Document Type: Unique Identifier:

PROCEDURE NEON/PROC/004
Title: Version Number:
Handover of Care of Neonates 1

Status:
Ratified
Scope: Classification:
All staff involved in the care of newborns within the Departmental
Women and Children’s Unit
Author/Originator and title: Responsibility:
Shelley Piper, Neonatal Lead Nurse Women and
Children’s Division
Replaces: Description of amendments:
New Policy

Name Of: Date of Meeting: Risk Assessment:

Divisional/Directorate/Working Not Applicable
Group: Financial
Implications
Not Applicable
Validated by: Validation Date: Which Principles
Child Health Directorate Meeting 15/08/2012 of the NHS
Constitution
Apply?
Principle 1-4
Ratified by: Ratified Date: Issue Date:
Clinical Improvement Committee 02/10/2012 02/10/2012

Review dates may alter if any significant changes are Review Date:
made 01/08/2015

Does this document meet the requirements of the Equality Act 2010 in relation
to Race, Religion and Belief, Age, Disability, Gender, Sexual Orientation,
Gender Identity, Pregnancy & Maternity, Marriage and Civil Partnership,
Carers, Human Rights and Social Economic Deprivation discrimination? Initial
Assessment
1. PURPOSE

To ensure a robust handover of care takes place when a newborn infant is transferred
within the hospital setting or to another hospital for further care. This procedure should be
read in conjunction with the Admission and Transfer of the Newborn policy
(SCBU/Pol/001) which identifies the processes to follow when transferring a newborn
infant between all care settings.

2. SCOPE

All staff involved in the care of a newborn infant working within the Women and Children’s
Unit

3. PROCEDURE

3.1 Handover Requirements Between All Care Settings, to Include both Giving and
Receiving of Information
All care will be verbally handed over using a description of the locally agreed handover of
care tool - SBAR (Situation, Background, Assessment and Recommendations) between
shifts on the NNU or when transferring a newborn to another care setting. As a minimum
a nursing team handover will take place at each shift change, i.e. early shift, late shift and
night shift. In the event of staff working long days and covering both early and late shifts
clinical handover of care may not be necessary for the late shift. All handovers will be
tailored to individual patients and will include some of the following dependent upon the
baby’s clinical condition at the time of handover.

Situation
• Patient’s name, Age , Gestation,
• Reason for Admission or Transfer

Background
• Mode of delivery
• Condition at birth and admission
• Events overview (i.e respiratory, cardiovascular, surgical, transfers)
• Safeguarding issues
• Maternal history

Assessment
• Current condition including:
• Respiratory/ cardiovascular
• Nutrition and elimination
• Thermoregulation
• Drugs/Investigations/other/medication
• Skin assessment

Recommendations
• Plan of care from ward round
• Including further investigations and follow up required
• Changes to feeds
• Drug review

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• Discharge plans
• Family/ parentcraft issues

3.2 How Handover is Recorded

3.2.1Handover between shifts on the Neonatal Unit
• At the end of each shift the nurse responsible for the baby’s care during the shift, will
provide a nursing summary which will be written in the baby’s notes.
• The Nurse in charge will complete the NNU SBAR handover sheet (see appendix 1)
and file this in the SBAR folder. This information will be stored in line with
Corp/Proc/508 (See Section 7).

3.2.2 Handover from the Delivery Suite/ Maternity wards to the Neonatal Unit
• A ‘Baby Transfer Notification form will be completed on Euroking by the transferring
midwife. This form will be printed and signed by both the transferring and receiving
Nurse/Midwife and filed in the baby notes

3.2.3 Handover from Neonatal Unit to the Delivery Suite/ Maternity Wards
• A ‘Handover of Care from the Neonatal Unit to Delivery Suite / Maternity Wards / Other
Hospitals’ form will be completed by the transferring nurse/midwife and signed by both
the transferring and receiving Nurse/Midwife and filed in the baby notes (see appendix
2)

3.2.4 Handover between NNU and other hospitals

The following documentation will be given to the transport team, organised by the
Neonatal team.
• Completed electronic Badger NNU summary form, copy to be filed in baby notes.
• Completed Handover of care from Neonatal Unit form
• Xrays (may require hard or CD copy depending on receiving unit’s compatibility with
PACS).
• Photocopies of:
• Prescription chart
• Blood gas charts
• Blood results charts

3.3 Out of Hours Handover Process

3.3.1 Handover within the Maternity wards and Neonatal Unit
Handover of infants will follow the same process out of hours within the hospital setting.

3.3 Process for Monitoring Compliance

The process for monitoring compliance is outlined in Appendix 3 and the audit proforma
Appendix 4.

4. ATTACHMENTS
Appendix 1 NNU SBAR Handover Sheet
Appendix 2 Handover of care from the Neonatal Unit to Delivery Suite/Maternity
Wards/Other Hospitals
Appendix 3 Process for Monitoring Compliance
Appendix 4 Audit Proforma
Appendix 5 Equality Analysis Form

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5. ELECTRONIC AND MANUAL RECORDING OF INFORMATION
Electronic Database for Procedural Documents
Held by Policy Co-ordinators/Archive Office

6. LOCATIONS THIS DOCUMENT ISSUED TO

Copy No Location Date Issued
1 Intranet 02/10/2012
2 Wards and Departments 02/10/2012

7. OTHER RELEVANT/ASSOCIATED DOCUMENTS

Unique Identifier Title and web links from the document library
SCBU/Pol/001 Admission and Transfer of the Newborn

8. SUPPORTING REFERENCES/EVIDENCE BASED DOCUMENTS

References In Full

9. CONSULTATION WITH STAFF AND PATIENTS

Name Designation

10. DEFINITIONS/GLOSSARY OF TERMS

11. AUTHOR/DIVISIONAL/DIRECTORATE MANAGER APPROVAL

Issued By Shelley Piper Checked By Dr P Curtis
Job Title Neonatal Lead Job Title Clinical Director
Nurse
Date October 2012 Date October 2012

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 Appendix 1 Neonatal SBAR Handover Sheet - DATE: …………………………….

ROOMING-IN SAFEGUARDING ISSUES

ITU
HDU STAFF on duty PENDING DISCHARGES

SCBU SICKNESS PENDING ADMISSIONS

TC WARD ATTENDERS am pm N

Resuscitaire & Grab Bag Check

Uniform Policy Check

Staff
Situation Background Assessment Recommendation
Allocation
Early shift Name: Brief update Respiratory Plan/changes
Outstanding issues
Nutrition
Late Shift
Gestation: Drugs

Age:
Night Investigations
Room:
Other
Early shift Name: Brief update Respiratory Plan/changes
Outstanding issues
Nutrition

Late Shift
Gestation: Drugs

Age:
Night Investigations
Room:
Other
Early shift Name: Brief update Respiratory Plan/changes
Outstanding issues
Nutrition

Late Shift
Gestation: Drugs

Age:
Night Investigations
Room:
Other
Early shift Name: Brief update Respiratory Plan/changes
Outstanding issues
Nutrition

Late Shift
Gestation: Drugs

Age:
Night Investigations
Room:
Other

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Appendix 2: Handover of Care from the Neonatal Unit to Delivery Suite / Maternity Wards /
Other Hospitals

FILE IN SECTION 4

Handover of care from the Neonatal Unit to Delivery Write patient details or affix Identification
Suite / Maternity Wards / Other Hospitals label

Abbreviations used in this Hospital Number:

document to be listed here with the Name:
full description: Address:

NNU – Neonatal Unit Date of Birth:

Date of Time of
S Gestation Age
Handover Handover
Reason for NNU admission

Condition at birth and admission

Events Overview
B i.e. respiratory& cardiovascular,
surgical transfers
Safeguarding issues

Maternal history

Current condition including:

Respiratory

Nutrition and elimination

Thermoregulation

A Drugs/investigations/other/
Medication

Medication
(date & time of last doses)

Skin assessment

Plan of care from ward round:

Including further investigations &
follow up required
Changes to feeds

R Drug Review

Discharge Plans

Family / parentcraft issues

Handed over by: Received by:

Designation: Designation:

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Appendix 3: Process for Monitoring Compliance

Responsible Responsible individual/ Responsible individual/

Process for Responsible
Minimum requirement to be Frequency of individual/ group/ group/ committee for group/ committee for
monitoring e.g. individual/ group/
monitored monitoring committee for review development of action monitoring of action plan and
audit committee
of results plan Implementation

a) Handover requirements Audit Neonatal Lead Annual Women and Children’s Neonatal Lead Nurse Women and Children’s
between all care settings, to Nurse Divisional Governance Women and Children’s Divisional Governance Group
include both giving and Group Divisional Governance
receiving of information Group
b) How handover is recorded Audit Neonatal Lead Annual Women and Children’s Neonatal Lead Nurse Women and Children’s
Nurse Divisional Governance Women and Children’s Divisional Governance Group
Group Divisional Governance
Group
c) Out of Hours Handover Audit Neonatal Lead Annual Women and Children’s Neonatal Lead Nurse Women and Children’s
Process Nurse Divisional Governance Women and Children’s Divisional Governance Group
Group Divisional Governance
Group

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Appendix 4: Audit Proforma Clinical Handover of Care – Neonates

AUDIT PROFORMA
Handover requirements between all care settings, to include giving, receiving and
recording of information
No. Question Yes No N/A
1 In all handover situations was care verbally handed over
using a description of the locally agreed handover of care
tool (SBAR), tailored to the individual baby’s clinical
condition, between shifts (as a minimum, early, late (as
applicable), night) on the neonatal unit or when
transferring a newborn to another care setting?
a) Early shift
b) Late shift (if applicable)
c) Night shift
d) Transferring a newborn to another care setting
Handover between shifts on the Neonatal Unit
2 At the end of each shift did the nurse responsible for the
baby’s care during the shift write a nursing summary in
the baby’s notes for the following shifts?
a) Early shift
b) Late shift (if applicable)
c) Night shift
3 At the end of each shift did the nurse in charge complete
the NNU SBAR handover sheet and file this in the SBAR
folder for the following shifts?
a) Early shift
b) Late shift (if applicable)
c) Night shift
4 At the beginning of the new shift did the nurse
responsible for the baby’s care ensure a verbal handover
was provided to the receiving nurse using the SBAR tool
as follows and was this tailored to the individual baby’s
clinical condition at the time of handover and include
some of the following:
Situation
a Patient’s Name
b Age
c Gestation
Reason for admission or transfer
d
Background
e Condition at birth and admission
f Events overview (i.e. respiratory, cardiovascular, surgical,
transfers)
g Safeguarding issues
h Maternal history
Assessment
Current condition including:
i Respiratory
j Nutrition and elimination
k Thermoregulation
l Drugs/investigations/other/medication
m Skin assessment
Recommendations
n Plan of care from ward round
o Including further investigations and follow up required
p Changes to feeds
q Drug review
r Discharge plans
s Family / parentcraft issues
No. Question Yes No N/A
Handover from Delivery Suite / Maternity Wards to the Neonatal Unit
5 On transfer from Delivery Suite / Maternity Wards to the
Neonatal Unit was a ‘Baby Transfer Notification’ form
completed electronically on Euroking by the transferring
midwife?
6 Was the ‘Baby Transfer Notification’ form printed and
signed by the transferring midwife
7 Was the ‘Baby Transfer Notification’ form signed by the
receiving nurse / midwife
8 Was the ‘Baby Transfer Notification’ form filed in the baby
notes
Handover from Neonatal Unit to the Delivery Suite / Maternity Wards
9 On transfer from Neonatal Unit to the Delivery Suite /
Maternity Wards was a ‘Handover of Care from the
Neonatal Unit to Delivery Suite/Maternity Wards/Other
Hospitals’ form completed by the transferring
nurse/midwife?
10 Was the ‘Handover of Care from the Neonatal Unit to
Delivery Suite/Maternity Wards/Other Hospitals’ form
signed by the transferring nurse / midwife?
11 Was the ‘Handover of Care from the Neonatal Unit to
Delivery Suite/Maternity Wards/Other Hospitals’ form
signed by the receiving nurse / midwife?
12 Was the ‘Handover of Care from the Neonatal Unit to
Delivery Suite/Maternity Wards/Other Hospitals’ form filed
in the baby notes?
Handover between Neonatal Unit and Other Hospitals
13 On transfer from Neonatal Unit to Other Hospitals was
the following information given to the transport team:
a A completed electronic Badger NNU summary form
b Was a copy of the Badger NNU summary filed in baby’s
notes
c Completed photocopied ‘Handover of care from Neonatal
Unit to Delivery Suite/Maternity Wards/Other Hospitals
form’
d Xrays
Photocopies of the following:
e Prescription chart
f Blood gas charts
g Blood results charts
Out of hours handover process
14 Where handover of infants took place out of hours did the
same procedure as above take place

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Appendix 5: Equality Impact Assessment Tool

To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval.

Would the relevant Equality groups be affected by the document? (If Yes please explain why you
believe this to be discriminatory in Comment box)
Title & Identification Number of the Document: Handover of Care of Neonates
Neon/Proc/004

Questionnaire Yes/No Comments

Double click
and select
answer
1 Grounds of race, ethnicity, colour,
nationality or national origins e.g. No
people of different ethnic
backgrounds including minorities:
gypsy travellers and refugees /
asylum seekers.

2 Grounds of Gender including No

Transsexual, Transgender people

3 Grounds of Religion or belief e.g. No

religious /faith or other groups with
recognised belief systems

4 Grounds of Sexual orientation No

including lesbian, gay and bisexual
people
5 Grounds of Age older people, No
children and young people

6 Grounds of Disability: Disabled No

people, groups of physical or
sensory impairment or mental
disability

7 Is there any evidence that some No

groups are affected differently?

8 If you have identified potential No

discrimination, are any exceptions
valid, legal and/or justifiable?

9 Is the impact of the No

document/guidance likely to be
having an adverse/negative affect on
the person (s)?
10 If so can the negative impact be N/A
avoided?

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11 What alternatives are there to avoid Please Comment
the adverse/negative impact?

12 Can we reduce the adverse/negative N/A Please Identify How

impact by taking different action?
13 Q1 (a) Is the document Q2 (b) (i) Is the document Q3 (c) Is the document
directly discriminatory? indirectly discriminatory? intended to increase equality of
No No opportunity by positive action or
b (ii) If you said yes , is this action to redress disadvantage
(under any discrimination
justifiable in meeting a N/A
legislation)
legitimate aim Please give details
• Racial Discrimination
N/A To safeguard vulnerable adults
• Age Discrimination
• Disability Discrimination
• Gender Equality
• Sexual Discrimination

14 If you have answered no to all the above questions 1-13 and the document does not
discriminate any Equality Groups please go to section 15

If you answered yes to Q1 (a) and no to Q3 (b) this is unlawful discrimination.

If you answered yes to Q2 (b) (i) no to Q2 (b) (ii) and no to Q3 (c), this is unlawful discrimination

If the content of the document is not directly or indirectly discriminatory, does it still have
an adverse impact?
No

Please give details

If the content document is unlawfully discriminatory, you must decide how to ensure the
organisation acts lawfully and amend the document accordingly to avoid or reduce this
impact
15 Name of the Author completing the Equality Impact Assessment Tool.

Name Shelley Piper

Signature

Designation Neonatal Lead Nurse

Date August 2012

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