The current Vanderbilt NICU has adequate bedspace to optimally care for a maximum of 70 babies.  Vanderbilt administration and neonatology desire to admit all newborns to Vanderbilt that seek to come, and consider diversion only when all possible strategies to make bedspace available have failed.  However, when demand for admission to the NICU exceeds available bedspaces, neonatology fellows and attending physicians must seek flexible alternatives to ensure that all newborn patients in the Middle Tennessee area receive the medical care they need. 

Before considering diversion, the neonatology staff should first ensure that all patients who are ready to go home have been discharged.  Patients who are > 1500g and medically stable may be back-transported to hospitals closer to their homes, if parents and accepting physicians are interested, and the accepting hospital is able to provide the level of care needed by the patient.  Higher acuity patients may be back-transported to other Level III hospitals as appropriate.

Patients whose care can be adequately provided by the medical teams on the pediatric floors at VCH, in the term newborn nursery, or in the Pediatric Intensive Care Unit may be transferred to another area of Vanderbilt Children's Hospital..

Surgical infants who do not require mechanical ventilation may be transferred to the floor.  Newborn nursery can manage mildly preterm infants who need an isolette for thermoregulation if the infant does not have apneic events. Term cardiac and surgical infants can be transferred to the PICU.

If a transport call is received during a bed shortage/census crisis, the VUMC physician taking the call should never refuse a patient.  If diversion appears to be necessary, the neonatology fellow taking the referring physician’s call should involve Vanderbilt’s attending physician to assist in this process. 

The neonatology attending should ensure that all possibilities for establishing bedspace have been exhausted, and notify Vanderbilt administration via nursing supervisors before considering diversion.  Vanderbilt administration may be able to alleviate certain obstacles to discharge or increase nurse staffing or equipment availability. 

If the patient in question has a problem whose needs can be uniquely met at Vanderbilt, all possible efforts should be made to bring the baby to VCH.  Because Vanderbilt is the only facility in its region which can provide cardiac and pediatric surgery services for newborns, patients with cardiac and surgical issues must be accepted.  Term cardiac patients, however, can frequently be admitted to the PICU.  These decisions need to be made in conjunction with the NICU attending, the cardiology or surgical attending, and the PICU attending.

Potential ECMO patients should not be deferred unless all ECMO capacity at VCH is occupied.  Similarly, patients who are candidates for iNO therapy should be considered potential ECMO patients and are uniquely served by VCH.  If the NICU cannot admit an ECMO patient, contact the PICU before sending the patient to Louisville or Arkansas.  ECMO triage decisions should be made in conjunction with the ECMO Coordinator and Dr. Bill Walsh.

A patient who requires pediatric subspecialty consultation (genetics, neurology, etc.) should also be considered an essential VCH admission.

If admission to Vanderbilt is absolutely not possible, a patient whose needs could be met by another Level III NICU (prematurity, respiratory distress, etc.) may be transported by the Angel team to either Centennial Hospital or Baptist Hospital here in Nashville.  The physician taking the transport request should contact the on-call neonatologist at these institutions to request bed space. 

Babies who could be managed in a Level II Special Care Nursery and are located in the vicinity of Clarksville (Ft. Campbell, Russellville, Paducah, Bowling Green, Tennessee Christian, etc.) can sometimes be transported directly to Gateway.  The nurses, physicians, and respiratory therapists at Gateway can manage ventilated patients. The transport physician should contact Dr. Bradley Stancombe to assess this possibility.

If Angel is used to transport an acute patient to another facility, the transport physician at VUMC should make sure the referring physician understands that the patient is not being admitted to Vanderbilt.  The transport team will also make sure this is clear to the parents when obtaining consent for transport. The transport team should bring the original medical record forms for the patient to VCH to create an outpatient medical record.  The receiving hospital should receive photocopies.  The medical receptionist should request an outpatient blue addressograph card with the patient’s information.

Because VCH was responsible for transporting a patient admission to an alternate nursery, VCH will also take responsibility for back-transporting that patient at the accepting nursery’s request.

Discussed at the Clinical Division Meeting 7/15/2002.  Revisited at the Clinical Division Meeting 11/18/02.