Transported neonates by a specialist team - how STABLE are they

Changing the outcomes of newborns with surgical conditions at a tertiary-level hospital in Kenya: a cluster randomized trial

Background

Globally, 10% of neonatal mortality in low-/middle-income countries (L/MIC) is directly attributed to surgical conditions, and appropriate referral and transport of newborns to tertiary-level hospitals for surgical care often underlie their survival. This study aimed at evaluating the outcomes of newborns with surgical conditions in a low-resource setting, in the context of a structured standard operating procedure (SOP) for newborn transport. 

Methods

A cluster randomized controlled trial was conducted. Ten county hospitals that refer newborns with surgical conditions to the Moi Teaching and Referral Hospital (MTRH) were selected and randomized into intervention group (A) and control group (B). A structured standard operating procedure (SOP) for transport of newborns was introduced in the hospitals in group A via an education module. Thereafter, 126 newborns (63 in group A and 63 in group B) were enrolled, upon their admission to the MTRH. All the newborns from both groups of referring hospitals were given standard surgical care upon admission. Data on study variables was collected and analyzed, and the outcomes of the newborns in the two groups were compared to assess the effect of the structured SOP.

Results

The median age at admission was 4.1 days in group A and 4.6 days in group B. The top 4 surgical conditions were gastroschisis, hydrocephalus, Hirschsprung’s disease, and anorectal malformations. There was a statistically significant difference (p < .05) in all parameters that measured the clinical status of the newborns at admission, in the two groups. Mortality rate was 3.2% in group A and 28.6% in group B (p < .001), and hospital stay was 11 days in group A and 18 days in group B.

Conclusion

Appropriate transport of newborns with surgical conditions significantly improved their outcomes at the MTRH.

Level of evidence

II

Risk factors predicting early in-hospital mortality among underfive children and need for decentralization of pediatric emergency care services

Background

Lack of pediatric triage and emergency care system in peripheral healthcare centers leads to unnecessary referral of low- and medium-risk patients. This study was conducted to study the risk factors predicting mortality within 48 h of admission in neonates and under-five children referred to the pediatric emergency of a tertiary care hospital in India.

Methods

This prospective study was conducted on children (0-5 years) referred to the pediatric emergency who were enrolled and followed up. The outcome was defined as "survival" or "death" at 48 hours. Logistic regression analysis was conducted to assess the predictors of early in-hospital mortality.

Results

A total of 246 consecutive pediatric (62 neonates, 52 young infants, and 132 children aged 1-5 years) referral cases were enrolled; mortality within 48 hours was 20%. Lack of pediatric intensive care (odds ratio [OR] 4.07, 95% confidence interval [CI] 2.0, 8.32, P = 0.02), lack of neonatal intensive care (OR 2.10, 95% CI 1.01,4.28, P ≤ 0.001), distance from referral center >20 km (OR 4.61, 95% CI 2.01, 10.58, P = 0.0003), >1 h taken during transport (OR 7.75, 95% CI 2.93, 20.46, P < 0.001), lack of ambulance facility (OR 0.04, 95% CI 0.009, 0.143, P < 0.0001), very sick condition on arrival (OR 210.1, 95% CI 12.1, 3643.41, P = 0.0002), and unstable temperature-oxygenation-perfusion-sugar on arrival were the independent risk factors predicting in early in-hospital mortality.

Conclusion

Developing a pediatric triage and monitoring system, tele-pediatric intensive care unit, regionalizing referral-back-referral services with robust interhospital communication, and strengthening pediatric emergency services are the need of the hour to reduce early in-hospital mortality.

Closing the communication gap in neonatal inter-hospital transfer: a neonatal referral form for resource-limited settings - a modified e-Delphi-consensus study

Background: Standardised neonatal referral forms (NRFs) facilitate effective communication between healthcare providers and ensure continuity of care between facilities, which are essential for patient safety. We sought to determine the essential data items, or core clinical information (CCI), that should be conveyed for neonatal inter-hospital transfer in resource-limited settings (Rounds 1 to 3) and to create an NRF suitable for our setting (Round 4).

Methods: We conducted an international, four-round, modified Delphi-consensus study. Round-1 was a literature and internet search to identify existing NRFs. In Round-2 and -3, participants were Rwandan clinicians and international paediatric healthcare practitioners who had worked in Rwanda in the five years before the study. These participants evaluated the draft items and proposed additional items to be included in an NRF. Round-4 focused on creating the NRF and used five focus groups of Rwandan general practitioners at district hospitals.

Results: We identified 16 pre-existing NRFs containing 125 individual items. Of these, 91 items met the pre-defined consensus criteria for inclusion in Round-2. Only 33 items were present in more than 50% of the 16 NRFs, confirming the need for this consensus study. In Round-2, participants proposed 12 new items, six of which met the pre-defined consensus criteria. In Round-3, participants scored items for importance, and 57 items met the final consensus criteria. In Round-4, 29 general practitioners took part in five focus groups; a total of 16 modifications were utilised to finalise the NRF.

Conclusions: We generated a novel, robust, NRF that may be readily employed in resource-limited settings to communicate the essential clinical information to accompany a neonate requiring inter-hospital transfer.

The Casualty Stabilization–Transportation Problem in a Large-Scale Disaster

We address the problem of picking up, stabilizing, and transporting casualties in response to mass-injury disasters. Our proposed methodology establishes the itinerary for collecting, on-site stabilization, and transporting victims considering capacitated vehicles and medical care centers. Unlike previous works, we minimize the time required to achieve on-site stabilization of each victim according to his age and level of severity of the injuries for their subsequent transfer to specialized medical centers. Thus, more critical patients will be the first to be stabilized, maximizing their chances of survival. In our methodology, the victims’ age, the injuries’ severity level, and their deterioration over time are considered critical factors in prioritizing care for each victim. We tested our approach using simulated earthquake scenarios in the city of Iquique, Chile, with multiple injuries. The results show that explicitly considering the on-site stabilization of the vital functions of the prioritized victims as an objective, before their transfer to a specialized medical center, allows treating and stabilizing patients earlier than with traditional objectives.

Incidence and predictors of mortality among neonates referred to comprehensive and specialized hospitals in Amhara regional state, North Ethiopia: a prospective follow-up study

Background

Neonatal mortality is a major global public health problem. Ethiopia is among seven countries that comprise 50 % of global neonatal mortality. Evidence on neonatal mortality in referred neonates is essential for intervention however, there is no enough information in the study area. Neonates who required referral frequently became unstable and were at a high risk of death. Therefore, this study aimed to assess the incidence and predictors of mortality among referred neonates.

Method

A prospective follow-up study was conducted among 436 referred neonates at comprehensive specialized hospitals in the Amhara regional state, North Ethiopia 2020. All neonates admitted to the selected hospitals that fulfilled the inclusion criteria were included. Face-to-face interviews, observations, and document reviews were used to collect data using a semi-structured questionnaire and checklists. Epi-data™ version 4.2 software for data entry and STATA™ 14 version for data cleaning and analysis were used. Variables with a p-value < 0.25 in the bi-variable logistic regression model were selected for multivariable analysis. Multivariable analyses with a 95% confidence level were performed. Variables with P < 0.05 were considered statistically significant.

Result

Over all incidence of death in this study was 30.6% with 95% confidence interval of (26.34–35.16) per 2 months observation. About 23 (17.83%) deaths were due to sepsis, 32 (24.80%) premature, 40 (31%) perinatal asphyxia, 3(2.33%) congenital malformation and 31(24.03%) deaths were due to other causes. Home delivery [AOR = 2.5, 95% CI (1.63–4.1)], admission weight < 1500 g [AOR =3.2, 95% CI (1.68–6.09)], travel distance ≥120 min [AOR = 3.8, 95% CI (1.65–9.14)], hypothermia [AOR = 2.7, 95% CI (1.44–5.13)], hypoglycemia [AOR = 1.8, 95% CI (1.11–3.00)], oxygen saturation < 90% [AOR = 1.9, 95% (1.34–3.53)] at admission time and neonate age ≤ 1 day at admission [AOR = 3.4, 95% CI (1.23–9.84) were predictors of neonatal death.

Conclusion

The incidence of death was high in this study. The acute complications arising during the transfer of referral neonates lead to an increased risk of deterioration of the newborn’s health and outcome. Preventing and managing complications during the transportation process is recommended to increase the survival of neonates.

Transport characteristics and predictors of mortality among neonates referred to a tertiary care centre in North India: a prospective observational study

OBJECTIVE

The paucity of specialised care in the peripheral areas of developing countries necessitates the referral of sick neonates to higher centres. Organised interhospital transport services provided by a skilled and well-equipped team can significantly improve the outcome. The present study evaluated the transport characteristics and predictors of mortality among neonates referred to a tertiary care centre in North India.

DESIGN

Prospective observational study.

SETTINGS

Tertiary care teaching hospital in North India.

PATIENTS

1013 neonates referred from peripheral health units.

MAIN OUTCOME MEASURES

Mortality among referred neonates on admission to our centre.

RESULTS

Of the 1013 enrolled neonates, 83% were transferred through national ambulance services, 13.7% through private hospital ambulances and 3.3% through personal vehicles. Major transfer indications were prematurity (35%), requirement for ventilation (32%), birth asphyxia (28%) and hyperbilirubinaemia (19%). Hypothermia (32.5%, 330 of 1013), shock (19%, 192 of 1013) and requirement for immediate cardiorespiratory support (ICRS) (10.4%, 106 of 1013) on arrival were the major complications observed during transfer. A total of 305 (30.1%, N=1013) deaths occurred. Of these, 52% (n=160) died within 24 hours of arrival. On multivariate logistic analysis, unsupervised pregnancy (<4 antenatal visits; p=0.037), antenatal complications (p<0.001), prematurity ≤30 weeks (p=0.005), shock (p=0.001), hypothermia (p<0.001), requirement for ICRS on arrival (p<0.001), birth asphyxia (p=0.004), travel time >2 hours (p=0.005) and absence of trained staff during transfer (p<0.001) were found to be significant predictors of mortality.

CONCLUSION

The present study depicts high mortality among infants referred to our centre. Adequate training of peripheral health personnel and availability of pre-referral stabilisation and dedicated interhospital transport teams for sick neonate transfers may prove valuable interventions for improved outcomes.

Polish Medical Air Rescue Crew Interventions Concerning Neonatal Patients

The purpose of the study was to present the characteristics of Helicopter Emergency Medical Service (HEMS) and Emergency Medical Service (EMS) interventions concerning newborns in Poland. The study involved a retrospective analysis of missions by Polish Medical Air Rescue crews concerning newborns, carried out in Poland between January 2011 and December 2020. Polish Medical Air Rescue crews were most commonly dispatched to urban areas (86.83%), for patient transfer (59.67%), using an airplane (65.43%), between 7 AM and 6:59 PM (93.14%), and in the summer (28.67%). Further management involved handing over the neonatal patient to a ground neonatal ambulance team. Most of the patients studied were male (58.02%), and the most common diagnosis requiring the HEMS or EMS intervention was a congenital heart defect (31.41%). The most common medical emergency procedure performed by Polish Medical Air Rescue crew members for the neonatal patients was intravenous cannulation (43.07%). The odds ratio for congenital malformations was higher in male newborns. The type of Polish Medical Air Rescue mission was associated with the location of the call, time of the call, ICD-10 diagnosis associated with the dispatch, selected clinical findings, most commonly performed medical emergency procedures, and mission duration and distance covered.

Procedural Interventions and Stabilization Times During Interfacility Neonatal Transport

OBJECTIVE

Transport teams perform multiple procedural interventions during the stabilization of critically ill neonates. The setting of this study was a national cohort of interfacility neonatal transports from nontertiary centers.

METHODS

A retrospective cohort study of neonatal transports having interventional procedures using the Canadian Neonatal Transport Network database during 2014 to 2016. Demographics and procedures associated with stabilization times ≤ 120 versus > 120 minutes were analyzed. Predictors of stabilization time were evaluated using multivariable logistic regression analysis.

RESULTS

Among 3,350 neonatal transports analyzed, the 3 most frequently performed procedures were peripheral intravenous insertion, arterial blood gas sampling, and endotracheal tube insertion, with success rates of 85.2%, 89.1%, and 95.3%, respectively. The frequency of procedures varied across gestational age subgroups, and success rates were lower for umbilical arterial catheter insertions. After adjustment for confounders, more invasive procedures and a higher number of interventions were associated with longer stabilization times.

CONCLUSION

The type and frequency of procedures performed had a significant impact on stabilization time. Any procedures that are nonessential for stabilization at the nontertiary center, such as umbilical arterial catheter insertion, could be minimized to promote timely admission to tertiary centers. The demonstrated variations in procedural success among teams provide useful information for benchmarking and promote the sharing of training practices.

Golden hour of neonatal life: Need of the hour

"Golden Hour" of neonatal life is defined as the first hour of post-natal life in both preterm and term neonates. This concept in neonatology has been adopted from adult trauma where the initial first hour of trauma management is considered as golden hour. The "Golden hour" concept includes practicing all the evidence based intervention for term and preterm neonates, in the initial sixty minutes of postnatal life for better long-term outcome. Although the current evidence supports the concept of golden hour in preterm and still there is no evidence seeking the benefit of golden hour approach in term neonates, but neonatologist around the globe feel the importance of golden hour concept equally in both preterm and term neonates. Initial first hour of neonatal life includes neonatal resuscitation, post-resuscitation care, transportation of sick newborn to neonatal intensive care unit, respiratory and cardiovascular support and initial course in nursery. The studies that evaluated the concept of golden hour in preterm neonates showed marked reduction in hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). In this review article, we will discuss various components of neonatal care that are included in "Golden hour" of preterm and term neonatal care.

Golden 60 minutes of newborn's life: Part 1: Preterm neonate

"Golden 60 minutes "or "Golden Hour" is defined as the first hour of the newborn after birth. This hour includes resuscitation care, transport to nursery from place of birth and course in nursery. The concept of "Golden hour" includes evidence based interventions that are done in the first 60 min of postnatal life for the better long term outcome of the preterm newborn especially extreme premature, extreme low birth weight and very low birth weight. The evidence shows that the concept of "Golden 60 minutes" leads to reduction in neonatal complications like hypothermia, hypoglycemia, intraventricular hemorrhage, chronic lung disease and retinopathy of prematurity. In this review, we have covered various interventions included in "Golden hour" for preterm newborn namely delayed cord clamping, prevention of hypothermia, respiratory and cardiovascular system support, prevention of sepsis, nutritional support and communication with family.

Handover and transport of critically ill children: An integrative review

BACKGROUND

The handover and transport of critically ill pediatric patients requires communication amongst multiple disciplines. Poor communication is a leading cause of sentinel events and human factors affect handover and transport.

OBJECTIVES

To synthesize published data on pediatric handover and transport and identify gaps to provide direction for future investigation.

METHODS

Integrative literature review.

RESULTS

Forty research studies were reviewed and revealed the following themes: risk for patient complications, standardized communication, and specialized teams and teamwork were associated with improved outcomes. No articles were identified regarding transportation of critically ill pediatric patients from the emergency room to the intensive care unit. There was a knowledge gap in best practices in handover and transport within the unique subsets of the pediatric population including neonate, toddler, school-aged, and adolescents.

CONCLUSIONS

Research supported a combined approach of specialized teams using standardized communication in the handover and transport of the pediatric patient to improve outcomes. Further study is warranted on interprofessional (team to team) handover practices, select subsets of the pediatric population, and the handover and transport of critically ill patients from the emergency room to the intensive care unit.

Mortality in newborns referred to tertiary hospital: An introspection

Background:

India is one of the largest contributors in the pool of neonatal death in the world. However, there are inadequate data on newborns referred to tertiary care centers. The present study aimed to find out predictors of mortality among newborns delivered elsewhere and admitted in a tertiary hospital in New Delhi between February and September 2014.

Materials and Methods:

Hospital data for were retrieved and analyzed for determining predictors for mortality of the newborns. Time of admission, referral and presenting clinical features were considered.

Results:

Out of 1496 newborns included in the study, there were 300 deaths. About 43% deaths took place in first 24 hours of life. Asphyxia and low birth weight were the main causes of death in early neonatal period, whereas sepsis had maximum contribution in deaths during late neonatal period. Severe hypothermia, severe respiratory distress, admission within first 24 hours of life, absence of health personnel during transport and referral from any hospital had significant correlation with mortality.

Conclusions:

There is need for ensure thermoregulation, respiratory sufficiency and presence of health personnel during transport.

Predictors of unfavorable thermal outcome during newborn emergency retrievals

OBJECTIVE

Maintenance of normal body temperature is a challenge during transports. We aimed to identify predisposing factors for unfavorable thermal outcome during emergency retrievals of neonates.

METHODS

Demographic data and clinical variables for transports performed over a 2-year period were extracted from the Newborn Emergency Transport Service (Victoria, Australia) database. Arrival temperatures outside normothermia (36.5°-37.5°C) were defined as an unfavorable outcome.

RESULTS

Normothermia on arrival at the receiving hospital was achieved in 78% of 1,261 transports. The strongest predictor of unfavorable thermal outcome was an abnormal temperature at the start of the retrieval (odds ratio [OR] = 8.04; 95% confidence interval [CI], 5.91-10.95; P < .001) followed by very low weight on transport (< 1,500 g; OR = 2.49; 95% CI, 1.63-3.80; P < .001) and respiratory support (OR = 1.81; 95% CI, 1.29-2.54; P = .001). Medications (eg, inotropes and sedation/muscle relaxation) or central/peripheral venous/arterial lines were not significant predictors of outcome when temperature at retrieval start, weight at transport, and respiratory support were adjusted as cofactors. Mode of transport (road, fixed wing, or rotary wing aircraft) and outside temperature were not associated with thermal outcome.

CONCLUSION

Abnormal temperature at the start of the retrieval, very low transport weight, and respiratory support were strong predictors of unfavorable thermal outcome during neonatal emergency transports.