Transport to tertiary facility

In order to maximize perinatal outcomes, delivery of preterm infants should occur at facilities capable of providing the appropriate level of neonatal resuscitative and supportive care commensurate with the gestational age. The American Academy of Pediatrics has recently redefined levels of neonatal care providing recommendations to ensure each newborn infant is delivered and cared for in a facility most appropriate for his or her needs, see Table 1: Levels of Neonatal Care. (Pediatrics, 2012) The importance of place of delivery is underscored by the improved survival of these neonates when delivered at tertiary care centers. (Cunningham et al., 2010)

Table 1: Levels of Neonatal Care

(Pediatrics 2012)

Level of Care Capabilities Health Care Provider Types
Level I Well newborn nursery • Provide neonatal resuscitation at every delivery
• Evaluate and provide postnatal care to stable term newborn infants
• Stabilize and provide care for infants born 35-37 weeks GA who remain physiologically stable
• Stabilize newborn infants who are ill and those born at < 35 wks gestation until transfer to a higher level of care
Pediatricians,
family physicians,
nurse practitioners,
and other advanced practice registered nurses
Level II Special Care nursery Level I capabilities plus:
• Provide care for infants born ≥ 32 wks GA and weighing ≥ 1500 g who have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis
• Provide care for infants convalescing after intensive care
• Provide mechanical ventilation for brief duration (<24 h) or continuous positive airway pressure or both
• Stabilize infants born before 32 wk gestation and weighing < 1500 g until transfer to a neonatal intensive care facility
Level I health care providers plus:
Pediatric hospitalists,
neonatologists,
and neonatal nurse practitioners
Level III NICU Level II capabilities plus:
• Provide sustained life support
• Provide comprehensive care for infants born < 32 wks GA and weighing < 1500 g and born at all GA and birth weights with critical illness
• Provide prompt and readily available access to a full range of pediatric medical subspecialists, and pediatric ophthalmologists
• Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled nitric oxide
• Perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI, and echocardiography
Level II health care providers plus:
Pediatric medical subspecialists, pediatric anesthesiologists,
pediatric surgeons, and
pediatric ophthalmologists
Level IV Regional NICU Level III capabilities plus:
• Located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions
• Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site
• Facilitate transport and provide outreach education
Level III health care providers plus:
Pediatric surgical subspecialists

 

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Hauth, J. C., Rouse, D. J., & Spong, C. Y. (2010). Williams Obstetrics (23rd ed.). New York, USA: McGraw-Hill.
Pediatrics, A. A. o. (2012). Levels of Neonatal Care. [Policy Statement]. Pediatrics, 130, 587-597.

Level I Well newborn nursery

Capabilities Provider Types
• Provide neonatal resuscitation at every delivery
• Evaluate and provide postnatal care to stable term newborn infants
• Stabilize and provide care for infants born 35-37 weeks GA who remain physiologically stable
• Stabilize newborn infants who are ill and those born at < 35 wks gestation until transfer to a higher level of care
Pediatricians,
family physicians,
nurse practitioners,
and other advanced practice registered nurses

Level II Special care nursery

Capabilities Provider Types
Level I capabilities plus:
• Provide care for infants born ≥ 32 wks GA and weighing ≥ 1500 g who have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis
• Provide care for infants convalescing after intensive care
• Provide mechanical ventilation for brief duration (<24 h) or continuous positive airway pressure or both
• Stabilize infants born before 32 wk gestation and weighing < 1500 g until transfer to a neonatal intensive care facility
Level I health care providers plus:
Pediatric hospitalists,
neonatologists,
and neonatal nurse practitioners

Level III NICU

Capabilities Provider Types
Level II capabilities plus:
• Provide sustained life support
• Provide comprehensive care for infants born < 32 wks GA and weighing < 1500 g and born at all GA and birth weights with critical illness
• Provide prompt and readily available access to a full range of pediatric medical subspecialists, and pediatric ophthalmologists
• Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled nitric oxide
• Perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI, and echocardiography
Level II health care providers plus:
Pediatric medical subspecialists, pediatric anesthesiologists,
pediatric surgeons, and
pediatric ophthalmologists

Level IV Regional NICU

Capabilities Provider Types
Level III capabilities plus:
• Located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions
• Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site
• Facilitate transport and provide outreach education
Level III health care providers plus:
Pediatric surgical subspecialists