Levels of dependency

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The Department of Health (DoH, 2009) and the British Association of Perinatal Medicine (BAPM, 2011) outline the four levels of dependency within neonatal care – transitional, special, high dependency and intensive care – relating to the level of support a neonate requires as well as the recommended staffing levels (nurse: patient ratio). Traditionally, neonatal units themselves have been classified according to levels.
A neonate can be admitted to any of these ‘levels’ or they may experience all of them during their neonatal unit stay. This can be illustrated by an example of a preterm neonate requiring respiratory support. The most preterm and/or sickest neonate is generally admitted to intensive care on day for full ventilation. Their subsequent journey through the neonatal unit then involves the progression to high dependency when their respiratory condition enables them to be extubated (endotracheal tube is removed) onto continuous positive airway pressure (CPAP), either standard or using biphasic pressure (2 levels). Thereafter the aim is for them to progress to special care where they may still require oxygen therapy and continuing support. As their need for support lessens and their condition improves, they may be able to wean off oxygen to be discharged home at an appropriate time or they may be discharged home on oxygen. The transition between hospital and home can take some time to fully prepare the family for discharge.

  • British Association of Perinatal Medicine (2011) BAPM http://www.bapm.org/publications/documents/guidelines/CatsofcarereportAug11.pdf

  • Dept. of Health (DoH; 2009) Toolkit for Neonatal Services http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/@sta/@perf/documents/digitalasset/dh_108435.pdf

INTENSIVE CARE This is care provided for neonates who are the most unwell or unstable and have the greatest needs in relation to staff skills and staff to patient ratios.

Definition of Intensive Care Day - Any day where a neonate receives any form of mechanical respiratory support via a tracheal tube

• Day of surgery (including laser therapy for Retinopathy of prematurity)

• Day of death

• Any day receiving any of the following

o Presence of an umbilical arterial line, umbilical venous line, peripheral arterial line, insulin infusion, chest drain, exchange transfusion, therapeutic hypothermia, Prostaglandin infusion, replogle tube, epidural catheter, silo for gastroschisis, external ventricular drain

HIGH DEPENDENCY CARE This is care provided for those who require highly skilled staff but where the ratio of nurse to patient is less than intensive care.

Definition of High Dependency Care Day - Any day where a neonate does not fulfil the criteria for intensive care where any of the following apply:

  • Any day receiving any form of non-invasive respiratory support (e.g. nasal CPAP, BIPAP)

  • Any day receiving any of the following:

o parenteral nutrition, continuous infusion of drugs (except prostaglandin &/or insulin), presence of a central venous or long line (PICC), tracheostomy, urethral or suprapubic catheter, trans-anastomotic tube following oesophageal atresia repair, nasal airway/nasal stent, observation of seizures / cerebral Function monitoring, barrier nursing, ventricular tap


General principle

Special care is provided for those who require additional care delivered by the

neonatal service but do not require either Intensive or High Dependency care.

Definition of Special Care Day - Any day where a neonate does not fulfil the criteria for intensive or high dependency care and requires any of the following:

o oxygen by nasal cannula, feeding by nasogastric, jejunal tube or gastrostomy, continuous physiological monitoring (excluding apnoea monitors only), care of a stoma, o presence of IV cannula, o baby receiving phototherapy, o special observation of physiological variables at least 4 hourly


General principle- Transitional care can be delivered in two service models, within a dedicated transitional care ward or within a postnatal ward. In either case the mother

must be resident with her neonate and providing care. Care above that needed

normally is provided by the mother with support from a midwife/healthcare

professional who needs no specialist neonatal training. Examples include low

birth-weight neonates, those who are on a stable reducing programme of opiate

withdrawal for Neonatal Abstinence Syndrome and those requiring a specific

treatment that can be administered on a post-natal ward, such as antibiotics or


| Julia Petty

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