A Review of Out-of-hours Outpatient Neonatal Presentations to a Standalone Tertiary Neonatal Centre

S. Coyne1, L. Flynn1, M. McGovern1,2, J. Miletin1,3,4,5

1. Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.
2. Academic Department of Paediatrics, Trinity College, Dublin, Ireland.
3. Institute for the Care of Mother and Child, Prague, Czech Republic.
4. 3rd School of Medicine, Charles University, Prague, Czech Republic.
5. UCD School of Medicine and Medical Sciences, Dublin, Ireland.

Dear Editor,

Most large neonatology centres within Ireland provide an out-of-hours service to review neonates presenting from the community, though this service is rarely provided in maternity hospitals in continental Europe. Within Ireland there is rarely specific funding or additional staff available for these services. We present results of a study evaluating the nature of these out-of-hours presentations to our centre (Coombe Women and Infants University Hospital) and the timeliness of care provided.

A record of babies presenting out-of-hours to a tertiary neonatal centre from January-June 2018 was obtained from the hospital database. Sixty-five presentations were recorded and a retrospective chart review was performed. The ‘Review of Paediatric and Neonatology Services and Framework for Future Development – 2013’, and ‘A National Model of care for paediatric Healthcare Services in Ireland’ were used as reference standards for care provided 1, 2.

Most presentations were non-urgent with jaundice and feeding issues being the most common presentations representing 15/65 (23%) and 14/65 (21%) respectively. 

62% of presentations were self-referrals, 34% came on the advice of a healthcare professional and 4% were undocumented. In 14/65 (21.5%) cases nursing staff were unavailable to triage the patient upon arrival and vital signs were incomplete in 10/65 (15%) of cases. 

66% required no intervention and 85% of presentations were ultimately discharged directly home following assessment.10/65 (15%) patients were transferred to a paediatric hospital; nine of these were for suspected infectious issues and the remaining transfer was for failure to thrive. No infants were readmitted to our centre.

Triage quality and waiting times within our centre compared unfavourably to available standards 1, 2. The lack of specifically designated staff contributes heavily to delays as staff designated to attend to such external presentations are assigned to other clinical areas and are therefore not immediately free to review unplanned attendances. Many of the infants in our study would have been assigned to category 2 in a paediatric ED, mandating a medical review within 10 minutes of presentation. The average 50-minute delay in medical review which we recorded is therefore not meeting the needs of this population. 

Most of our presentations (98%) lived closer to a separate paediatric hospital but opted to travel a longer distance to attend our centre. This has important implications for the cohort of patients who are ill at presentation and require admission (15% of our infants) as these patients attended a service which is unable to provide definitive care despite being in closer proximity to a more appropriate centre.

We conclude that non-urgent presentations are frequent outside of routine hours and are usually self-referrals.  Most of these presentations require no medical intervention and could be seen routinely at the hospital ‘baby clinic’ or at the GP. Improved parental knowledge of available healthcare services may lessen presentations and improve health-seeking behaviours. Triage quality and time to medical review do not represent best-practice, indicating that there is a need to either invest further resources to improve the service or amend the way in which service currently operates.  

Corresponding Author
Dr Sheena Coyne,
Coombe Women and Infants University Hospital,
Cork Street,
Dublin
Email: scoyne@tcd.ie
Phone: +353 879206043

References

1. Neonatology NCPfPa. Review of Paediatric and Neonatology Services and Framework for Future Development: Clinical Strategy and Programmes Directorate, HSE, Royal College of Physicians of Ireland 2013 [Available from: https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/review-of-paediatric-and-neonatology-services-and-framework-for-future-development.pdf.
2. HSE. A National Model of care for paediatric Healthcare Services in Ireland: HSE, Ireland; 2016 [Available from: https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/model-of-care-for-paediatric-healthcare-executive-summary.pdf.

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