Submission to the Inquiry into Perinatal Services From Melbourne Children's Campus

(incorporating University of Melbourne Department of Paediatrics, MCRI and RCH)

Dear Dr Everall and Members of the Inquiry committee,

Thank you for the opportunity to respond to this important inquiry.

This is a joint submission by heads of the Melbourne Children's campus Prof Cheryl Jones, Mr John Stanway, and Prof Kathryn North, on behalf of clinical, academic and research staff from each of our respective entities on this campus, prepared by Associate Prof Rod Hunt. These entities are the University of Melbourne Department of Paediatrics (UMDP), The Royal Children's Hospital (RCH), and the Murdoch Childrens' Research Institute (MCRI) at a purpose built co-located facility in Parkville. We have prepared our submission after consultation with key members of our staff who have expertise in Perinatal Services including Associate Prof Rod Hunt (Director of Neonatal Medicine, RCH; Co-Director of Neonatal Research, MCRI; Associate Professor, University of Melbourne) Prof Peter McDougall (Executive Director, Medical Services, RCH), Prof Paul Monagle, Prof Sharon Goldfeld (Deputy Director of the Centre for Community Child Health at The Royal Children's Hospital Melbourne; Co-Group Leader of Child Health Policy, Equity and Translation at the Murdoch Childrens Research Institute), Dr Michael Stewart (Director, Perinatal, Infant and Paediatric Emergency Retrieval, RCH),Prof Trevor Duke (Director of the Centre for International Child Health, University of Melbourne). A separate submission from the University of Melbourne Dept of Obstetrics and Gynaecology will be provided by Prof Sue walker, with comments from Prof Cheryl Jones.

Our response to the terms of reference are as below:

1. the availability, quality and safety of health services delivering services to women and their babies during the perinatal period;

Regionalised perinatal care has been the central planning principle that underpins the internationally benchmarked outstanding outcomes for women and babies in Victoria. Systematically implemented in the early to mid 1970s the Victorian system was one of the first examples of regionalised perinatal care in the world.

Perinatal Care is closely monitored in Victoria and the majority of babies receive excellent care. However, some populations remain vulnerable (e.g. babies of Aboriginal mothers), and there is variability in access to, and quality of, care (see response to point 2 below). The majority of mothers and babies in Victoria deliver without complication at a local medical facility and receive excellent medical care, in line with current best practice. This is monitored and reported in a timely way through a number of mechanisms including the Perinatal Safety and Quality Committee, reporting in the annual Victorian Perinatal Services Performance Indicator Report (most recently published for 2015-16)1, and the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) also reporting annually2• Notwithstanding these monitoring and review structures, there are a few examples where poor standards of care have occured in the perinatal area. Some of these, together with system failures that contributed, are detailed in the Duckett review.

1

Birthing options for Victorian women have expanded recently with the introduction of targeted home birthing programs supported through the public hospital sector.

Most recently, Victoria has published a slight increase in the number of annual births with a total of 78,961 births in 20~5. This is associated with a slight reduction in crude birth rate to 62.4 per 1000 estimated female resident population aged 15-44 years.

The Victorian Perinatal Mortality Rate (PMR) is as low as it has been in 15 years at 9.0 per 1000 births. which compares favourably to the most recently published national perinatal mortality rate of 9.6 per 1000 births for 2014. PMR comprises neonatal mortality and stillbirths with the latter being the major contributor. While there remains a small number of avoidable neonatal deaths it is universally accepted in developed countries that reducing stillbirths is the major priority in further reducing the PMR.

There has been a significant reduction in the perinatal mortality rate for women of Aboriginal and Torres Strait Island status, down to 13.6 per 1000 for the period 2013-2015. However the perinatal mortality in babies of Aboriginal women is still1.4 times higher than for babies of non-Aboriginal women. highlighting that our indigenous population remain vulnerable in this regard.

We recommend that: further resources be provided to support availability quality and safety of perinatal services for Aboriginal women and their babies in Victoria to enable further reductions in perinatal mortality and morbidity.

2. the adequacy of the number, location, distribution, quality and safety of health services capable of dealing with high-risk and premature births in Victoria;

There are currently facilities for high-risk and premature deliveries at three tertiary maternity centres (The Royal Women's Hospital (RWH), Mercy Hospital for Women (MHW) and Monash Medical Centre (MMC)), and facilities for the care of premature babies in four tertiary newborn intensive care units (RWH, MHW, MMC and The Royal Children's Hospital (RCH)). There are plans for the imminent expansion of these services with the graded opening of a new facility at Sunshine Hospital- the Joan Kirner Nursery. Infants with complex medical needs, or who require neonatal surgery, are cared for in one of two centres in Melbourne - RCH or MMC.

The current Neonatal and Maternity capability frameworks define 6 levels of care. Tertiary neonatal services are now referred to as Level 6 (6A for perinatal centres and 68 for services with surgical and other paediatric subspecialty services). The criteria used to assign a baby as L6 acuity (previously referred to as neonatal intensive care unit (NICU)) have been revised and the new definitions were implemented in June 2017.

Current experience with the new definition of L6 acuity suggests there will be an oversupply of L6 acuity cots in Victoria particularly in L6 health services where high risk birthing services are collocated (RWH, MHW, MMC). It is also clear that the demand for L6 total hospital nursery beds (containing L6 acuity, and high dependency L3-5 acuity babies) remains high with total occupancy close to or above 100% some of the time. A rebalancing of agreed L6 acuity and level 3 to 5 cots situated in L6 services is required in the near future to reflect the reality of acuity distribution.

2

With these system refinements there is an expectation that there will be adequate Level 6 capacity in Victoria, and that babies who do not, or no longer, meet L6 acuity or high dependency criteria could in the future be transferred to level 3-5 nurseries, or be transferred closer to home. While the occupancy of the State's L3-5 capacity rarely approaches 100% there is a geographic maldistribution of combined public and private cots across the State that is often the source of delays in transfers from LG to L3-5 nurseries.

Service planning continues with the intention that services will allow mothers and babies to be kept together wherever practicable, and that care be safely provided as close to home as practicable. There are some important issues to raise that need to be taken into account when forming policies around "decentralised care" of L3-5 babies:

a) Evidence of the high standard of perinatal care in Victoria exists in the outcomes of very preterm babies reported by the Victorian Infant Collaborative Studies (VICS).

b) VICS is regarded internationally as one a robust research cohort and its data shows Australia benchmarks favourably compared to many other developed countries.

c) As VICS deals with a very preterm cohort its outstanding outcomes largely reflect the standard of care in perinatal L6 centres

d) In the future a change to the place of care of these high risk preterm babies for a part of their hospital stay requires careful planning and monitoring.

e) Historically there has been a capability gap between L5 care in a L6 health service and LS care in a L5 health service and it is important to recognise this potential gap in the future.

To maximise appropriate down transfer to level 3 to 5 services, further work is required to resource and train services and staff in regional and rural centres. In this regard, professional bodies such as The Royal Australasian College of Physicians (RACP) and The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) have an ongoing obligation to ensure that training of medical staff produces highly competent medical specialists. The same obligation exists for other essential disciplines such as nursing, midwifery, anaesthesia and general practice.

Experts in the sector recognise that there is currently inequity in access to the highest quality perinatal care, with variation in expertise spread through the outer metropolitan, regional and rural sectors. This inequity has the potential to result in the delivery of suboptimal care.

More specialists with expertise in perinatal medicine are needed in rural/regional Victoria.

The RACP has an extensive national training program for physician trainees wishing to specialise in perinatal medicine. Training of sufficient numbers of specialists, both in general paediatrics and perinatal specialists, will ensure that staff are available to work in all geographic areas. Currently places in both training programs are unrestricted.

We therefore recommend that: Incentives for specialists to work in regional and rural services need review.

3. the quality, safety and effectiveness of current methods to reduce the incidence of maternal and infant mortality and premature births

More data is needed on Level 3-5 nurseries

3

Maternal and infant mortality rates are addressed above. Current monitoring suggests that current practice in Victoria is achieving excellent outcomes, whilst at the same time identifying vulnerable groups such as women with elevated BMI, and indigenous mother­infant dyads and adolescent pregnancies.

There is an increasing focus on Quality Improvement initiatives in the perinatal sector, both internationally3 and nationally4

• The tertiary NICU's in Victoria all participate in the Australian and New Zealand Neonatal Network {ANZNN). The ANZNN provides a mechanism within which all NICU's in Australia and New Zealand can compare outcomes on a range of morbidities associated with prematurity, and this benchmarking will stimulate the development of care bundles by centres with the best outcomes, so that all centres can optimise their outcomes from premature birth.

The challenge for Victoria, is that whilst all tertiary NICU's (level 6A and 68) currently participate in the ANZNN, the level3, 4 and 5 special care nurseries currently do not. With current focus on more efficient utilisation of NICU cots {through tighter definition of NICU patients) and transfer of babies with less intensive care needs out to level 3 - 5 nurseries, it will be important that a minimum dataset is collected by these special care nurseries so that outcomes, beyond those currently reported in the Perinatal Services Performance Indicator report, can be measured, compared and improved upon.

We recommend that: resources and infrastructure be provided to collect data (through ANZNN} of babies on /eve/3-5 nurseries to enable benchmarking, better resource allocation and monitoring of outcomes including increased safety.

4. access to and provision of an appropriately qualified workforce, including midwives, paediatricians, obstetricians, general practitioners, anaesthetists, maternal and child health nurses, mental health practitioners and lactation consultants across Victoria;

Further work is required to resource and train services and staff in regional and rural centres. In this regard, professional bodies such as The Royal Australasian College of Physicians (RACP) and The Royal Australian and New Zealand College of Obstetricians and Gynaecologists {RANZCOG) have an ongoing obligation to ensure that training of medical staff produces highly competent medical specialists. The same obligation exists for other essential disciplines such as nursing, midwifery, anaesthesia and general practice.

We therefore strongly recommendation that variation in practice is minimised through: 1. adequately resourcing Level 3 to 5 nurseries with staff, equipment and funded cots 2. the development of effective linkages between levell-2 services and regional L3-5 services. 3. ensuring that staff working in Level 3 to 5 nurseries are trained and accredited in the

provision of neonatal resuscitation, and 4. staff in Level 3 to 5 nurseries having formalised links to the Level 6a and 6b nurseries for

appropriate support, and that best practice guidelines are immediately available. This already occurs to a substantial degree5•

More specialists with expertise in perinatal medicine are needed in rural/regional Victoria. For the minority of newborns who require level 6 intensive care, there is some published evidence to support the premise that outcomes are optimised where care is centralised to

4

centres where expertise and experience can be concentrated eg. in the care of extremely preterm infants, and infants with certain surgical conditions6•

The RACP has an extensive national training program for physician trainees wishing to specialise in perinatal medicine. Training of sufficient numbers of specialists, both in general paediatrics and perinatal specialists, will ensure that staff are available to work in all geographic areas. Currently places in both training programs are unrestricted.

We therefore recommend that: Incentives for specialists to work in regional and rural services need review.

5. disparity in outcomes between rural and regional and metropolitan locations;

As discussed above, the PSPI annual report1 provides a suite of 10 indicators that capture outcome measures across the antenatal, perinatal and postnatal period for mothers and babies. This currently provides a comparison between all maternity services in the public sector, with a current intention that private hospitals will also soon report their site outcomes through this mechanism. When care of babies with mild to moderate prematurity, or mild to moderate conditions, is decentralised to regional and rural centres, then this will precipitate an increasing need to collect more rigorous data on neonatal outcomes from smaller centres to ensure that decentralised care does not increase risk.

As discussion under point 3, we strongly recommend that smaller centres are resourced sufficiently to participate in increased data collection through ANZNN to remove disparity in outcomes of babies between regional /rural and metropolitan parts of Victoria.

6. identification of best practice.

The perinatal sector in Victoria is currently actively engaged in basic and clinical research, that is then translated into clinical care. This activity is supported both through the professional colleges (RACP, RANZCOG), and internationally recognised research at Melbourne Children's Campus at the Murdoch Childrens Research Institute (MCRI) and the Department of Paediatrics at University of Melbourne, and RCH. Research into antenatal services conducted by the Dept of Obstretrics and Gynaeology at the University of Melbourne is discussed elsewhere. There are many examples of this research translating to improved clinical practice, one such example being the use of therapeutic hypothermia for newborn term infants with birth asphyxia. A local research group supported through MCRI conducted one of the many randomised controlled trials into hypothermia 7•

8, local

researchers systematically reviewed the evidence for its widespread use9, and this information is now available to clinicians across Victoria through the Neonatal e-handbook5

,

that is managed through the Maternity and Newborn Clinical Network in the Department of Health and Human Services.

The Neonatal Research Group at MCRI continues to lead and participate in nation wide random/sed controlled trials to ensure that best evidence is available for improving clinical practice, and ultimately improving outcomes for mothers and babies in Victoria.

5

Prepared by:

Associate Professor Rod W Hunt, BMBS, MMed(CiinEpi), PhD, DCH, FRACP, MRCP(UK) Director, Neonatal Medicine, The Royal Children's Hospital Director, Neonatal Research Group, MCRI Chair, Perinatal Safety and Quality Committee, DHHS NICU Director for ANZNN

Signed

Prof Cheryl Jones MBBS (Hons) PhD FRACP Stevenson Chair of Paediatrics, Head of Department, University of Melbourne Infectious Diseases Consultant, Royal Children's Hospital Leader, Brain infection group, Murdoch Children's Research Institute NHMRC CRE in Emerging Infectious Diseases (CREID) President, Australasian Society for Infectious Diseases Inc. (ASID)

Royal Children's Hospital

Prof Kathryn North Director Murdoch Children's Research Institute

6

References: 1. Victorian perinatal services performance indicators 2015-16. (https:/ /www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal­reproductive/maternity-newborn-services/vic-perinatal-services-performance-indicators)

2. Victoria's Mothers, Babies and Children 2014 and 2015: findings, recommendations and data (https:/ /www2. he a It h. vic.gov .a u/hospita Is-and-health-services/qua I ity-safety­service/consultative-councils/council-obstetric-paediatric-mortality/mothers-babies­children-report)

3. Shah V, Warre Rand Lee SK. Quality Improvement initiatives in neonatal intensive care unit networks: Achievements and Challenges. Academic Pediatrics 2013; 13 S75-S83.

4. Bowen JR, Callander I, Richards R, Lindrea KB; Sepsis Prevention in NICUs Group. Decreasing infection in neonatal intensive care units through quality improvement. Arch Dis Child Fetal Neonatal Ed. 2017 Jan;102{1):F51-F57. doi: 10.1136/archdischild-2015-310165. Epub 2016 May 2.

5. https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal­reprod uctive/ neonata 1-eha nd book/procedures/in itiation-hypotherm ia-scn

6. Bucher BT, Guth RM, MPH, Saito JM, MD, NajafT, MD and Warner BW. Impact of Hospital Volume on In-Hospital Mortality of lnfantsUndergoing Repair of Congenital Diaphragmatic Hernia. Ann Surg 2010;252: 635--642

7. Susan E. Jacobs, MD; Colin J. Morley, MD; Terrie E. lnder, MD; Michael J. Stewart, MD; Katherine R. Smith, MBiostat; Patrick J. McNamara, MD; lan M. R. Wright, MD; Haresh M. Kirpalani, MD; Brian A. Darlow, MD; Lex W. Doyle, MD; for the Infant Cooling Evaluation Collaboration. Whole-Body Hypothermia for Term and Near-Term Newborns With Hypoxic­Ischemic Encephalopathy A Randomized Controlled Trial. Arch Pediatr Adolesc Med. 2011;165{8):692-700. doi:10.1001/archpediatrics.2011.43

8. lnder TE, Hunt RW, Morley CJ, Coleman L, Doyle LW and Jacobs S. Systemic hypothermia selectively protects the cortex in term encephalopathy. Journal of Pediatrics 2004; 145: 835-7.

9. Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, lnder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD003311. 001: 10.1002/14651858.CD003311.pub3.

7