This document provides guidance to managers and clinicians for the critical care management of neonates and babies requiring neonatal care during the COVID-19 pandemic.
The current state of COVID-19 in Australia remains at a critical point. Both federal and state governments have implemented strategies to help stop the spread of COVID-19. Neonates appear to be less commonly affected by COVID-19 than adults, however planning and preparedness for a neonatal intensive care unit (NICU) response to the management of neonates during the pandemic is essential.
It is expected that critical care services will experience a significant increase in demand for personnel, specialised equipment and beds in the event of a significant increase in presentations to our hospitals.
New South Wales (NSW) Health will continue to work with critical care service providers to monitor and proactively manage demand in intensive care units (ICUs), close observation units (COUs), paediatric intensive care units (PICUs), NICUs, special care nurseries (SCN) and medical retrieval services.
This document aligns to the principles identified in the strategic health plan for children, young people and families 2014–24.1
The purpose of this document is to provide guidance to managers and clinicians for the critical care management of newborn babies requiring neonatal care during the COVID-19 pandemic.
The goal is to maintain existing best practices for managing conditions that require NICU admission, while alerting clinicians and managers to the additional complexities and changes to practice that will be necessary, while working in the already established ‘Tiered Maternity and Neonatal Networks’.8 Acknowledging that while this advice is for neonates, mothers and babies are seen to be inextricably linked and will need to be considered.8
This document also aims to identify alternate strategies that should be considered during the COVID-19 pandemic, when existing resources are nearing or are at capacity.
This document aligns to existing NSW Health documents and is designed to complement these, while providing specific COVID-19 advice for NICUs at level 5 and level 6 neonatal services.2,3
Neonatal services in NSW provide special care, high dependency and intensive care beds across a variety of service levels and locations. This may be in a SCN looking after lower acuity babies, up to a dedicated ICU (NICU), which can provide extensive critical care services and retrieval for babies across the state.
NICUs are part of level 5 and level 6 neonatal services as defined by NSW role delineation.9
These services are available at John Hunter Children’s Hospital (JHCH), The Children’s Hospital Westmead (CHW) and Sydney Children’s Hospital Randwick (SCH).
These services are available at Liverpool, Nepean, Royal North Shore, Royal Hospital for Women, Westmead and Royal Prince Alfred.
While there are no NICUs located in private hospitals in NSW, there are special care nurseries attached to private hospitals.
Having oversight of the locations and capacity of these beds will be required if NICU capacity is reduced in public hospitals.
It is recommended that communication channels should be established and formalised between private and public hospital units for potential capacity.
While tertiary units will likely be well staffed and equipped for the pandemic, consideration will need to be given to supporting lower level units during times of increased activty.4
Currently there is no evidence to suggest there will be an increase in the demand for NICU or SCN beds for the management of COVID-19 positive babies.
During a pandemic, the established communication and coordination process should be utilised to coordinate the safe care of neonates and their mothers.
Facilities should have local processes for the consultation, escalation and transfer that is reflective of their service capabilities, which are already established.8 Level 5 and level 6 NICUs should facilitate a communication and coordination role for the state to ensure effective use of vital resources and meet the COVID-19 demand with an effective distribution of burden on units, while maintaining service delivery.
All patient movements at NICUs can be tracked by the patient flow portal (PFP).
Staff must update the PFP at least every four hours to ensure accurate information on current bed status is available across NSW.
Options for increasing NICU capacity is limited and the most logical option is to identify surge capacity.
During a pandemic-related surge it will be important that consistent decisions are made regarding both admission to NICU and continuing care when a meaningful recovery is unlikely, with the use of end of life plans where appropriate. It is important that the triage principles to maximise access to NICU are used for all potential admissions, not just infection-related admissions.
The ANZICS COVID-19 Guidelines recommend that admission to intensive care should reflect routine practice, be open and transparent, and incorporate a shared decision-making model, which includes the treating intensivist, other clinicians and the family. Similar principles should be considered for NICUs if overwhelmed in a pandemic situation.11
Telehealth should be considered to increase ICU capacity across NSW. Effective telehealth models of care could reduce patient transfers, keep neonates closer to home longer, and support medical, nursing and allied health staff in providing critical care to neonates who are assessed clinically appropriate for this model.
Rural and regional facilities have limited ventilation capacity and capability. With additional support, neonates could be managed in these facilities for a period of time. Any extended period would require significant workforce and equipment support.
These hospitals will need to develop operational plans as part of the Tiered Perinatal network, that specify the STEPs required to create capacity at higher level facilities. This includes staffing, location, equipment and procedures and guidelines.8
Telehealth could play an important role in preparing and supporting rural and regional sites.
All SCN and NICUs will need to be aware of the number of ventilators that are available in their service, including the number of transport ventilators and the types of patients the ventilators are capable of ventilating, maintenance cycles and availability of associated equipment and consumables.
NETS is the state-wide emergency service for medical retrieval of critically ill newborns, infants and children in NSW.
NETS should also review their current equipment, including incubators that would be required for managing an increase in demand for its services.
It will also be important to understand unit configurations and variables for specific clinical management eventualities.
The NSW Ministry of Health has provided advice on the management of newborn babies born to women with suspected or confirmed cases of COVID-19.5,
A baby born to a woman with suspected or confirmed COVID-19 is considered a close contact of the woman and will require precautions in the acute healthcare setting. This does not necessarily include separation and should be monitored on a case-by-case basis. The Ministry encourages a multidisciplinary approach to the management of babies that fall into this category.
If resuscitation of the baby is required, the team involved in the resuscitation must comprise of only the essential team managing the resuscitation, wearing appropriate PPE. Only essential equipment should be taken into the room, while other equipment should made available outside the room, and cleaned as appropriate.
SCNs should follow the
Guidance for neonatal services.
If babies require respiratory support, they should be managed in a single room or in a closed crib, two metres between babies. If transfer is required, NETS should be contacted.
Emergency departments will be required to manage babies with respiratory problems in line with existing COVID-19 protocols.
Other considerations for emergency departments will be the safe transportation of the neonates and babies through the hospital to the required neonatal or paediatric ward.
Currently, the time for returning results for COVID-19 tests varies. The requirement to expedite COVID-19 tests should be identified as urgent and communicated to the testing laboratory.
Neonates should be assessed and screened in line with the latest national recommendations for COVID-19.
If the patient is identified as ‘at risk’, they should be isolated and tested for COVID-19 until results confirm otherwise.
NETS should be informed of any changes in the physical access to hospitals due to COVID-19 strategies.
This section refers to newborn babies who require admission to a neonatal unit from the birth environment or postnatal ward.
A suspected or confirmed COVID-19 maternal infection is not itself an indication for the baby to be admitted to a neonatal unit.6
Local indications for admission to a NICU or SCN should be followed.
It is recommended that babies are cared for in closed incubators (humidicrib) and, when available, in a single room.
If necessary, areas 1 and 2 could be combined with physical distancing. A separate area is required for 3.
Mothers who have suspected or confirmed COVID-19 are not able to visit the neonatal unit.5
Where possible, mothers and babies will be kept together, especially in the immediate postnatal stage.
There are existing cross border arrangements and formal agreements for the management of neonates requiring access to a NICU.
The processes for activating these pathways should be reviewed to ensure there are minimal barriers to accessing the right people to initiate the transfers.12
There are multiple scenarios for consideration in relation to parents, carers and families in the NICU.
Each unit will have policies that cover these scenarios but they should be reviewed to ensure they align with current COVID-19 advice.
Information for families must align with current COVID-19 information.
The information should cover confirmed cases, suspected cases and close contacts.
Information should be displayed in a prominent place and available in multiple languages.
Neonatal units should be actively screening all visitors in addition to general facility screening (front entrance). This should include, as per NSW Health advice, anyone with flu-like symptoms, recent travel (including domestic travel due to community transmission), and close contact with a COVID-19 case.
NICU/SCN units are also encouraged to review current practice and consider how they can further eliminate or reduce opportunities for transmission.
All non-essential people should not enter NICU or SCN.
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Planning for surge capacity staffing will need to cover at least the next 72 hours and be reassessed daily, with monitoring for staff fatigue and stress, and include hospital or district and network strategies to mitigate these.
A team oriented approach should be considered during the pandemic if less experienced staff are assigned in the NICU to support skilled staff.7
If a unit has COVID-19 positive neonates or parent, NICUs and SCN should consider establishing two nursing teams to minimise cross infection during a shift. Typically, these teams are known as Team A and Team B.
The aim is to prevent teams from coming into contact with each other during the shift and while on breaks. Consideration will also need to be given to how staff access equipment, medication and other supplies so that the teams do not cross paths. Some medical teams have divided themselves into teams that will not mix at all during the pandemic.
While there is currently no evidence to suggest there will be an increase in the demand for NICU or SCN beds during the
COVID-19 pandemic, level 5 and 6 services should consider planning for a scenario of increased demand.
There will be a need to review and provide additional training to clinical staff managing COVID-19 infected patients and all other staff who will be near COVID-19 positive patients.
The Clinical Excellence Commission (CEC) and the Health Education and Training Institute (HETI) have resources to assist with staff education. These resources provide general advice, however there will be a requirement for units to provide unit specific material.
It is important to recognise that simulated training is essential for minimising infection and protecting staff.
Clinical Director and Project Officer from the Maternity and Neonatal Network