Hospital Transfers

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There have been some articles in the press in the past few days about women being transferred from one hospital - the one they were booked to give birth in - to a different hospital. See here and here.

Of course the women and families concerned are, well ... concerned. Any time a woman's birth plans are disrupted without notice, the situation can be stressful.

In one situation, a woman was transferred from Campbelltown Hospital in Sydney to John Hunter Hospital in Newcastle. She was in threatened premature labour with twins. The ambulance trip took three hours. This journey happened because there were no neonatal beds available in Sydney to care for these twins.

On the surface, this seems appalling ... a woman transferred by road, for three hours, carrying twins, with the possibility of delivering them in the ambulance! However, looking beneath the surface, the detail reveals that the care provided was appropriate. According to the media reports, the woman was only 26 weeks pregnant. This is called "extreme prematurity". In cases of premature babies, we have a task of matching their care needs to the right hospitals. We have hospitals of different levels. Some are only equipped to care for term babies, being those born after 37 weeks, while others can care for babies born after 34 weeks. And very few - only 8 across NSW and ACT- can care for babies as young as these twins were.

Caring for babies as young as these ones requires immense resources. Intensive care babyA specialised neonatal cot, sophisticated monitoring equipment, syringe drivers, 24/7 access to pathology and radiology, a neonatologist (this is a paediatrician who specialises in the care of newborn babies) and dedicated NICU nurses. These are specialised nurses who have completed additional graduate certificates and have extensive clinical experience. In smaller hospitals, the requirement of having these skilled and competent practitioners - as well as the purchasing and maintenance of equipment that is seldom used - would represent a significant cost inefficiency. The vast majority of babies are born at term, with a mere 0.7% babies born at - or prior to - 26 weeks.

The Health Minister, Jillian Skinner, advised that there were more than enough beds to cater for the State - and this is true. On average. Averages work well most of the time, but sometimes we need more beds than we have available, and this is when babies are transferred to another hospital. Sometimes this is as simple as transferring from say Canterbury Hospital to the near-by Royal Prince Alfred Hospital. Other times, rarely, babies are transferred further away, and even interstate. And other times - though this never reaches the news - there are very few babies in our neonatal intensive care units .... and the full complement of staff has very few babies to care for. Neonatal beds lie idle. This is never newsworthy but according to the law of averages, it happens as often as babies are transferred to another hospital.

Some have argued that the woman should have been able to birth her babies at Campbelltown and then move the mother and babies to another hospital. This situation is what we call an ex-utero transfer, where babies are transferred after they have been born. unfortunately this is always worse for the babies for a couple of reasons: first, the birthing hospital may not have the facilities, staff, equipment and expertise to care for the babies, and second, when the specialised team arrives to transfer the babies, this complex transfer takes hours just to set-up in the hospital because the babies need to be switched over to the helicopter equipment and stabilised before they can be moved. Having been involved in these situations, I know it can take hours and this is all time that the fragile and delicate babies are being disturbed. So for many reasons (more than I have listed here), it is far better to do an in-utero transfer - that is, transferring babies while they are still inside their mothers.

In this woman's case, her babies remained safe inside and were not born.

In another case, a woman was transferred in labour from a low-risk birth unit to a unit that handled higher-risk births when it became apparent that she had risk factors associated with her labour. This was a good call. A risk was anticipated that could not be dealt with at the local hospital, and the woman was safely moved to a unit that had the resources to provide safe care to her. This is no different to a woman moving from the birth centre to the delivery suite, or from a planned homebirth to hospital at any stage of the pregnancy or birth.

What's important is that the care that is provided is safe, and part of providing safe care is recognising the limitations of a service and having a good back-up plan or transfer plan. NSW has a specialised network that communicates well to advise all hospitals of which ones have available NICU beds. In this way, a midwife or doctor can quickly arrange a transfer. Likewise, a smaller hospital will be buddied with a nearby larger hospital with formal transfer plans and agreed indications for transfer, so that if a woman presents with something that is higher risk than what the smaller hospital can safely care for, the smaller hospital will have a plan in place to communicate with the larger hospital and to arrange a safe transfer.