacuum and electrical outlets for each intensive careposition;

•adequate lighting, preferably able to be dimmed at each infant position;

•isolation room(s);

office and lounge for staff;

•laboratory;

•rooming-in for parents;

•clinical research space;

•visitors' room; and

•treatment room(s) (Basler 1983; Sheridan 1983).

Those interviewed for this review were asked if the physical design of their units wassatisfactory. Table 5.2 summarises their responses. Those who worked in the newer,purpose built units were generally considerably more satisfied with their physicalworking conditions. Units with the least satisfactory designs (Christchurch, Taranaki)were being replaced. Isolation facilities were not ideal in several units.


Table 5.2: Comments on the physical design of newborn units

HospitalCommentsNationalDesign is 'pretty reasonable'. Special care area could be shorter in length.Women'sSpace may not be ideal to have flexible staffing arrangements. Parents

thought that mothers should be able to be roomed closer to babies.MiddlemoreNot an adequate design for a level Ill unit - will have to be redesigned.WaikatoNew unit in 1980. Need more space - particulaily staff office and rooms

for parents. Registrar room has been lost so that it can be used as abreast feeding room. Bigger store rooms needed, and more daylightwould be an improvement. Nurseries should be bigger, less noisy.Teaching space needed. Better isolation area required.

Taranaki BaseCurrent unit is outmoded, not enough room, no breast feeding area,'grotty' parents area. Isolation unit is only separated from main unit by asliding door. New, purpose built unit is currently being build, project to beopened in April 1992.

HastingsUnit built about 6 years ago. Plenty of space. Staff generally satisfied.Isolation unit was considered to be on the wrong side of the unit becausedirty linen has to be taken across the unit. Located next to delivery suite.Need _high _risk theatre _in_ delivery _suite.

WellingtonGenerally satisfactory design, good layout. Need more power and gasoutlets. Because of increased workload, need a second intensive carearea. Side rooms, which are currently used, are not designed for intensivecare.

ChristchurchFacilities are 'shocking', under-resourced, inadequate. Lack of space is amajor problem, with staff often colliding with equipment. No privacy orfacilities for parents. Electrical wiring and air-conditioning have beenrecently upgraded as an interim measure. There have been 4 plans since1984 to replace the unit. The current plan is to revamp the current unit -will increase space considerably - building due to start very soon.

DunedinNewly modified area next to adult intensive care area - opened 1990.Staff generally very satisfied. Design of isolation room not ideal - shouldhave an ante-room. Have just arranged the use of an extra 4 bed room inthe post natal unit.


5.3 Diagnostic and transfusion servicesDiagnostic services, such as radiology, biochemistry, microbiology and pathologyservices, are essential to the management of neonates in intensive care. The availabilityof blood and blood products is also vital.


The Consultative Committee on Obstetric and Neonatal Services (1987:46)recommended that diagnostic services in South Australia level ifi units include:

biochemistry, hematology and microbiology services that are immediatelyavailable. These services should utilise micro-measurement techniques;

radiology facilities, including portable x-ray with paediatric timers, that areimmediately available during normal working hours and available within 30minutes after hours;

a full range of ultrasound facilities on-site;-

•pathology services that are readily available. Level ifi centres should provide- autopsy services for level I and II units; and

appropriate technology for laboratory and diagnostic services.

Similar criteria were set by the Australian Health Ministers' Advisory Council (1990:28)which specified that the following services should be on site for a level ifi unit on a 24hour basis:

blood gas analysis/pH micro-analysis equipment (in the newborn unit);

biochemical laboratory with micro-techniques;

hematology including blood bank;

radiology; and

•microbiology.

The Council specified that medical and surgical sub-specialties and biomedicalengineering services should also be available 24 hours a day, although not necessarily onsite.

Staff interviewed for this review were asked if facilities such as laboratories and x-rayswere available to an adequate level.

There was a high level of satisfaction in most centres. The exceptions were inChristchurch and Hastings. Laboratory samples from Christchurch Women's newbornunit have to go to Christchurch Public Hospital to be analysed. This means that testswhich cannot be done in the newborn unit itself run the risk of getting lost in transit (thishas happened occasionally). Results also take time to come back. A fax machine hasbeen suggested to the area health board as the best way of communicating test results,and one may be purchased in the next year.


In Hastings, biochemical tests are sometimes hard to arrange out of hours, and the rangeof tests available is not considered by clinical staff to be ideal. For example, additionalbiochemical tests to aid in the diagnosis of infection would be helpful. Transfusionservices were also criticised. The situation was described as a 'running battle' as freshblood was 'never available'. This problem was attributed to the reorganisation oftransfusion services into one regional centre in Palmerston North.

Minor problems included the lack of mobile ultrasound machines in Hastings andTaranaki Base and better ultrasound machines needed at National Women's. Theincreased workload for laboratories if Middlemore became a level III unit was also notedas a potential difficulty.

5.4 New technology

In addition to equipment and diagnostic services, newborn care involves the use ofspecial technology. The cost of such technology is often high.

The major neonatal intensive care advances are being made in respiratory medicine(Australian Health Ministers' Advisory Council 1990). These advances include positivepressure ventilation, which has been used in New Zealand for several years,extracorporeal membrane oxygenation (ECMO); and surfactant replacement. The lattertwo interventions are discussed below.

Extracorporeal membrane oxygenation (ECMO)

Extracorporeal membrane oxygenation (ECMO) was developed in the 1970's and is usedin some overseas countries such as the United States. Only two units in Australia wereapproved to use ECMO (Australian Health Ministers' Advisory Council 1990).

ECMO is used as a last resort when conventional treatments for respiratory problems innear- or full-term infants have failed:

ECMO is a temporary life support circuit for neonatal intensive care thatduplicates, after birth, gas exchange performed before birth by theplacenta. It ensures adequate oxygen supply and eliminates carbondioxide when lung function is compromised. EMCO by-passes the baby'slungs allowing for healing and/or other interventions. The technique isextremely invasive... (Australian Health Ministers' Advisory Council1990:4).

EMCO is only used when infants have possibly reversible respiratory failure and about a20% or less chance of survival. It is not suitable for preterm infants because of the riskof intracerebral haemorrhage. It is only suitable treatment for a small minority of infantsadmitted to neonatal intensive care units, including some with meconium aspiration


syndrome, persistent pulmonary hypertension, congenital diaphragmatic hernia,respiratory distress syndrome or sepsis.

The outcomes of ECMO treatment are still being evaluated. Survival rates have beendifficult to establish because of ethical constraints in performing clinical trials, althoughit appears that ECMO is effective in conjunction with other interventions in selectedinfants. Follow-up studies have suggested that ECMO may be associated with long termneuro-developmental problems (ibid.).

Those interviewed believed that there is no place for ECMO in New Zealand at themoment. A few said that if ECMO was introduced, it should only be introduced to onecentre (Auckland was usually suggested by both Auckland and non-Auckland staff).Most neonatal staff stated that very few infants need ECMO and that in many cases theneed could be prevented with better medical management, including the use ofsurfactant.

Surfactant

The lungs of babies, from a variable period between 24 and 36 weeks gestation, normallyproduce surfactant - a mixture of fats and proteins. The substance helps gas exchange inthe lungs and is needed for normal breathing at birth. Natural surfactant, which is notpresent in some premature babies, can be replaced with human, animal or syntheticsurfactant.

Surfactant replacement has been shown, in several studies, to significantly reducemorbidity and death from respiratory distress syndrome (RDS). Merritt et al. (1990:416)stated:

As with few other treatments introduced into neonatal medicine, multiplestudies of surfactant therapy have shown that complication of RDSincluding airleak can be reduced and the degree of ventilatory supportlessened by one or more doses of these surface-active drugs.

The authors noted that some trials suggested that surfactant treatment may be associatedwith adverse effects, such as intraventricular and pulmonary haemorrhage. However,Merritt et al. suggested that surfactant improves infant survival and does not prolongdying. From their review, Merritt et al. concluded that surfactant treatment should onlybe used for infants less than 30 weeks gestation with diagnosed surfactant deficiency orinfants over 30 weeks gestation with evidence of 'moderately severe' RDS.

In another review, Morley (1991) summarised the results of controlled clinical trials onsurfactant. Morley reported that none of the trials showed an increased mortality andconcluded that infants of less than 30 week's gestation benefit from the treatment.However, Morley noted that, where natural surfactant had been used in 'rescue'situations, there was an increased incidence of patent ductus artenosus (an adversecondition). Prophylactic (preventive) treatment was beneficial and did not appear to

FACILITIES AND STAFFING - 57

have any harmful side effects. The clinical trials suggested synthetic surfactant is aseffective as natural surfactant in preventing complications of RDS.

The Fetal and Newborn Committee of the Paediatric Society of New Zealand (1992)recently recommended in a position paper that surfactant be used in situations where it isknown to be most effective. In particular, surfactant treatment can be effective:

as an early rescue treatment in infants with birthweights of 700-1350g who areintubated, have probable respiratory distress syndrome, require 40% oxygen ormore or 'have ventilatory reqirements such that the mean airways pressure is 7cmH20 or more and the a/A ratio is less than 0.22';

in infants with higher birthweights who have proven respiratory distresssyndrome or the above criteria; and

in infants of less than 700g who are being offered intensive care facilities, withthe above criteria.

The Committee stated that surfactant treatment should be limited to units which regularlyventilate infants (that is, level ifi and Ha units) and that its availability should notinfluence the decision to transfer infants to higher level centres.

In New Zealand, all the neonatal units visited for this review had surfactant available foruse. The five level ifi centres (National Women's, Waikato, Wellington, ChristchurchWomen's and Dunedin) had been involved in an international trial of synthetic surfactantin 1991 and obtained free surfactant during the trial. They have had to pay for the drugsince the trail ended (towards the end of 1991). Hastings and Taranaki Base had also justreceived surfactant supplies. Other level H centres, for example, Southland, werereported to have surfactant available and were using it. The cost effectiveness ofreplacement surfactant is still being investigated. Overall costs (e.g., for a hospital) canincrease because of an increase in the number of survivors, who may require more beddays, other treatments and diagnostic tests. Some studies, however, have shown the costper survivor is lower than if surfactant is not used (Merrit etal. 1990).

All the units visited were having to make special arrangements to fund the treatment,which costs about $2,000-$3,000 per infant ($1,000 per vial). The special arrangementsincluded using money from the child and adolescent service (as a whole) and thepharmacy budget. That is, in most centres, the normal neonatal unit budget is notconsidered to be sufficient to pay for this treatment.

Almost all the staff interviewed thought that neonatal units were obliged to use surfactantbecause it is an effective treatment which can save the lives of a significant number ofinfants (one interviewee suggested up to 50 infants per year in New Zealand). Several ofthose interviewed stated that surfactant replacement has been shown to be cost-effectiveand helps the earlier transfer of infants from level III to level H care.


5.5 Staff resources

This section summarises the staff resources of each of the units visited for this review.Staff training, development and performance appraisal are discussed in Section 6.

Table 5.3 shows the nursing and medical staff resources of the newborn units which werevisited.

Table 5.3 Staff resources of newborn intensive/special care units

HospitalNursing staff resources Medical staff resourcesNational Women's Intensive care 40.5 FTE staff nurses.Paediatric service overall - 6.2 FTE

Special care 64 FTE. All intensive careconsultants, 10 registrars, 7 housestaff registered. Special care staff 701%surgeons. At any one time, 1-2registered and 30% enrolled/Karitane.consultants; 2 registrars and 1 house1:1 staff ratios for most dependentofficer resident on call.infants; 1:1.5 for less dependent (e.g.,lust on ventilation), a few nurse aides.

Middlemore2 charge nurses; 24 FTE registered2.2 FTE consultants; 3 registrars. Onnurses; 5 onroled nurses, 1 hospitalcall staff cover neonatal unit,aide. paediatrics, postnatal and A&E.

Waikato 48 FTE 2.2 FTE consultants (4 people); 4paediatrics registrars, 2 anaestheticregistrars. House officers and SHOsrotate for 5 weeks each. Alwayscovered by registrar on site,consultant on call within 15 minutesaway.

Wellington40 FTE (All registered nurses except 2.8 1.7- 1.8 FIFE neonatal consultants (1FTE). is full time director of unit); 2

registrars; 3 SHOs.ChristchurchNICU/SCBU - 1 charge nurse and 321.4 FTE neonatal consultants; 4

FTE staff nurses plus hospital aides. Up paediatric and 1 anaesthetic registrar.to 1:1 nurse:infant ratios. Intermediatenursery - 1 Karitane nurse and 4 othernurses.

Dunedin 22 FTE. Up to 1:1 nursing ratios.1.4 FTE neonatal consultants; 2Nurses never look after more than 1registrars (no senior).level III infant at once.

Taranaki Base15.3 FTE registered nurses plus 13.5 general paediatric consultants; 2charge nurse; 1 hospital aide part-timeregistrars; 2 house officers. Always(not funded by neonatal unit). have junior staff on call, on site.

Cover all paediatric services.Hastings 16.7 FTE including charge nurse3.8 FTE general paediatric consultants

(includes 11.5 staff nurses, 2 enroled,and 4 registrars for paediatrics overall.2.2 hospital aides). Have 1:1 ratios forRegistrars and consultants cover bothventilated infants. Napier and Hastings - paediatric

house surgeon always on call in eachhospital.

SHO = Senior house officerFTE Full time equivalent


I


Those interviewed were asked if there was an adequate number of staff to cover thenewborn units. The interviewees expressed satisfaction with the current. medical staffinglevels at National Women's, although the nursing situation is tight. Accrual of annualleave for nurses is a problem, and nursing ratios do not always conform to thoserecommended (e.g., there are sometimes 1:2 nurses:ventilated infants, rather than 1:1.5).

Middlemore was believed to have an adequate number of nursing staff at the moment,but it needed two more junior medical staff. Those interviewed stated an increase in staffwould be necessary if they became a level ifi unit.

Waikato interviewees considered there were 'just enough' nursing staff, although thisdoes not cover all annual leave or sick leave. Annual leave is therefore accruing. Ananalysis by the newborn unit of extra duties has suggested that an extra 2 FTE nurseswould be ideal to cover the workload.

Those interviewed thought that there were enough medical and nursing staff at Hastings.However, the fact that paediatricians have to cover both Napier and Hastings hospitalswas believed to decrease the efficiency of the staff because of the travel involved and theseparate service management arrangements.

Interviewees believed that Wellington was short of one neonatal paediatrician and about15 nursing staff. The paediatricians cover both newborn care and general paediatricswhen they are on call. This can cause delays in newborns being seen by thepaediatricians. However, newborn care is regarded as the priority because delays aremore dangerous in small babies, and therefore it is often other paediatric patients whohave to wait to be seen.

Christchurch Women's staff stated that there were not enough medical or nursing staff.They perceived a need for one more neonatologist with experience in developmentalpaediatrics. The number of nursing staff was also considered to be insufficient - up to anadditional seven were needed. They also suggested establishing a nurse educatorposition. The unit was staffed for 80% occupancy, whereas in 1991 the averageoccupancy was over 90%.

5.6 Home care services

Wellington, National Women's, Waikato, Taranaki Base and Dunedin providedomiciliary care to infants who have been discharged from newborn intensive and specialcare units. Lack of funding in Christchurch precludes a home care service. Funding forhome care nurses comes from the child health and/or community health services budget.Home care staff generally have paediatric and/or midwifery nursing experience. Theyusually see the infant before discharge and familiarise the main caregiver with anyequipment which will be used at home (e.g., apnoea monitors). Caregivers are alsotaught cardiopulmonary resuscitation. Home care staff will visit the infants frequently at


home. At first, these visits are more frequent than once a day if required, and thencontact is gradually decreased. Staff refer infants with problems to other health careworkers as necessary. Most of them are also available to give advice by telephone at anytime.

This home care system seems to be successful in decreasing readmissions to neonatalintensive care units. For example, in Wellington, readmissions have fallen by 90% sincethe scheme's introduction. Parents interviewed for this review also supported home care.However, they thought that the care should continue for a longer time.

Interviewed home care nurses stated that it was difficult to cover out-of-town infants.They are unable to visit infants who live too far away, even if they are in the same areahealth board. Although general practitioners, Plunket nurses and district nurses areavailable elsewhere, they do not always have the experience to deal with infants from thenewborn units.

Section 6 Quality assurance and informationrequirements

This section begins by defining quality assurance (QA), summarising New Zealandlegislation and describing measures currently undertaken by newborn intensive careunits. It discusses follow-up services, current data collection and information needs.Finally, the section briefly examines the research programmes of the newborn unitsvisited for this review.

6.1 What is quality assurance?

The Consultative Committee on Obstetric and Neonatal Services (1987:48) stated thatformalised quality assurance (QA) programmes for South Australia level III newbornservices should include:

documented policy which provides clear directives for nursing and medical staffoutlining the scope and limitations of their functions and responsibilities;

continued audit of referral practices and review of any babies with birthweightless than 2500g born in the hospital;

a staff performance appraisal system (including self and peer evaluation);

nomination of a person to be responsible for quality assurance matters in alldisciplines;

documented protocols for the management of obstetric and neonatal conditionsand procedures for nursing and medical staff (e.g., hypoglycaemia, hypothermia,embolic episodes, jaundice, cord care);

educational programmes (in house or refresher courses at level III outreach atlevel II hospitals) to maintain knowledge and skills in health care providers;

collection of data to assist in the compilation of statistics by the PregnancyOutcome Unit; and

•multidisciplinary and consumer review and assessment of philosophy,environment and information provided by the service.

The committee also recommended that hospitals should seek outside assistance (e.g.,from colleges, other level ifi hospitals and the South Australia Health Commission) todevelop and implement their quality assurance programmes.

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6.2 New Zealand legislation on newborn care

The Obstetric Regulations 1986 (and Amendment No. 1, 1990), currently being reviewedby the Department of Health, contain a number of clauses which relate to the quality ofcare of newborns and their mothers. The regulations therefore apply to infants innewborn intensive and special care units. Provisions for infants in the regulations statethat:

•no infant shall occupy a room which is intended for reception or treatment ofnon-maternity patients or for staff use [s.4(b) and (c)];

•every preparation room, first-stage room and delivery room shall be usedexclusively for obstetric purposes [s.4(d)];

• medical practitioners and registered midwives have to notify the medicalsuperintendent or hospital manager of any septic condition, communicabledisease or neonatal infection in infants and of the precautions being taken. Thesuperintendent/manager is then obliged, as soon as practicable, to taken steps toprevent the infection [s.6];

the medical practitioner or registered midwife in charge of a birth have to notifythe birth to the Medical Officer of Health within 7 days 'on a form to beprovided, or in a manner approved, by the Department of Health' [s.7];

registered midwives and registered nurses in domiciliary practice have to keepclinical records which include: the sex of the infant, whether the infant was bornalive or stillborn, duration of the pregnancy, weight and record of examination of

•infant at birth and on date when care of the infant ceases, method of feeding on•date when care of the infant ceases, the date of death or admission to hospital if

these occur and the cause of death or reason for admission [s.91;

• registers and clinical records kept by registered, domiciliary midwives and nurseshave to be: legible and indelible, available on demand to the Medical Officer ofHealth, authorised Department of Health officers and the mother's or , infantsmedical practitioner and retained for at least three years [s.10].

6.3 Quality assurance in New Zealand newborn units

Formalised comprehensive quality assurance programmes have been developed onlyrecently in this country. This was evident from the responses of those interviewed forthis review. Some newborn services such as National Women's, Waikato and Dunedinhad specific quality assurance programmes, whereas others were less formalised. Someof the units had introduced quality assurance measures for accreditation purposes.Details of some of the current quality assurance measures in the newborn units visited for

QUALITY ASSURANCE AND INFORMATION REQUESTS 63

this review are in Appendix 6, Table 1 These responses were collated from questionsrelating to monitoring and evaluation of services, protocols, training, data collection andfollow-up. Responses are summarised below.

Data collectionThe extent of data collection was variable throughout the units visited. Some units, suchas Waikato and Dunedin, had fairly comprehensive computerised systems. Other units,such as Middlemore, Christchurch Women's, Taranaki Base and Hastings, had manualsystems, with limited data. Lack of computerisation, time and personnel constraintsmeant that regular annual reports and comprehensive collation of medical statistics areonly carried out by a few centres.

Staff Training

All the hospitals visited provided neonatal nursing training. The level II units(Middlemore, Hastings and Taranaki Base) had less advanced training than the level ifiunits, and Christchurch had problems funding nurses for post-graduate training andconferences. Waikato are sending two nurses on a neonatal nurse practitioners' course inCanada. They will be able to provide advanced training to nurses and registrars whenthey return.

Most centres provided ongoing education and conference attendance for medical staff.However, Wellington paediatricians reported some difficulty in arranging study leavebecause of the limited amount of medical cover.

Mortality/morbidity reviews

Mortality and morbidity reviews were regularly carried out by all the units visited, withlevel ifi units generally having more frequent reviews (usually monthly) than level IIunits. These reviews are used to audit and discuss outcomes and treatments.

Follow-up

The Maternity Services Committee (1982:35) stated that 'a proper follow-up should beregarded as an integral part of a newborn intensive care service'. The Committee notedthe importance of monitoring the quality of newborn intensive care survivors. Allneonatal units except Christchurch, Wellington and Middlemore had multidisciplinarydevelopmental follow-up programmes for some years after birth - some were moreformalised than others. Paediatricians in Wellington made a three month follow-up.Infants with bu-thweights 1000g or 1500g, or with other high risk factors (such as severeasphyxia), are followed-up. This is a less extensive follow-up than recommended by theConsultative Committee on Obstetric and Neonatal Services (1987), which recommendedan audit of all infants <2500g.


Nursing/medical treatment protocols

All of the newborn units visited had a large number of treatment protocols, usuallyavailable in folders located in an accessible place in the unit. Medical handbooks hadalso been written in some units. Most protocols were reported to have been reviewed orupdated recently. It was beyond the scope of this review to assess all the protocols in anydetail. The lack of standardisation of protocols throughout the country was criticised byseveral of those interviewed, and suggests an important topic for future investigation andpolicy development.

Staff performance

Middlemore, Waikato, Wellington and Dunedin neonatal units have 'staff performanceappraisal systems, particularly for nursing staff.

Consumer feedback

Some of the units, for example, Waitako, have sought consumer feedback on theirservices. These have tended to be one-off surveys rather than an ongoing process.Results have been positive, with some minor criticisms about communication. Theconcerns have been addressed. In Waikato, the breast-feeding room was established inresponse to consumer feedback.

6.4 Research

Research is seen as an essential role for regional centres (see Section 2). The neonatalunits visited were doing very little nursing research, although several nursing staffexpressed interest in doing research.

Out of the units visited for this review, medical research was carried out mainly in thelevel ifi units, rather than the level II units. The association of many level III medicalstaff with universities is an important influence in research programmes within newbornunits. All five level III units participated in the international surfactant trials last year.Ongoing research in the larger centres includes:

National Women's

TRH trial (lung maturation treatment)

Growth hormone

Measuring brain damage from asphyxia

Ductus artenosus ultra sound


•Steroid treatment of preterm labour

•Long term follow-up

Middlemore

•No medical research because there is no full time neonatologist

•Have some ideas for nursing research

•Are interested in preventive research (antenatal)

Waikato

•Mainly do clinical auditing

•Have had four papers published recently on septicaemia, seizures, birth asphyxiaand dexamethasone treatment

•Part of meningitis study (although unit has very few cases)

•Marcain as pain relief for thoracotomies

•Some nursing research on breastfeeding

Taranaki Base

•No medical research except some analysis of outcome/admissions statistics

Hastings

•Some antibiotic research, otherwise low-key, do not publish articles

•No nursing research

Wellington

•No nursing research of their own, but assist in medical research and in nursingresearch in other areas

•Will have a full time medical research fellow in three years

•Research on breast milk -B 12, folate, aluminium

•Pharmacokinetics of morphine for pre-term infants


•Involved in international meningitis study

Jaundice

Asphyxia

Staphylococcal catheter infectious

Heart rate

Christchurch

Do a considerable amount of medical research, mostly funded by the HealthResearch Council

No nursing research because of lack of funding

Dunedin

Research is a very important aspect of the role of the neonatal unit staff. Severalof the medical staff work part time for Otago University

Effectiveness of delivering surfactant by nebuliser

Oxygen free radical damage and how to minimise this (controlled trial)

Apnoea study

Cot death prevention study

6.5 Information requirements

Section 4 discussed the data quality of neonatal mortality and morbidity statistics.Interviewees were asked what information they thought should be collected on neonatalhealth status and service use. Most expressed concern about the lack of informationavailable at a national level and the inability to compare outcomes between regions.Lack of local management information was also criticised where few data were collected.

Many commented that there needed to be an integrated national system for collectinginformation. Generally, they wanted access to data on births, deaths and morbidity.Recording variables at a local level, such as gestational age, birthweight, types of disease,ventilation, total parenteral nutrition (TPN), length of stay, any new treatments, transfers,follow-up information and nursing ratios, was seen to be very important. Interviewees


thought that this information should be collected locally so that it could be collatednationally.

Most of the interviewees supported the proposed perinatal database (see below) andstated that they would be very willing to participate in this. Even staff in hospitals whichhad already established neonatal databases were enthusiastic about changing to adifferent system so that national statistics could be collected in a consistent way. Oneinterviewee suggested that information collection should be part of hospitals' contracts toprovide newborn services.

Perinatal database

In 1988, a proposal for a national perinatal information system was made by a NationalWorking Party (National Working Party on Perinatal Information 1988). The WorkingParty stressed the importance of collecting information to improve the health of children.

Information on infants that the Working Party considered to be 'essential' or desirable islisted in Appendix 6, Table 2. Other recommended information referred to mothers. TheWorking Party also considered father's occupation as essential information.

Details of the functional requirements for a national perinatal database were drawn up forthe Department of Health by Azimuth Consultants in September 1988. However, theperinatal information system has not yet been implemented, primarily because there hasbeen a review of all health statistics, and a new health information strategy has beenannounced (Health Information Strategy Steering Group 1991). Many of thoseinterviewed for this review expressed considerable concern about the delay inimplementing a national perinatal database.

Perinatal epidemiology unit

The National Working Party on Perinatal Information (1988:3) recommended that:

the Department [of Health] establishes a national perinatal epidemiology unit toanalyse to international standards the information obtained [from the nationalperinatal information system] and to provide regular reports on national andregional maternal and child health.

Several of the staff interviewed expressed their support for this proposal.

Section 7 Financial issues

This section will explore some of the financial issues relating to newborn intensive care.Sections 7.1-7.3 use information from interviews and New Zealand literature. Thelimited availablity of accurate costing information in this country meant that intervieweesmade comments mainly from their personal experience and from overseas literature.Costs of newborn care in New Zealand are reported, cross boundary charging isexamined, and then other funding issues in New Zealand are discussed. Finally (Section7.4), selected economic analyses from overseas are reviewed briefly. Core services,which the new health system will use to allocate funding, are discussed in Section 8.

7.1 Costs of newborn care in New ZealandCurrently, information on the costs of newborn care (and other services) is limited inNew Zealand. In the future, such data will be more readily available with theintroduction of information systems, such as RUS, into area health boards. Estimates ofthe costs of treating infants in newborn units in New Zealand are shown in Table 7.1.

Table 7.1: Costs of treating infants in newborn units in New Zealand

Newborn unit/typeApproximate cost Sourceof infant per infant per day

($)National 1,250Auckland Area Health Board (1991)Women's/NICUNational 600Auckland Area Health Board (1991)Women's/SCBUDunedin/<1 000g 768Report of the Dunedin Newborn Intensive Carebirthweight Unit (1992) from RUS analysis of 10 infantsWellington/level III1150Darlow (1991)Waikato/level III 1300Darlow (1991) - 1988 dataWaikato/level II 500Darlow (1991) - 1988 data

Source: Table by author from specified sources

Although the relatively high costs of newborn care were generally acknowledged byinterviewed staff, they stated that outcomes are good. They asserted that most infantstreated in intensive and special care grow up to be normal, healthy children. This wasbased on overseas evidence and from data available in New Zealand on outcomes.

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FINANCIAL ISSUES 69

From overseas studies, Darlow (1991) suggested that the cost per quality adjusted lifeyear gamed for the care of low birthweight infants is comparable to those of otherservices, such as screening and adult medicine. Darlow also asserted that the cost of non-survivors in New Zealand is low, because such infants tend to die quickly (80% of verylow birthweight non-survivors in Christchurch die within 48 hours).

As found overseas (Marshall et al. 1989), by far the main cost of newborn intensive andspecial care is nursing staff salaries. The Dunedin Newborn Intensive Care Unit (1992)estimated that nursing salaries accounted for 62% of the unit's current budget (excludingradiological tests). Costs of medical staff (15% estimate), non-salaried expenses such assupplies (8%), pharmacy items (6%), pathology services (5%) and capital replacement(4%) accounted for the remainder of the budget.

7.2 Cross boundary charging and diagnosis-related groups(DRG5)

Cross boundary charging is a specific funding issue of relevance to regionally organisedservices such as newborn care. Essentially, cross boundary charging in New Zealand isan adjustment made to population-based funding allocations. It takes into account theextra cost of treating people who are domiciled outside an area health board. Funding istransferred from the board of domicile to the board of treatment. The largest crossboundary flows occur towards the larger, regional centres which provide morespecialised services.

According to the Department of Health (pers. comm.), the current system involves areahealth boards charging one another using the Department's guidelines on the amountthey charge. Area health boards sign contracts with each other in which they agree topay a bulk amount based on the previous year's patient flows. A later adjustment of upto 10% can then be made, depending on the actual number of patients treated. Theguidelines for charging are based on a cashflow model which is related to DRGs(diagnosis-related groups) and a per day allowance which weights for long stay patients.

Staff interviewed for this review were asked if there were any problems with crossboundary charging when babies and/or their mothers are transferred between area healthboards. Their responses indicated there is a considerable confusion about the nature ofthe current system because the system has changed several times in the past few years.

In the future, a real (actual cost) charging system will probably be used by area healthboards, based on information from the RUS system. At present, RUS is not yet runningin some area health boards.

A few of those interviewed stated that cross boundary charging worked satisfactorily.Some of the clinical staff said they had nothing to do with the administration of crossboundary charging. In most hospitals, information on admissions was sent by the


newborn unit to the area health board office, which then dealt with charging from acentral board fund.

The main concerns of some interviewed staff were:

a perceived inadequacy of the DRG classification for infants in neonatal care.There is a limited number of DRGs which can be used because of the 1CD94classification groups. At one hospital, only about one third of infants were ableto be charged for because of the classification problem;

the existence of a standard charge per infant, independent of the length of theirhospital stay. Staff stated that the standard charge was inadequate to cover thecosts of care;

the perception of some level 111 unit staff that level H units were not transferringinfants because of cross boundary charging. This was thought to be contributingto deregionalisation of newborn services. However, most staff from the two levelH hospitals stated that the health of the infant was the only criterion used in thedecision to transfer or not to transfer. They said they tried not to send infants outof their region because of the disruption to families. They also believed that theycould safely treat these infants; and

uncertainty about whether any money came into or went out of the newborn unitbudget itself.

Interviewed staff suggested improvements to the current cross boundary charging system,including:

the introduction of an actual cost system. A few of the interviewed staffsuggested that there should be a ceiling on this charge. They believed this isneeded because an infant who had a very long stay could.cost a small area healthboard a significant proportion of its budget;

central co-ordination of funding, because newborn care is a national service. Thiswould encourage co-operation between area health boards; and

• the use of DRGs based on the new ICD10 classification, which may be moreuseful for cross boundary charging in newborn care. The lCD 10 classificationwill be introduced soon.

International Classification of Diseases (Clinical Modification) 9.

FINANCIAL ISSUES 71

An unpublished report (c.1980) to the Maternity Services Committee recommended that:

the additional costs of referral centres (with a level II or level ifi unit)be funded by some equitable means that, on the one hand, providesfairly for the extra costs of patients treated from outside the recipientboard's district, and on the other, does not deter the referring boardfrom seeking necessary help (pers. comm.)

The Auckland Area Health Board reported an example of how DRGs are used for crossboundary charging in the review of their neonatal services (1991). The DRGs andapproximate costs are shown in Table 7.2.

Table 7.2: DRGs used by Auckland Area Health Board for costingtreatment of out-of-board infants, 1990


The fact that DRG 387 (prematurity with major problems) cost $2,000 less than DRG388 (prematurity without major problems) may be an example of the difficulties of usinga DRG-related charging system. In this case, costs do not seem to relate to thesenorusness of the infants' condition. This could also reflect a problem with the RUScosting system.

Auckland Area Health Board (1991) also analysed the costs of treating out-of-boardinfants in 1990 (Table 7.3).


Table 7.3: Number of discharges, total days stay and total costs oftreating out-of-board infants, 1990

Area health boardNo. of babiesNo. of daysApprox. Total costs ($000)Northland 33489 287.0Bay of Plenty 5 147 39.0Waiora Waikato 12136 79.3Taranaki 4 53 27.5Manawatu-Wanganui 2 45 31.2Hawkes Bay 2 12 25.2Wellington 10126 94.8Tairawhiti 1 8 3.2Canterbury 3 25 18.0Otago 1 1 4.5Overseas/non NZ resident1 2 12.6TOTAL 741044 622.3


Cross boundary charging mainly occurred for infants who came from area health boardsadjacent to Northland and Waikato Area Health Boards (61% of infants). Most of theremainder came from other North Island boards.

The Fetal and Newborn Committee surveyed newborn units to investigate the effects ofcross boundary charging. From the survey:

It [was] clear that a significant proportion of babies transferred cannot becharged for. This means that the regional centres are not recovering fullcosts and this is putting them under great pressure. On the other hand, ifsmaller. centres did pay full costs this may exceed their present budget andperhaps influence them not to transfer an infant even if it clearly in theinfant's interests (Darlow 1991:8).

Darlow suggested a fairer system would be based on the number of days of intensive orspecial care.

Studies in the United States showed that federal DRG price rates were not predictive ofthe actual costs of neonatal intensive care. In one study (Resnick et al. 1986), onlybetween 9% and 56% of actual costs would have been covered by the DRG system. Inanother assessment (Phibbs et al. 1986), actual costs were from 97% to 708% more thanthe proposed DRG reimbursement levels.

Both studies suggested that a pricing system based on severity of illness was morepredictive of actual costs than using DRGs. Birthweight, the need for assisted

FINANCIAL ISSUES 73

ventilation, survival, multiple births and discharge to another hospital were identified asbetter predictors of costs.

Alternative ways of charging in New Zealand could be investigated further.

7.3 Other funding issues in New Zealand

Although interviewees were not specifically asked about funding issues other than crossboundary charging, several comments were made on other funding topics.

Several of those interviewed thought that there should have been a recent increase infunding for newborn units because of the recent increase in births and a higherproportion of extremely low birthweight infants. If in vitro fertilisation programmes arefunded as 'core services', further resources for newborn units would be necessarybecause of the high risk of low birthweight among the resulting infants.

The lack of capital for funding equipment in several hospitals has already beenmentioned in Section 5. As a result, equipment is not replaced, so that some newbornunits are having to use old equipment which is outdated and which breaks downfrequently. Voluntary funding has been used to buy new equipment in some centres suchas Taranaki Base, which has set up a trust fund.

Partial or total self funding for staff training outside the hospital and conferences wascommon among interviewed staff, particularly neonatal nurses, who often find it difficultto obtain subsidies from area health boards. This lack of funds for training nurses standsin contrast to the expenditure on nurses' salaries.

Financial support from area health boards for parents' accommodation, travel costs andfacilities within the newborn unit is variable throughout the country. Some area healthboards provide free accommodation for out-of-town mothers, whereas others chargearound $20-25 per night. Some also provide reimbursement for restricted travel costs.Most area health boards provide little financial support for out-of-town fathers to staywith their infants. These factors were cited as a major stress for families, particularly inplaces where funding for these purposes is muted.

Where no home care services are available, staff mentioned that the recent decrease infunding for Plunket nurses is a problem for parents of infants who have needed high-riskcare. For instance, in South Auckland, a loss of 17 nurses is anticipated. Staff expectedthis to have a negative impact on infants who require home care services.

Interviewed staff also thought funding for preventive programmes to decrease the risk ofneeding intensive or special care was important. For example, discouraging earlypregnancy and smoking during pregnancy can reduce the risk of low birthweight. The


South Auckland clinic for teenagers was cited as an example of a successful preventionstrategy.

Many interviewees believed that funding for follow-up and home care services is anessential part of the newborn services budget. Continued financial support from the areahealth board and government for the Parent Care Centre in Auckland was also seen asvital for the continued existance of the centre (see Section 5).

7.4 Overseas economic analyses

A large number of overseas economic analyses, such as cost-benefit and costeffectiveness studies, have examined intensive care of newborns in various birthweightgroups. They have shown that costs are inversely related to birthweight (examples areBoyle etal. 1983; John etal. 1983;. Phibbs etal. 1981; Tudehope etal. 1989; Walker etal. 1984; Yu etal. 1981). Cost-benefits are less favourable in lower birthweight infants.

There is considerable debate about the cost effectiveness of prevention programmes.Some authors have advocated preventing low birthweight as an effective and ethical wayof lowering the overall costs of newborn intensive care (Kuhse et al.; Schwartz 1989;Young and Stevenson 1990). However, others such as Storch (1990) believe that recenttechnological advances are already improving outcomes and lowering costs of care.Storch cited the examples of surfactant replacement, continuous oxygen monitoring (tominimise retinopathy) and the use of indomethacin and pancuronium (to limitintraventricular haemorrhage).

In summary, the main financial issues relating to newborn intensive and special care inNew Zealand are cross boundary charging, the appropriateness of DRGs and financialsupport for parents, associated services and equipment.

Section 8 Newborn services and the new healthsystem

This section explores issues relating to newborn care in the new health system. The latterwas outlined in Your Health and the Public Health, the 'Green and White Paper' (Upton1991). The introduction of regional health authorities (RHAs) and core services arediscussed, and the effect of interim charging is briefly described.

8.1 Regional health authorities (RHA5)As described in Section 2 of this report, four regional health authorities (RHAs) will beestablished in New Zealand by 1993. Their role will be to purchase health services forthe population in their area, determine which services are needed and contract providerswhich offer 'the best value for money' and innovative ways of providing services (Upton1991).

Those who were interviewed for this review were asked if they thought the new healthsystem would affect the country's neonatal care in any way. Several of the interviewees'responses related to RHAs. Most thought that there was the potential for RI-lAs tostrengthen regionalisation, which they saw as an advantage.

They based this opinion on the assumption that cross boundary charging would not occurwithin RHAs (see Section 7). Because there will be fewer RHAs than area health boards,there should be a reduced need to transfer infants outside RHA boundaries.Consequently, cross boundary charging between RHAs will become less common.However, infants will still have to be transferred to the national centres for someprocedures. The potential to establish integrated obstetric and neonatal services asCrown Health Enterprises was seen as viewed positively.

Conversely, respondents thought that there was potential for the new system to create amore fragmented system if there were a large number of providers and funders ofnewborn care. They saw this as a negative situation, as it would tend to deregionalisenewborn care. The effect of competition between two level ifi units within one RHAwas considered hard to predict. Several interviewees mentioned the possibility thatquality of care could be compromised by competition.

Overall, those interviewed were unsure about the overall impact of the new healthstructure on newborn care.

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Stahlman (1991) described the situation in the United States where 'deregionalisation' ofhigh-risk newborn care has started:

[Deregionalization has been] brought about by an over-abundant numberof trainees flocking into an exciting new field, the realization by hospitaladministrators that newborn intensive care can be profitable for thehospital and the willingness of third-party payers to pay both hospitals andphysicians for high-risk care.

Private hospitals have chosen to leave the network and rely on their ownfacilities and personnel for this highly visible service. The consequence,in many instances, is the skimming off of paying and insured patients,leaving the regional centre, usually a university teaching hospital, to carefor the uninsured, the poor, and the highest-risk and most costly patients...

This has some relevance to the future system in New Zealand.

8.2 Core services

Core services were defined in the 'Green and White Paper' as being:

The acceptable minimum range of health services which Regional HealthAuthorities and health care plans will have to provide for their clients.This will provide certainty so that all New Zealanders will have access toa guaranteed core of services, no matter where they live or what theircircumstances, and whether they are enrolled with a Regional HealthAuthority or with a health care plan (Upton 1991:15 1).

Staff interviewed for this review were asked what aspects of neonatal intensive careshould be 'core services'. Most were aware of the concept of core services, and somehad sent submissions on how 'core services' should be chosen.

A large majority of interviewees said that all the currently provided newborn intensivecare services should be 'core services'. They said that guidelines are already followed onwhich infants to treat/not to treat. Many interviewees opposed any kind of criteria lists,although some did not object if there were guidelines only, rather than absolute rules.

An exclusive list, rather than an inclusive list, was usually supported by the minority whodid not oppose the idea of having a list of criteria. However, most interviewees felt thatdevising criteria based on birthweight and/or gestational limits was inappropriate becauseof the variability of the condition of individual infants. The rapid improvements inoutcomes of newborn care, in terms of survival and quality of life of survivors, alsoprovides a problem for criteria lists. One group suggested that the lists should beregularly reviewed. They also thought it would be essential to revise criteria in response

NEWBORN SERVICES AND THE HEALTH SYSTEM 77

to submissions from clinicians at regular intervals, for example, because of rapid clinicaldevelopments.

One interviewee stated that core services should be defmed in terms of the quality ofservice, in addition to functional, economic and medical grounds. This issue stresses theimportance of equal access to the same service and the same quality of service.

One interviewee said:

The attempt to generalise and to produce something to fit every individualcase leads to the danger of treating every individual patient without all thefacts... The more you treat patients as generalisable objects as thoughthey're like products on a production line.., the more you're in danger oflosing essential flexibility. That doesn't mean you shouldn't try toprevent ineffective and pointless procedures - it doesn't justify badmedicine... [There is] a terrific danger, that if a baby doesn't meet thecriteria, parents (if they are knowledgeable enough) may say "I'll pay foranything over and above [what is provided as a core service]". Thiswould be inappropriate paying, and would be terribly dangerous - peoplecould buy themselves into bad medicine.

A few staff suggested that core services could be limited on birthweight and gestationalage, for example less than 500g and less than 24 weeks. The ad hoc national meeting(Special and Intensive Care Services for the Newborn in New Zealand 1991) describedthe usual practice as follows:

750g plus or 27 weeks plus =presumption to treat

DISCRETIONARY ZONE

Under 550g or under 24 weeks =presumption not to treat

One practical issue raised by interviewees was that infants' gestational age andbirthweight is often not precisely known, and that there is no time to find out before thedecision has to be made to treat, for example, to resuscitate.

Interviewees pointed out that some kind of service would still have to be offered toinfants who did not meet the criteria, that is, services for dying babies need to beprovided.

Suggestions on services which should be included on an inclusive list of newbornservices included follow-up and home care services and adequate resuscitation of infants'everywhere' - in all levels of obstetric service, including domiciliary.


Chalmers (1983:117) stated that in relation to allocating resources to neonatal intensivecare units:

What we need is a constant review process to try and achieve some harmonybetween:

technological advances and professional expertise;

legislation and legal responsibilities; and

ethical standards and community attitudes.

In addition, Upton (1991) stated that services should be at a cost the country can afford.

Kuhse et al. (1988:238) examined the allocation of resources in perinatal medicine.Discussing various ways to cut the costs of neonatal intensive care, the authors state:

An alternative would be to have a policy against treating any infant undera given birthweight. But simplistic, hard and fast rules are not what isrequired. They replace clinical assessment of individual cases by amechanical rule of thumb which would make egregious mistakes in bothdirections, denying treatment to babies who, though light, have goodprognoses, and giving it to some who meet the weight criterion but havetoo many other difficulties to be good prospects for healthy survival. Themost probable actual effect of a simple birthweight rule would be todecrease the proportion of babies recorded with a birthweight just below,and increase the proportion recorded just above, the stipulated figure.Birthweight alone is not an adequate measure...

Kuhse et al. proposed that criteria could be based on a scale which determined if aninfant was 'eligible' or 'ineligible' for neonatal intensive care unit treatment. Eligibilitycould be determined by automatic criteria, clinicians' recommendations or amultidisciplinary committee (which could include parents, ethicists and lay people).

8.3 Interim charging

Until core services are defined and a related funding system is devised, an interimcharging system is being used. The interim patient charging system, which wasintroduced in February 1992, includes a provision for a $50 a day charge for an in-patienthospital stay, up to an annual maximum of $500. There is an exemption to this chargefor infants up to 14 days after their birth. This 14 day criterion is based on maternitybenefit provisions, and the historical 14 day hospital stay of mothers after birth.Outpatients appointments also have associated charges. Families with Group 1 or 2

NEWBORN SERVICES AND THE HEALTH SYSTEM 79

Community Services Cards (regarded as indicating 'low' or 'moderate' incomes) areexempted from these charges (Group 1) or pay reduced charges (Group 2).

A significant number of those interviewed criticised this charging system (some wereinterviewed before the system came into effect, others were interviewed afterwards).They said that the 14 day criterion was 'inappropriate' or 'ridiculous' in relation tonewborn intensive care, because of the long average length of stay per infant. Severalexpressed concern that there would be pressure to send infants home as soon as possibleafter 14 days, and that this could be a disadvantage to their health.

Many believed that the system was unfair because parents did not choose to havepremature or low birthweight infants, and they were already under enough stress becauseof the critical nature of their infant's health and the financial burden of travel andaccommodation. One interviewee predicted that because only some parents of infants inneonatal intensive care will have to pay charges it could cause friction in such a close-knit group. Interviewees also suggested that outpatient charges would be likely to affectattendance for follow-up examinations. This was true in Hastings where, two weeksafter the system was introduced, several parents cancelled appointments because of thecharges. The interviewees were concerned about this, as follow-up is a preventivemeasure to diagnose neuro-developmental problems which could be very costly in thelong term if not treated. It is possible, but not certain, that the number of cancellationswill reduce as patients become used to paying charges.

Several other interviewees thought the charging system was morally wrong because theState had an obligation to provide free health care to children.

8.4 Gaining contracts

A few of the staff interviewed for this review mentioned issues relating to newborn unitsgaining contracts with RHAs in the future. The comments included:

new born services will have to market themselves in the future;

accreditation would give units a better chance of gaining contracts;

quality of care needs to be an important aspect of contracts; and

units which currently have poor facilities and equipment will be at a disadvantagewhen they apply for contracts.

Section 9 Recommendations

This section provides some recommendations for policy on New Zealand newbornintensive and special care services. These recommendations are based on informationfrom the literature review, interviewees' comments and the statistical analysis. Reasonsfor the recommendations are discussed.

9.1 Data collection

Recommendation 1:Comprehensive data on newborns should becollected in a consistent way by all obstetric andnewborn units throughout the country.

Recommendation 2:These data should be brought together in anational data base.

Recommendation 3:Nationally agreed definitions of newborn specialand intensive (and/or level II and level Ill) careshould be developed.

The major barrier to planning newborn intensive and special care services in NewZealand is the lack of basic information available on admissions, particularly at anational level. For example, although local newborn special and intensive care unitscollect data on the number of admissions to their own units, the nationally collected dataon the number of admissions are too unreliable to use.

It is essential that detailed information is collected by all units on variables such as placeof birth, birthweight, days stay, reasons for admission, days on treatment such asventilation and total parenteral nutrition, and outcomes (short and long term mortalityand morbidity).

Data should be collected on all newborns (not just those in special or intensive care) sothat valid rates of need for care, outcomes and projections can be calculated on apopulation basis. A link with obstetric data would enable risk factors and preventionmeasures to be evaluated and would also help to predict future needs for newborn specialand intensive care (Recommendation 1).

A national perinatal data base, such as the one already planned (National Working Partyon Perinatal information 1988), could meet these information needs. The main aim of

[80]

RECOMMENDATIONS 81

the data base should be to collect enough information to regularly monitor the healthstatus of newborns and the effectiveness and appropriateness of services. Input fromservice planners, epidemiologists and clinicians would be needed to ensure the usefulnessof the data (Recommendation 2).

Consistent definitions of newborn special and intensive care, possibly based ondependency levels of individual infants, would help in planning some aspects of newbornservices, for example, national planning for regionalising services and local planning forstaff and cot requirements (Recommendation 3).

9.2 Research and monitoring

Recommendation 4:Research and monitoring on infants needingspecial and intensive care services (and otherinfants) should be undertaken at a national level.

Recommendation 5:Research and policy development should beundertaken to investigate the increasingincidence of very low birthweight infants andidentify means of reducing the rates of low

- birthweight infants.

A national data base, as described above, would allow research on a large number oftopics relating to newborn care in New Zealand. Much of this research is essential beforefurther policy on newborn services can be developed. A national perinatal epidemiologyunit, such as the one already proposed, could provide the resources and impetus neededfor such research. Priorities for research include:

• international and local comparisons on long term and short term outcomes(mortality and morbidity). Comparisons should take into account variables suchas birthweight, congenital abnormalities and other medical conditions, such asrespiratory distress;

•

comprehensive needs assessments to help determine the regional allocation ofservices, including the number of cots provided;

•

identifying risk factors for low birthweight and other conditions with the potentialto reduce the need for intensive and special care;


• continuing evaluations of intensive and special care treatment, such as the recentsurfactant trial. Information from these medical research studies could be used toproduce national standards and protocols. Assessing services for infants afterthey leave special and intensive care, such as home care and long term follow-up,would also be valuable;

•economic research, such as cost-benefit analyses and cost-effectiveness studies, tohelp in planning the funding of newborn services; and

•ethical and social research on issues such as the allocation of resources fornewborn care.

Figure 3.4 demonstrates the increase in the survival rates of very low birthweight infants.This trend should be investigated and causal facotrs identified. The review by Morrell(1990) also indicated a rise in low birth weight infants as a percentage of live births.Morrell outlined some factors which appear to be associated with successful preventionprogrammes. The development and impact of prevention programmes which have beeninstituted in New Zealand require investigation.

9.3 Geographic distribution of newborn services/regionalisation

Recommendation 6:Regionalisation of newborn services shouldcontinue to be encouraqed.

Recommendation 7: Until accurate comparisons on local outcomescan be made, the current distribution of level liiservices should remain.

Recommendation 8:The current practices of some level II units inproviding advanced level Ill care should be morewidely documented and debated, and a nationalconsensus sought.

Recommendation 9:Consideration should be given to increasing thenumber of newborn intensive and special carecots.

Overseas literature and local opinion favour regional organisation of newborn services.However, regionalisation of level ifi care in New Zealand is not complete. Theintroduction of regional health authorities has the potential to assist in strengtheningregionalisation (Recommendation 5).

RECOMMENDATIONS 83

Because of the lack of local and national data on outcomes, conflicting results ofprevious studies, opinions of interviewees and problems of geographic distance, adecision to reduce the number of level ifi units (for example, in the South Island) shouldnot be made now. Once accurate outcome data are obtained and compared, thedistribution of level III services should be reassessed. Any future decision will have toweigh up the importance of clinical and social considerations (Recommendation 6).

Many of the interviewees were worried that the best possible outcomes were not beingachieved in New Zealand because some level H units are providing long term ventilationand are caring for very and extremely low birthweight infants. Some overseas and localdata supports this contention. However, the lack of outcome data and the fact that only aminority of level H units were visited for this review means that further discussion isrequired for policy purposes.

It may be possible to get a consensus between level II and level ifi unit staff throughoutthe country. For example, level H- units may agree on guidelines to ventilate only larger,less sick infants. The influence of the current cross boundary charging system ontransfer decisions also needs to be clarified. An agreement might be achieved, forexample, through a national meeting. If there is to be any change in treatment policies, itis essential that level II staff are involved in decision making (Recommendation 7).

Indications from overseas recommendations and interviewees' experiences are that NewZealand may be short of some intensive and special care cots. That some units stated thatthey run at very high occupancy rates supports this view.

Nevertheless, overseas guidelines on cot requirements (e.g., criteria based on populationnumbers or births) should not be accepted without question. Overseas criteria may notbe appropriate in this country, for example, some New Zealand mothers are more likelyto have low birthweight babies than others. Comprehensive data on variables such asoccupancy rates, dependency needs and risk factors are required for a proper evaluationof the ideal number and distribution of cots. Demographic projections and trends in thesurvival and proportion of very and extremely low birthweight infants should be takeninto account (Recommendation 8).


9.4 Core services

Recommendation 10:Because of the rapidly changing nature ofnewborn intensive care services andimprovements in outcomes, the definition of coreservices should be able to be updated at regularintervals.

Recommendation 11: Quality measures should be specified as integralto core newborn services, and therefore could beincluded in contracts.

Recommendation 12:Facilities, accommodation and travel for familiesshould be considered as essential aspects ofcore newborn services.

Recommendation 13:Retrieval and back-transport services should besDecif led as core newborn services.

Recommendation 14:Consideration should be given to include longterm follow-up and home care as core services.

Overseas economic studies have shown a decrease in cost-benefits with decreasingbirthweight. However, there was very little support from interviewees for excluding anycurrently available newborn services. Birthweight and/or gestational age may not beclinically, ethically or practically appropriate criteria for excluding services, except asguidelines only.

Neonatal medicine is developing rapidly, particularly in terms of outcomes and availabletreatments. Specifications of core services may need to changed frequently and thereshould be enough flexibility to allow this to occur (Recommendation 10).

Interviewees considered that the quality of newborn care is very important to healthoutcomes. One way to encourage quality maintenance in a competitive environmentwould be to include quality assurance measures in contracts between providers andfinders. Measures could include:

collecting data for local and national purposes;

monitoring local short and long term outcomes;

staff training and performance appraisal;

using and helping to update standard treatment protocols and guidelines;

RECOMMENDATIONS 85

seeking feedback on services from families;

developing local policy guidelines;

maintaining and replacing equipment regularly;

providing adequate diagnostic services; and

providing enough staff to maintain recommended staffing ratios(Recommendation 11).

Facilities provided within newborn units, such as rooms for families and visitors, breastfeeding and mothercraft, vary throughout the country. Accommodation and travelarrangements to support out-of-town families are also inconsistent between area healthboards and are a major cause of stress for families. Fathers and siblings are particularlypoorly catered for by many boards.

Newborn and special care services should address the needs of the whole family, not justthe sick infant. Parents need the opportunity to bond with their infant, mothers need tobe close by for breast feeding, and families need to learn how to look after their infant athome. One way to encourage providers to cater for these needs may be to specifyfacilities for families as core services (Recommendation 12).

Effective transport is essential in any regionally organised service. Access to all levels ofnewborn care should be available for the whole New Zealand population(Recommendation 13).

Some evidence exists that home care services reduce readmissions to newborn intensivecare. Long term follow-up services can detect neurodevelopmental disorders early, andthus help prevent more severe problems later on. New Zealand evaluations of theseservices could confirm their effectiveness (Recommendation 14).

9.5 Cross boundary charging

Recommendation 15: Serious consideration should be given to changingthe current diagnosis-related groups-based crossboundary charqinq system.

Overseas and local evidence suggests that a charging system based on diagnosis-relatedgroups is not ideal for newborn intensive care. The Department of Health and areahealth boards should consider introducing another cross boundary charging system, suchas an actual cost system (although sufficient information is not available in all hospitals


for this). The introduction of regional health authorities could decrease the extent of thisproblem in the future.

9.6 Replacing equipment

Recommendation 16:Resources to replace outdated equipment shouldbe a priority for crown health enterprises andregional health authorities.

Several newborn intensive care units have outdated equipment which frequently breaksdown. Other units have equipment which will need replacing very soon. Replacing thisequipment is an urgent priority.

9.7 Nurse training, conferences and research

Recommendation 17:Nursing staff should have improved access tooutside training, conferences and researchoDDortunities.

Most hospitals with level ifi newborn units provide good in-hospital training for nurses.However, compared with medical staff, neonatal nurses find it much more difficult togain support to go to conferences and to get outside (advanced) training. Considering thespecialist nature and intensity of neonatal nursing, such opportunities could improveoutcomes of care.

Similarly, an increase in nursing research in New Zealand could have a positive effect onneonatal care. Further investigation on whether the current system discourages thetransfer of infants to level ifi centres is needed.

9.8 New technology

Recommendation 18: Adequate funding should be provided for newtechnology which is proved to be effective innewborn intensive and special care.

Currently, treatment which has been proven overseas to be clinically and cost-effective isnot always accommodated for within newborn unit budgets. For example, a considerable

RECOMMENDATIONS 87

amount of evidence exists that surfactant replacement is effective in improving outcomesin certain infants. However, only temporary arrangements have been made by most unitsfor funding this treatment. A permanent financial allowance for surfactant treatmentshould be made, particularly by level ifi units.

Appendix

Table 1: Definitions of levels of neonatal care

Level 0MaternityGeneral practitioner unit not attached to a general hospital and withoutServicesimmediate cover by specialist obstetricians or paediatricians.Committee(1982)MinisterialMother and baby delivered elsewhere returning to local hospital.NeonatalHealthy baby, emphasis on parenting, bonding and breastfeeding.ServicesBasic Life Support for neonates available. Midwives, and/orWorkingmothercraft nurses and GP care. Experienced registered nurse inParty (1990)charge on each shift. Continuing nursing educational programs(level 1")available specific to the needs of the service. Quality assurance

activities. Interpreters.Level I

MaternityAttached to a general hospital, with all facilities for normal birth. UnitServicesattached to a general hospital, with facilities for casarean section, butCommitteeno specialist paediatric services.(1982)MinisterialAs "level 1", plus provision for good risk pregnancies and healthyNeonatalinfants of greater than 36 weeks gestation. Accredited medicalServicespractitioners in obstetrics and paediatrics. Has 24 hour access toWorkingmedical officer(s) on site or available within 10 minutes. Nursing unitParty (1990)manager. (Experience desirable for general ward.) Some nurses with(level 2")experience in neonatal or paediatric care and/or undertaking relevant

post basic studies. Structured periodic medical refresher program.Link with level 3 (lIb) or level 5 (III) unit.

AustralianProvide services primarily for uncomplicated maternity and newbornHealthpatients. The number of deliveries is insufficient to provide anMinisters'adequate economic base or the caseload for complex obstetric orAdvisoryneonatal care. Generally serves a population of healthy infants withCouncilgestations >35 weeks. Appropriate facilities and personnel must be(1990)available to provide initial care of the unanticipated 'at risk' neonate

until recovery or transport (only 2/3 of problems can be recognisedbefore labour and delivery). In metropolitan and suburban areas, suchservices should be encouraged to consolidate into larger units withinfewer hospitals. Level I units are necessary in relatively isolated orrural communities, but must be supported by consultation, referral andtransport channels for high-risk mothers and neonates.

1881

APPENDIX

Table 1 (continued)

Level IIMaternityHave specialist obstetric and paediatric services and cater for theServicesmajority of complicated obstetric problems and certain neonatalCommitteeproblems. In USA, 2,000 deliveries per year. Level II units have an(1982)active and formal relationship with a level Ill unit. Provide the same

services as a level I units plus:- Antenatal care (laboratory services to assess fetal and maternalwellbeing, diagnostic x-ray and ultrasound of the fetus). Antenatalinpatient beds must be available.- Care in labour and delivery - ability to undertake Caesarean sectionwithin 15 minutes in operating room close to delivery suite. Isolationfacilities. Management of cardiac arrest. 24 hour service foranaesthesia, blood bank, radiology, and clinical laboratory.- Postpartum and newborn care - ability to manage ill infants withcardiorespiratoty monitoring and short term assisted ventilation.

MinisterialLevel lIb As "level 2", plus manages moderate risk pregnancies.NeonatalSpecial care nursery with minimum of six beds. Management ofServicesbabies > 32 weeks gestation with minimal complications and smallWorkingbabies growing up. Facilities include humidicnbs, cardiorespiratoryParty (1990)monitoring, IV fluid therapy, tube feeds, and phototherapy.(level 3")Obstetricians and paediatricians on call 24 hours; accredited medical

practitioners or medical officer(s) on site. Nursing ratio of 1:4 cotsdesirable. Nursing unit manager. (At least 3 years experience inspecialty desirable). Access to clinical nurse specialist desirable.Some registered nurses with paediatric or neonatal/pennatal training.Established link with level 5 (III) unit. Allied health professionals andliaison psychiatry available. Formalised quality assurance program inplace.

Level Ila As level 3, plus provides short term assisted ventilator care(<6 hours) pending transfer. Special care nursery with minimum of 15beds. Accredited specialist physician (neonatal paediatrician)responsible for management of the Unit. Paediatric registrar on call

("Level 4")24 hours. A minimum of one registered nurse (preferably with post-basic qualifications) per shift. Link with level 5 (Ill) unit includesrotation of physicians/neonatologist(s).

AustralianGenerally located in larger urban/suburban hospitals with obstetricHealthservices. Provide services for complicated obstetric problems andMinisters'neonatal diseases. Provide special care area for neonates who areAdvisorymoderately ill. Serve a neonatal population which includes sickCouncilneonates born in that hospital as well as those transferred from(1990)adjacent rural hospitals and level I facilities. Normal nursery care of

term infants born within the hospital are available (as level I hospital).Appropriate facilities and availablity of obstetric and paediatricconsultants allow responsibility for care of most sick neonates withoutcomplex equipment, major personnel commitments or elaborateexpenditure, referring only those cases of a complex nature to a levelIll centre. Infants are generally >32 weeks gestation and >1,500gbirthweight.

89

90 A REVIEW OF NEWZEALAND NEWBORN INTENSIVE CARE SERVICES 1992

Table 1 (continued)

Level Ill (Regional centres)MaternityRegional centre responsible for the intensive and most intensive levelServicesof obstetric and newborn care.Committee1982

Regional centres serving 8,000-12,000 deliveries per year. Providecare for normal patients and for all complications, including a newbornintensive care unit with full facilities able to provide prolonged assistedventilation and total parenteral nutrition. Responsibilities are to wholeregion, specifically providing:- Consultation - a 24 hour telephone consultation service by specialistswho are familiar with other units in the region.- Transport of patients - emergency transport services for mothers andbabies with problems, before and after birth.- Education - most units will be associated with medical schools anduniversities and be actively involved in teaching medical and nursingstaff. There should be full provision for education without interferingwith service to patients. Level Ill units will be responsible forcontinuing and refresher education throughout the region.- Evaluation of functions and results - the regional centre will developa monitoring system in which all parts of the region must participate.- Research - regional centres have a special responsibility to carry outresearch.

MinisterialAs "level 4", plus manages high risk pregnancies. Provides for allNeonatalaspects of neonatal care including intensive care for the critically illServicesbaby and medium/long term ventilation and total parenteral nutrition.WorkingFull time neonatologist director. Neonatal intensive care trainedParty (1990)nursing staff. Access to clinical and diagnostic paediatric(level 5")subspecialties. Multi-disciplinary follow-up services provided. Role in

post-graduate medical and nursing education. Undertakes researchand evaluation.

AustralianSituated in major general, maternity or children's hospitals - usuallyHealthregional or State centres associated with universities. Most level IllMinisters'units have obstetrical services and take responsibility for managingAdvisorynormal pregnancies in their immediate area, and a high proportion ofCouncilthe high-risk pregnancies referred from the region/State. Provide(1990)neonatal care at all three levels: normal, special and intensive care.

Treat critically ill neonates from high risk population born in thathospital and those referred from levels I and II. Facilities are requiredto transport neonates from levels I and It units to level Ill units; and totransport consultants to level I and II units. Level Ill units co-ordinateeducation and conduct basic, clinical and operational research in theregion.

APPENDIX 91

Table 1 (continued)

Level IV (NationalMinisterialAs "level 5", and also provides neonatal surgery and care for complexNeonatalcongenital and metabolic diseases of the newborn. On site clinicalServicesand diagnostic paediatric subspecialty services. Has level 6 paediatricWorkingmedicine and level 6 paediatric surgery. Congenital malformation withParty (1990)a frequency of 1 in 2,500 or less should be treated in a level 6("level 6")paediatric surgery service. Commitment to clinical nurse specialist on

Sources: As stated in table


Table 2: New Zealand hospitals with neonatal units by unit level and areahealth board, 1991 - as stated by area health boards

Hospital Area health boardLevel ofneonatal

unitMiddlemore Auckland 3National Women'sAuckland 3Waikato Waikato 3Taranaki BaseTaranaki 3Hastings Hawkes Bay 3Wellington Wellington 3Christchurch Women'sCanterbury 3Dunedin Otago 3Northland BaseNorthland 2Rotorua Bay of Plenty 2Tauranga Bay of Plenty 2Whakatane Bay of Plenty 2Thames Waikato 2Napier Hawkes Bay 2Gisbome Tairawhiti 2Palmerston NorthManawatu/Wanganui2Wanganui ManawatuiWanganui2Hutt Wellington 2Masterton Wellington 2Nelson Base Nelson/Marlborough2Wairau Nelson/Marlborough2Timani Canterbury 2Southland Southland 2Bay of IslandsNorthland 1Kaitaia Northland 1Northshore Auckland 1Taumaranui Waikato 1Hawera Taranaki 1Dannevirke Manawatu/Wanganui1Grey West Coast 1Ashburton Canterbury 1Burwood Canterbury 1Balclutha Otago 1Oamaru Otago 1

Source: Data supplied by area health boards to the Department of Health

APPENDIX 93

Table 3: Indications for transfer of infants for special care in NewZealand (guidelines accompanying Obstetric Regulations 1975)

Definite need to Probable need totransfer transfer

Low birthweightUnder 2,000g 2,000-2,500gBirth asphyxiaSevere depression, e.g.Less severe

Apgar 6 or less at 5 depressionminutes with littleimprovement by 10minutes

Respiratory 1. Apnoea Other respiratoryproblems 2. Any cyanosis or distress, more than

grunting one hour3. Possibility of

meconium aspiration4. Other respiratory

distress, more than 2hours

Jaundice 1. Any within 24 hours1. Plasma bilirubin2. Any with other 170 micromol/l or

symptoms more within 48hours

2. Plasma bilirubin250 micromol/l ormore at any time

Gastro- 1. Bile stained vomiting1. No passage ofintestinal 2. Definite feeding meconium by 36problems problems e.g., hours

persistent vomiting 2. Less definite"gone off feeds" feeding problems,

3. Abdominal mass or e.g., vomitingdistension without bile or

4. Persisent fresh blood bloodin stools

Renal problemsFailure to pass urine inof 36 hours

Blood 1. Haemorrhage fromcord or other site

2. Evidence of bleedingtendency:haematemesis,melaena, haematuria,purpura

CardiovascularPersistent or recurrent1. Brief cyanosisproblems cyanosis 2. Cardiac murmur

with no otherproblem


Table 3 (continued)

CNS (central1. Convulsions 1. Irritabilitynervous 2. Unresponsiveness,2. Questionablesystem) limpness, lethargy under-problems responsivenessMalformationsCongenital anomalies

that may require earlytreatment

Infant of With any abnormal With no abnormaldiabetic motherfindings e.g., findings

hypoglycaemia,respiratory distress

Postmaturity With evidence ofgrowth retardation

Prolonged Over 24 hours with anyOver 24 hours, norupture of other suspicious featuressuspicious featuresmembranesMiscellaneous1. Inability to pass gastric1. Significant birth

tube in mucousy babytrauma2. Marked pallor 2. Non specific3. Undiagnosed change in

temperature instabilitybehaviour orcondition, "notlooking right"

Source: Maternity Services Committee (1982: Appendix II)

APPENDIX .95

Table 4: Numbers of liveborn infants by area health boards andbirthweight, 1990 (provisional data)

<500g5009-1000g-1500g-2000g-2500g-TotalNorthland 5813258122192351Auckland 35581212197001723218365Waikato 314376224157226079Bay of Plenty69314417235783840Tairawhiti 1201143847904Hawkes Bay329299623082447Taranaki 21011259017721910Manawatu/ 312194313936723888WanganuiWellington15303610428768817353Nelson 156165415251607West Coast023628486525Canterbury 326326821662866631Otago 11015249621872333Southland 256174717791856New Zealand80193339693122905649460089

Source: Data supplied by Health Statistical Services

Table 5: Percentage of liveborn infants in birthweight categories by areahealth boards, 1990 (provisional data)

<1000 1000-1499 1500-24992500+Northland 0.550.554.5194.39Auckland 0.510.665.0093.83Waikato 0.280.614.9894.13Bay of Plenty 0.390.815.6393.20Tairawhiti 0.330.005.9793.69Hawkes Bay 0.200.375.1194.32Taranaki 0.630.586.0292.77Manawatu/Wanganui0.390.494.6894.44Wellington 0.610.495.3293.59Nelson 0.370.374.3694.90West Coast 0.380.576.4892.57Canterbury 0.440.484.2894.80Otago 0.470.645.1493.74Southland 0.380.323.4595.85New Zealand 0.450.564.9694.02

Source: Calculated by author from data supplied by Health Statistical Services


Table 6: Numbers and percentages of live births by birthweight groups forNew Zealand, 1973-1990

<1000g-1000-1499g1500- 2499gYearNumbers% Numbers% Numbers%1973920.152640.4329344.8319741080.182550.4328264.761975960.172830.5026774.731976890.162090.3824424.431977860.162310.4324194.461978880.172420.4723244.551979900.172240.4323344.461980860.172420.4823294.611981990.192250.4424174.761982940.192220.4422644.5319831210.242710.5423364.631984940.182950.5723394.5319851320.252880.5624284.6919861560.302990.5725474.8219871760.323160.5727134.9119881930.343160.5526944.6819892050.353120.5328324.881990*2730.453390.5629834.96

* Provisional data

Sources:1973-1988Howie (1990)1989 and 1990Data supplied by Health Statistical Services

APPENDIX 97

Table 7: Numbers of neonatal deaths of liveborn infants 1978-88, bybirthweight categories

Year500-999g1000-1 499g1500-1999g 2000-2499g197865 81 49 30197970 55 29 39198055 48 35 32198158 41 36 24198259 45 35 28198375 48 20 28198453 30 22 28198560 28 23 31198672 34 13 26198764 27 21 23198872 34 15 26

Sources:1978-87Howie (1990)1988Data supplied by Health Statistical Services

Table 8: Percentage of survivors of liveborn infants 1978-88, bybirthweight categories

Year500-999g1000-1499g1500-1999g 2000-2499g197817.766.590.098.4197920.575.594.297.9198031.380.293.698.2198136.381.893.998.7198234.479.793.098.4198334.282.396.498.4198442.489.895.798.5198552.090.396.098.3198652.388.697.998.7198761.591.596.598.9198859.189.297.598.8

Sources:1978-87Howie (1990)1988Calculated from data supplied by Health Statistical

Services


Table 9: Quality assurance measures in visited newborn units

National Women's -

•Quality of service programmes just beginning - have set up a quality assurance group.

•Medical staff keep some data. Regular annual report has not been put together in thepast. Computer is being provided this year.

•Management report is produced - includes, for example, number of infants admitted.

•Medical training: includes education of paediatric registrars;only partial funding provided for conferences.

•Nursing training: full orientation course;run 6 module neonatal nurse course in conjunction with technicalinstitue;study days.

Regular training on CPR, fire, evacuation procudures, intravenous treatment for all staff.

Regular morbidity/mortality reviews, journal clubs, 'grand rounds'.

Protocols:one book on drugs;one book on equipment;all have been reviewed this year;have to have combined nursing/medical protocols.

Follow-up - a Child Development Unit exists to follow-up all infants born at NationalWomen's <1500g birthweight or with neurodevelopmental problems to about the age of41/2 years. Those with very high risk (<1 000g, broncho-pulmonary dysphasia, severeasphyxia) are seen by a paediatrician. The unit has 3 staff including a full-timedevelopmental psychologist and one paediatrician (1/10 time). The unit assesses thechildren using a comprehensive range of developmental tests. If any problems arefound, the children are referred to appropriate services, for example, neuro-developmental therapists or special education services. Because of lack of resources,there is currently a delay in getting special educational sevices. Outcomes aredocumented in regular reports.

APPENDIX 99

Middlemore

Quality assurance programme will be required in future.

•Data collection: Admissions and discharges book (manual system). Will havecomputerised system by June 1992.

•Medical training: opportunities to take part are restricted. Should be better in futurewith 'full time, dedicated services';consultants hope to work 2 months per year at National Women's tomaintain level Ill experience in the future;have 2 weeks per year study leave.

•Nursing training: 3 week orientation period - work through booklet with supervisor,ventilation training will be given in future;

take part in National Women's neonatal courses;

need a nurse educator.

•Annual reviews on nurses' performance - have CPA, fire evacuation procedures,intravenous therapy knowledge. Set own targets for management and clinicalperformance. Peer review every two months.

•Regular monthly mortality/morbidity meetings.

•Have protocols/guidelines for 'most' procedures which were all updated when they had anurse educator.

•Advantage of being a small unit is that they can implement QA requirements quickly.

•No follow-up service.


Waikato

•Have quality assurance programme, with special QA group co-ordinating activities,weekly administrative meeting which always includes QA issues.

•Have computerised medical and administrative databases.

•Produce reports on outcomes, admissions, staffing etc.

•Medical training: informal teaching of registrars, have orientation booklet for them,provide orientation teaching, check-list for skills registrars have learnt.Registrars will also be taught by nurse practitioners in future;informal ongoing education for consultants, talking with other cliniciansparticularly heldful, funding to go to conferences, reading, Fetal andNewborn Committee, audiotapes.

Nurse training:extensive. Have orientation course, basic course and are going to setup an advanced course with Polytechnic when 2 nurses have beentrained as nurse practitioners in Edmondton in 1992. Have studydays. Nurse practitioners will be particularly helpful at Waikato wherethe registrars are relatively inexperienced.

•Neonatal nursing conference held by Waikato for first time in New Zealand.

•Incident monitoring done.

•Protocols - are currently being standardised by QA group, so that they can be audited.Were all revised in 1990 Have separate nursing and medical protocols.

•Job descriptions prepared.

•Formal staff appraisals being introduced.

•Intend to perform audits on outside staff who work with infants from newborn units.

•Follow-up programme of infants <1 000g birthweight, severe asphyxia. Follows up to theage of 4 years.

•Have a parent information booklet.

•Have done consumer surveys to determine consumer satisfaction and have responded tosuggestions (e.g., provided a breastfeeding room).

•Hospital has consumer group, where any complaints can go.

APPENDIX 101

New Plymouth

Getting ready for accreditation.

Some medical statistics are kept and collated manally in an annual report. Medical andmanagement data will be computerised in the new unit (April 1992).

Nursing training: 6 week orientation course for level I and II care;

will have more regular ongoing training once new unit opened;

no funding for higher level training, for example, at Waikato - havesent staff there in past;

not many study days or much conference leave;

a lot of staff went to recent midwifery refresher course.

Medical training: junior staff get weekly tutorial session which is a teaching ward round.

Have pennatal mortality/morbidy meetings about 3-4 times a year. Also one every 1 or 2years in Stratford and Hawera.

Have recently written/updated all protocols - 2 large volumes which are organised bylevels of care. Asked around the country for standard protocols, but these did not exist,therefore had to compile their own. Some protocols are joint nursing/medical, others areseparate. There are plans to review the protocols again.

Hoping to make videos of some procedures.

Have photographs for parents of infants of different ages, and show parents around unitif it is known they will have a premature delivery. All antenatal classes are shown aroundunit.

Follow-up service consists of team including psychologist, neurodevelopmental therapist,paediatrician. Follow-up all infants with birthweight <1 500g and any others with specialneeds. Frequency of follow-up depends on need. If well, infants are seen annually up to5 years old.


Hastings

•No annual medical report - have plans to collate data but no resources to do so.

Manual records system (admissions book) plus some information (monthly statistics) forRUS.

•Have clinical meeting paediatric journal club every week, infant morbidity/mortality reviewevery 3 months.

•Nursing training: 3 week orientation programme, modified according to experience;

talks by nursing and medical staff about every 2 weeks.

•Use drug protocols from Waikato. Have protocols from procedures such as vitamintherapy, resuscitation, alimentation, ventilator use. Some protocols are medicalguidelines, others are in nursing protocol folder.

•Child development follow-up programme for infants from special care baby unit up to ageof 5 or 6 years to identify any problems. Do not regularly evaluate follow-up statistics.Staff include nurse, paediatricians and occupational therapists.

APPENDIX 103

Wellington

•Report on performance against budget, admissions, transfers.

•Difficult for medical staff to take study and conference leave because of shortage of staff.

•Nursing training: 6 week orientation course;

basic and intense phases of reorientaiton course;

post-graduate annual neonatal intensive care course for certification(30 day course;

ongoing in-service education.

•Nursing standards and staff retention have improved since nursing training increased.

•Provide training for Polytechnic nurses, ambulance officers, nurses from PalmerstonNorth, Blenheim, Masterton.

•Nurses have performance apprasials and remedial training if standards drop.

•Questionnaires for consumer feedback are given to parents on discharge.

•Monitor physical outcomes - bronchopulmonary dyoplasia, retrolental fibroplasia,intraventricular haemorrhage.

•Have protocols for all nursing care procedures which are 'constantly updated'. Have a-medical procedures manual - have trouble getting funding for printing this.


Christchurch Women's

•Annual report.

•Data 'inadequately' collected manually - no funding for computerisation. Somemanagement data are computerised.

•Do regular audits of outcomes.

•Submit monthly reports on staffing, budgeting, workload.

•Medical training: ongoing training for junior staff;university or hospital provides some funding for training.

• Hard for nurses to get post-graduate training because of inadequate funding - have toraise funds. Trying to start up introductory neonatal nursing course for current boardemployees instead of having to go outside the board for training.

•Have 6-8 week orientation programme. Formal teaching through Polytechnic (limitednumbers have attended).

•Have 4-5 manuals with nursing protocols - reviewed at least once a year.

Have medical handbook on medical treatment.

•No multidiscipinary follow-up, no developmemntal paediatrician, psychologist orphysician. Some follow-up from paediatricians.

APPENDIX 105

Dunedin

•Have neonatal data base which was established 4 years ago. Do not do regular annualreports from this because of lack of time and no data entry operator. Analysis of thedatabase will be one of tasks of research fellow who is starting work in June 1992.

•Produced a report to give information for this review.

•Have written policy and goals for the unit.

•Weekly policy round - consultants, ethicists, senior nurses, pharmacist. Research andrecord all policy changes.

•Combined weekly pennatal meeting with obstetricians.

•Weekly x-ray review.

Perinatal mortality review and pennatal mortality classification every 2 months.

•Annual review of survival rates.

•Have a .6 FTE nurse educator positon - one of her main roles is to implement qualityassurance programme.

•Nursing training: have orientation course;neonatal intensive care course (4 modules) which all permanent staffmembers undertake;have regular study days;journal articles and quizzes are put on notice board for all staff.

•Good support for nurses to go to conferences.

•Nursing standards are being rewritten so nurses have objectives to aim for

•Nursing protocols are currently being updated - a folder is kept in the unit.

Have staff development unit run by hospital.

•Follow-up - all infants with a birthweight <1 000g, or others at risk of developmentalproblems are routinely followed up by paediatrician at 6 weeks, 6 months and 1 year. Ifhave short term problems, seen by community nurse. If have chronic lung disease, seenby the apnoea nurse weekly and have regular oxygen monitoring at outpatients. Infantsare visited at home by developmental staff from Vera Hayward Clinic. Children agedover 1 year go to Vera Hayward Clinic. Physiotherapists and speech therapists are alsoavailable. Plan for Vera Hayward Clinic staff to visit infants while they are in newbornunit to get to know them.

Source: Interviews


Table 10: National Working Party's recommendations for 'management'data relating to infantsBirth

Abnormal delivery indicationApgar score - 1 mmApgar score - 5 mmDelivery methodFeeding typeGestation, completed weeksLocation of birth (home etc.)Order of birthOutcome of birthPresentation at deliveryResuscitation requiredTime of birthVitamin K administrationWeight at birth

Infant Birth

Birth dateBirth placeEthnic originFather IdMother IdName (surname and first)Normal GPSex

EssentialEssentialEssentialEssentialEssentialEssentialEssentialEssentialEssentialEssentialEssentialEssentialDesirableEssential

EssentialEssentialEssentialEssentialEssentialEssentialEssentialEssential

Infant Discharge

BCGCrown-heel lengthDiagnosis lCD code )for4Diagnosis lCD code) diagnosesDate of dischargeDays (completed) on oxygenDays (completed) on TPNDays (completed) on ventilationFollow-' up - eye clinicFollow-up - GPFollow-up - neonatal unitFollow-up - orthopaedic clinicFollow-up - plastic surgeryNeonatal blood spot

DesirableEssentialEssentialEssentialEssentialEssentialEssentialEssentialDesirableDesirableDesirableDesirableDesirableEssential

APPENDIX 107

Table 10 (continued)

Head circumferenceHepatitis B vaccineHip examinationJaundiceOn oxygen (V/N)On TPN (V/N)On ventilation (V/N)Operation lCD code 1) for 3Operation lCD text 1) operationsOutcome/destination at dischargeS.C.B.U. admission (V/N)

Infant Death

Death cause - for 4 causesDeath datePost mortem held

EssentialEssentialDesirableDesirableEssentialEssentialEssentialEssentialEssentialEssentialEssential

EssentialEssentialDesirable

Source: National Working Party on Perinatal Information 1988:45-47

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