How to handover in NICU

Neonates can be daunting for any paediatric trainee when they first start. The NICU is often the first intensive care environment a trainee may have experienced, and problems, physiology and size are just a few things that mark Neonates out from the rest of Paediatrics.

Knowing what to hand over can be challenging and, in part, relies on baseline knowledge that can take time to accumulate.

We know from multiple college reports that effective handover is key to patient safety; therefore, to help you get to grips with handing over the neonate, we have developed a simple structure that will allow you to carry out a safe handover with the essential information.

As you become more familiar with Neonates, you can build on this over time and add or take away what you feel is relevant to the patient.

Before you start: Safety brief

Before every handover, ensure to start with the Safety briefing. This helps create situational awareness, enables job prioritisation, and allocates roles. Broadly speaking, the following areas will be covered as shown above. While reading, reflect on your own unit and how they might conduct the Safety brief.

Staffing (e.g nurses, doctors)

Clarify who is on the long day/night/on for admissions (i.e. your essential staff, which you cannot do without). Has anyone phoned in sick? Are you aware of nursing shortages? Remember that admitting capacity depends partly on the number of staff as well as beds!

Bed availability

Flag up the number of beds available and if you are expecting any discharges later in the day. This will help with workforce planning, as you may allocate someone to oversee the discharge paperwork. If you are coming onto a night shift, then you may be expected to complete discharge paperwork to help flow throughout the day.

Sick patients on the unit

If there are multiple patients flagged as unstable, then this may affect how you divide your work, so it’s helpful information to have at handover.

Similar names (including twins!)

Safeguarding concerns

Safeguarding is present in all spheres of paediatrics, including neonatal care. Safeguarding concerns may relate to individuals not allowed onto the unit, using code words when relatives want updates over the phone, or if there are concerns about drug and alcohol abuse in parents.  

Procedures

Planned procedures in neonates typically include gaining further IV access, such as inserting a PICC line or umbilical lines, performing lumbar punctures, or taking a patient to a scan. As a paediatric trainee, have a look at your key capabilities and make a list of all the conditions you need signing off. Flag up at handover what procedures you would like to do, and if anyone could supervise you if required.  

Then start with your patients—you could either do this in bed order or hand over the sickest patient first. I prefer to hand over the sickest patient first, as you can go into more detail with them and give shorter, succinct summaries for the stable patients.

This article will focus on how to hand over the Neonate in the NICU. In part 2, we will cover The Neonate on Transitional Care/SCBU and The Newborn.

I used an SBAR (Situation, Background, Assessment, Recommendation) format, then included a systems-based assessment to ensure all organ systems are covered when handing over the critically ill neonate.

The Neonate in the NICU

Situation/Headliner:

Depending on how familiar your team is with the patient, this may be the only thing that you mention. The “Headliner” should give the listener a snapshot in time of this patient and their needs. Succinct headlines make information retention easier.

Information I like to include in the headline:

In Bed 4 is Bob Smith, born at 24 weeks and now corrected to 26+1, who is being treated for Line sepsis with vancomycin and flucloxacillin. He is currently intubated and ventilated. He is for full resuscitation.

If the team has never met the patient before, follow up the headliner with background, a complete systems assessment, and the outstanding jobs. For the familiar, follow up the headliner with any pertinent changes over the last 24 hours plus any outstanding jobs.

Background

This can be a challenging part of handover to gauge, as the patient’s background may be extensive, depending on the patient’s complexity and the duration of admission.

It can be tempting to list every diagnosis they have, or go into the minutia of how they were born; however, unless it’s going to add situational awareness to their current state, I would not mention it. Remember that your receiving team will be doing a ward round soon, during which all the background will be discussed or documented electronically.

If we look at Bob, then we might decide to include information about why he has a line in.

Bob has been TPN dependent since day 1 of life due to prematurity and having an emergency laparotomy on day 3 of life due to volvulus, which has led to short bowel syndrome.

Assessment/Clinical status

There are several ways to discuss this section. Some clinicians like to discuss things in a “Head to Toe” fashion (start with the head, eyes…) or take a systems approach, going through Airway, Breathing, Circulation, etc. Unlike in a typical SBAR, where “E” is “everything else”, all systems are considered separately.

I personally prefer the systems approach, which, although it can take a little getting used to, allows me to consider each system in detail so I don’t miss anything out. It also helps me when I assess the patient and make plans for them.  

Airway

Airway and Breathing are considered separately, especially if the neonate is intubated. Helpful information to convey includes the grade of airway (how easy it is to see their vocal cords—see the diagram below and the referenced article) and the size and length of the Endotracheal tube (ET) they have.

Mention whether the patient has been intubated for several days, including whether there have been any failed extubation attempts. This will tell you that the patient is dependent on their ET tube and would therefore need to be replaced quickly if it accidentally fell out (in neonates, uncuffed ET tubes are preferred and have been known to slip!).

A good habit is to review the CXR to see for yourself where the ET tube was positioned when it was first inserted. This becomes especially pertinent if you are called to review a desaturating, intubated patient in the middle of a shift, as a slight “displacement” of the ET tube can compromise oxygenation.

Respiratory

I personally believe respiratory status should be handed over regardless of the patient’s acuity. Respiratory support forms one of the mainstays of neonatal treatment, and our understanding around this topic has helped improve neonatal survival and morbidity over the years.

Bob is on Pressure control Volume Guarantee, with a total volume of 6ml/kg and needing pressures of 20/8. He is on 30% Oxygen.

Non-invasive support (NIV) can be considered a “step-down” from invasive ventilation and can help patients transition to breathing on their own in room air. Increasingly, we are putting premature infants straight onto CPAP and trying to avoid intubation by giving surfactant through Less Invasive means (LISA – Less Invasive Surfactant administration).

NIV can be provided via three main modes: bilevel support, which supports breathing in and out; CPAP, which provides constant pressure to keep alveoli open; and high-flow, which washes the dead space and airways with oxygen.

You may also want to mention here if the patient is receiving any medication to help their breathing, e.g. steroids as part of the DART regimen? Caffeine to help their respiratory drive? On nitric oxide to help reduce pulmonary hypertension?

Cardiovascular

Your interaction with the neonatal cardiovascular system will depend on the type of neonatal centre you work in.

If you work in surgical centres, you will be looking after patients born with congenital heart defects, which may or may not need IV prostaglandin to help keep the Ductus Arteriosus open (for example, hypoplastic arch, critical aortic stenosis).

Patent ductus arteriosus (PDA) is found in any neonatal centre and is more common with increasing prematurity. PDAs are important to know about if they are “haemodynamically significant” and may affect the patient’s ventilation (think of a left-to-right shunt flooding the lungs and causing them to be very wet). Treatment, if required, is medical or surgical.

Disability (i.e Neurological status)

A lot of information can be gleaned from the neonate’s neurological status. An alert, moving all four limbs, neonate who “handles well” is a well baby.

A floppy neonate is concerning and requires investigation. Neurological status is affected by gestation and can be formally assessed using the Ballard score.

Main concerns to handover regarding Disability include diagnoses such as Intraventricular haemorrhage (especially if Grade 3 or 4), hypoxic ischaemic brain injury (in which case knowing the birth history is important – see below), any seizures, and hypoglycaemia has been a problem. If the patient is floppy, do we have a reason? Has a hypotonia screen been started?

Exposure

I like to think of exposure in terms of skin and temperature. The integrity of the neonatal skin depends heavily on gestational age, with premature infants at greatest risk of skin barrier injury (Oranges et al. 2015).

Cannula dressings, ECG stickers, and tape from oxygen saturation monitors all cause skin burns.

The skin is so fragile at this point that it represents a major source of fluid loss, and temperature regulation is impaired; therefore, patients need to be kept in humid incubators. Temperature regulation may also be impaired if they are small for gestation, as they have less subcutaneous fat to retain heat.

An additional factor to bear in mind when looking at skin are pressure sores from CPAP masks and prongs. Skin breakdown over the bridge of the nose can be uncomfortable for the patient and limit the options for NIV.

Also consider bruising from sampling and the condition of the heels after multiple heel pricks.

Fluids and Feeding Status

The type of fluid required for a neonate will depend on their age, gestation and any underlying co-morbidities.

In Bob’s situation, he has been on TPN since day 1, most likely due to his gestation and his short gut, which has led to impaired absorption.

Neonatal nutrition is a massive topic. Familiarise yourself with your unit’s feeding policy and how many mls/kg they like to feed neonates according to their age and gestation. Get one of the nurses or dieticians to talk you through the feeds, as the options of enteral feeds are vast, including breast milk, fortified breast milk and formulas of various calorific density.

Finally, in fluids and feeding, I personally focus on urine output, electrolytes, and overall kidney function. It is not uncommon for neonates in the early stages of illness to drop their sodium and retain fluid due to SIADH, so it’s helpful to monitor sodium on blood gases.

Gastroenterology

The most common problem falling under Gastroenterology in a neonate is Jaundice. Especially if premature.

Become familiar with your local treatment threshold graphs (or use an electronic form, which may be found on your digital noting system) and what your unit’s policy is on Jaundice management. Handover when to check the next serum bilirubin (SBR) as this can help timing of other blood tests.

Other abdominal concerns will be partially influenced by the type of unit you are working in.

Necrotising Enterocolitis (NEC) can appear in any unit. Surgical units may deliver neonates with Gastroschisis, exomphalos and imperforate anuses who need defunctioning stomas..

Hand over any surgical plans or targets surgeons may have set, and let the team know if they need to contact the surgical team again for further support. If the patient is receiving treatment for NEC, then you might want to bring up the AXR during your handover to give an idea of the severity.

I tend not to mention bowels unless it’s a significant problem – for example, the patient hasn’t opened their bowels for a week, or stools were unusual – as the bedside nurse will give you a much more detailed history during the ward round.   

Haematology

Handing over Haematology reminds me to check FBC and Coagulation as anaemia and low platelets are common problems (with anaemia most likely caused iatrogenically).

Coagulation might be deranged if the patient is extremely sick and has developed DIC. Has the patient required any blood products? Are there coagulation concerns for which repeat bloods are required?

Infection

Infection is harder to identify in neonates as presentation is non-specific: The patient may be a little cooler, quieter, and floppier.

Remember that for neonates, a temperature above 37.5 degrees Celsius is considered a fever, and sepsis should be considered if the baby is cold (temperature below 36 degrees Celsius). Hand over any infection concerns, and if the patient is receiving treatment for sepsis, what antibiotic are they on? Do any drug levels need monitoring? Vancomycin and gentamicin are notorious for their monitoring requirements. Do any cultures need chasing?  

Lines

Lines in Neonates mainly consist of Umbilical lines (central lines), PICC lines and cannulas. For umbilical lines, mention how many days old they are, as we tend to switch to PICC lines as soon as possible.

Ophthalmology

Retinopathy of Prematurity (ROP) is a whole other topic which we will not cover in-depth here. To be brief, RCPCH recommend that all neonates less than 31 weeks gestation when born, and birth weight less than 1501g should be screened, with timing of exam dependent on age vs corrected gestation.

If they are having a ROP exam, do eye drops need to be prescribed to help dilate the eye? If known to have ROP, do they have lower oxygen targets?

Radiology

Beware of any imaging which needs requesting – e.g cranial USS and CXR, and if imaging showed significant findings, e.g. lobar collapse, dilated bowel loops, IVH on cranial USS.

Social

Social factors can be forgotten when doing a business handover; however, I would encourage you to think about the communication we have with parents and to ensure any concerns about parents are handed from one team to the next.

Perhaps parents are finding adjustment to NICU life difficult, and they need psychological support? Perhaps you spoke to them during your shift, and it’s clear they want to speak to the consultant to clarify what is going on? Are there any safeguarding concerns which may impact on who the neonate goes home with?

And finally…

Hand over any tasks that need completing or chasing. Mention any escalation plans should the patient become more unwell.

Last words…

The more you practice and take a lead on handover, the better you will become. As part of your core training, you will be assessed on Handover using the Handover Assessment Tool (HAT).

Below is a link to the RCPH website that explains what a HAT is and how it is marked.

I have also included a template for how someone might mark you—print it out and give it to your assessor to use as a marking sheet! If the unit allows (as we know how unpredictable NICU can be) then try to give yourself half an hour to get to grips with what you need to handover.

Update your list, chat through the events of the day with a colleague, and if there are any plans you don’t understand, ask your colleagues or consultant, who will be glad to help.

To help guide your learning and to think about what keywords to mention in your handover when talking about these conditions, I have made a little table of common conditions and grouped them according to the organ system they predominantly affect.

Resources

Conditions list:

HATs:

https://www.rcpch.ac.uk/resources/assessment-guide#handover-tool-hat

https://www.rcpch.ac.uk/sites/default/files/HAT_2017.pdf

References

Shires P, Harlow G, Holecova A. Fifteen-minute consultation: Airway management in the acutely unwell child requiring intubation for the general paediatrician. Archives of Disease in Childhood – Education and Practice 2023;108:29-37.

Skin Physiology of the Neonate and Infant: Clinical Implications. Teresa Oranges, Valentina Dini, and Marco Romanelli. Advances in Wound Care 2015 4:10, 587-595