Tiered Perinatal Network Operational Plan- South Eastern Local Health District and Illawarra Shoalhaven Local Health District

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Contents POLICY STATEMENT ...... 4 RESPONSIBILITY ...... 4 REVISION HISTORY ...... 5 LEGAL AND LEGISLATIVE REQUIREMENTS ...... 5 TIERED NETWORKS: ...... 6 SERVICE CAPABILITIES 2019 ...... 7 SOUTH EASTERN SYDNEY LOCAL HEALTH DISTRICT (SESLHD) ...... 8 Royal Hospital for Women: ...... 8 St George Hospital: ...... 9 The Sutherland Hospital: ...... 9 Sydney Eye Hospital; War Memorial Hospital; Prince of Wales Hospital; Calvary Healthcare, Garrawarra Centre and Gower Wilson (Lord Howe Island): ...... 10 Norfolk Island: ...... 10 PRIVATE HOSPITALS WITHIN SESLHD: ...... 10 Prince of Wales Private ...... 10 St George Private ...... 10 Hurstville Private ...... 11 Kareena Private ...... 11 ILLLAWARA SHAOLHAVEN LOCAL HEALTH DISTRICT (ISLHD): ...... 11 The Wollongong Hospital: ...... 11 Shoalhaven District Memorial Hospital: ...... 12 Milton Ulladulla Hospital: ...... 12 PRIVATE HOSPITALS WITHIN ISLHD: ...... 12 Wollongong Private ...... 12 NETWORK MATERNITY AND NEONATAL SERVICE CAPACITY ...... 13 TRANSFER PROCESSES ...... 14 1.1 In-Utero transfer to Royal Hospital for Women (RHW Level 6), Tiered Perinatal Network (TN) ...... 14 1.2 In-Utero transfer from St George / Wollongong Hospitals (Level 5) ...... 16 1.3 In- Utero transfer from The Sutherland Hospital (TSH) (Level 4) ...... 17 1.4 In- Utero transfer from Shoalhaven District Memorial Hospital (SDMH) (Level 3) ...... 18 1.5 In- Utero transfer from Milton - Ulladulla Hospital (Level 1) ...... 19 1.6 Transfer Process for Non - Birthing Services ...... 19 1.7 In-Utero transfer to Royal Hospital for Women (RHW Level 6) from Norfolk Island (NI) ...... 20 MATERNAL TRANSFERS DECISION MAKING TOOL INTERPRETATION ...... 23 2 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

CLINICAL PRESENTATIONS – Assessment of Risk: ...... 25 PATIENT FLOW PORTAL INTERHOSPITAL TRANSFERS: ...... 26 Maternal transfers- timing and mode of transport ...... 26 Entering maternal transfers onto the Patient Flow Portal (PFP) & transport arrangements ...... 26 TIERED NETWORK COMMUNICATION FOR TRANSFER: ...... 26 TIERED NETWORK DEMAND ACCESS ESCALATION (STEP) ...... 27 Introduction ...... 27 Core Roles and Responsibilities: ...... 28 STEP ESCALATION: ...... 29 RHW MATERNITY SERVICES ESCALATION MEASURE ...... 30 RHW NEONATAL SERVICES ESCALATION MEASURE ...... 32 ST GEORGE HOSPITAL STATUS & STRATEGY ...... 33 THE SUTHERLAND HOSPITAL STATUS & STRATEGY ...... 34 THE WOLLONGONG HOSPITAL STATUS & STRATEGY ...... 35 SHOALHAVEN DISTRICT MEMORIAL HOSPITAL STATUS & STRATEGY ...... 36 DATA AND REPORTING REQUIREMENTS ...... 37 APPENDIX ...... 38 TIERED FACILITIES AND CONTACT DETAILS ...... 38 TIERED FACILITIES AND CONTACT DETAILS ...... 38 MP1 - TIME CRITICAL TRANSFER TO ROYAL HOSPITAL FOR WOMEN (LEVEL 6 ...... 39 MP2 AND MP3 TRANSFERS TO ROYAL HOSPITAL FOR WOMEN (LEVEL 6)...... 40 MP1 TIME CRITICAL TRANSFER FROM ST GEORGE/ WOLLONGONG HOSPITAL (LEVEL 5) ...... 41 MP2 AND MP3 TRANSFERS FROM ST GEORGE/ WOLLONGONG HOSPITAL (LEVEL 5) ...... 42 MP1 - TIME CRITICAL TRANSFER FROM SHOALHAVEN DISTRICT MEMORIALHOSPITAL (LEVEL 3) ...... 45 MP2 AND MP3 TRANSFERS FROM THE SHOALHAVEN DISTRICT MEMORIAL HOSPITAL (LEVEL 3) ...... 46 NORFOLK ISLAND TRANSFERS TO SESLHD – RHW – time urgent ...... 47 NORFOLK ISLAND TRANSFERS TO SESLHD – RHW - non urgent ...... 48 FETAL FIBRONECTIN LEVELS AND RISK OF DELIVERY ...... 49 MATERNAL TRANSFERS CONSULTATION FORM ...... 51

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POLICY STATEMENT The operational plan provides a framework for safe patient flow and the management of maternal transfers within the Tiered Perinatal Network (Tiered Network) for South Eastern Sydney Local Health District (SESLHD)/ Illawarra Shoalhaven Local Health District (ISHLHD). The operational plan is a frame of reference for the provision of optimal maternity care where referral, consultation or transfer is required with the aim of having the woman in the right place at the right time. In situations of extreme demand, demand for beds may exceed capacity. This document outlines strategies to implement when beds are unavailable within the facility and processes to follow non-time urgent maternal patient transfers, when no capacity is available within Tiered Network

RESPONSIBILITY The operational plan will identify the specific responsibilities of each service in the Tiered Network. Higher level maternity and neonatal services have a responsibility to: • Provide consultation to clinicians at lower level facilities 24 / 7 as required • Support shared care arrangements for women and / or neonates when care can be provided at a lower level service with appropriate support • Accept referrals and / or transfers from networked services when higher level care is needed (including in time critical situations and/or when bed capacity is limited) • Take a leadership role in the Tiered Network including education and training; quality and safety; policy and guideline development; service planning and review; and bed management (working in collaboration with networked services to monitor bed capacity across the Tiered Network and negotiate with their networked services on bed management strategies when demand is nearing capacity).

Lower level services have a responsibility to accept referrals, transfers and return transfers from within the Tiered Network commensurate with their service capability. All services have a responsibility to provide care for women and/or neonates commensurate with their service capability and manage service demand within their capability. Each Tiered Network is ultimately responsible for managing the service demands of its catchment population. Requests for ‘out of network’ transfers must be made at obstetric consultant level to an alternate Level 6 Tiered Network. The Tiered Network Level 6 maternity obstetric consultant will work in collaboration with the lower level Maternity Services to coordinate a communication triage strategy and develop an agreed management plan. Such plans may include: • The mother remaining in a network facility for observation • The mother being transferred to an appropriate facility elsewhere within the Tiered Network • The mother being transferred to/ or remaining in the network level 5 or 6 facility irrespective of capacity, where the transfer is time critical or no other appropriate solution is available. • The mother being transferred to a facility in another Tiered Network • The Statewide Obstetric Consultant (SOC) can invoke the default protocol and mediate between L6 consultants if required, and controls final decision. Where appropriate, may involve the Executive on call in the transferring and / or receiving LHDs. 4 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

REVISION HISTORY Version Approved By Amendment Notes May - 2020 Revision and inclusion of GL2020_008, PD2020_014, GL2020_015, IB2020_015, IB2020_016. Inclusion of In-Utero transfer to Royal Hospital for Women from Norfolk Island - transfer process and flow chart Pages that have been updated include: • Page 5:Revision History • Page 5: Legal and Legislative Requirements (removed from page 33 old document and renamed) • Page 20/21 1.5 In-Utero transfer to Royal Hospital for Women (RHW Level 6) from Norfolk Island (NI) • Page 23: Maternal Transfers Decision Making Tool Interpretation • Page 37: Data and reporting Requirements • Page 47: Appendix 10: Norfolk Island Transfers to SESLHD- RHW – time urgent • Page 49:8 Appendix 11: Norfolk Island Transfers to SESLH- RHW – non urgent • Page 51: Updated form

November-2019 Endorsed by CE- New Operational Plan Tiered Perinatal Network SESLHD/ISLHD Operational Plan- 7 February 2020 SESLHD/ISLHD

LEGAL AND LEGISLATIVE REQUIREMENTS The contents of the Operational Plan need to be read in conjunction with: PD2020_008 Maternity - National Midwifery Guidelines for Consultation and Referral PD2020_014 Tiered Network Arrangements for Perinatal Care in NSW GL2020_009 Maternity - Management of Threatened Preterm Labour IB2020_015 Neonatal Consultation, Referral and Transfer Arrangements in Collaboration IB2020_016 Replacement of the Perinatal Advice Line with The Statewide Obstetric PD2018_011 NSW Critical Care Tertiary Referral Networks and Transfer of Care GL2016_018 NSW Maternity and Neonatal Service Capability Framework PD2020_015 Recognition and Management of Patients who are deteriorating PD2010_030 Critical Care Tertiary Referral Networks (Paediatrics)

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TIERED NETWORKS: There are 8 Tiered Perinatal Networks across the State, each Tiered Network, bar Westmead, is led by a Level 6 Birthing Unit which oversees and supports the maternity services within a number of associated LHDs. Each hospital within the network has responsibilities commensurate with their service capability. NETWORK LINKED LHD MATERNITY AND NEONATAL SERVICES AND FACILITIES WITHOUT PLANNED BIRTHING SERVICES (PUBLIC AND PRIVATE HOSPITALS WITHIN THE LHDs) Centenary Hospital for ACT Women and Children Southern NSW Murrumbidgee (noting parts of Murrumbidgee link with Victoria) John Hunter Hospital Hunter New England Mid North Coast Northern NSW (noting parts of Northern NSW link with Queensland) Liverpool Hospital South West Sydney Nepean Hospital Nepean Blue Mountains Western NSW Royal Hospital For South Eastern Sydney Women Illawarra Shoalhaven Royal Prince Alfred Sydney Far West (noting Far West links with South and Victoria) Royal North Shore Northern Sydney Central Coast Westmead Western Sydney

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SERVICE CAPABILITIES 2019 Maternity and Neonatal services are classified according to the GL2016_018 NSW Maternity and Neonatal Service Capability Framework. The framework is a rigorous tool for maternity service planning and risk management, supporting the provision of safe maternity care across NSW.

Each Maternity and Neonatal Service is assessed and assigned a Service Capability Level from 1 to 6. This is the basis for planned care, with the acknowledgement that unplanned emergencies can arise, and each service must have contingency plans in place for such situations. For example, a Level 1 Service may provide antenatal care to well women with low-risk pregnancies but have no planned birthing service whilst a Level 6 Service can provide care for unwell women with high risk pregnancies. A Level 6 Maternity Service must have access to a Tertiary Level Neonatal Service. Generally the Neonatal Service Capability is one level below the Maternity Service Capability. Thus a Level 4 Maternity Service may accompanied by a Level 3 Neonatal Service.

The risk categories in the Australian College of Midwives, National Midwifery Guidelines for Consultation and Referral1. When a variance from normal is identified during a woman’s care, the level of consultation requires one or more actions from across the following three categories:

• Category A- Discussion with a colleague (midwife, medical practitioner and/or other health care provider); and/or • Category B- Consultation with a medical practitioner and/or other health care provider; and/or • Category C- Referral of the woman or her infant to a medical practitioner for specialised care.

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SOUTH EASTERN SYDNEY LOCAL HEALTH DISTRICT (SESLHD) Provides health care to over 930,000 residents, from Sydney’s CBD to the outskirts of the southern suburbs. SESLHD has nine hospitals and a range of high-quality, community- based health care services. Sydney Eye Hospital; War Memorial Hospital; Prince of Wales Hospital; Royal Hospital for Women; St George Hospital; Calvary Healthcare; The Sutherland Hospital, Garrawarra Centre, Gower Wilson (Lord Howe Island), Norfolk Island and St Vincents Hospital

Royal Hospital for Women: The Royal Hospital for Women Sydney, as the only women’s hospital in NSW and with an international reputation, has a key role in the provision of women’s health care leading the way in fertility, preconception, obstetric medicine, birthing, neonatal care, , gynaecological oncology and breast care, especially with complex conditions. Each year we help deliver more than 3,700 babies; care for more than 600 premature babies; treat more than 400 women for gynaecological cancer; provide surgery for more than 80 women with breast cancer; attend to over 450 women requiring acute care services and help more than 600 women through endo-gynaecological procedures. Level 6 Maternity Service - Provides: • Providing consultation to clinicians at lower level facilities 24 / 7 as required • Supporting shared care arrangements for women and / or neonates when care can be provided at a lower level service with appropriate support • Accepting referrals and / or transfers from networked services when higher level care is needed (including in time critical situations and/or when bed capacity is limited) • Taking a leadership role in the Tiered Network including education and training; quality and safety; policy and guideline development; service planning and review; and bed management (working in collaboration with networked services to monitor bed capacity across the Tiered Network and negotiate with their networked services on bed management strategies when demand is nearing capacity). • Planned care for all women regardless of gestational age or clinical risk

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• State wide high risk pregnancy care • Complex specialist care including vaginal breech service • Complex specialist care • Complex major obstetric surgical procedures • There are both Obstetrician-led and Midwifery-led birthing models (MGP) available • On site dedicated adult acute care Close Observation Unit • Access to adult Intensive Care Unit (ICU) Level 6 Neonatal Service: 16 NICU cots; 28 SCN cots • Supra Local Health District role for neonatal care • Comprehensive neonatal care for all newborns, within a multidisciplinary management model (excluding surgical, cardiac and metabolic services) • Collaborative multidisciplinary care As for Level 5 Neonatal Service plus: • Specialist neonatal and neonatal surgical services to the whole of NSW • Access to care for complex congenital and metabolic diseases of the newborn (provides onsite or has links to specialist services). • Support for women with pregnancies with known fetal abnormality requiring consultation, treatment or surgery immediately following birth. St George Hospital: The St George Hospital and Health Services is part of the South Eastern Sydney Local Health District. It is an accredited, principal of the University of New South Wales and is not only the largest hospital within the Local Health District but is among the leading centres for trauma and emergency management in the State. The Hospital has a very high trauma load and accepts referrals from outside its immediate area. The hospital’s areas of special expertise also include cancer services, critical care, cardiothoracic surgery, mental health services and women’s and children’s health care. Level 5 + Maternity Service - Provides: • Planned care for women ≥ 32+0 weeks gestation with no additional fetal risk factors • There are both Obstetrician-led and Midwifery-led birthing models (MGP) available. • Planned care for those women identified as category A or B and the majority of women identified as category C

Level 4 Neonatal Service: – 12 SCN cots + 4 surge cots • Immediate newborn care for infants ≥ 32+0 weeks gestation where the mother: • Had no identified risk factors or was identified as Categories A or B • Was identified as category C (in consultation with the specialist obstetrician or maternal- fetal specialist within the Tiered Network) but did not require transfer for birth • Ongoing care for return transfers of preterm and convalescing infants of any weight no longer requiring higher level service ≥ 30 +0 weeks corrected age and considered stable by a Level 5 or 6 neonatal service

The Sutherland Hospital: The Sutherland Hospital and Community Health Service is located in the ('the Shire'), approximately half an hour drive south of 9 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

Sydney, in the suburb of . The Sutherland Hospital was established in 1958 and is a major metropolitan hospital and teaching hospital. The hospital motto, from its inception, is "Endeavour to Serve". We offer a comprehensive range of inpatient and outpatient healthcare services to the residents of the Sutherland Shire. We have 375 inpatient beds and each year we care for more than 50,000 patients in our Emergency Department and around 28,000 patients are admitted to our hospital Level 4 Maternity Service - Provides • Planned care for Women ≥ 34+0 weeks gestation with no identified risk factors or women identified as category A and B • There are both Obstetrician-led and Midwifery-led birthing models (MGP) available. • Planned care for some women identified as category C (in consultation with the specialist obstetrician or maternal-fetal medicine specialist within the Tiered Network) Level 3 Neonatal Service: 4 SCN cots + 3 surge cots + 1 resuscitation cot • Immediate newborn care for infants ≥ 34 +0 weeks gestation, where the mother: • Had no identified risk factors or was identified as Categories A or B • Was identified as a category C (in consultation with the specialist obstetrician or maternal-fetal specialist within the Tiered Network) but did not require transfer of care for birth • Ongoing care for return transfers of preterm and convalescing infants with a corrected gestation age ≥ 32+0 weeks. Newborns return transferred to a level 3 neonatal service should not require intensive care interventions Sydney Eye Hospital; War Memorial Hospital; Prince of Wales Hospital; Calvary Healthcare, Garrawarra Centre and Gower Wilson (Lord Howe Island): – Provides: • No Maternal or Neonatal Services Norfolk Island: Provides: • A holistic integrated Multi-Purpose Service (MPS) delivering safe, quality and person centered healthcare to their community. Norfolk Island Health and Residential Aged Care Service in Norfolk Island, 2899, offers the following services - Hospital, Aged Care Residential, Ambulance, Dental practitioner service, Emergency Department Services, Endocrinology Services, General Medicine, General Practice/GP (doctor), – antenatal and postnatal care and Gynaecology.

PRIVATE HOSPITALS WITHIN SESLHD: Prince of Wales Private; St George Private; Hurstville Private; Kareena Private- Licensing arrangements listed below however in practice these facilities do not have service capability for planned care below 34 weeks. Prince of Wales Private – licensed to: • Planned care for women ≥ 32+0 weeks gestation, those with no risk factors; • Immediate newborn care for infants ≥ 32+0 weeks gestation where the mother had no identified risk factors St George Private – licensed to:

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• Planned care for women ≥ 32+0 weeks gestation, those with no additional fetal risk factors • Immediate newborn care for infants ≥ 32+0 weeks gestation where the mother had no identified risk factors Hurstville Private – Licensed to: • Planned care for women ≥ 32+0 weeks gestation with no additional fetal risk factors • Immediate newborn care for infants ≥ 32+0 weeks gestation where the mother had no identified risk factors Kareena Private – Licensed to: • Planned care for women ≥ 32+0 weeks gestation with no additional fetal risk factors • Immediate newborn care for infants ≥ 32+0 weeks gestation where the mother had no identified risk factors

ILLLAWARA SHAOLHAVEN LOCAL HEALTH DISTRICT (ISLHD): Coledale Hospital; Bulli hospital; Wollongong; Port Kembla Hospital; Shellharbour Hospital; David Berry Hospital; Shoalhaven Hospital; Milton – Ulladulla Hospital.

The Wollongong Hospital: Level 5 Maternity Service - Provides: • Planned care for women ≥ 32+0 weeks gestation, those with no risk factors; • Planned care for those women identified as category A or B and the majority of women identified as category C

Level 4 Neonatal Service: – 12 SCN Cots • Immediate newborn care for infants ≥ 32+0 weeks gestation and not <1500grams • Ongoing care for return transfers of preterm and convalescing infants of any weight no longer requiring higher level service ≥ 30 +0 weeks corrected age and considered stable by a Level 5 or 6 neonatal service

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Shoalhaven District Memorial Hospital: Level 3 Maternity Service – Provides:

• Planned collaborative care for women ≥ 37+0 weeks gestation and < 42+0 weeks gestation with no identified risk factors or women identified as category A • Some women identified as category B following consultation and the development of a management plan with a suitably qualified clinician within the Tiered Network (eg. obstetrician, GP, endocrinologist, psychiatrist, dietician, physiotherapist).

Level 2 Neonatal Service: - 3 SCN cots + 1 Resuscitation cot Immediate newborn care for infants’ ≥ 37+0 weeks gestation where the mother:

• Had no identified risk factors or was identified as categories A or B following consultation and collaboration with a suitably qualified clinician in the Tiered Network Short term care for simple neonatal problems, for example: • Jaundice requiring single light phototherapy only • Hypoglycaemia treated with supplemental feeds (short-term intravenous dextrose infusions may be considered when under the supervision of a paediatrician or neonatologist at a higher role delineated service, with the understanding that transfer will be required if no improvement occurs) • Mild respiratory distress (oxygen requirements as determined by oximetry) that normalises within four hours post birth. Ongoing care for return transfers of preterm and the convalescing baby ≥ 35+0 weeks corrected age requiring minimal ongoing care.

Milton Ulladulla Hospital: Level 1 Maternity Service – Provides:

• Planned antenatal care with referrals to high risk doctor’s clinic as required. Shared care also provided with GPs at the woman’s request. • No planned intrapartum care. • Training provided so staff are able to manage unexpected presentations of women who are about to have imminent births and mothers and newborns following birth before arrival. • Postnatal care in the home provided following discharge home.

PRIVATE HOSPITALS WITHIN ISLHD: Wollongong Private - Provides: • Planned care for women ≥ 34+0 weeks gestation, those with no risk factors; • Immediate newborn care for infants ≥ 34+0 weeks gestation where the mother had no identified risk factors

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NETWORK MATERNITY AND NEONATAL SERVICE CAPACITY Facility Bed type Physical

Birth rooms 13 Assessment Chairs 3

Royal Hospital Recovery 5 for Women Close Observation Unit- Acute Care Ward 5 Postnatal Ward 40 Antenatal Ward 12 Well Baby Cots 57 Neonatal Intensive Care 16 Special Care Nursery 28 Birth rooms 8 Assessment room(s) 1+2 chairs St George Hospital Maternity Ward –Combined Postnatal/Antenatal 26 Ward Well Baby Cots 26 Special Care Nursery 12

The Sutherland Birth rooms 5 1Assesment Hospital Assessment room(s) 2 Maternity Ward – Combined Postnatal/Antenatal 15 Ward Well Baby Cots 15 Special Care Nursery 4 Birth rooms 7 Assessment room(s) 3 The Wollongong Hospital Maternity Ward –Combined Postnatal/Antenatal 28 Ward Well Baby Cots 28 Special Care Nursery 20 Shoalhaven Birth rooms 4 District Assessment room 1 Memorial Hospital Maternity Ward –Combined Postnatal/Antenatal 13 Ward Well Baby Cots 13 Special Care Nursery 4 13 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

TRANSFER PROCESSES 1.1 In-Utero transfer to Royal Hospital for Women (RHW Level 6), Tiered Perinatal Network (TN) • RHW is to provide support and advice to the TN facilities around consultation, referral and transfer for maternity patients. The RHW TN supports 5 public and 5 private facilities with maternity services. Non urgent (MP5) requests for maternal transfer: • Requests for non- urgent Maternal Fetal Medicine (MFM) referral can be made to the RHW “fetus phone” 0800-17:00 for an appointment in MFM on 0437 537 448 or 93826098. Fax copies of previous ultrasounds, consultations, relevant pathology and maternal blood group to 93826038.

Urgent (MP1-4) requests for maternal transfer: • The referring obstetric registrar and/or consultant at the referring site will review the woman and make an assessment regarding her risk of preterm delivery and her need for an ongoing high level of obstetric care in consultation with the Maternal Decision Making Tool. • The consultant at the referring site must authorise the transfer request. • MP1 and 4 cases will be accepted at RHW regardless of NICU capacity. • Registrars are not to be involved in bed finding

Coordination of maternal transfer: • All requests for transfer are to be coordinated through the RHW Access Demand Manager (ADM) / After Hours Nurse Manager (AHNM) on 0434 565 264/or phone 95651577- page 44020 who will undertake the ‘Transfer Coordinator role’ for the network as per the Tiered Network Operational Plan. • The obstetric consultant, registrar and transfer coordinator with the referring registrar or consultant are to be joined into a conference call immediately for all MP1 - time critical transfers which must be automatically accepted • Between 0700-2200 Mondays to Friday the ADM will host a conference call for all transfer requests with the obstetric consultant and registrar on duty for the birthing unit for advice on the need for transfer and urgency. • Between 2200 - 0700 hours the AHNM and registrar may accept a MP2-4 case if there is capacity at RHW and inform the obstetric consultant and team at morning handover unless consultation required overnight Clinical handover: • Following acceptance clinical handover should occur from the referring clinician to the RHW obstetric registrar and the patient details entered in the Patient Flow Portal (PFP) as an Inter Hospital Transfer (IHT) and pending admit. • Transfer Coordinator to confirm bed in the PFP/ IHT • All decisions for refusal of transfer must be made by both the RHW consultant obstetrician and the RHW consultant neonatologist on call.

Transfer out of RHW Network:

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Transfers from RHW to other Tiered Network level 6 Hospitals can only be requested by the consultant obstetrician and the consultant neonatologist. The RHW executive on call must be notified. • If the RHW obstetric consultant has indicated that transfer is appropriate for an MP2-3 case, this means that: o the woman cannot be accommodated at RHW o the obstetric consultant has indicated that there is time to safely transfer the woman out of the Tiered Network • Transfer Coordinator will: o use the PFP Neonatal and Birthing Unit Bed Status /Emergency Access View (EAV- Meave/Neave) report to identify available bed in the state: o conference call with the obstetric consultant and the destination facility. o notify the sending hospital of the agreed destination to arrange IHT, handover and arrange appropriate transport. Statewide Obstetric Consultant (SOC) advice: • Where an alternate destination within NSW cannot be identified the woman will be accepted at RHW (default protocol). Maternal transfers to JHH and Canberra should be avoided as much as possible to reduce the dislocation of the family unit. • The RHW obstetric consultant only may contact the SOC consultant for advice on clinically or logistically complex transfers on 1300 362 500 Transfer may not be appropriate in the following circumstances: • Maternal condition unstable (eg eclampsia, severe uncontrolled hypertension, haemorrhage) • Birth is imminent >26 weeks (eg fully dilated, rapidly progressing) • Significant fetal distress De-escalation of care: Referral and transfer from RHW to St George or Sutherland (including return transfers) when a woman and / or neonate no longer requires a higher level of care. Shared care: Where care can be provided at a lower level service with the support of a RHW and the St George Specialist Obstetrician

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1.2 In-Utero transfer from St George / Wollongong Hospitals (Level 5) In-utero transfers from St George / Wollongong Hospitals for women who do not meet the service categorisation for Level 5 care should be referred to the RHW as the Tiered Network level 6 hospital. Maternal Transfer process: • All transfers need to be discussed with the attending obstetric consultant • Consultant to consultant contact between level 5 and level 6 is desirable depending upon the time of day and clinical urgency; and essential in cases of clinical uncertainty, regarding safety to transfer, and where they may be disagreement between sites. • Ensure MUM BU or midwifery in-charge (after-hours) is aware of transfer • MUM BU/T/L to arrange MW escort • Assess for tocolysis/ steroids ( MgSO4 should not be infused during transfer) • MUM or in-charge to place woman on Patient Flow Portal (PFP) as a inter hospital transfer (IHT) • Consideration of risk of delivery en route – this may require repeat vaginal examination prior to transfer • Ensure appropriate copy of clinical records are sent to RHW • Organisation of transport: transport will vary dependent on urgency and may be provided by state-wide services such as NSW Ambulance Service, and other Patient Transport Services (PTS) and NETS for out born baby transfer • Inform PFU Neonatal exclusion criteria for care at St George/ Wollongong Hospital: • EFW <1800g (St George) EFW <1500g (Wollongong) • Gestational Age <32 weeks gestation • Fetal morbidity requiring delivery at tertiary centre • Special Care Nursery (SCN) at capacity • 23+0-25+6 gestation when imminent birth is likely • 23+0-31+6 with progressive cervical dilation >3cm • Deteriorating fetal or maternal condition where urgent birth is required Transfer is contraindicated in the following circumstances: • Maternal condition unstable (eg eclampsia, severe uncontrolled hypertension, haemorrhage) • Birth is imminent >26 weeks (eg fully dilated, rapidly progressing) • Significant fetal distress De-escalation of care: Referral and transfer from St George/ Wollongong Hospital (including return transfers) when a woman and / or neonate no longer requires a higher level of care. Shared care: Where care can be provided at a lower level service with the support of RHW and the St George/ Wollongong Specialist Obstetrician

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1.3 In- Utero transfer from The Sutherland Hospital (TSH) (Level 4) In-utero transfers from TSH for women who do not meet the service categorisation for Level 4 care should be referred to the St George/ Wollongong/RHW as the Tiered Network level 5/6 hospitals. Maternal Transfer Process: • All transfers need to be discussed with the attending obstetric consultant at TSH • Consultant to consultant contact between Level 4 and Level 5 or Level 6 is desirable depending upon the time of day and clinical urgency; and essential in cases of clinical uncertainty, uncertainty regarding safety to transfer, and where they may be disagreement between sites. • Ensure MUM Birthing Services or midwifery in-charge (after-hours) is aware of transfer • Arrange MW escort • Assess for tocolysis/ steroids (MgSO4 should not be infused during transfer) • MUM or in-charge to place woman on Patient Flow Portal (PFP) as a inter hospital transfer (IHT) • Consideration of risk of delivery en route – this may require repeat vaginal examination prior to transfer • Ensure appropriate copy of clinical records are sent to the receiving facility • Organisation of transport: transport will vary dependent on urgency and may be provided by state-wide services such as NSW Ambulance Service, and other Patient Transport Services (PTS) and NETS for out born baby transfer • Inform PFU Transfer to St George/ Wollongong Hospitals is indicated if: • Delivery is not imminent • Gestational Age <34weeks gestation • Special Care Nursery (SCN) unable to accommodate due to workload • At the discretion of the paediatric and SCN team • The obstetric and paediatric consultants should be involved in decisions to transfer Transfer to RHW is indicated if: • Delivery is not imminent • EFW <1800g (St George) EFW ,1500g (Wollongong) • Gestational Age <32 weeks gestation • Fetal conditions requiring delivery at tertiary centre • At the discretion of the paediatric and SCN team • In the event of uncertainty regarding whether referral to the Fetal Maternal Centre (FMC) St George Hospital or referral to MFM at the RHW is the most appropriate pathway. Advice should be sought (during business hours) from the: o FMC Obstetrician at St George Hospital via the Genetics Department on 91133635 o Department of Maternal-Fetal Medicine at the RHW on 93826098. Transfer is contraindicated in the following circumstances: • Maternal condition unstable (eg eclampsia, severe uncontrolled hypertension, haemorrhage) • Birth is imminent >26 weeks (eg fully dilated, rapidly progressing) • Significant fetal distress De-escalation of care: Referral and acceptance of return transfers from TSH to SDMH when a woman and / or neonate no longer requires a higher level of care. Shared care: Where care can be provided at a lower level service with the support of a RHW and the St George Specialist Obstetrician 17 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

1.4 In- Utero transfer from Shoalhaven District Memorial Hospital (SDMH) (Level 3) In-utero transfers from SDMH should be referred to Wollongong Hospital within the ISLHD or The Sutherland Hospital, St George Hospital or Royal Hospital for Women in SESLHD, Tiered Network unless their nursery criteria are not met Maternal Transfer Process: • All transfers need to be discussed with the attending obstetric consultant at SDMH • Consultant to consultant contact between TWH, TSH, St George or RHW is desirable depending upon the time of day and clinical urgency; and essential in cases of clinical uncertainty, uncertainty regarding safety to transfer, and where they may be disagreement between sites. • Ensure MUM Birthing Services or midwifery in-charge (after-hours) is aware of transfer • Arrange MW escort • Assess for tocolysis/ steroids (MgSO4 should not be infused during transfer) • MUM or in-charge to place woman on Patient Flow Portal (PFP) as a inter hospital transfer (IHT) • Consideration of risk of delivery en route – this may require repeat vaginal examination prior to transfer • Ensure appropriate copy of clinical records are sent to the receiving facility • Organisation of transport: transport will vary dependent on urgency and may be provided by state-wide services such as NSW Ambulance Service, and other Patient Transport Services (PTS) and NETS for out born baby transfer • Inform PFU Transfer to Wollongong/ St George / The Sutherland Hospital is indicated if: • Delivery is not imminent • Gestational Age <37weeks gestation (TSH) and <34 weeks Wollongong/ St George • Special Care Nursery (SCN) unable to accommodate due to workload • At the discretion of the paediatric and SCN team • The obstetric and paediatric consultants should be involved in decisions to transfer Transfer to RHW is indicated if: • Delivery is not imminent • EFW <1800g • Gestational Age <32 weeks gestation • Fetal conditions requiring delivery at tertiary centre • At the discretion of the paediatric and SCN team • In the event of uncertainty regarding whether referral to the Fetal Maternal Centre (FMC) Wollongong or St George Hospital or referral to MFM at the RHW is the most appropriate pathway. Advice should be sought (during business hours) from the: o FMC Obstetrician at St George Hospital via the Genetics Department on 91133635 o Department of Maternal-Fetal Medicine at the RHW on 93826098. Transfer is contraindicated in the following circumstances: • Maternal condition unstable (eg eclampsia, severe uncontrolled hypertension, haemorrhage) • Birth is imminent >26 weeks (eg fully dilated, rapidly progressing) • Significant fetal distress De-escalation of care: Accepting of return transfers from RHW, St George, TWH or TSH when a woman and / or neonate no longer requires a higher level of care.

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Shared care: Where care can be provided at a lower level service with the support of a RHW, St George, TWH or TSH Specialist Obstetrician. 1.5 In- Utero transfer from Milton - Ulladulla Hospital (Level 1) In-utero transfers from Milton Ulladulla should be referred to Shoalhaven District Memorial Hospital for referral consultation and escalation 1.6 Transfer Process for Non - Birthing Services In this case the non-birthing unit is to contact the nearest birthing unit for consultation and transfer. If birth is imminent the non-birthing unit is to contact the NSW Ambulance Service as a ‘000’ call to provide support and postnatal transfer

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1.7 In-Utero transfer to Royal Hospital for Women (RHW Level 6) from Norfolk Island (NI) • RHW is to provide support and advice to the Tiered Network (TN) facilities around consultation, referral and transfer for maternity patients. The RHW TPN supports 5 public and 5 private facilities with maternity services, Norfolk Island and Lord Howe Island.

Non urgent (MP5) requests for maternal transfer: • Norfolk Island Health and Residential Aged Care Service (NIHRACS) General Practitioner (GP) and Manager requests non-urgent Maternal Fetal Medicine (MFM) referral. Contacts RHW “fetus phone” 0800-17:00 (Mon- Fri) for an appointment in MFM on 0+61 437 537 448 or +61 2 93826098. Fax copies of previous ultrasounds, consultations, relevant pathology and maternal blood group to +61 2 93826038.

Urgent (MP1) requests for maternal transfer: • urgent specialist care (<24hrs) – indicates where patients require specialist intervention to prevent or manage further deterioration within a short time frame (Immediate to within 24 hours). • NIHRACS GP and Manager contacts RHW Transfer Coordinator (TC) on telephone number +61 434 565 264 to coordinate teleconference with the obstetric consultant on-call at RHW to: o Confirm maternal transfer is required o Ensure the woman is safe to transfer • the consultant at the RHW must authorise the transfer request

Coordination of maternal transfer: • all requests for transfer are to be coordinated through the RHW Access Demand Manager (ADM) / After Hours Nurse Manager (AHNM) on +61 434 565 264/or phone +61 2 95651577- page 44020 who will undertake the ‘Transfer Coordinator (TC) role’ for the network as per the Tiered Network Operational Plan. • NIHRACS Manager to: o identify those pregnancies that are high risk and to consider moving the woman off the island at around 35 weeks gestation o contact CareFlight +61 1300 655 855 / +61 2 98937683 o check availability of a retrieval team as required (may include a Doctor, a critical care nurse and an experienced midwife) with education and training in aeromedical retrieval -CareFlight to enact parallel response - senior consultant, obstetric consultant RHW, NETS and a midwife as available for ongoing consultation and retrieval o If unable to source a midwife CareFlight and NIHRACS will have consultations on whether NIHRACS can provide local midwife, if not possible NIHRACS to work on alternatives, possibly sourcing other transport providers to other possible locations via Retrieval Service Queensland (RSQ) +61 1300 799 127 and/or New Zealand airlines if CareFlight unavailable o arranges the patient transfer, including where clinical and /or security escort and /or Medevac as required o liaises with RHW TC after clinical discussion, with the decision to transfer the woman to RHW o ensures appropriate copy of clinical records are sent to RHW o provide a comprehensive clinical handover should occur, as close as possible to the referred person departing the NIHRACS facility o handover is to include transport arrangements and expected time of arrival at RHW o phone contact details are to be exchanged between NIHRACS and RHW to enable communication between the escorting team and RHW • following acceptance clinical handover should occur from the referring clinician to the RHW Consultant / or obstetric registrar • RHW TC to: o enter the patient details in the Patient Flow Portal (PFP) as an Inter Hospital Transfer (IHT) and pending admit 20 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

o accepts transfer in the PFP/ IHT.

Semi Urgent (MP4-5) requests for maternal transfer (commercial air travel appropriate): • NIHRACS GP and Manager contacts RHW TC on telephone number +61 434 565 264 to coordinate teleconference with the obstetric consultant on-call at RHW to: o Confirm maternal transfer is required o Ensure the woman is stable and suitable to transfer by commercial flight without medical or midwifery escort • the consultant at the RHW must authorise the transfer request

Coordination of maternal transfer: • all requests for transfer are to be coordinated through the RHW TC • NIHRACS Manager to: o contacts RHW TC +61 434 565 264 to handover clinical information o book and confirm flight on commercial airline o arrange the patient transfer, including where clinical and/or security escort and/or Medevac as required o liaise with RHW TC after clinical discussion, with the decision to transfer the woman to RHW o ensure appropriate copy of clinical records are sent to RHW o provide a comprehensive clinical handover should occur, as close as possible to the referred person departing the NIHRACS facility. o handover is to include transport arrangements and expected time of arrival at RHW o phone contact details are to be exchanged between NIHRACS and RHW to enable communication between the escorting team and RHW • RHW TC to: o enter the patient details in the PFP as an IHT and pending admit o accepts transfer in the PFP/ IHT.

Escalation to SESLHD Organisational Performance Support Manager: • where there are delays or issues relating to the acceptance of and admission to a SESLHD facility the SESLHD Organisational Performance Support Manager (OPSM) should be contacted to ensure timely and safe coordination of inter-facility transfers for patients requiring access to specialist care unresolved issues are to be managed as per Procedure Rule SESLHDPR/596at the Director Nursing and Midwifery or SESLHD Executive on-call level. Queensland Maternal Transfers: Women who are registered to birth with QLD facilities are to be transferred to the booking facility and not to NSW Health/ SESLHD/ RHW.

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22 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

MATERNAL TRANSFERS DECISION MAKING TOOL INTERPRETATION

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MATERNAL TRANSFER FLOWCHART

MATERNAL TRANSFER IDENTIFIED RISK OUTSIDE SERVICE CAPABILITY

MP1 - immediate MP2 - < 3 hours MP3 - <12 hours MP4- 24 hours

MP5- Referral

Level 6 facility transfer Maternal Transfer required to facility within Tiered Network (TN) within service capability Non-urgent & follow

TN Operational Plan MP1 –time critical transfer

23-25.6/40

Transfer accepted and Transfer declined Level 5-4 contacted by Transfer accepted and Contact NETS for out admit escalated through TN Level 6 and must accept admit born retrieval Premature Labour to next facility in TN transfer 1300 362 500 <32 weeks Progressive

dilatation >3cms Declined requires Escalation to alternate No capacity- original L6 must accept transfer outside TN Level 6 facility to accept transfer (default Protocol) transfer within TN

Transfer accepted and Direction to admit at Escalation SOC admit alternate Level 6 24 NOVEMBER 18 2019 Statewide Obstetric Consultant (SOC) available for additional advice for all MP1, END 2 ORSED& 3 Transfers SESLHD with AND the ISL HDLevel CHIEF 6 consultant, EXECUTIVE NSW FEBRUARY Ambulance, 7 2020 ACC and NETS and final decision if mediation required

CLINICAL PRESENTATIONS – Assessment of Risk: Level 6: Gestation: All gestations Level 5: Gestation > 32/40 – 34/40 weeks Level 4: Gestation > 34/40 weeks

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PATIENT FLOW PORTAL INTERHOSPITAL TRANSFERS: Maternal transfers- timing and mode of transport • Women classified as a Maternity Priority 1 (MP1) or Maternity Priority 2 (MP2) should be transported by NSW Ambulance/ Aeromedical within the ‘Medically agreed time frame’ of 1 hour for MP1 and 3 hours for MP2. • Women classified as Maternity Priority 3 (MP3), should be transported by the Patient Transport Service (PTS) within the ‘Medically agreed time frame’ of 12hours, unless maternal or fetal deterioration escalation to MP1 or MP2 then NSW Ambulance/Aeromedical • Women classified as Maternity Priority 4 (MP4), should be transported by the PTS within the ‘Medically agreed time frame’ of 24 hours. • Women classified as Maternity Priority 5 (MP5), should be transported by PTS or private vehicle within the ‘Medically agreed time frame’ of 72 hours. Entering maternal transfers onto the Patient Flow Portal (PFP) & transport arrangements • All maternal transfers must be entered onto the PFP/IHT. This should never delay an urgent or immediate transfer. • NSW Ambulance should be contacted directly for inter-hospital transfers where the woman is classified as MP1 or MP2. • Maternal transfers must be entered into the PFP/IHT by the BU MUM/ T/L or the midwife caring for the woman being transferred. Transfer coordinator (ADM/AHHNM/BU MUM/ T/L) to confirm PFP/IHT • Transport can be arranged at the same time that the transfer is entered onto the PFP and as soon as a bed is confirmed at the receiving hospital, by choosing the ‘Bed confirmed- yes’ option. • *NB: The receiving hospital does not have to ‘accept’ the transfer on the PFP for transport to be allocated

TIERED NETWORK COMMUNICATION FOR TRANSFER: Communication Transfer Consultant Registrar PFP/ Birthing Unit NCC NCC Admissions NSW Patient Private NETS Transfer Coordinator IHT MUM/ T/L Consultant/ NUM/ T/L Office Ambulance/ Transport Out born Fellow Aeromedical Services baby only PTS MP1- Immediate

MP2 - 3 hours

MP3 - 12hours ? MP4 – 24 hours (ANW) MP5 -72 Hours (MFM) (referral)

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TIERED NETWORK DEMAND ACCESS ESCALATION (STEP) Introduction Effective bed management practice will always aim to ensure that there are sufficient beds available to meet the demands placed on the Tiered Maternal Neonatal Network - (South Eastern Sydney Local Health District (SESLHD)/ Illawarra Shoalhaven Local Health District (ISLHD) It is recognised however that there will be times when demand may exceed availability, particularly during seasonal fluctuations and escalation from the Tiered Network will be required In this circumstance, this plan will provide a framework for managing the situation.

Aim The aim of the escalation plan is to provide a high level approach for effectively managing escalation to support key services to manage capacity across each health domain.

Objective The objective of this escalation plan is to provide: • A focussed and timely response to predicted and actual capacity mismatch being experienced • The plan will formalise and ensure an integrated response from all Departments and Divisions • Efficient, robust and resilient internal operational procedures to ensure a timely and appropriate response to optimise outcomes. • Assurance that actions taken are enabling and effective

Roles and Responsibilities Once the escalation level is known and adequately communicated the risk status matrix processes commence. Both clinical and management team engagement across the Tiered Network is important to ensure internal pro‐active approach to effective flow and capacity. Early escalation of capacity problems is key to enabling awareness to ensure patient flow is efficient and can respond to the need for increased capacity creation.

De- escalation: This process will also ensure appropriate and timely de‐escalation so that all parties are aware when normal service function has resumed. Communicated appropriately through patient flow capacity report indicating change to site status. Patient Flow Portal (PFP) Electronic Patient Journey Board (EPJB) updating the bed availability and /or Consultant Details in the EPJB as changes occur: • Paediatric and Neonatal ICUs must be updated at least every 4 hours. • Birthing Units must be updated at least every 8 hours. • If nothing has changed since the last update, you must still go into the update window and click No Changes

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Core Roles and Responsibilities:

General Manager: is the Executive Sponsor of patient flow, and should receive escalations of a critical nature regarding flow challenges and impediments, and should be briefed on action plans to resolve those. The General Manager is also accountable for initiating a level 3 escalation if required. The DCE is the reinforcing sponsor and delegated to assist sites accordingly at the request of the GM or DDONM.

Director/Deputy Director of Nursing and Midwifery (D/DDON&M): holds primary site responsibility for the daily operational aspects of the facility and daily management of the access agenda. The DONM collaborates to ensure that networking opportunities across the LHD and other related demand management issues are coordinated and optimised.

Patient Flow Unit Manager - Access Demand Manager (ADM), Bed Manager (BM): Has responsibility for the Demand Management and flow of patients throughout the hospital and is the main contact and communication conduit for all issues related to patient flow at the site and has a key responsibility in managing patient flow and in the proactive management of delays. Ensuring targets are met to the best of service ability. Assists with the management of operational issues that are impacting on patient flow through the hospital. Manages the AHNM team and directly reports flow issues to D/DDON and Executive as required.

After Hours Nurse Manager (AHNM)/ Roster Office: The AHNM is the main contact and communication conduit for all issues related to patient flow after hours at the site. They also problem-solve with ward-based NUMs; and encourage discharge patients to be moved immediately to the PDU where possible (or other suitable local ward area). Escalate if there are unresolvable issues and ensure communication and feedback between all ward areas is optimised; as well as over-seeing the Patient Flow Portal, demand management predictions, and applying and working within the models of care across the facility and policy directions including Inter-facility Transfer (PD2011_031)

Medical Teams/Ward N/MUM/TL: Work closely with the ADM/AHNM to identify beds currently free and available for utilisation; beds with patients for discharge who are required to remain on the ward, and that clinical rationale; patients waiting medical review for potential discharge; patients for discharge the following day that could be reviewed if escalation occurs; any practical issue that prevents patient flow/access – for example patient acuity or staffing skill mix issues.

Clinical Services, Department Heads & Allied Health: holds primary responsibility for implementing and working within the Care Coordination Policy: Planning from Admission to Transfer of Care in NSW Public Hospitals (PD2011_015); ensuring timely ward rounds, optimised patient flow across the system, patient assessment and monitoring of clinical goals and clinical endpoints; timely execution of interventions and diagnostics . The Expected Date of Discharge/Transfer is also an important element of inpatient ward-based care.

Co- Directors/Operations Managers/ Nurse Managers: also have a daily responsibility in relation to the escalation of inpatient bed capacity management issues and in the strategic elements of the access agenda, which includes LOS management of stranded patients and development of strategies/models of care to improve patient flow through the clinical units. If there are delayed responses by inpatient teams either in the ward environment or in response to request for review, these should be escalated to the team consultant in the first instance then the DCS.

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STEP ESCALATION: Level Core business Ensure all standard operational procedures are functioning as 0 as usual efficiently as possible to maintain flow Respond quickly to manage and resolve emerging pressures Level Moderate that have the potential to inhibit flow. Initiate contingencies. De- 1 pressure escalate when applicable. Prioritise available capacity in order to meet immediate Level Severe pressures. Put contingencies into action and bring pressures 2 pressure back with in organisational control. De- escalate when applicable and as soon as possible. Ensure all contingencies are operational to recover the situation. Level Extreme Executive command and control of the situation. 3 pressure De- escalate when applicable and as soon as possible.

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STATUS RHW MATERNITY SERVICES ESCALATION MEASURE RESPONSIBILITY ACTION REQUIRED LEVEL 0 Level 0: • Co- Directors Maternity Nil Business as normal • Maternity Handover 0830 hours Birthing Unit BU Services • Patient Flow meeting to discuss demand, access, and staffing requirements for Maternity Services • ADM/AHNM Business as o Review PFP Neonatal and Birthing Unit Bed Status Snapshot • Maternity Service usual o Patient Flow Portal (PFP) Electronic Patient Journey Board (EPJB) updating the bed availability and /or Consultant Details in the MUM's EPJB as changes occur: • O&G Team o Birthing Units must be updated at least every 8 hours. • Paediatric Team o If nothing has changed since the last update, you must still go into the update window and click No Changes o Handover of admissions and activity from previous 24 hours to the daily rostered team o Actual and potential discharges are identified from Postnatal Services (PNS) and Antenatal Ward (ANW) and Acute Care Ward (ACW) o Identify and plan for next day's activity- planned Caesarean sections (LSCS) and Induction of labours (IOL) identified o Review of Patient Flow Portal for potential transfers to and from RHW o Routine rounds attended by O&G to discharge women o Midwifery Support Programme (MSP) offered to all postnatal maternity patients as clinically indicated o Midwifery Group Practice Postnatal and ANW patients reviewed by MGP Midwives • Direct discharge from Birthing Services 4 hours post- partum LEVEL 1 Level 1: Level 0 strategies actioned • Co- Directors Maternity • RHW Management • Escalation for Birthing Unit (BU) is to be enacted. This could be coupled with an increase in activity/ acuity in other areas of the hospital Services Executive • ADM/ AHNM to re-deploy staff to BU • ADM/AHNM • Co- Directors Maternity • Review IOL's and Planned Elective Caesarean Sections • Obstetric Consultant Services Actions • Inutero Cases cannot be REFUSED without consultation with the Obstetric Consultant • Maternity Service • Obstetric Consultant undertaken aim • Inutero transfer cases cannot be REFUSED without consultation with Neonatal consultant in cases where it is anticipated a neonatal MUM's SESLHD District Manager to achieve Alert bed will be required • O&G Team Access and Clinical Status return to • Review Midwifery Support Programme (MSP) for capacity to support PNS activity • Anaesthetic Consultant Services Level 1 • Utilise Maternity surge beds PNS (6) and ANW (4) as approved by RHW Management Executive • Randwick Campus • Support workforce to assist in patient processing. Operating Suite (RCOS) • Assess additional porter services, transportation requests, assess staffing levels. NM • Department Heads to seek urgent review by all medical consultants whose patients are deemed ‘possible discharges’ to identify with the • Neonatal Team N/MUM’s which patients are able to be discharged. • NCC NUM/NM • During business hours 1200hrs if capacity is not meeting demand an urgent meeting to be organised of the Divisional Nursing Co Directors, Maternity MUM's and ADM/AHNM to discuss strategies. Level 2 Level 2: Level 0 and 1 strategies actioned • Co- Directors Maternity • RHW Management • Social Work is to report greater than 4 patients waiting for external accommodation for inpatient Newborn Care support - conversion to Services Executive Actions Border patient • ADM/AHNM • Co- Directors Maternity undertaken aim • Liaise with Networked Hospitals - St George and POW Private Hospital re capacity to divert low risk labouring women • Obstetric Consultant Services to achieve Alert • Escalate to RHW management executive and Maternity Co Directors to divert activity out of SESLHD – Network Level 5 –St George or • Maternity Service • Obstetric Consultant status return to Wollongong, RPAH, POW Private Hospital re capacity to divert low risk labouring women MUM’s • NETS/SOC Level 2 • Alert NSW Neonatal and Paediatric Emergency Transport Service (NETS) - NETS will facilitate the bed-finding process for critically ill or • O&G Team • SESLHD District high risk babies for more complex or definitive care. • Neonatal Team Manager Access and • NCC NUM/NM Clinical Services 30 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

• Where there is a variance in view regarding the clinical appropriateness of the transfer, the final decision of the transfer will be made • SESLHD District by the NETS medical retrieval consultant (babies) and/ or the Senior Obstetric Consultant (mothers) following conference call between Executive on-call the referring clinician and the, receiving medical consultant (A/H's) • Escalation to RHW Management Executive and Co Directors • Escalation to District Manager - Access and Clinical Services, (business hours) and after hours to SESLHD District Executive On-Call on 9540 8866 Level 3 Level 3: Level 1,2 & 3 strategies actioned • RHW Management • RHW Management • Statewide Default protocol to be enacted for Maternity and NCC services Executive Executive Actions • Cancel all Elective surgery • Co- Directors Maternal • undertaken aim • Escalation to RHW Management Executive and Co Directors Services to achieve Alert • Escalation to District Manager - Access and Clinical Services, (business hours) and after hours to SESLHD District Executive On- • ADM/AHNM status return to Call on 9540 8866. Brief to SESLHD Executive Unit Level 3

31 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

STATUS RHW NEONATAL SERVICES ESCALATION MEASURE RESPONSIBILITY ACTION REQUIRED LEVEL 0 Level 0: • ADM/AHNM Nil Business as normal • Review of PFP for potential transfers to and from RHW • Co- Directors NCC • Review PFP Neonatal and Birthing Unit Bed Status Snapshot • NCC NUM/NM Business as usual • Patient Flow Portal (PFP) Electronic Patient Journey Board (EPJB) updating the bed availability and /or Consultant Details in the EPJB as • Neonatal Team changes occur: • Paediatric and Neonatal ICUs must be updated at least every 4 hours. • If nothing has changed since the last update, you must still go into the update window and click No Changes • Routine rounds attended by Neonatologist and Teams in NICU and SCN • Neonatal reviews take place by the Neonatal team in postnatal services • Identify and plan for next day's activity- Surgical interventions, planned Caesarean sections (LSCS) and Induction of Labours (IOL) identified • Maternal Fetal Medicine and Psychosocial cases discussed LEVEL 1 Level 1: Level 1 strategies actioned • ADM/AHNM • RHW Management • Neonatal Intensive Care Unit (NICU- 16 beds) capacity at 90 % occupancy of actual requirement • Co- Directors NCC Executive Actions • Special Care Nursery (SCN- 28 beds) capacity at 80% occupancy of actual requirement • NCC NUM/NM • ADM/AHNM undertaken aim • Escalate to the Roster office to increase staffing levels • Neonatal Team • Co- Directors NCC to achieve Alert • No cases can be REFUSED without consultation with Neonatal consultant in cases where it is anticipated a neonatal bed will be required • Obstetric Consultant Status return to • PFP Neonatal bed restricted admission to Level 5-6 NICU units- services AMBER Level 1 Level 2 Level 2: Level 2 Strategies actioned • ADM/AHNM • RHW Management • Neonatal Intensive Care over capacity with NICU beds utilised in SCN • Co-Directors NCC Executive Actions • Special Care Nursery over capacity and back flow into NICU • Obstetric Consultant • ADM/AHNM undertaken aim • Utilise Neonatal surge beds (2) as approved by RHW Management Executive • NCC NUM/NM • Co- Directors NCC to achieve Alert • PFP Neonatal bed restricted admission to Level 5-6 NICU units- services RED • Neonatal Team • Obstetric Consultant status return to • NETS will facilitate the bed-finding process for critically ill or high risk babies for more complex or definitive care. • NETS /SOC Level 2 • Where there is a variance in view regarding the clinical appropriateness of the transfer, the final decision of the transfer will be made by the Neonatal consultant (babies) and/ or the Senior Obstetric Consultant (mothers) following conference call between NETS, the referring clinician & the receiving medical consultant • Escalation to RHW Management Executive and Co Directors • Escalation to District Access Demand Manager - Access and Clinical Services, (business hours) and after hours to SESLHD District Executive On-Call on 9540 8866 Level 3 Level 3: Level 1,2 & 3 strategies actioned • RHW Management • RHW Management Actions • Statewide Default protocol to be enacted for Maternity and NCC services Executive Executive RHW undertaken aim • Cancel all Elective surgery • Co- Directors to achieve Alert • Escalation to RHW Management Executive and Co Directors Neonatal Services status return to • Escalation to District Manager - Access and Clinical Services, (business hours) and after hours to SESLHD District Executive On-Call • ADM/AHNM Level 3 9540 8866. • Brief to SESLHD Executive Unit

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STATUS ST GEORGE HOSPITAL STATUS & STRATEGY Responsibility: Escalate & liaise: LEVEL 0 • NUM/ MUMs Nil –business as Level 0 • Actual and potential discharges are identified from all specialty areas as well as planned caesarean sections • O&G team usual Business as usual and induction of labours at commencement of day shift in Maternity • Paediatric team • Routine medical rounding by all specialties through all specialities • Specialty medical team • Midwifery Support Programme (early discharge) offered to all Maternity patients if clinically suitable (applies to EDO) • Direct discharge from Birthing Services 4 hours post-partum is promoted if clinically appropriate • Identify and plan for next day’s activity and potential discharges LEVEL 1 • NUM/MUMs • W&CH’s NM Level 1 • Phase 0 strategies actioned • O&G Team • Relevant medical Moderate Compromise • + / - Additional meeting further in the day to explore other strategies in light of Phase 1 outcomes Rounds • Paediatric Team team attended by M/NUM / NM and all inpatients reviewed for each speciality by relevant medical team • Specialty medical team • PA&D NM/ Aim to achieve • Liaise with LHD hospitals to ascertain current activity for information &/or action (for Maternity and Birthing (applies to EDO) DDON&M / Alert Status Services only) return to Level 0 • In charge of shift (after AHNM hours) LEVEL 2 • W&CH’s NM • PA&D NM/

• Phase 0 and 1 actioned • NUM / MUM DDON&M/ Level 2 Severe • Use Maternity overflow beds with consultation in 1 West Gynaecology for increased Maternity activity • In charge of shift (after AHNM Compromise • Discharge boarder mums from Maternity or admit (if capacity allows) into single rooms in Paediatric ward hours) with Paediatric HOD and DDON&M approval for increased Maternity demand Aim to achieve • Transfer suitable Gynae women to Maternity beds for increased Gynae demand Alert Status return to Level 1 • Risk assessment of booked induction of labours and elective surgery for rescheduling or 0 • Liaise with hospitals within LHD for possible networking of patients to inpatient bed/cots or for labouring women (for Maternity and Birthing Services only) • Surge cots (over 12) with DDON approval in instances where SCN is over census Level 3 LEVEL 3 • W&CH’s NM • PA&D NM / Extreme • Phase 0, 1 and 2 actioned • Birth Unit/Maternity Unit DDON&M/ Compromise Aim to achieve • Escalate need to DDON&M/AHNM need to divert activity out of SESLHD (for Maternity and Birthing Services managers AHNM Alert Status only). Approval required from GM • In Charge of shift (after return to Level 2 • Co – Locate adults with children in Children’s ward in accordance to approved criteria for increased Gynae hours) or 1 activity when maternity cannot assist with beds. Approval required from Paediatric HOD and final approval from GM (as per PD) • Utilise Birth Unit capacity for delivered women as a last resort

33 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

STATUS THE SUTHERLAND HOSPITAL STATUS & STRATEGY Responsibility: Escalate & liaise: • Actual and potential discharges are identified. Identify and plan for next day’s activity and potential discharges • W&CH’s site NM Nil – Level 0 business as usual Maternity / Gynaecology • Birthing Suite MUM Business as usual • Planned caesarean sections and induction of labour identified at commencement of day shift • Maternity Unit MUM • Routine rounds take place by O&G to clear women • O&G team • Midwifery Support Program (early discharge) offered to all Maternity patients if clinically suitable • Paediatric team • Direct discharge from Birthing Services 4 hours post-partum is promoted if clinically appropriate • NUM / NM Paediatrics Paediatrics • NUM Children’s ward • Routine rounds take place by Paediatric team in Special Care Nursery (SCN) and Paediatric wards • Review (Patient Flow Portal) PFP for potential transfers to and from SCN / Paediatrics • Level 1 strategies actioned • W&CH’s site NM • W&CH NM Level 1 Maternity / Gynaecology • Birthing Suite MUM • Specialty consultant Moderate • + / - Additional meeting further in the day to explore other strategies in light of level 1 outcomes If there was no Compromise • Maternity Unit MUM capacity in Birthing • Rounds attended by MUM / NM and all inpatients reviewed for each specialty by O&G team / Paediatric team • O&G team Suite Aim to achieve • Liaise with Networked hospital to ascertain current activity for information &/or action • Paediatric team Alert Status Paediatrics • Site PFC • NUM / NM Paediatrics return to Level 0 • Consider nil further PFP transfers (SCN or Paediatric) • DDON&M • NUM Children’s ward • Further bed meeting planned to explore additional capacity creation Level 1 and 2 actioned • W&CH’s site NM • DDON&M Maternity / Gynaecology • Birthing Suite MUM • Site PFC Level 2 • Discharge boarder mums or admit (if capacity) into single rooms in Children’s Ward with Paed/Exec approval Severe • Maternity Unit MUM • Risk assessment of booked induction of labour and elective surgery for rescheduling Compromise • O&G team • Liaise with St George Hospital and Royal Hospital for Women for possible networking of patients • Paediatric team Aim to achieve • Escalate need to DDON/AHNM need to divert activity out of SESLHD • NUM Children’s ward Alert Status • Utilise Birth Unit capacity for delivered women as a last resort return to Level 1 • Use Maternity surge beds, approval required by General Manager or 0 Paediatrics • Surge beds utilisation in SCN and Paediatrics if required, approval required by General Manager • No PFP transfers accepted (SCN or Paediatrics) • Escalate need to DDON/AHNM need to divert activity out SCN / Paediatrics / Southern Sector and / or SESLHD Level 3 • Contact RHW demand manager, if unable to accommodate RHW will contact PSN to arrange for appropriate transfers. • All above • DDON&M Extreme Once suitable hospital identified for transfer, O&G or Paediatrician to liaise with Medical team at receiving hospital • General Manager Compromise Aim to achieve Alert Status return to Level 2 or 1 34 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

STATUS THE WOLLONGONG HOSPITAL STATUS & STRATEGY Responsibility: Escalate & liaise: Maternity / Gynaecology • Birthing Suite MUM Nil – Level 0 business as usual • Actual and potential discharges are identified. • Maternity Unit MUM Business as usual • Planned caesarean sections and induction of labour (IOL) identified at commencement of day shift • O&G team • Routine rounds take place by O&G to clear women • Paediatric team • Midwifery Support Program (early discharge) offered to women as per the admission criteria. • Children’s ward NUM • Direct discharge from Birthing Services 4 hours post-partum is promoted if clinically appropriate • SCN NUM Paediatrics • Actual and potential discharges are identified • Routine rounds take place by Paediatric team in Special Care Nursery (SCN) and Paediatric ward • Review (Patient Flow Portal) PFP for potential transfers to and from SCN / Paediatrics • Level 0 strategies actioned as above • Birthing Suite MUM • Operations Level 1 Maternity / Gynaecology • Maternity Unit MUM Manager Moderate • Additional bed meeting later in the day to explore other strategies if and when required • Consultant on call if Compromise • O&G team no capacity in • Rounds attended by MUM and all inpatients reviewed for each specialty by O&G team • Paediatric team Birthing Suite Aim to achieve • Liaise with Networked hospital to ascertain current activity for information &/or action • Children’s ward NUM Alert Status Paediatrics • Patient Flow • SCN NUM manager return to Level 0 • Additional bed meeting later in the day to explore other strategies if and as required • DON&M • Rounds attended by MUM and all inpatients reviewed by Paediatrics team • Consider nil further PFP transfers (SCN or Paediatrics) • Level 0 and 1 strategies actioned as above • Operations Manager • Patient Flow

Maternity / Gynaecology • Birthing Suite MUM manager/AHNM Level 2 • Discharge boarder mums or admit (if capacity) into single rooms in Children’s Ward with Operation Managers approval • DON&M or Severe • Maternity Unit MUM Executive on call Compromise • Conduct risk assessments of all booked IOL and elective surgeries for possible rescheduling • O&G team afterhours. • Utilise Birth Unit capacity for delivered women • Paediatric team Aim to achieve • Review all laboring women for suitability for 4 hour discharge post birth • Children’s ward NUM Alert Status Paediatrics return to Level 1 • SCN NUM • Utilise surge beds in SCN and Paediatrics if available – consideration to be given to safe staffing levels or 0 • No PFP transfers accepted (SCN or Paediatrics) Level 3 • Level 0, 1 and 2 strategies actioned as above • All of the above plus • Exec on call Extreme Compromise Aim to achieve Alert • Escalate need to General manager, need to divert activity out of Maternity/SCN / Paediatrics • Patient Flow/AHNM • General Manager Status return to Level 2 or 1 • DONM

35 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

STATUS SHOALHAVEN DISTRICT MEMORIAL HOSPITAL STATUS & STRATEGY Responsibility: Escalate & liaise: Maternity / Gynaecology • Maternity Unit MUM Nil – Level 0 business as usual • Actual and potential discharges are identified • O&G team Business as usual • Planned caesarean sections and induction of labour (IOL) identified at commencement of day shift • Paediatric team • Routine rounds take place by O&G to clear women • Children’s ward/SCN NUM • Midwifery Support Program (early discharge) offered to all Maternity patients if clinically suitable • Direct discharge from Birthing Services 4 hours post-partum is promoted if clinically appropriate Paediatrics • Actual and potential discharges are identified • Routine rounds take place by Paediatric team in Special Care Nursery (SCN) and Paediatric ward • Review (Patient Flow Portal) PFP for potential transfers to and from SCN / Paediatrics • Level 0 strategies actioned as above • Maternity Unit MUM • Operations Level 1 Maternity / Gynaecology • O&G team Manager Moderate • Additional bed meeting later in the day to explore other strategies if and when required • Consultant on call if Compromise • Paediatric team no capacity in • Rounds attended by MUM and all inpatients reviewed for each specialty by O&G team • Children’s ward/SCN NUM Birthing Suite Aim to achieve • Liaise with Networked hospital to ascertain current activity for information &/or action Alert Status Paediatrics • Patient Flow manager return to Level 0 • Additional bed meeting later in the day to explore other strategies if and as required • DON&M • Rounds attended by MUM and all inpatients reviewed by Paediatrics team • Consider nil further PFP transfers (SCN or Paediatrics) • Level 0 and 1 strategies actioned as above • Operations Manager • Patient Flow

Maternity / Gynaecology • Maternity Unit MUM manager/AHNM Level 2 • Discharge boarder mums or admit (if capacity) into single rooms in Children’s Ward with Operation Managers approval manager Severe • O&G team • DON&M Compromise • Conduct risk assessments of all booked IOL and elective surgeries for possible rescheduling • Paediatric team

• Utilise Birth Unit capacity for delivered women • Children’s ward/SCN NUM Aim to achieve • Review all laboring women for suitability for 4 hour discharge post birth Alert Status • Relocate any outliers from maternity to increase capacity return to Level 1 Paediatrics or 0 • Utilise surge beds in SCN and Paediatrics if available – consideration to be given to safe staffing levels • No PFP transfers accepted (SCN or Paediatrics) Level 3 • Level 0, 1 and 2 strategies actioned as above • All of the above plus • Exec on call Extreme • Escalate need to General manager, need to divert activity out of Maternity/SCN / Paediatrics • Patient Flow/AHNM • General Manager Compromise Aim to achieve • DONM Alert Status return to Level 2 or 1 36 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

DATA AND REPORTING REQUIREMENTS Each Tiered Network is responsible for establishing the mechanism for data capture for the agreed key performance indicators and the mechanism for dissemination of outcome information. • In the absence of a state-wide process the system should be electronic and where possible not subject to human preference / behaviour. There should be sufficient connectivity to electronic systems, such as the patient flow portal, to ensure accuracy of data • There should be an agreed process developed for the dissemination of outcome data to the Tiered Network and an agreed process for response to data e.g. education, case review, escalation of data to Tiered Network executive as per local processes o PFP Neonatal / maternity Functionality- development & education o Emergency Access View (EAV)- development & education o PFP/ IHT o ematernity o eMEDS/ eMR • All hospital with SESLH/ISHLHD are to use patient flow portal in recording and facilitating antenatal in-utero transfer • All medical, midwife, nursing, and clerical staffs are to have regular education session regarding use of patient flow portal • All hospital in the tiered network are to run regular audit meeting regarding in-utero transfer • Any adverse outcome or difficult transfer are to be flagged to the Clinical Lead and Redesign lead of the LHD email [email protected]

37 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

APPENDIX Appendix 1: TIERED FACILITIES AND CONTACT DETAILS

TIERED FACILITIES AND CONTACT DETAILS • RHW LEVEL 6 – 02 9382 6111 o TRANSFER COORDINATOR – 0434 565 264/ 02 95651577 page 44020 o BIRTHING UNIT – 02 93826100 o BIRTHING UNIT MUM – 0437 762 964 o OBTETRIC CONSULTANT MOBILE per PFP o MATERNAL FETAL MEDICINE (MFM) – 0437 537 448 or 02 9382 6098 http://www.seslhd.health.nsw.gov.au/rhw/Maternal_Fetal_Medicine/referrals.asp • Fax form to 02 93826038 • ST GEORGE LEVEL 5 – 02 9113 1111 Distance Time to L6 - 30 mins

o BIRTHING UNIT – 02 9113 2125 o BU MUM/ T/L – 02 9113 2458 o OBSTERIC CONSULTANT MOBILE per PFP o FETAL MATERNAL CENTRE (FMC) – 02 9113 3635 o PFU – 0429 369 599 (07-2300) /0463 477 768 (07-1430) o AH – 0414192008 • WOLLONGONG LEVEL 5 – 02 4222 5000 Distance Time to L6 - 80 mins o BIRTHING UNIT – 02 4222 5270 / 02 42225305 o BU MUM/ T/L – 02 42225190 o OBSTERIC CONSULTANT MOBILE per PFP o PFU – 02 4222 5000 page 109

• SUTHERLAND LEVEL 4 – 02 95407111 Distance Time to L6 - 40 mins o BIRTHING UNIT – 02 95407981 o BU MUM – 02 9540 7989 o OBSTERIC CONSULTANT MOBILE per PFP o PFU – 0404 067 624 • SHOALHAVEN LEVEL 3 – (02) 4421 3111 o BIRTHING UNIT – 02 4423 9207 Distance Time to L6 - 130 mins o BU MUM – 02 4423 9455 o VMO CONSULTANT MOBILE o PFU – 02 4423 9738 • NSW AMULANCE – 131 233

• NETS – 1300 362 500 • ACC – Aeromedical Control Centre – 131 233 General admin 9553 2222

•

38 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

Appendix 2: MP1 - TIME CRITICAL TRANSFER TO ROYAL HOSPITAL FOR WOMEN (LEVEL 6) Obstetric registrar identifies that a Time Critical Transfer is required ↓ Obstetric registrar discusses case with the on-call consultant at referring facility to • Confirm meets criteria for time critical transfer - MP1 • Ensure that the woman is safe to transfer ↓ ↓ Woman safe to transfer Woman not safe to transfer ↓ ↓ ↓ Paediatrician contacts Obstetric registrar contacts RHW TC on telephone number NETS and prepare for

95651577 page 44020 or 0434 565 264 imminent delivery 1300 362 500 ↓ ↓ A conference call may be required between referring facility and RHW obstetric consultants if: • RHW must always • clinical uncertainty accept MP1 time • uncertainty regarding safety to transfer critical transfers • differences of opinion

↓ RHW confirms transfer ↓ ↓ • Referring hospital MUM Birthing Services or midwifery in-charge (after-hours) is aware of transfer and responsible: - book urgent NSW Ambulance for Transfer to RHW - 131 233 - arranges MW escort - assess for tocolysis (MgSO4 should not be infused during transfer) - place maternal transfer on PFP/IHT - inform PFU - ensure appropriate copy of clinical records are sent to RHW - MP1 time critical transfers are: MP1 who are unsafe to transfer are • 23+0-26 gestation when imminent birth • Maternal condition unstable (e.g. is likely eclampsia, severe uncontrolled • >26 gestation with progressive cervical hypertension, haemorrhage) dilation >3cm • Birth is imminent >26 weeks (e.g. fully • Deteriorating fetal or maternal dilated, rapidly progressing) condition where urgent birth is required • Significant fetal distress

39 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

Appendix 3: MP2 AND MP3 TRANSFERS TO ROYAL HOSPITAL FOR WOMEN (LEVEL 6)

Obstetric registrar identifies that a Obstetric registrar identifies that a Transfer within 3 hours Transfer within 12 hours is required is required ↓ ↓ Obstetric registrar discusses case with the on-call consultant at referring facility to • Confirm meets criteria for time critical transfer - MP1 • Ensure that the woman is safe to transfer ↓ ↓ Woman safe to transfer Woman not safe to transfer ↓ ↓ ↓ Paediatrician contacts Obstetric Registrar contacts RHW Transfer Coordinator on phone NETS and prepare for

number 95651577 page 44020 / 0434 565 264 imminent delivery 1300 362 500 ↓ ↓ ↓ A conference call may be required between referring Decision may be RHW unable to RHW facility and RHW obstetric made at consultant accept, notifies → accepts consultants if: level to remain and referring facility of transfer • clinical uncertainty → deliver at referring alternate hospital • uncertainty regarding facility safety to transfer • differences of opinion ↓ ↓ ↓ ↓

Obstetric registrar contacts receiving hospital to handover clinical BU informs paeds/ NCC information and prepares for imminent delivery ↓ ↓ • Referring hospital MUM Birthing Services or midwifery in-charge (after-hours) is aware of transfer and responsible: - book NSW Ambulance for Transfer to RHW or other facility (MP2) - 131 233 - book Patient Transport (PTS) through PFP/ IHT (MP3) - arranges MW escort - assess for tocolysis (MgSO4 should not be infused during transfer) - place maternal transfer on PFP/IHT - inform PFU - ensure appropriate copy of clinical records are sent to RHW

MP2 (within 3 hours) transfers include: MP3 (within 12 hours) transfers include:

• 26-31.6 weeks, 1-3 cm dilated and • 23-31.6 weeks dilated <1 cm with labour supressed supressed labour • Deteriorating fetal or maternal condition • TPL with fFN >200 ng/mL where urgent birth is required

40 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

Appendix 4: MP1 TIME CRITICAL TRANSFER FROM ST GEORGE/ WOLLONGONG HOSPITAL (LEVEL 5)

Obstetric registrar identifies that a Time Critical Transfer is required ↓ Obstetric Registrar discusses case with the on call consultant at facility to • Confirm the diagnosis/ criteria for time critical transfer • Ensure that the woman is safe to transfer ↓ ↓ Woman safe to transfer Woman not safe to transfer ↓ ↓ ↓

Obstetric Registrar contacts Birthing Unit Paediatrician contact NETS and arrange for imminent RHW Transfer Coordinator 95651577 page 44020/ 0434 565 264 delivery (23-31.6 gestation) 1300 362 500 ↓ ↓ A conference call may be required between Level 5 and 6 obstetric consultants if: • RHW must always • clinical uncertainty accept MP1 time • uncertainty regarding safety to transfer critical transfers • differences of opinion

↓ RHW confirms transfer ↓ ↓ • Referring hospital MUM Birthing Services or midwifery in-charge (after-hours) is aware of transfer and responsible: - book urgent NSW Ambulance for Transfer to RHW - 131 233 - arranges MW escort - assess for tocolysis (MgSO4 should not be infused during transfer) - place maternal transfer on PFP/IHT - inform PFU - ensure appropriate copy of clinical records are sent to RHW

MP1 time critical transfers are: MP1 who are unsafe to transfer are • 23+0-26 gestation when imminent • Maternal condition unstable (e.g. birth is likely eclampsia, severe uncontrolled • >26 gestation with progressive hypertension, haemorrhage) cervical dilation >3cm • Birth is imminent >26 weeks (e.g. fully • Deteriorating fetal or maternal dilated, rapidly progressing) condition where urgent birth is • Significant fetal distress required

41 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

Appendix 5: MP2 AND MP3 TRANSFERS FROM ST GEORGE/ WOLLONGONG HOSPITAL (LEVEL 5)

Obstetric registrar identifies that a Obstetric registrar identifies that a Transfer within 3 hours Transfer within 12 hours is required is required ↓ ↓ Obstetric Registrar discusses case with the on call consultant at facility to • Confirm the diagnosis/ criteria for time critical transfer • Ensure that the woman is safe to transfer ↓ ↓ Woman safe to transfer Woman not safe to transfer ↓ ↓ ↓

Obstetric Registrar contacts Birthing Unit Paediatrician contacts Wollongong 4222 5270 / 42225305 (32-33.6 gestation) NETS and prepare for St George 9113 2125 (32-33.6 gestation) imminent delivery RHW Transfer Coordinator 95651577 page 44020/ 0434 565 264 1300 362 500 (23-31.6 gestation) ↓ ↓ ↓ A conference call may be required Decision may be Level 5/6 unable between Level 3,4,5, and 6 Level 5/6 made at consultant to accept, notifies obstetric consultants if: → accepts level to remain and referring facility of • clinical uncertainty transfer → deliver at referring alternate hospital • uncertainty regarding safety to transfer facility • differences of opinion ↓ ↓ ↓ ↓

Obstetric registrar contacts receiving hospital to handover clinical BU informs paeds/ information NCC and prepares for imminent delivery ↓ ↓ • Referring hospital MUM Birthing Services or midwifery in-charge (after-hours) is aware of transfer and responsible to: - book NSW Ambulance for Transfer to receiving facility (MP2) - 131 233 - place maternal transfer on PFP/IHT - book Patient Transport (PTS) through PFP/ IHT (MP3) - arranges MW escort - assess for tocolysis (MgSO4 should not be infused during transfer) - inform PFU - ensure appropriate copy of clinical records are sent to receiving Level 5/6

MP2 (within 3 hours) transfers include: MP3 (within 12 hours) transfers include:

• 26-31.6 weeks, 1-3 cm dilated and labour • 23-31.6 weeks dilated <1 cm with supressed supressed labour • Deteriorating fetal or maternal condition • TPL with fFN >200 ng/mL where urgent birth is required

42 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

Appendix 6: MP1 TIME CRITICAL TRANSFER FROM THE SUTHERLAND HOSPITAL (LEVEL 4) Obstetric registrar identifies that a Time Critical Transfer is required ↓ Obstetric Registrar discusses case with the on call consultant at facility to • Confirm the diagnosis/ criteria for time critical transfer • Ensure that the woman is safe to transfer ↓ ↓ Woman safe to transfer Woman not safe to transfer ↓ ↓ ↓ Obstetric Registrar contacts Birthing Unit Wollongong 4222 5270 / 42225305 (32-33.6 gestation) Paediatrician contact NETS and arrange for imminent St George 9113 2125 (32-33.6 gestation) delivery RHW Transfer Coordinator 95651577 page 44020/ 0434 565 264 1300 362 500 (23-31.6 gestation) ↓ ↓ A conference call may be required between Level 5/6 confirms transfer Level 3, 4, 5 and 6 obstetric consultants if: request • clinical uncertainty • Level 5/6 must always • uncertainty regarding safety to transfer accept MP1 time • differences of opinion critical transfers ↓ Level 5/6 confirms transfer ↓ ↓ • Referring hospital MUM Birthing Services or midwifery in-charge (after-hours) is aware of transfer and responsible: - book urgent NSW Ambulance for Transfer to Level 5/6- 131 233 - place maternal transfer on PFP/IHT - arranges MW escort - assess for tocolysis (MgSO4 should not be infused during transfer) - inform PFU - ensure appropriate copy of clinical records are sent to receiving Level 5/6

MP1 time critical transfers are: MP1 who are unsafe to transfer are • 26-31.6 gestation where time • Maternal condition unstable (e.g. permitted to reach RHW or Level 5 eclampsia, severe uncontrolled • <34 gestation with progressive hypertension, haemorrhage) cervical dilation >3cm if safe to • Birth is imminent >26 weeks (e.g. fully transfer to St George/ TWH dilated, rapidly progressing) • Deteriorating fetal or maternal • Significant fetal distress condition where urgent birth is required

43 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

Appendix 7: MP2 AND MP3 TRANSFERS FROM THE SUTHERLAND HOSPITAL (LEVEL 4) Obstetric registrar identifies that a Obstetric registrar identifies that a Transfer within 3 hours Transfer within 12 hours is required is required ↓ ↓ Obstetric Registrar discusses case with the on call consultant at facility to • Confirm the diagnosis/ criteria for time critical transfer • Ensure that the woman is safe to transfer ↓ ↓ Woman safe to transfer Woman not safe to transfer ↓ ↓ ↓

Obstetric Registrar contacts Birthing Unit Paediatrician contacts Wollongong 4222 5270 / 42225305 (32-33.6 gestation) NETS and prepare for St George 9113 2125 (32-33.6 gestation) imminent delivery RHW Transfer Coordinator 95651577 page 44020/ 0434 565 264 1300 362 500 (23-31.6 gestation) ↓ ↓ ↓ A conference call may be required Decision may be Level 5/6 unable between Level 3,4,5, and 6 Level 5/6 made at consultant to accept, notifies obstetric consultants if: → accepts level to remain and referring facility of • clinical uncertainty transfer → deliver at referring alternate hospital • uncertainty regarding safety to transfer facility • differences of opinion ↓ ↓ ↓ ↓

Obstetric registrar contacts receiving hospital to handover clinical BU informs paeds/ information NCC and prepares for imminent delivery ↓ ↓ • Referring hospital MUM Birthing Services or midwifery in-charge (after-hours) is aware of transfer and responsible to: - book NSW Ambulance for Transfer to receiving facility (MP2) - 131 233 - place maternal transfer on PFP/IHT - book Patient Transport (PTS) through PFP/ IHT (MP3) - arranges MW escort - assess for tocolysis (MgSO4 should not be infused during transfer) - inform PFU - ensure appropriate copy of clinical records are sent to receiving Level 5/6

MP2 (within 3 hours) transfers include: MP3 (within 12 hours) transfers include:

• 23-31.6 gestation 1-3 cm dilated and labour • 23-31.6 gestation dilated <1 cm with supressed to RHW supressed labour to RHW • 32-34 gestation 1-3 cm dilated and labour • 32-34 gestation dilated <1 cm with supressed to St George/TWH supressed labour to St George/TWH • Deteriorating fetal or maternal condition • TPL with fFN >200 ng/mL where urgent birth is required

44 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

Appendix 8: MP1 - TIME CRITICAL TRANSFER FROM SHOALHAVEN DISTRICT MEMORIALHOSPITAL (LEVEL 3) Obstetric registrar identifies that a Time Critical Transfer is required ↓ Obstetric Registrar discusses case with the on call consultant at facility to • Confirm the diagnosis/ criteria for time critical transfer • Ensure that the woman is safe to transfer ↓ ↓ Woman safe to transfer Woman not safe to transfer ↓ ↓ ↓ Obstetric Registrar contacts Birthing Unit Sutherland Hospital 9540 7981 (34-36.6 gestation) Paediatrician contact NETS Wollongong 4222 5270 / 42225305 (32-33.6 gestation) and arrange for imminent

St George 9113 2125 (32-33.6 gestation) delivery RHW Transfer Coordinator 95651577 page 44020/ 0434 565 264 1300 362 500 (23-31.6 gestation) ↓ ↓ A conference call may be required between Level 3, 4, 5 and 6 obstetric consultants if: Accepts transfer request • clinical uncertainty • Receiving facility must always accept MP1 • uncertainty regarding safety to transfer time critical transfers • differences of opinion ↓ Receiving facility confirms transfer ↓ ↓ • Referring hospital MUM Birthing Services or midwifery in-charge (after-hours) is aware of transfer and responsible: - book urgent NSW Ambulance for Transfer to receiving facility - 131 233 - place maternal transfer on PFP/IHT - arranges MW escort - assess for tocolysis (MgSO4 should not be infused during transfer) - inform PFU - ensure appropriate copy of clinical records are sent to receiving facility

MP1 time critical transfers are: MP1 who are unsafe to transfer are • 23+0-26 gestation when imminent birth is • Maternal condition unstable (e.g. likely eclampsia, severe uncontrolled • >26 gestation with progressive cervical hypertension, haemorrhage) dilation >3cm • Birth is imminent >26 weeks (e.g. fully • Deteriorating fetal or maternal condition dilated, rapidly progressing) where urgent birth is required • Significant fetal distress

45 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

Appendix 9: MP2 AND MP3 TRANSFERS FROM THE SHOALHAVEN DISTRICT MEMORIAL HOSPITAL (LEVEL 3) Obstetric registrar identifies that a Obstetric registrar identifies that a Transfer within 3 hours Transfer within 12 hours is required is required ↓ ↓ Obstetric Registrar discusses case with the on call consultant at facility to • Confirm the diagnosis/ criteria for time critical transfer • Ensure that the woman is safe to transfer ↓ ↓ Woman safe to transfer Woman not safe to transfer ↓ ↓ ↓ Obstetric Registrar contacts Birthing Unit Sutherland Hospital 9540 7981 (34-36.6 gestation) Paediatrician contacts NETS and prepare for Wollongong 4222 5270 / 42225305 (32-33.6 gestation) St George 9113 2125 (32-33.6 gestation) imminent delivery RHW Transfer Coordinator 95651577 page 44020/ 0434 565 264 1300 362 500 (23-31.6 gestation) ↓ ↓ ↓ A conference call may be Decision may be Receiving facility required between Level 3,4,5, made at consultant Accepts unable to accept, and 6 obstetric consultants if: → level to remain and transfer notifies SDMH of • clinical uncertainty → deliver at referring alternate hospital • uncertainty regarding safety to transfer facility • differences of opinion ↓ ↓ ↓ ↓ BU informs paeds/ Obstetric registrar contacts receiving hospital to handover clinical NCC and prepares for information imminent delivery ↓ ↓ • Referring hospital MUM BU or midwifery in-charge (after-hours) is aware of transfer and responsible to: - book NSW Ambulance for Transfer to receiving facility (MP2) - 131 233 - place maternal transfer on PFP/IHT - book Patient Transport (PTS) through PFP/ IHT (MP3) - arranges MW escort - assess for tocolysis (MgSO4 should not be infused during transfer) - inform PFU - ensure appropriate copy of clinical records are sent to receiving facility

MP2 (within 3 hours) transfers include: MP3 (within 12 hours) transfers are:

• <36.6 gestation, 1-3 cm dilated and labour • <36.6 gestation dilated <1 cm with supressed supressed labour • Deteriorating fetal or maternal condition • TPL with fFN >200 ng/mL where urgent birth is required

46 NOVEMBER 18 2019 ENDORSED SESLHD AND ISLHD CHIEF EXECUTIVE FEBRUARY 7 2020

Appendix 10: NORFOLK ISLAND TRANSFERS TO SESLHD – RHW – time urgent

NIHRACS General Practitioner (GP) assess and recognises Maternal Transfer immediate or within 24 hours is required ↓ NIHRACS GP and Manager contacts RHW Transfer Coordinator (TC) on telephone number +61 434 565 264 to coordinate teleconference with the obstetric consultant on-call at RHW to: • Confirm maternal transfer is required- MP1-3 • Ensure that the woman is safe to transfer NIHRACS GP and Manager to contact Queensland Health direct for QLD Bookings. Do not contact RHW ↓ ↓ Woman safe to transfer Woman not safe to transfer ↓ ↓ ↓ NIHRACS Manager to contact

CareFlight Birth imminent - woman’s clinical RHW TC contacts NSW NETS +61 1300 655 855 / management is supported by +61 1300 36 2500 +61 2 9893 7683 RHW until determined that clinical NETS plan post-natal neonatal CareFlight to enact parallel condition is stable transfer in consultation with L6 response - senior consultant, MFM & Neonatologist obstetric consultant RHW and a RHW to update CareFlight with midwife as available for ongoing patient condition. Retrieval options: consultation and retrieval 1) 1) NETS’ team & charter jet

CareFlight liaises with NETS 2) 2) NeoResQ team via RSQ/LF NIHRACS to contact Retrieval regarding logistics of concurrent Services Queensland (RSQ) neonatal transfer / retrieval May require concurrent maternal +61 1300 799 127 if NSW transfer / retrieval CareFlight unavailable ↓ ↓ ↓

CareFlight to update NIHRACS NIHRACS team to deliver the baby with NETS to support local clinical 0011 6723 22091 support and assistance from RHW and team with clinical management of and RHW TC CareFlight neonate pending retrieval +61 434 565 264 of flight time

↓ ↓ ↓

Maternal condition clinically stable - CareFlight team to commence NETS team treats and stabilises emergency retrieval of the woman to SESLHD- RHW patient prior to transport to RHW or NIHRACS Manager to handover to RHW appropriate alternative destination RHW to enter PFP/IHT

NIHRACS Manager Responsibility: NIHRACS Manager Escalation to SESLHD: • arranging the patient transfer, including where clinical • Where there are delays or issues relating to the and/or security escort and/or Medevac as required acceptance of and admission into a SESLHD facility, the • liaising with RHW Access Demand Manager (ADM) / SESLHD Organisational Performance Support Manager After Hours Nurse Manager (AHNM) after clinical (OPSM) should be contacted discussion, with the decision to transfer the woman to • To ensure timely and safe coordination of inter-facility RHW transfers for patients requiring access to specialist care • ensure appropriate copy of clinical records are sent to unresolved issues are to be managed at the Director RHW Programs and Performance or SESLHD Executive on-call level.

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Appendix 11: NORFOLK ISLAND TRANSFERS TO SESLHD – RHW - non urgent

NIHRACS General Practitioner (GP) assess and recognises Maternal Transfer but not within 24 hours is required ↓ ↓ NIHRACS GP and Manager contacts RHW Transfer Coordinator (TC) on telephone number +61 434 565 264 to coordinate teleconference with the obstetric consultant on-call at RHW to: • Confirm maternal transfer is required and timeframe- MP4-5 • Ensure that the woman is safe to transfer NIHRACS GP and Manager to contact Queensland Health direct for QLD Bookings. Do not contact RHW ↓ ↓ Woman safe to travel Woman not safe to transfer ↓ ↓ ↓ A conference call may be required between NIHRACS NIHRACS Manager and RHW obstetric Decision may be made at RHW Manager to book consultants if: consultant level to escalate accepts → and confirm flight to immediate transfer or to transfer • Change in maternal or fetal → on commercial condition remain and deliver at

airline • clinical uncertainty Norfolk Island • uncertainty regarding safety to transfer ↓ ↓ ↓ ↓ NIHRACS Manager contacts RHW ADM / AHNM Refer to Transfer Process for +61 434 565 264 to handover clinical information immediate within 24 hour flow RHW ADM/AHNM enters inter hospital transfer in PFP/IHT sheet ↓ ↓ NIHRACS Manager Responsibility: Norfolk Island contact details and flight times • arranging the patient transfer, including where • NIHRACS 24 hrs number is international clinical and/or security escort and/or Medevac 0011 6723 22091 as required • liaising with RHW ADM/AHNM after clinical discussion, with the decision to transfer the Commercial Flights - Norfolk to Sydney - Air woman to RHW New Zealand • ensure appropriate copy of clinical records are • Direct to Sydney (2hrs 45 mins) sent to RHW - Sunday 1500 (only in summer) • a comprehensive clinical handover should - Monday and Friday 1445* occur as close as possible to the referred - Saturday and Tuesdays 1555* - person departing the NIHRACS facility. Sydney through Brisbane (arrival time • handover is to include transport arrangements to Sydney varies depending on and expected time of arrival at RHW connecting flights (approx 5 hrs 45 • phone contact details are to be exchanged mins) between NIHRACS and RHW to enable *Subject to change. communication between the escorting team and RHW

For all transfers with prior booking arrangements to Queensland Health do not contact RHW for transfer. Transfers to QLD coordinated through RSQ – +61 1300 799 127

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Appendix 12: FETAL FIBRONECTIN LEVELS AND RISK OF DELIVERY

Aspect Consideration Context Fetal fibronectin (fFN) is a glycoprotein thought to promote adhesion between the fetal chorion and maternal decidua. It is normally present in low concentrations in the cervicovaginal secretions between 18 and 34 weeks gestation, rising as term approaches. Elevated levels of fFN (typically > 50 ng/mL) in cervicovaginal secretions after 22 weeks’ gestation are associated with an increased risk of PTB. A negative fFN (< 50 ng/mL) is associated with a 99.5% negative predictive value for PTB within 7 days and 99.2% in the next 14 days. Quantitative fFN testing may improve assessment of overall risk, reduce transfer where there is a low / very low likelihood of birth and ultimately reduce longer term costs and burden for women and families. Indications Symptomatic TPL between 23+0 and 36+0 weeks’ gestation and Intact membranes and Cervical dilatation less than or equal to 3 cm and Where knowledge of result will change the clinical management Contraindications Cervical dilatation more than 3 cm Ruptured membranes Bleeding Cervical cerclage insitu Presence of soaps, gels, lubricants, disinfectants, semen in the vagina Relative Potential for FALSE NEGATIVE RESULT contraindications • After the use of lubricants or antiseptics Potential for FALSE POSITVE RESULT • Within 24 hours of sexual intercourse • Within 24 hours of digital cervical examination Procedure Performed during sterile speculum examination prior to any examination or manipulation of the cervix or vagina Use only sterile water as a lubricant Obtain the sample for testing from the posterior fornix of the vagina as per test kit instructions

Quantitative fFN Quantitative fFN testing can: testing o Quantify the likelihood of preterm birth o Assist with risk assessment and planning o Avoid unnecessary interventions o Identify women for targeted interventions o Provide reassurance to health care providers and the woman

Imminent birth fFN assessment is not required when birth is imminent (*MP1 category) Interpreting fFn results Action fFN As for all women requiring admission and >200/mL Commence tocolysis if delay of birth indicated and no contraindications (*MP3 Category) (29% chance birth WILL occur <14 days) As for all women requiring admission and fFN 50 – o Consider tocolysis if delay of birth indicated and no contraindications 199ng/mL o Consider all clinical circumstances including previous history of PTB (*MP4 category)

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(8% chance birth WILL occur <14 days)

fFN < 50 ng/mL Admission is not required provided there are no other risk factors / indications. (negative) Arrange follow up and provide the women with targeted information False positive may occur as a result of recent: (98% chance birth o Coitus will NOT occur <14 o Digital vaginal examination days) o Transvaginal ultrasound o Bleeding (*MP5 category)

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Appendix 13: MATERNAL TRANSFERS CONSULTATION FORM

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