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| Immunology, Rheumatology & Infection | Neurology, Developmental Paediatrics & Neurohabilition |
| Paediatric Intensive Care & Neonatology |

Clinical Sub-specialties
Paediatric Intensive Care & Neonatology

Paediatric Intensive Care & Neonatology
Dr Nai-shun Tsoi
Dr Kar-yin Wong
Dr Yiu-ki Ng
Dr Stella Chim
Associate Consultant
Dr Rosanna Wong
Associate Consultant
Fellows: Dr Mabel Wong
Ward Managers: Ms Catherine So-chun Chan
  Ms Constance Po-fun Chan
Nurse Specialists: Ms Audrey Wing-seung Chan
  Ms May Suk-yee Yeung
  Ms Tomcy Suet-fong Leung
  Ms Josephine Sze-wai Lee

Activity & Service
Team photoThe team provides clinical service in Paediatric Intensive Care, Neonatal Intensive Care and high-risk neonatal care. It is also responsible for the care of all neonates born in Queen Mary Hospital.

The PICU is a tertiary centre admitting patients up to 18 years of age. Referrals are mainly from General Paediatrics, Haematology, Oncology, Neurology, Paediatric surgery, Neurosurgery, Trauma, ENT, Liver transplant, Bone marrow transplant, Orthopaedics and Oral Maxillofacial units. Highly specialized services such as liver transplantation, epileptic surgery, and Laser therapy for airway obstruction are territory-wide as they are only performed in Queen Mary Hospital.

The NICU is also a tertiary centre accepting Team photoreferrals from public and private institutions. Admissions include low birth weight neonates, multiple pregnancy and severe congenital malformations especially those requiring urgent medical or surgical interventions after birth. The team also provides and coordinates long-term follow up and rehabilitation programmes for those high-risk neonates discharged from the unit.

The PNICU is located on the 10th floor of K-block at Queen Mary Hospital. It was just renovated in 2001 to improve the capacity and facilities for the relocation of Tsan Yuk neonatal service. It has 7 PICU, 15 NICU, 1 HDU and 35 SCBU beds. A multidisciplinary team provides comprehensive and quality care with expertise in neonatology, critical care, respiratory medicine, acute nephrology, nursing, nutrition, pharmacology, rehabilitation and psychosocial services. All the ICU beds are fully equipped with state of the art patient monitors and ventilators. Modern treatment modalities including high frequency oscillatory ventilation, inhaled nitric oxide, haemodialysis, peritoneal dialysis and plasmapheresis are developed for critically ill patients. All patient documentations are now computerized. Isolation facilities capable of handling highly infectious disease such as SARS are also available.

The neonatal intensive care service continues to implement evidence based modern intensive care treatment including early surfactant replacement therapy, prevention of nosocomial infection, optimal nutrition management and the judicious use of non-invasive ventilatory support. Much focus has been put on improving total patient care including minimum handling and clustering of nursing care, breast feeding promotion, developmental care programme, antenatal parental counselling with NICU visitation for expectant parents of preterm delivery, pre-discharge programme and parents support group. A designated neonatal transport team is also available for transfer of critically ill neonates.

The annual PICU admission was around 300, of which 30% are from General Paediatrics, 10% from Haematology/ Oncology, 25% from Paediatric surgery and 20% from Neurosurgery. For Neonatal Service, the annual delivery rate in QMH is about 3500, most of which are high-risk obstetrics cases. The NICU admission is around 300 each year of which approximately 70% are inborn babies and 30% are outborn babies. The annual SCBU admission is around 2800.

Relocation of Tsan Yuk Neonatal Service
Neonatal transport team arrived at new NICUThe Department started the neonatal service more than 30 years ago in Tsan Yuk Hospital. It is the teaching hospital of The University of Hong Kong and the only maternity hospital in Hong Kong. With the devoted staff and neonatal expertise, the quality of service was highly respected in the territory. With advances in neonatal intensive care and declining birth rate in the territory, it is considered more cost effective to combine the neonatal and obstetric service with Queen Mary Hospital, where there are fully equipped on-site supporting facilities including imaging studies such as CT and MRI scans, paediatric surgery or neurosurgery specialties consultations. The neonatal and obstetrical services were thus relocated to Queen Mary Hospital in October 2001.

This relocation provided a chance to improve the existing service in Queen Mary Hospital. Major alteration of ward K10S was carried out for better PICU operation and provision of standard isolation facilities. Ward K10N was modified for NICU and SCBU purpose. The patient monitor system was upgraded and computerized patient documentation (Clinical Information System) for ICU patients was installed. This renovation opportunity also allowed the relocation of the delivery suite from a separated main building of QMH to ward K9, which was in close proximity to the neonatal unit. The integration enhanced quality and cost effectiveness of the neonatal clinical services and further consolidated the role of Queen Mary Hospital as a high-risk tertiary perinatal centre.

Joint High-Risk Perinatal Programme
Neonatal team roundWith advancement in prenatal diagnosis and obstetrical service, more and more high-risk pregnancies are detected early. These include premature labour, multiple pregnancies, severe intrauterine growth retardation and congenital malformations such as chromosomal disorders, congenital diaphragmatic hernia or hydrocephalus. Participation of the neonatal team in the antenatal period is essential in quality perinatal service.

The Joint High-Risk Perinatal Programme was further consolidated after the establishment of Perinatal Centre. The neonatal and obstetrics team have regular weekly meetings to review the high-risk cases and arrive at a management consensus. Paediatrician and obstetricians provide joint antenatal counseling for expectant parents complicated by preterm deliveries or babies with congenital malformation. For cases that required ICU support, the parents were further counseled by our nurse specialist during NICU visitations to make them better prepared for the stressful neonatal course. This programme provides a high standard and quality of care.

The monthly perinatal audit meeting provides an important channel for discussion on patient outcomes and improvement in patient management. It also provides an opportunity to share updated scientific knowledge in perinatology.

Liver Transplantation Programme
The first successful paediatric liver transplant in Hong Kong was performed at Queen Mary Hospital in 1995. QMH is now the only centre designated for liver transplantation in Hong Kong. The PICU team participates in the pre-operative and post-operative support. On average, 6-8 patients are transplanted each year.

Cadaveric donors are not readily available in Hong Kong, and most organs for transplantation were from living donors, mainly parents or close relatives. It is, therefore, more important for every discipline involved to provide a very high standard of care to achieve the greatest success. Of the 45 liver transplants performed, only 11 patients received cadaveric liver. The indications for liver transplantation include biliary atresia (30 cases), acute or chronic hepatic failure of other causes (11 cases) and liver tumour and metabolic disease (2 cases). Two patients required a second transplant. We have achieved the best long-term survival of more than 90%.

Clinical Information System

New CIS systemThe renovation in K10 allowed an opportunity to install the Clinical Information System (CIS) for better documentation. A total of 28 bedside and 4 wireless mobile stations were installed. Since November 2002, all ICU patient documentations were done electronically. The interface with patient monitors, medical devices and hospital Clinical Management System (CMS) allows more convenience in patient data charting. Errors related to poor documentation or illegible handwriting is now kept to the minimum. With the increasing complexity of ICU care, implementation of CIS is necessary to maintain the standard and quality. Another benefit of the CIS is that the electronic information can be easily retrieved for clinical audit and research purpose. Currently, data from the CIS is used for studies on neonatal infection, drug utilization and oro-gastric tube insertion.

Nutritional Support Team
Since 2001, a parenteral nutritional support team was established to minimize the complications related to parenteral nutrition. The members consist of paediatricians, paediatric surgeons, nurse specialist and pharmacist. They provide a consultative, supervisory and educational role. Complications, especially on TPN cholestasis and line infections, were much decreased. The team's service is now expanded to other nutritional support issues such as home parenteral nutrition, mucus fistula refeeding in ileostomy patients, and special formulations for patients with short gut syndrome.

Preparing parenteral nutritionPreparing expressed breast milk

Cardiopulmonary resuscitation training
Resuscitation in PICUThe PNICU team is also responsible for ensuring the quality of paediatric and neonatal resuscitation in Queen Mary Hospital. Guidelines were developed and updated regularly, according to the best available evidence. Regular training courses were conducted for trainees, nurses and midwives in the labour room. To ensure competent and efficient teamwork during resuscitation, regular CPR drills were conducted in various paediatric and neonatal areas.

Strength & Development
Through years of development, with support from the hospital and The University of Hong Kong, the PNICU service is well established. The team is well organized with active participation from nursing and allied health services. It facilitates the operation and development of tertiary/ quaternary services in Queen Mary Hospital. The combined Paediatric and Neonatal Intensive Care service allow better utilization of the very limited resources. The sharing of expertise within team members on neonatology, paediatric intensive care, respirology, nephrology and gastroenterology help to provide better development in the two sub-specialties. Indeed, we are able to maintain a leadership role and a distinct identity for the two sub-specialties in the territory.

Nurse training in ICUFor PICU, we will continue to support the development of tertiary/ quaternary services especially in oncology and transplantation. We will also support the integration of paediatric cardiology service from Grantham Hospital to Queen Mary Hospital in order to provide a better comprehensive multidisciplinary care for the cardiac patients. At the same time, this allows the PICU service in Queen Mary Hospital to reach international standard by having the full spectrum of patients. There will be more collaboration with other sub-specialties on quality improvement and research. We will try to improve the network with other PICU centres, especially PYNEH, to provide a high quality cost effective service to the critically ill children in Hong Kong.

For Neonatology, the partnership with the Obstetric service and the Pre-natal Diagnostic Centre in Tsan Yuk Hospital on high-risk pregnancy should be further strengthened, both on clinical service and research. The plan is to have the service accredited for Neonatology sub-specialty training by the Hong Kong College of Paediatricians upon formal establishment of the sub-specialty programme.

Research/ Grant & Awards
Areas of research interest:

  1. Newborn hearing screening.
    Studies on universal hearing screening and high-risk screening are performed in collaboration with other paediatric units. We are currently conducting a study on the implementation and cost effectiveness of a universal newborn hearing screening programme by Two-stage Automated Auditory Brainstem Evoked Response for all babies before hospital discharge. This project was collaborated with the Paediatric Department of PYNEH and was supported by the SK Yee Foundation.
  2. Changing pattern of congenital malformations in Hong Kong.
    A pilot study on the pattern of congenital malformations in a regional perinatal centre was conducted, with emphasis on the impact of prenatal diagnosis. A joint programme with the Department of Health is planned to provide a more accurate territory-wide congenital malformation reporting system. The study is collaborated with the Department of Obstetrics and Prenatal Diagnostic Centre.
  3. Postnatal growth and neuro-developmental outcome of severe small for gestational age neonates including twin babies with severe growth discrepancies.
  4. Survey on infection control, hand hygiene and nosocomial infection in NICU.
  5. MR imaging study on birth asphyxia infants and other neonatal encephalopathy. It is collaborated with the Department of Diagnostic Radiology.
  6. Surgical management of necrotizing enterocolitis.
  7. Application of the Clinical Information System in ICU.
  8. Ventilation strategies for critically ill patients.

The NICU has been subscribing to the Vermont Oxford Network since 1998. It is an international collaboration to collect data on high-risk neonates from major neonatal centres in order to improve the quality and safety of medical care. Queen Mary Hospital is the only centre from Hong Kong and is one of the three studied centres in Asia among a total of 408 centres in US and other countries. The compiled vital statistics is very useful for peer review and individual centre's quality improvement.

The PNICU team works closely with other service partners, in particular with paediatric surgery for better patient care, and the ventilator care centre in the Duchess of Kent Children's Hospital for pre-admission evaluation and emergency support.

With the increasing complexity of care, treatment options, alternative medical treatment and end-of-life decisions faced in the ICU, the collaboration with the medical ethics service became much closer. Premature babies parents support group was also established to provide better support and counseling. The team also provides PNICU support for critically ill neonates and paediatric patients under the care of the cardiac team at Grantham Hospital.