Perspectives on non-emergent neonatal intensive care unit to pediatric intensive care unit care transfers in the United States

Table 1 Respondent demographics and transfer characteristics, n (%)

n = 81		Value
Role	Attending	81 (100)
Hospital type	Academic/University-Affiliated	68 (84)
	Teaching hospital/non-university	13 (16)
PICU type	Stand-alone PICU	54 (67)
	Mixed PICU/Pediatric Cardiac Intensive Care Unit	27 (33)
ACGME fellowship program	PICU	56 (69)
	NICU	68 (84)
Unit size (beds)	PICU, median (IQR)	24 (19, 32)
	NICU, median (IQR)	57 (40, 80)
Non-emergent transfer criteria	Ad hoc (no clinical criteria)	42 (52)
	Always initiated by set clinical criteria	8 (10)
	Combination of both	29 (36)
	Other	2 (2)
Clinical criteria used in non-emergent transfer (n = 37)	Postnatal or corrected age	29 (78)
	Size (weight) of patient	11 (29)
	Specific medical diagnoses	19 (51)
	Need for specific medication	3 (9)
	Other	9 (24)
Protocol to facilitate non-emergent transfer	No	49 (61)
	Yes	27 (33)
	Unsure	5 (6)
Components of transfer process	Bedside nurse handoff	72 (89)
	Charge nurse handoff	39 (48)
	Frontline clinician handoff	60 (74)
	Attending to Attending handoff	70 (86)
	Other handoff1	4 (5)
	Pre-transfer multidisciplinary care team meetings	34 (42)
	Post-transfer bedside huddle	10 (13)
	Post-transfer multidisciplinary care team meetings	16 (20)
	Pre- and/or post-transfer checklists	4 (5)
	Other component2	11 (14)
	None	4 (5)

¹Other handoff: Fellow-to-Fellow (n = 1), Social worker (n = 1), Medical director-to-Medical director (n = 1), Nursing leadership (n = 1).

²Other component: Parental tour of the pediatric intensive care unit (PICU) (n = 6), PICU attendance on neonatal intensive care unit (NICU) rounds (n = 1), PICU nurses shadowing in the NICU (n = 1), Regular joint NICU-PICU meetings about patients (n = 1), Interdepartmental emails describing patients (n = 1), Transfer Center Activation (n = 1). ACGME: Accreditation Council for Graduate Medical Education; IQR: Interquartile Range.

Table 2 Issues raised in respondents’ evaluations of transfer practices

Preparing for transfer
Hospital vs patient needs	"[We need to] continue to improve the process of optimizing the transfer time for the Patient rather than for hospital census, etc. I preach the above statements to both the NICU and PICU in my institution frequently”
	"Having one, or multiple, chronic patients transferred to the PICU from the NICU will impact bed availability significantly more in the PICU than if these patients remain in the NICU. Having the PICU team consult might be a better solution if there are management questions by the NICU team"
	"[Our institutional] protocol is not always followed, and transfers always seem to occur at night or on weekends"
Expectation setting	"Parents are communicated about the need of transfer weeks before the actual transfer so they can start thinking about questions they want to bring up to the table prior to the transfer"
	"Parents get a lot of notice, opportunities to see the PICU, opportunities to meet the PICU clinicians and nursing, so that helps to make the transition smooth"
	"Having families visit and meet team members in the PICU is important. Sometimes, this involves multiple meetings. In addition, the goals of care need to be clearly defined. A few patients have significant medical conditions with poor prognosis and their chances are not improved by being transferred to another unit. Families need to understand this reality"
Transfer process
Benefits of multidisciplinary approach	"When able, having the multidisciplinary (primary and consulting physician teams) and interprofessional (MD, RN, RT, PT/OT/speech, CLS, chaplain, etc.) teams meet in advance to discuss the patient's course, status, and goals is beneficial"
	"Group discussion about the appropriateness of transfer including social work and nursing helps"
Care overlap	"The neonatologists remain easily available if we have questions about care or communicating to parents [in the PICU]"
	"We have a dedicated PICU attending who rounds every two weeks in the NICU on patients who are older and may need to be transferred. That physician facilitates the transfer and already has a working relationship with the family. A few days before the transfer nursing leadership and child life goes to the NICU and meets the family and the baby"
Post-Transfer adjustment
Medical care differences	"Preparing them [parents] for unit differences, new faces, how quickly PICU titrates/changes things vs NICU pace is needed"
	"Despite pre-transfer sign out and meetings, the new PICU team has a heightened sense of alertness and attention for at least a few weeks after transfer as we get to know the child. This might translate as repeating work ups that have previously been done, doing more lab draws, more ventilator adjustments, etc. I think this creates questions for parents about whether the PICU does too much or the NICU did too little"
Unit culture differences	"There is a difference in patient care workflow in the NICU and the PICU. This is not well explained to the families and creates 'culture shock' when the patients move"
	“We do a poor job preparing the parents for the physical change in space. Our NICU is very quiet with specialized sound panels, cozy rooms, dedicated/primary nursing. The PICU is LOUD and BRIGHT, has big sterile feeling rooms, and our unit does not practice primary nursing”

PICU: Pediatric intensive care unit; NICU: Neonatal intensive care unit.