NEO-SOP-005: Neonatal transfer to a higher level of care

Standard operating procedure (SOP) · NEO-SOP-005 · Version 0.1 · Draft for local review

Supports: 37.5

1. Purpose

To make sure a neonate who needs care at a higher level is transferred safely, at the right time, with the right team and equipment, and with a complete handover, so that the receiving team can continue care without a gap (37.5).

2. Scope

3. Definitions

4. Background

Transfers of sick neonates carry risks of hypothermia, hypoglycaemia, hypoxia, equipment failure and loss of information. Most transfer-related harm comes from delays in deciding, from unplanned transfers, from incomplete handovers and from poor preparation of equipment.

This SOP follows the principle that the receiving unit accepts the baby before transfer, and that the baby is stable and documented before departure.

5. Responsibilities

6. Materials and equipment

• Transport incubator, or transport cot with heat control, checked before each transfer.
• Portable ventilator, oxygen and suction, checked and charged.
• Infusion pumps and syringe drivers with the medicines needed for the journey, labelled and checked.
• Monitoring: heart rate, oxygen saturation, blood pressure and temperature, with spare batteries.
• Emergency equipment and drugs for the transport team, including resuscitation equipment sized for neonates.
• Transfer record, SBAR handover sheet, copies of the notes, the medicine chart and the parents' consent form.

7. Safety

Before any transfer, the baby must be stable enough to travel in the judgement of the transport team and the referring consultant. The baby is kept warm, the airway is secured, glucose and oxygen levels are checked, and the equipment is tested before the journey.

8. Before you start

1. Confirm the decision to transfer with the referring consultant and record the clinical reason.
2. Request acceptance from the receiving consultant. Record their name, the time of acceptance, the bed and the expected arrival time.
3. Check the baby's identity, the parents' identity and the consent for transfer.
4. Check that the transport team is available and that its equipment has been checked and recorded.

9. Procedure

9.1 Decision and acceptance

1. The referring consultant assesses the baby and decides on transfer, with the reason and the urgency recorded.
2. The referring team requests acceptance by telephone and, where the unit's system allows, in writing.
3. The receiving consultant accepts the baby and confirms the level of care, the bed, the team and the arrival time.
4. If no bed is available, the referring team asks the regional coordination service for an alternative unit, and records each request and response.

9.2 Preparation and stabilisation

1. Stabilise the baby, and record the baseline observations: heart rate, respiratory rate, oxygen saturation, blood pressure, temperature and blood glucose.
2. Secure the airway, the vascular access and the feeding route, and record the medicines given and the time of each.
3. Inform the parents about the transfer in person where possible. Explain the reason, the destination, how they can travel to the receiving unit, and who to call. Record their agreement.
4. Prepare the transfer record, the copy of the notes, the medicine chart, the imaging and the results.
5. The transport team checks the equipment and the battery levels, and confirms that the spare equipment is with them.

9.3 Journey

1. Check identity at departure against the identity band and the transfer record.
2. The transport team monitors the baby continuously and records observations at least every 15 minutes.
3. If the baby deteriorates, the transport team follows its emergency protocol and informs the receiving team immediately.
4. Keep the baby warm and avoid unnecessary handling. Record any problem during transport.

9.4 Arrival and handover

1. Identity is checked on arrival against the identity band and the transfer record.
2. The transport team gives an SBAR handover to the receiving team, covering the baby's diagnosis, the treatment given, the current status, the plan and the risks.
3. The receiving team repeats back the key points, and both teams sign the handover record.
4. The receiving team confirms arrival to the referring unit, and the referring unit records the time.

9.5 After transfer

1. The referring unit confirms the outcome of the transfer within 24 hours and records it.
2. The receiving unit informs the parents of the baby's arrival and the plan, and provides contact details.
3. Any problem during the transfer is recorded as an incident and reviewed under INC-SOP-001.

10. Decision points

11. Special situations

• Surgical transfers: the surgical team confirms the operating plan and the time before transfer, and the receiving team is informed of the surgical need.
• Maternal transfer with a baby still in the mother: follow the maternity transfer policy, and check that the baby's transfer and the mother's transfer are coordinated.
• Transfer of a baby on a ventilator or with a chest drain: the transport team must include a clinician trained in the equipment used.
• Transfer across a border or to a facility in another region: check the agreement, the licence and the consent process.

12. Escalation

• No acceptance within the time the unit sets: the consultant escalates to the medical director and the regional coordination service.
• Deterioration during transfer: the transport team follows its emergency protocol and informs the receiving consultant immediately.
• Serious incident during or after transfer: report under INC-SOP-001 and inform the unit manager within 24 hours.

13. Monitoring

The unit manager audits all transfers each quarter and reports to the neonatal governance meeting. The audit records the time from decision to acceptance, the time from acceptance to departure, the completeness of the handover record, and any adverse event.

14. Records

• Transfer decision and acceptance record, with names and times.
• Transfer record with observations, medicines and equipment.
• SBAR handover sheet, signed by both teams.
• Parents' information and consent record.
• Equipment check record for the transport team.
• Incident reports for any problem during transfer.

15. Training

Transport team members complete a neonatal transport course and a practical assessment at least every year. Referring and receiving staff complete training in the SBAR handover and the transfer procedure at induction and every two years, and take part in a transfer simulation at least once a year.

16. Related documents

17. Evidence

This SOP is based on the reference sources listed below, the requirement of criterion 37.5 of the ASF standards, and the national neonatal transfer agreements, which must be checked at each review.

E-learning for this document

• No course linked yet. Request a neonatal transfer and handover course from the academy (see the Standard 37 request list).

References

1. World Health Organization. Pocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. Second edition. 2013.
2. Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety. 2006.
3. National neonatal level of care criteria and national neonatal transport guidance (to be inserted by the unit at adoption).

Change history