Transferring to a Level 2 NICU

Having your baby in the Neonatal Intensive Care Unit (NICU) might be something you never expected. You have learned about the NICU, met your baby’s team members, and have (or are figuring out) a routine while in the NICU. However, you may be surprised to hear that babies sometimes are transferred to different NICUs depending on the care they need.

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Neonatal Transfers: Moving your baby to a community hospital

What are the different kinds of NICUs?

NICUs or Special Care Nurseries (SCN) are often referred to by a number or a “level of care.” Canada's provinces and territories may differ slightly in how they decide levels of NICU care.

Level 1 mother and baby care:

Care for healthy, term (or near-term) babies
Babies generally stay in the parent’s hospital room
Family doctors or pediatricians and other team members care for babies
Provide some special care, such as helping babies transition after birth and treatment for common medical issues like jaundice
Have a team ready to help in an emergency or if concerns arise
May need to transfer premature or sick babies to a higher level of care

Level 2 NICU or SCN:

Care for premature babies born as early as 30-34 weeks (depending on the hospital)
Care for sick or premature infants who need some specialized care (such as help with breathing, tube feeding, IV medicines and other special care)
Pediatricians and other team members care for babies
May need to transfer babies to a higher level of care if babies are very premature (less than 30-34 weeks, depending on the hospital) or if babies are sick needing a higher level of special care.
Take care of babies who are well enough to be transferred from a level 3 NICU

Level 3 NICU:

Care for babies who are very premature, very sick or have medical conditions that need very specialized care
Have neonatologists (pediatricians who are specialists in premature or sick babies) and other team members to care for babies.
Have sub-specialists available (such as heart specialists, brain specialists and many others)
When a baby is ready, they will usually transfer babies to a level 2 NICU that can meet the baby’s needs closer to where the parents live.

Why might babies be transferred?

The most common reasons babies move between NICUs are:

A baby is in a level 1 unit and needs special care in a level 2 or 3 NICU
A baby is in a level 2 NICU and needs special care in a level 3 NICU
A baby in a level 3 NICU is now well enough to be cared for in a level 2 NICU
A baby is moved to a NICU closer to home to make it easier for the baby’s family

Why are babies transferred from a level 3 to a level 2 NICU:

Moving babies to a level 2 NICU when they are ready is helpful because:

Level 3 NICUs need to make space for babies who need them
Level 2 NICUs specialize in helping babies learn to eat and reach other milestones needed before going home
Level 2 NICUs are experts in helping new parents learn to care for their babies
Level 2 NICUs are often located in or closer to the community where babies and their families live. They help arrange any needed follow-up close to home.

Will I be part of the decision to transfer my baby?

If your baby is in a level 3 NICU, your baby’s team will talk to you about the possible transfer when your baby is ready. They may ask you what hospital is closest to your home and speak with you about which hospitals can meet your baby's needs. Sometimes parents wish their baby could stay in the level 3 NICU. The level 3 NICUs must make space for the very premature and sick babies who need them. The transfer will often still need to happen, even when parents wish their babies could stay. Your baby’s team will talk to you about your questions.

How does the transfer work?

When it comes time for a baby to move to a level 2 NICU, your baby’s team will ensure that you and your baby’s new team have all the information needed. The process usually works like this:

Your baby’s team chooses a level 2 NICU as close to your home as possible and one that can meet all your baby’s needs
The level 3 NICU team will talk with the level 2 NICU and tell them all about your baby
The level 2 NICU will let your baby's team know when they have space for your baby (sometimes called "a bed"). This can happen right away or take many days.
Your baby's doctor or nurse practitioner (NP) will talk to the doctor or NP in the level 2 NICU and give them all the details about your baby. They will discuss your baby’s birth, medical issues, treatment, progress, and plans.
Your baby's nurse will place your baby in a special "transport incubator,” an incubator just like the ones in the NICU but one that can go in an ambulance. An ambulance will take your baby to the new hospital. Your baby's nurse will be with your baby the whole time. Your baby’s nurse will talk to the new NICU team and ensure they have all the details needed to care for your baby.

What might be different in the level 2 NICU:

Every NICU has their routines. Some things you might notice are:

Things look different.

Some level 2 NICUs have individual, private rooms for babies. Others have a more open layout where babies are in an open space (with each baby having their own space that can be divided by curtains or other barriers for privacy when needed). Equipment may also look different between units.

Nurses have more patients.

As babies mature and get well, nurses take care of more babies. Nurses may have 2-4 babies in a level 2 NICU.

Your baby’s team may wear gowns and gloves.

All patients moving between units or hospitals (of any age) are checked for infection. Your baby's teams will wear gowns and gloves when touching your baby for at least two days.

This is normal for infection prevention and control when patients move between hospitals.

The team seems smaller.

Level 3 NICUs often have big teams of doctors, residents, and fellows (doctors completing training in a specialty), medical students, nursing students, nurses and “allied health” teams (social workers, dietitians, occupational therapists, respiratory therapists etc.). These same team members are often at the level 2 NICU but in smaller numbers. Your baby's team will ensure the level 2 NICU has all the team members your baby needs before transferring.

Routines are different.

Your baby's nurse in the level 2 NICU will talk to you about things that might differ from the level 3 NICU. Every NICU has routines, which might seem a bit different.

Less freezer room for breast milk.

Some level 2 NICUs do not have as much room to store frozen breast milk as level 3 NICUs. Therefore, they may ask you to keep some of your milk in your freezer at home.

Visiting rules may be different.

Parents are not visitors and are generally encouraged to be with their babies as much as they want. However, hospital rules about other family members coming to the NICU may differ.

What can I do to help my baby and family through this change?

Whether you have been in the level 3 NICU for hours, days, weeks, or months, moving to a new NICU is a big change. You may feel worried or stressed; this is normal. Your baby's team in the level 3 and 2 NICU understands that this may feel hard even though it is “a step closer to home.”

Here are some suggestions of things that you might find helpful:

Before transfer, ask your baby’s team for information about the new unit (address, phone number to the NICU, or any other information they have)
Call the level 2 NICU before your baby arrives. Ask for the name of the nurse and doctor who will take care of your baby on arrival (sometimes it helps to know their names). Ask about their visiting guidelines for other family members or policies for parents in the NICU. Ask about where you should park and for directions to the NICU once you reach the hospital.
When you arrive at the new NICU, remember that things will look and feel different and that this is normal.
Ask your baby's nurse and team any questions you have. Write questions down or put a note on your phone. Some examples of questions you might find helpful:
- What are the parental presence and visiting guidelines?
- What time are “rounds” (when the doctor and team come and see each baby)?
- If I can’t be there during the day, how can I get updates from the doctor?
- What is the best phone number to talk to my baby’s nurse?
- What changes do you see coming for my baby the next day? In the next week?
- Are there breast pumps available? What is supplied, and what do I need to provide? How do you want me to label my milk?
- How do I sterilize bottles or breast pump supplies while at the hospital?
- Is there anything you would like me to bring from home for my baby?
- Can I bring clothes for my baby?
- Is there a parent space available outside the NICU? Is there a fridge or microwave I can use?
- Where can I buy meals, coffee, and snacks?
- Where is the parent/visitor bathroom?

You are the most important member of your baby’s team.

Tell your baby’s team and nurse if there are things you want them to know about your baby. Also, tell your baby’s nurse how you have been involved in your baby’s care. For example, if you have been bathing your baby by yourself and would like to continue this routine, tell your baby's nurse. If you haven't yet had a chance to hold your baby, help with a bath, breast, or bottle feed your baby and are feeling nervous, talk to your baby’s nurses about that too, they can help!

One step closer to home

"One step closer to home" is often something NICU team members will say when a baby moves to a level 2 NICU. Transferring to a level 2 NICU can be challenging for parents. It can be an exciting step forward, but it can also be hard to leave the level 3 NICU. Ask questions and seek whatever support you need to feel comfortable in your new NICU. Let your baby's team know how you are feeling. They have helped countless families through this change.

Resources across Canada:

Canadian Premature Babies Foundation – Video Series

Transferring your baby from a level 3 NICU – What, Why and How! With Dr. Doug Campbell

https://www.youtube.com/watch?v=5NFDYRdtEYo

Canadian Premature Babies Foundation – support information:

https://www.cpbf-fbpc.org/support

Canadian Premature Babies Foundation – Peer Support Information:

https://www.cpbf-fbpc.org/peer-support-for-nicu-families

Sunnybrook Health Science Centre - Toronto, Ontario:

https://sunnybrook.ca/content/?page=nicu-transfer

Mount Sinai Hospital - Toronto, Ontario:

https://www.mountsinai.on.ca/care/nicu/going-home/transferring-your-baby-to-a-level-2-nursery-closer-to-home