Storks

Sydney Children’s Hospitals Network (SCHN) in partnership with HealthShare NSW is developing a standardised service delivery model for the safe, timely and efficient transport of newborn babies to appointments and back, and to local hospitals.

View a poster from the Centre for Healthcare Redesign graduation, May 2018.

Aim

To reduce client complaints and patient incidents related to the transfer of newborn babies from specialist services to local services in the Greater Metropolitan Sydney Area, by 50 per cent by July 2018.

Benefits

• Provides safe, timely and efficient transfers for newborn babies in the Greater Metropolitan Sydney Area.
• Improves health outcomes of newborn babies in a Neonatal Intensive Care Unit (NICU) or Special Care Nursery (SCN).
• Meets the needs of parents and carers with newborn babies in a NICU or SCN.
• Minimises transport distance and delivers care as close to home as possible.
• Provides a statewide governance model to oversee non-critical newborn back transfers, transfer to medical appointments and special investigations in NSW.
• Improves NICU staff satisfaction due to safe and efficient transition of care.
• Aligns to the NSW Kids and Families Strategic Plan 2012-2017, SCHN Strategic Plan 2017-2022 and NSW Maternity and Neonatal Capability Framework.
• Aligns to HealthShare NSW Strategic Goals 2017-2020.

Background

Newborn babies who are inpatients at a NICU or SCN often require transfer to a hospital closer to home when they no longer need specialist care. In some cases, a transfer from the NICU or SCN to another facility for diagnostic appointments is also required. During these transfers, the baby either travels in a humidicrib or capsule. While these patients no longer need intensive care, transporting them remains a niche and specialised service, requiring appropriate coordination, equipment and trained clinicians.

Prior to the project, there was no clear pathway for the safe, timely and efficient transfer of newborn babies in the Greater Metropolitan Sydney Area. The Newborn and Paediatric Emergency Transport Service (NETS) ran a Return Transport Service trial for a period of 27 months from January 2013 to April 2015. During this time, a service was provided for NICUs returning inpatients to local SCNs. However, it was not considered financially viable as a long-term solution. During this time, more than 10 pieces of equipment including incubators were purchased locally by local health districts to transfer SCN inpatients to specialist appointments.

The introduction of the Ambulance Reform Plan 2012 established the HealthShare NSW Patient Transport Service (PTS). Non-emergency newborn transfers were not a consideration or included in the Ambulance Reform Plan. PTS began operations in May 2014. At the conclusion of the NETS trial in April 2015, no succession plan was put in place and the transfer of these patients sat with PTS as they were classified as non-emergency transfers. As such, one vehicle in the PTS fleet was retrofitted to carry out these transfers. The demand of these transfers across the Greater Metropolitan Sydney Area outweighed the capacity available. As PTS did not have a workforce to accommodate these patients, a NICU nurse was required to accompany babies on every transfer, increasing the costs associated with each transfer and reducing the efficiency of NICUs.

While PTS continued to respond to transfer requests, the clinical complexities of newborn transfers, lack of specialised equipment in the PTS fleet and appropriately trained staff meant the needs and expectations of parents, carers and NICU staff were not met. Between 2015 and 2017, there were 4415 booked transfers and only 2812 of these transfers were completed. An audit of transfers conducted in 2016 found that 54 (1.3 per cent of all bookings) resulted in Incident Information Management System (IIMS) notifications and complaints, not including those not entered into the system.

Between 2015 and 2017, PTS completed 2812 humidicrib transfers, including transferring babies to and from appointments, as well as to local hospitals following specialist care. That year, 210 humidicrib transfers were cancelled, with equipment failure or offline equipment one of the primary reasons for the cancellation. It was determined that identifying a standardised service delivery model for the Greater Metropolitan Sydney Area would provide safe, timely, efficient and cost-effective transfers for newborn babies.

Implementation

• A PTS audit was conducted in July 2017 to analyse transport data, cancellations, staff overtime and missed appointments.
• An audit of IIMS notifications and complaints regarding PTS newborn transfers was conducted in July 2017. This revealed that the main causes of complaints were:
  • poor timeliness of service
  • inadequate equipment
  • poor service of equipment
  • insufficient and/or inefficient staff education.
• A tour of NICUs and SCNs in Greater Metropolitan Sydney Area was undertaken from April to May 2017 along with interviews, surveys and meetings with nursing and medical staff to identify common problems with newborn transfers.
• Surveys with parents and carers was undertaken in June 2017, to identify their needs and the impact of PTS transfers on their family. One interview was filmed on camera with the parent’s permission and used in presentations, to demonstrate the impact of a successful transfer and highlight the need for an improved service.
• A process mapping workshop was held with PTS team members in June 2017, to understand the current state of scheduling and undertaking transfers.
• The diagnostic phase of the project identified a lack of policies and guidelines that determine how these transfers should be undertaken. As a result, there were safety concerns with practices that required urgent and immediate changes, as well as gaps in governance of the non-emergency transfer of newborn babies.
• An interim solution called ‘Baby Bus’ was implemented in March 2018. This involved allocating one vehicle for newborn transfers. This temporary, one-vehicle solution was designated for the transfer of newborn babies only, with dedicated staff chosen through an expression of interest in this type of transport. Staff were very well trained in the use of equipment, dealing with NICU staff and families in an empathetic and gentle manner. The allocation of this vehicle allowed for safe, timely and appropriate transfer of these patients.
• A consumer was invited to join the project steering committee in May 2017, to ensure parents and carers were involved in developing solutions. Unfortunately, due to their child’s illness, the consumer was unable to attend.
• Key staff were invited to an advisory day, held on 22 November 2017. The following topics were discussed and voted on using an electronic voting system:
  • equipment required during transfers
  • clinical status inclusion and exclusion
  • age of newborns suitable for transport
  • distance to travel
  • key performance indicators for transport arrival times
  • nursing staff required for transfer.
• A literature review was undertaken to inform evidence-based best practice. This was shared with staff prior to the advisory day and 95 per cent of staff stated they had read the document prior to attending.
• The project team is in the process of developing a policy framework, including a governance structure, which will be presented to the steering committee in April 2018. The policy will include a clear scope for patients and prescriptive equipment requirements to safely undertake these transfers.
• Once a policy framework has been established and published, it will be used to govern the implementation of a standardised service delivery model to undertake the transfers.

The following steps were undertaken to manage resistance throughout the project.

• Ensure the project team and sponsor understand the target group frame of reference.
• Clear and honest communication, with updates shared widely and regularly.
• Listening to concerns, addressing them and considering concerns raised.
• Avoiding unintentional increases in scope.
• Following through on commitments and providing feedback.
• Including resistant staff in appropriate working groups and meetings.
• Using questionnaires, process mapping, stakeholder meetings and parent stories.
• Using the Plan, Do, Study, Act cycle to test improvements on a small scale.
• Engaging senior leaders who are trustworthy, influential, respected and believed.
• Ensuring project goals are clear and shared.
• Assessing the ‘can do’ culture of each facility visited by the project team.
• Ensuring time is dedicated to identifying and managing resistance issues.
• Developing a win-win solution focus.
• Cultivating a safe reporting philosophy with a strong focus on problem solving and communication.
• Maintaining the focus on the case for change.
• Using family and patient stories to support and drive the change.

Status

Pre-implementation – Planning for the project is well underway. Clinician and consumer consultation has occurred but no solutions have been developed.

Dates

April 2017 – July 2018

Implementation sites

• All NICUs and SCNs in Greater Metropolitan Sydney Area
• HealthShare NSW Patient Transport Service

Partnerships

• Centre for Healthcare Redesign
• NSW Ambulance
• HealthShare NSW
• Illawarra Shoalhaven Local Health District
• Northern Sydney Local Heath District
• Nepean Blue Mountains Local Heath District
• South Eastern Sydney Local Heath District
• South Western Sydney Local Heath District
• Sydney Local Heath District
• Western Sydney Local Heath District
• Hunter New England Local Heath District
• ORH Consultancy

Evaluation

As of March 2018, the project has established strong relationships, trust and credibility. A full evaluation of the Baby Bus will be undertaken in 2018, measuring patient numbers, staff hours and overtime, number of pick-ups and drop-offs, and project costs. Preliminary data from one facility showed the Baby Bus was successful in reducing staff overtime by 50 per cent, and the timeliness of transport had improved. The following outcomes will be considered in the final evaluation:

• number of IIMS notifications and complaints related to newborn transfers
• number of successful inter-hospital and appointment transfers undertaken
• number of transfer cancellations and reasons for the cancellation
• number of appointments missed due to lack of appropriate transport
• clinical status of the newborn baby transferred from the NICU or SCN
• other key performance indicators as agreed by the steering committee.
• staff overtime and associated costs related to newborn transfers.

PTS and SCHN will work with the Ministry of Health to deliver and implement a NSW Health policy framework for this project and provide an options analysis for future service direction. The evaluation of Baby Bus in combination with adherence to statewide policy will inform future implementation.

Lessons learnt

• Communication is vital to the success of a project.
• Adequate time is required to build relationships with the project team, in addition to the time required to produce the project’s deliverables.
• The Centre for Healthcare Redesign framework is concise, efficient and valuable tool to follow.
• The use of patient stories is a very powerful way to engage stakeholders.
• Face-to-face meetings can enhance the development of the project.
• The diagnostic phase is valuable for setting the scene and understanding the problem.
• It’s important to document all processes to ensure consistency and maintain sustainability.
• Continued sponsor support is vital to maintain project momentum and ensure success.
• Commitment, open lines of communication and passion are necessary to sustain drive and energy for the project.
• Prioritisation of activities are a must when meeting deadlines.

Further reading

• Attar MA, Lang SW, Gates MR et al.  Back transport of neonates: effect on hospital length of stay. Journal of Perinatology 2005;25(11):731-36.
• Foo A. North Trent Neonatal Network Clinical Guideline. London UK: North Trent Neonatal Network; 2011.
• NSW Health. Inter-Facility Transfers of HNE Health Paediatric Patients. Clinical Guideline 13_20. Newcastle NSW: Hunter New England Local Health District; 2013.
• Kronforst KD. Interhospital Transport of the Neonatal Patient. Clinical Pediatric Emergency Medicine 2016:17(2):140-46.
• Saxon S, Simmons P, Harrison J. Planned Back Transfers. London UK: Southern West Midlands Newborn Network; 2010.
• Steven & Alexandra Cohen Children’s Medical Center of NY. Paediatric and Neonatal Transfer Guidelines. New York USA: Northwell Health; 2018.
• NHS Trust. Transfer of Neonates Standard Operating Procedure. Devon UK: North Devon Healthcare; 2017.

Contacts

Romana de Beer
Innovation Manager
NSW HealthShare Patient Transport Service
Phone: 02 9685 4585
romana.debeer@health.nsw.gov.au

Fionnuala Torrisi
Project Manager
The Sydney Children’s Hospitals Network
Phone: 0409 851 828
fionnuala.torrisi@health.nsw.gov.au