Improving thermoregulation in transported preterm infants: a quality improvement initiative

Hypothermia in preterm infants admitted to low-resource neonatal units in northern Nigeria: an observational study of occurrence and risk factors

BACKGROUND

Hypothermia is an important cause of morbidity and mortality among preterm and low-birth-weight neonates. In resource-constrained settings, limited referral infrastructure and technologies for temperature control potentiate preterm hypothermia. While there is some documentation on point-of-admission hypothermia from single center studies, there are limited multicenter studies on the occurrence of hypothermia among preterm infants in resource-limited-settings. Therefore, we conducted a multicenter study to determine the prevalence and risk factors for hypothermia at the time of admission and during the first 72 h after admission in northern Nigeria.

METHOD

We carried out a prospective cohort study on preterm infants admitted to four referral hospitals in northern Nigerian between August 2020 and July 2021. We documented temperature measurements at admission and the lowest and highest temperatures in the first 72 h after admission. We also collected individual baby-level data on sociodemographic and perinatal history data. We used the World Health Organization classification of hypothermia to classify the babies' temperatures into mild, moderate, and severe hypothermia. Poisson regression analysis was used to identify risk factors for moderate-severe hypothermia.

RESULTS

Of the 933 preterm infants enrolled, 682 (72.9%) had hypothermia at admission although the prevalence of hypothermia varied across the four hospitals. During the first 24 h after admission, 7 out of every 10 babies developed hypothermia. By 72 h after admission, between 10 and 40% of preterm infants across the 4 hospitals had at least one episode of moderate hypothermia. Gestational age (OR = 0.86; CI = 0.82-0.91), birth weight (OR = 8.11; CI = 2.87-22.91), presence of a skilled birth attendant at delivery (OR = 0.53; CI = 0.29-0.95), place of delivery (OR = 1.94 CI = 1.13-3.33) and resuscitation at birth (OR = 1.79; CI = 1.27-2.53) were significant risk factors associated with hypothermia.

CONCLUSION

The prevalence of admission hypothermia in preterm infants is high and hypothermia is associated with low-birth-weight, place of delivery and presence of skilled birth attendant. The prevalence of hypothermia while in care is also high and this has important implications for patient safety and quality of patient care. Referral services for preterm infants need to be developed while hospitals need to be better equipped to maintain the temperatures of admitted small and sick newborns.

Skin-to-Skin Contact for Transferring Preterm Infants from the Delivery Room to the Neonatal Intensive Care Unit Is Promising Despite Moderate Heat Loss during the Procedure

OBJECTIVE

The principal aim of this prospective observational study was to assess the feasibility of skin-to-skin contact (SSC) with fathers during the transfer of preterm infants from the delivery room to the neonatal intensive care unit (NICU) in comparison with incubator transfers.

STUDY DESIGN

The study population comprised preterm singletons born between May and December 2019 in our maternity ward who did not require invasive ventilation. Physiological parameters (axillary temperature, heart rate, and fraction of inspired oxygen) of the newborns were recorded at prespecified steps during the transfers. The impact of the transfer mode on early blood glucose level, blood gas, and neonatal morbidities and mortality and the delay in the first SSC in the NICU and breastfeeding implementation and maintenance were also analyzed.

RESULTS

Twenty-eight preterm infants were transferred in incubators, and 29 infants were transferred using SSC. The SSC transfer induced heat loss (mean, -0.45°C; standard deviation [SD], 0.58). However, the decrease in temperature was similar to that observed during transfer in the incubator (mean, -0.30°C; SD, 0.49; p = 0.3). The transfer using SSC was not an independent factor associated with hypothermia at admission in the NICU (adjusted odds ratio, 2.6 [0.68-9.75]; p = 0.16). Neonatal morbidities and mortality were similar regardless of the transfer mode. The SSC transfer promoted early SSC in the neonatal unit (median hour [range], incubator 26 [2-126] vs SSC 13 [1-136], p = 0.03) and breastfeeding at discharge (incubator 35.7% vs SSC 69%, p = 0.01).

CONCLUSION

The SSC transfer of preterm infants was feasible and promoted earlier SSC and breastfeeding. Nevertheless, the SSC transfer, like the transfer in the incubator, induced moderate heat losses that exacerbated hypothermia at admission in the NICU. The improvement of thermal conservation during infant positioning and the continuation of SSC in the unit could help in preventing hypothermia.

KEY POINTS

· The SSC transfer was associated with heat loss during the transfer procedure.. · The SSC transfer promoted earlier SSC in the neonatal unit.. · The SSC transfer was likely to encourage breastfeeding..

Thermoregulation of the Extremely Low Birth Weight Neonate

The birth of an extremely low birth weight (ELBW) neonate is complex because of their immaturity. Respiratory and hemodynamic stabilization often takes precedence in the immediate delivery period. While establishing effective breathing and circulation is vital to the survival of the neonate, it is crucial to understand that other adverse outcomes can occur during the resuscitation and transport of the ELBW neonate. Impaired thermoregulation is one of the most detrimental adverse outcomes during the golden hour period and later in the neonatal intensive care unit. Hypothermia is an independent risk factor for increased morbidity and mortality and can impact multiple body systems, making management even more challenging. This article discusses the physiology of thermoregulation while exploring interventions to maintain normothermia in the ELBW neonate, ultimately improving long-term outcomes.

Hypothermia and adverse outcomes during the transfer of extremely low birth weight infants

AIM

We aimed to explore whether hypothermia during the transfer of extremely low birth weight (ELBW) infants was associated with increased morbidity and mortality.

METHODS

Retrospective cohort study of transfers of ELBW infants by the London Neonatal Transfer Service between April 2015 and January 2017. Hypothermia was defined as an axillary temperature below 36.5°C.

RESULTS

Hypothermia was recorded in 36-47% of the 146 transfers depending on the time point of measurement from admission at the referring unit to admission at the receiving unit. Infants with hypothermia had a lower gestational age [25.1 (24.1-26.6) versus 26.0 (25.3-27.0) weeks, p < 0.001], birth weight [750 (600-830) versus 800 (730-885) gr, p = 0.004) and age at referral [1 (0.8-3) versus 1.5 (1-4) hours, p = 0.049] compared to infants without hypothermia. Infants with hypothermia had a longer median (IQR) duration of invasive ventilation [22(6-44) days] compared to infants without hypothermia [10 (4-21) days, p = 0.002]. Infants with hypothermia had a higher incidence of a patent ductus arteriosus and mortality before discharge from neonatal care compared to infants without hypothermia (79% vs. 27%, p = 0.043 and 29% vs. 13%, p = 0.025, respectively).

CONCLUSION

Among ELBW infants, hypothermia during transfer was common, particularly in infants of lower gestational age. Hypothermia was associated with a longer duration of ventilation and increased mortality before discharge from neonatal care.

Development, implementation, and evaluation of neonatal thermoregulation decision support web application

OBJECTIVES

Thermoregulation is important for all age groups, and in neonates, it is considered a crucial event to adapt to extrauterine life. Therefore, using systems that provide frequent reminders in different ways in the field of thermoregulation can help thermal stability in neonates. The present study aimed to develop, implement, and evaluate a neonatal thermoregulation decision support system (DSS) as a web application.

METHODS

The present research was a multi-method study because it included the three phases of development, implementation, and evaluation of the neonatal thermoregulation decision support web application. In the system designing phase, the waterfall model is used. The second and third phases of the study, implementation, and evaluation, were conducted as a quasi-experimental study.

RESULTS

The results of this study were presented in two parts: the developed web application, and the results of the evaluation of the web application. The results of the statistical tests revealed that the use of the web application had a positive and significant effect on both the adjustment of the temperature of the incubator (maintaining the neutral temperature) and the maintenance of the temperature of the neonate's body (p = 0.000).

CONCLUSIONS

These results indicate that a nurse's sensitization and guidance with a neonatal thermoregulation decision support system can help to effectively neonate thermoregulation and the nurse has brought the temperature care close to the standard care based on the conditions of each neonate.

Common Quality Improvement Methodologies Including the Model for Improvement, Lean, and Six Sigma

This article reviews several common quality improvement methodologies, including the Model for Improvement, Lean, and Six Sigma. We demonstrate how these methods are based on a similar improvement science foundation. We describe the tools used to understand problems in the context of systems and the mechanisms to learn and build knowledge, using specific examples from the neonatology and pediatric literature. We conclude with a discussion on the importance of the human side of change in quality improvement, including team formation and culture.

Using a Plastic Drape to Reduce Hypothermia in Premature Neonates During Peripherally Inserted Central Catheter Placement

BACKGROUND

Premature neonates require assisted heating devices for thermoregulation in the neonatal intensive care unit (NICU). Traditional use of a cloth blanket and cloth towels during peripherally inserted central catheter (PICC) placement may hinder heat transfer from the assisted heating mechanisms, increasing the risk for neonatal hypothermia.

PURPOSE

This quality improvement project's goal was to reduce the hypothermia rate in very low birth-weight (VLBW) neonates by replacing cloth blanket/towels with a plastic drape during PICC placement.

METHODS

The FOCUS-PDSA method was used to implement the intervention (plastic drape) over 3 months, during 58 PICC procedures in a level 3 NICU. A pre-/posttest design was used to evaluate the impact of the intervention on hypothermia rates compared with a baseline cloth group and a concurrent cloth cohort.

RESULTS

After the 3-month implementation period, the hypothermia rate for the intervention group was lower than that for the baseline cloth group (5.2% and 11.3%, respectively), but this difference was not statistically significant. Post-PICC hypothermia rates were significantly lower for the intervention group than for the concurrent cloth cohort (P = .004).

IMPLICATIONS FOR PRACTICE

Preliminary evidence demonstrated the plastic drape reduced the hypothermia rate in the NICU for VLBW neonates during PICC placement compared with cloth blanket/towels. A plastic drape shows promise in improving nursing practice by providing improved thermoregulation for premature neonates during PICC placement.

IMPLICATIONS FOR RESEARCH

Further research is recommended to replicate findings with larger samples of PICC insertions, using a plastic drape in the operating room and other NICU procedures.

Decreased moderate admission hypothermia in extremely preterm newborns

BACKGROUND

Admission temperature is inversely correlated with mortality and morbidity risk in extremely preterm newborns (EPNs). As almost all EPNs require advanced resuscitation at birth, we improved a simple and comprehensive management protocol to reduce admission hypothermia. This study reports the changes over the past 15 years in the rate of admission hypothermia in all EPNs. It clarified the distribution of admission temperature and the risk factors for developing admission hypothermia in recent EPNs.

METHODS

This single-center study retrospectively analyzed the EPNs delivered at our institution between January 2006 and December 2020. The comprehensive management protocol, including warming equipment, plastic wrapping, aluminum-polyethylene sheet, and room temperature, was applied to avoid heat loss during resuscitation. On admission, the rectal temperature was measured and defined as moderate (32.0-35.9 °C) or mild (36.0-36.4 °C) hypothermia.

RESULTS

Overall (n = 432), the rate of admission with moderate hypothermia decreased from 48% in 2006 to 8% in 2020. In the recent evaluation of 80 EPNs delivered in 2017-2020, 10 (13%) and 26 (33%) had moderate and mild hypothermia on admission, respectively. Extremely preterm newborns with moderate-to-mild hypothermia had a significantly smaller gestational age and lower birthweight than those without hypothermia. No significant differences in the other perinatal and environmental risk factors were observed between EPNs with and without hypothermia.

CONCLUSIONS

Our comprehensive management protocol reduced the rate of moderate hypothermia on admission in EPNs to only 13%. However, eliminating mild hypothermia remains a challenge and requires continuous improvement, especially in smaller EPNs.