Optimising neonatal transfer

Characteristics and special challenges of neonatal emergency transports

BACKGROUND

As a rule, newborns do not require special medical care. If unexpected complications occur peripartum or postpartum, support from and transport to specialised neonatal hospitals might be needed.

METHODS

In a retrospective study, all transport protocols of a supraregional paediatric‑neonatological maximum care hospital in northwestern Germany from 01.10.2018 through 30.09.2021 were analysed. The particular focus was on transports of newborns (<7 days) and the leading symptoms that led to contact.

RESULTS

A total of 299 patients were included (average age of 15.4 h, 61.6 % males). The average complete transport time was approximately 2 h. Five leading neonatal diseases (respiratory, infectious, asphyxia, cardiac, haematological) were found to represent the causes of >80 % of transfers. Respiratory adaptation disorders are the main reason for transferring a newborn to a centre, whereas asphyxia is the most severe condition. The various symptoms differ in their time of onset, a factor which must be taken into account in practice. Differences were also found between different types of hospitals: while a large proportion of transports were carried out from maternity hospitals (80.6 %), children transported from children's hospitals were generally more severely ill.

DISCUSSION

Transfers of neonates, especially from maternity hospitals to neonatal intensive care units due to special neonatal diseases, are not rare. In times of increasingly scarce resources, the effective care of sick or at-risk neonates is essential. For low-population regions, this means professional cooperation between maximum care providers and smaller children's hospitals and maternity-only hospitals.

Air Transportation Impact on a Late Preterm Neonate

BACKGROUND: Neonatal air transportation is a crucial means of moving critically ill or sick neonates to specialized neonatal intensive care units or medical centers for consultation, regardless of distance or geographical limits. Proper preparation and consideration of air transport can help alleviate medical emergencies and ensure safe delivery. However, crewmembers and neonates may face stress during transportation. To date, there are few studies on neonatal air transportation in Taiwan.CASE REPORT: We present the case of a late preterm neonate born with neonatal respiratory distress syndrome and polycythemia, who was also diagnosed with patent ductus arteriosus and mild pulmonary arterial hypertension on echocardiography. Due to disease progression, the neonate underwent endotracheal intubation and was subsequently transported to a medical center in Taiwan via a rotary-wing aircraft at 3 d of age. During takeoff and landing, a temporary oxygen desaturation event occurred. The physiological changes in these patients have seldom been discussed. This case emphasizes the important considerations of neonatal transport in Taiwan.DISCUSSION: The air transport process could be influenced by both the patient's medical condition and environmental factors. In preterm infants with cardiopulmonary conditions, thorough assessment is necessary for ensuring safe transportation.Li S-P, Hsu P-C, Huang C-Y, Wu P-W, Fang H-H. Air transportation impact on a late preterm neonate. Aerosp Med Hum Perform. 2024; 95(4):219-222.

[Does the nursing shortage in neonatal intensive care units (NICU) threaten the warranty of healthcare for newborns? : The "Mary and Joseph" project]

BACKGROUND

Germany has been experiencing a dramatic shortage of nursing staff for years that particularly affects neonatal intensive care units (NICUs). It is assumed that this situation leads to reductions in bed capacities, resulting in negative effects on the healthcare of newborns. These were investigated through a retrospective observational study using the example of three NICUs at the University Hospital of Munich (LMU).

METHODS

For the four-year observation period from August 2017 to May 2021, time series data from the "Quality Assurance Guideline for Premature and Mature Infants" (QFR-RL) of the Federal Joint Committee, bed resource analysis, planned personnel statistics, clinical logout data, and rescue service data were mutually examined using descriptive statistics and regression analysis.

RESULTS

During the observation period, around 21% of the necessary nursing staff positions were vacant, although the quality of nursing care for newborns seemed to have been guaranteed. However, to ensure quality, given the staff shortage, several available beds had to be blocked. In this context, both an increase in the number of hours the wards were logged off from population care and an increase in the relative risk of neonatal intensive care transfer were observed, resulting in a transfer every three days on average.

DISCUSSION

A shortage of nursing staff reduces the neonatal hospital bed capacity, since neonatal nursing care quality is regulated by strict legally binding guidelines, the QFR-RL. This is why the consequences for the security of care for the population through hospital cancellations and a risk of transfer must be accepted on a regular basis.

Managerial thinking in neonatal care: a qualitative study of place of care decision-making for preterm babies born at 27-31 weeks gestation in England

OBJECTIVES

Preterm babies born between 27 and 31 weeks of gestation in England are usually born and cared for in either a neonatal intensive care unit or a local neonatal unit-with such units forming part of Operational Delivery Networks. As part of a national project seeking to optimise service delivery for this group of babies (OPTI-PREM), we undertook qualitative research to better understand how decisions about place of birth and care are made and operationalised.

DESIGN

Qualitative analysis of ethnographic observation data in neonatal units and semi-structured interviews with neonatal staff.

SETTING

Six neonatal units across two neonatal networks in England. Two were neonatal intensive care units and four were local neonatal units.

PARTICIPANTS

Clinical staff (n=15) working in neonatal units, and people present in neonatal units during periods of observation.

RESULTS

In the context of real-world neonatal practice, with multiple (and rapidly-evolving) uncertainties relating to mothers, babies and unit/network capacity, 'best place of care' protocols were only one element of much more complex decision-making processes. Staff often made judgements from a less-than-ideal starting point, and were forced to respond to evolving clinical and organisational factors. In particular, we report that managerial considerations relating to demand and capacity organised decision-making; demand and capacity management was time-consuming and generated various pressures on families, and tensions between staff.

CONCLUSIONS

Researchers and policymakers should take account of the organisational context within which place of care decisions are made. The dominance of demand and capacity management considerations is likely to limit the impact of other improvement interventions, such as initiatives to integrate families into the neonatal care provision. Demand and capacity management is an important element of neonatal care that may be overlooked, but significantly organises how care is delivered.

Feasibility study of a novel portable digital radiography system modified for fluoroscopy in the neonatal intensive care unit

BACKGROUND

A portable radiographic system capable of fluoroscopic imaging in the neonatal intensive care unit (NICU) potentially benefits critically ill neonates by eliminating the need to transport them to a fluoroscopy suite.

OBJECTIVE

To evaluate whether a portable bedside fluoroscopy system in the NICU can deliver comparable image quality at a similar dose rate to a standard system in a fluoroscopy suite.

MATERIALS AND METHODS

In phase A, 20 patients <3 years of age and scheduled to undergo upper gastrointestinal series (upper GI) or voiding cystourethrograms (VCUG) in the radiology fluoroscopy suite were recruited to evaluate a portable fluoroscopic unit. A modified portable radiographic system with a cassette-sized detector and an in-room fluoroscopy system were sequentially used in the same examination. Four radiologists compared the image quality of 20 images from each system using the Radlex score (1-4) for five image quality attributes. The radiation dose rates for the portable and in-suite systems were collected. In phase B, fluoroscopy studies were performed in 5 neonates in the NICU and compared to the 20 previous neonatal studies performed in the department. Clinical workflow, examination time, fluoroscopy time, scattered radiation dose and patient radiation dose were evaluated.

RESULTS

In phase A, average dose rates for in-room and portable systems were equivalent, (0.322 mGy/min and 0.320 mGy/min, respectively). Reader-averaged Radlex scores for in-room and portable systems were statistically significantly greater (P<0.05) for all attributes on the portable system except for image contrast. In phase B, scattered radiation from the average fluoroscopy time (26 s) was equivalent to the scattered radiation of 2.6 portable neonatal chest radiographs. Procedure time and diagnostic quality were deemed equivalent. The average dose rate in the NICU with the portable system was 0.21 mGy/min compared to 0.29 mGy/min for the in-room system.

CONCLUSION

The portable fluoroscopy unit is capable of providing comparable image quality at equivalent dose levels to an in-room system for neonates with minimal risks to the staff and other patients in the NICU.

Necrotising enterocolitis-A 15-year outcome report from a UK specialist centre

AIMS

Necrotising enterocolitis (NEC) is a disease associated with high mortality and morbidity, low birthweight and prematurity are risk factors. This study reports outcomes of babies having emergency laparotomy for NEC, examining institutional trends and exploring impact of multiple variables on mortality at 30 days and 1 year post-operatively.

METHODS

Case records of babies with ICD coding for NEC were examined from 2000 to 2015. After exclusions, 243 cases were identified-confirmed by operative findings and histology. Cohort demographics and trends in mortality were investigated, and the relationship of common variables to mortality was modelled with univariate and multivariate logistic regression to generate a mortality prediction tool.

RESULTS

Mean gestational age was 28 + 4 weeks. A 30-day mortality was 18.9%. Gestation, birthweight and area of bowel affected were significant of outcome (mortality), and the presence of pre-operative pneumoperitoneum was strongly correlated. Year of surgery and congenital cardiac pathology requiring intervention were not significant. Using multivariate regression modelling, a mortality outcome prediction tool has been developed.

CONCLUSION

Good survival following operation for NEC (>70%) is feasible, even in those babies born extremely premature (<28 weeks) and post-operatively re-located to tertiary NICUs. With increasing gestational age (>32 weeks), mortality is uncommon.

Burden of Neonatal Surgical Conditions in Northern Ghana

Background

Congenital anomalies have risen to become the fifth leading cause of under-five mortality globally. The majority of deaths and disability occur in low- and middle-income countries including Ghana. This 3-year retrospective review aimed to define, for the first time, the characteristics and outcomes of neonatal surgical conditions in northern Ghana.

Methods

A retrospective study was conducted to include all admissions to the Tamale Teaching Hospital (TTH) neonatal intensive care unit (NICU) with surgical conditions between January 2014 and January 2017. Data were collected on demographics, diagnosis and outcomes. Descriptive analysis was performed on all data, and logistic regression was used to predict determinants of neonatal mortality. p < 0.05 was deemed significant.

Results

Three hundred and forty-seven neonates were included. Two hundred and sixty-one (75.2%) were aged 7 days or less at presentation, with males (n = 177, 52%) slightly higher than females (n = 165, 48%). The majority were delivered by spontaneous vaginal delivery (n = 247, 88%); 191 (58%) were born in hospital. Congenital anomalies accounted for 302 (87%) of the neonatal surgical cases and 45 (96%) deaths. The most common anomalies were omphalocele (n = 48, 13.8%), imperforate anus (n = 34, 9.8%), intestinal obstruction (n = 29, 8.4%), spina bifida (n = 26, 7.5%) and hydrocephalus (n = 19, 5.5%). The overall mortality rate was 13.5%. Two-thirds of the deaths (n = 30) from congenital anomalies were conditions involving the digestive system with gastroschisis having the highest mortality of 88%. Omphalocele (n = 11, 23.4%), gastroschisis (n = 7, 14.9%) and imperforate anus (n = 6, 12.8%) contributed to the most deaths. On multivariate analysis, low birthweight was significantly associated with mortality (OR 3.59, CI 1.4–9.5, p = 0.009).

Conclusion

Congenital anomalies are a major global health problem associated with high neonatal mortality in Ghana. The highest burden in terms of both caseload and mortality is attributed to congenital anomalies involving the digestive system, which should be targeted to improve outcomes.

Electronic supplementary material

The online version of this article (10.1007/s00268-019-05210-9) contains supplementary material, which is available to authorized users.

Impact of transport on arrival status and outcomes in newborns with heart disease: a low-middle-income country perspective

OBJECTIVES

We sought to systematically study determinants of "clinical status at arrival after transport" of neonates with CHD and its impact on clinical outcomes in a low- and middle-income country environment.

METHODS AND RESULTS

Consecutive neonates with CHD (n = 138) transported (median distance 138 km; 5-425 km) to a paediatric cardiac programme in Southern India were studied prospectively. Among 138 neonatal transports, 134 were in ambulances. Four neonates were transported by family in private vehicles; 60% with duct-dependent circulation (n = 57) were transported without prostaglandin E1. Clinical status at arrival after transport was assessed using California modification of TRIPS Score (Ca-TRIPS), evidence of end-organ injury and metabolic insult.Upon arrival, 42% had end-organ injury, 24% had metabolic insult and 36% had Ca-TRIPS Score >25. Prior to surgery or catheter intervention, prolonged ICU stay (>48 hours), prolonged ventilation (>48 hours), blood stream sepsis, and death occurred in 48, 15, 19, and 3.6%, respectively. Ca-TRIPS Score >25 was significantly associated with mortality (p = 0.005), sepsis (p = 0.035), and prolonged ventilation (p < 0.001); end-organ injury with prolonged ICU stay (p = 0.031) and ventilation (p = 0.045); metabolic insult with mortality (p = 0.012) and sepsis (p = 0.015).Fifteen babies needed only medical management, 10 received comfort care (due to severe end-organ injury in 3), 107 underwent cardiac surgery (n = 83) or catheter intervention (n = 24), with a mortality of 6.5%. Clinical status at arrival after transport did not impact post-procedure outcomes.

CONCLUSION

Neonates with CHD often arrive in suboptimal status after transport in low- and middle-income countries resulting in adverse clinical outcomes. Robust transport systems need to be integrated in plans to develop newborn heart surgery in low- and middle-income countries.

Premedication practices for tracheal intubation in neonates transported by French medical transport teams: a prospective observational study

OBJECTIVES

Premedication practices for neonatal tracheal intubations have not yet been described for neonatal transport teams. Our objective is to describe the use of sedation/analgesia (SA) for tracheal intubations and to assess its tolerance in neonates transported by medical transport teams in France.

SETTING

This prospective observational study was part of the EPIPPAIN 2 project and collected around-the-clock data on SA practices in neonates intubated by all five paediatric medical transport teams of the Paris region during a 2-month period. Intubations were classified as emergent, semiemergent and non-emergent. Sedation level and conditions of intubation were assessed with the Tonus, Reactivity, Awareness and Conditions of intubation to Help in Endotracheal intubation Assessment (TRACHEA score). The scores range from 0 to 10 representing an increasing ladder from adequate to inadequate sedation, and from excellent to very poor conditions of intubation.

PARTICIPANTS

40 neonates intubated in 28 different centres.

RESULTS

The mean (SD) age was 34.9 (3.9) weeks, and 62.5% were intubated in the delivery room. 30/40 (75%) of intubations were performed with the use of SA. In 18/30 (60.0%) intubations performed with SA, the drug regimen was the association of sufentanil and midazolam. Atropine was given in 19/40 intubations. From the 16, 21 and 3 intubations classified as emergent, semiemergent and non-emergent, respectively, 8 (50%), 19 (90.5%) and 3 (100%) were performed with SA premedication. 79.3% of intubations performed with SA had TRACHEA scores of 3 or less. 22/40 (55%) infants had at least one of the following adverse events: muscle rigidity, bradycardia below 100/min, desaturation below 80% and nose or pharynx-larynx bleeding. 7/24 (29.2%) of those who had only one attempt presented at least one of these adverse events compared with 15/16 (93.8%) of those who needed two or more attempts (p<0.001).

CONCLUSION

SA premedication is largely feasible for tracheal intubations performed in neonates transported by medical transport teams including intubations judged as emergent or semiemergent.

TRIAL REGISTRATION NUMBER

NCT01346813; Results.

Neonatal Respiratory Support on Transport

Respiratory support is frequently required during neonatal transport. This review identifies the various modalities of respiratory support available during neonatal transport and their appropriate clinical uses. The respiratory equipment required during neonatal transport and appropriate safety checks are also reviewed. In addition, we discuss potential respiratory emergencies and how to respond to them to decrease the risk of complications during transport and improve health outcomes.

Long-Distance, Nonstop Neonatal Transport From Shanghai, China, to Genoa, Italy

The purpose of this article is to describe the long-distance, nonstop intercontinental transport of a severely ill, mechanically ventilated newborn from Shanghai, China, to Genoa, Italy focusing in particular on the clinical and planning difficulties. The aircraft equipment, the assessment and preparation for transport are discussed.

Evaluation of Neonatal Transport in Western Switzerland: A Model of Perinatal Regionalization

Neonatal transport is an essential part of regionalization for highly specialized neonatal intensive care. This retrospective analysis of prospectively collected data on neonatal transport activity in a large Swiss perinatal network more than 1 year, aimed to quantify this activity, to identify the needs for staff, and the demands regarding know-how and equipment. Of the 565 admissions to the tertiary neonatology clinic, 176 (31.2%) were outborn patients, transported as emergencies to the level III unit. In 71.6% of cases, respiratory insufficiency was one of the reasons for transfer. Circadian and weekly distribution showed increased transport activity on workdays between 8 am and 10 pm, but regular demands for emergency transports regardless of the time frame require a neonatal transport team available 24/7. This study highlights the importance of neonatal transport and unveils several functional and infrastructural insufficiencies, which led to suggestions for improvement.

Noninvasive Respiratory Support During Transportation

To minimize ventilator-associated lung injury in neonates, use of noninvasive (NIV) respiratory support has markedly increased over the past decade, especially in neonates younger than 28-weeks gestational age and 1250 g. Previously, neonates with respiratory failure who required anything greater than an oxyhood or low-flow nasal cannula were intubated for transport. This increased use has required transport teams to develop or incorporate a new set of support tools to minimize lung injury. This article reviews the various modes of NIV used during neonatal transport, important patient selection criteria, appropriate assessment, and the associated risks and benefits.

Provision of Therapeutic Hypothermia in Neonatal Transport: A Longitudinal Study and Review of Literature

Background: Worldwide, a significant proportion of infants needing therapeutic hypothermia for hypoxia-ischaemia are transported to a higher-level facility for neonatal intensive care. They pose technical challenges to transport teams in cooling them. Concerns exist about the efficacy of passive cooling in neonatal transport to achieve a neurotherapeutic temprature. Servo-controlled cooling in the standard of care on the neonatal unit. The key question is whether the same standard of care in the neonatal unit can be safely used for therapeutic hypothermia during transport of neonates with suspected hypoxia-ischaemia.

Methods: A prospective cross-sectional survey of United Kingdom (UK) neonatal transport services (n=21) was performed annually from 2011-2014 with a 100% response. The survey ascertained information about service provision and the method of cooling used during transport.

Results: In 2011, all UK neonatal transport services provided therapeutic hypothermia during transport. Servo-control cooling machines were used by only 6 of the 21 teams (30%) while passive cooling was used by 15 of the 21 (70%) teams. In 2012 9 of the 21 teams (43%) were using servo-control. By 2014 the number of teams using servo-control cooling had more than doubled to 15 of the 21 (62%) services. Teams have done this through modification of transport trolleys and dedicated ambulances.

Conclusion: Servo-controlled cooling in neonatal transport is becoming more common in the UK. The question remains whether it should be endorsed as a standard of care. Some teams continue to passively cool neonates with hypoxia-ischaemia during transport. This article reviews the drivers, current evidence, safety and processes involved in provision of therapeutic hypothermia during neonatal transport to enable teams to decide what would be the right option for them.

The interfacility transport of critically ill newborns

The practice of paediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile intensive care units capable of delivering state-of-the-art critical care during paediatric and neonatal transport. While outcomes are best for high-risk infants born in a tertiary care setting, high-risk mothers often cannot be safely transferred. Their newborns may then have to be transported to a higher level of care following birth. The present statement reviews issues relating to transport of the critically ill newborn population, including personnel, team competencies, skills, equipment, systems and processes. Six recommendations for improving interfacility transport of critically ill newborns are highlighted, emphasizing the importance of regionalized care for newborns.

Is it feasible to identify preterm infants with respiratory distress syndrome for early extubation to continuous positive airway pressure post-surfactant treatment during retrieval?

AIM

Preterm infants with respiratory distress syndrome (RDS) requiring surfactant treatment are often retrieved mechanically ventilated to the receiving hospital. INSURE (INtubate, SURfactant, Extubate) technique is not routinely performed by Newborn and Pediatric Emergency Transport Services NSW (NETS) during retrieval. This study aims to evaluate the likelihood of using INSURE technique during retrieval. We attempted to study the clinical characteristics of preterm infants with RDS who were favourably extubated (FE) shortly after admission to the receiving hospital.

METHODS

Retrospective study of preterm infants, gestational age (GA) > 28 weeks with RDS requiring retrieval by NETS.

RESULTS

Two hundred twenty-three infants, median GA of 33 weeks (range 29-36), median birthweight 2200 g (1000-4080) were examined. A percentage of 49.7 received CPAP, and 50.3% required MV. Eighteen (16%) infants were FE (<6 h) at receiving hospital. FiO2 on stabilisation (FiO2 (st)) by NETS correlated with FiO2 on admission to receiving hospital (r = 0.863). A percentage of 81 of ventilated infants received premedications including morphine. No significant differences were noted for GA, stabilisation ventilator settings, surfactant dose (mean 155 mg/kg) and mode of transport between FE and non-FE groups. FiO2 (st) post-surfactant treatment was significantly lower in FE compared with non-FE group (mean 0.28 vs. 0.41 respectively). The area under the curve from receiver operating characteristic based on FiO2 (st) was 0.646 (P = 0.050), the sensitivity and specificity of FiO2 (st) cut-off points (between 0.25 and 0.30) was low.

CONCLUSION

FiO2 on stabilisation post-surfactant treatment has a weak predictive value and may not be adequate to be used as sole criteria to extubate to CPAP prior to transport. FiO2 at stabilisation should be included as an eligibility criteria for a randomised trial of INSURE during retrieval, but other clinical assessments are needed.

Comparison of neonatal transport scoring systems and transport-related mortality score for predicting neonatal mortality risk

OBJECTIVES

To predict the risk of mortality of neonates, birth weight and gestational age were previously used. However, these criteria were considered inadequate; therefore, various scoring systems have been developed in the recent years. The aim of the study was to evaluate the performance of predicting mortality by Mortality Index for Neonatal Transportation (MINT), Score for Neonatal Acute Physiology-Perinatal Extension II (SNAP-PE-II), and Transport Related Mortality Score (TREMS).

METHODS

All infants transferred to the neonatal intensive care unit between January 1 and December 31, 2011, were included. The scores of SNAP-PE-II, MINT, and TREMS of the all cases were calculated. TREMS is our proposed scoring system and it consists of 5 variables (hypoglycemia, hypoxia, hypercarbia, hypotension, and hypothermia). The scoring systems, SNAP-PE-II, MINT, and TREMS, were compared in terms of mortality risk.

RESULTS

A total of 306 newborn infants constituted the study population. The mean gestational age was 33.1 ± 5 weeks and the mean birth weight was 2031.2 ± 1018 g, and 183 (59%) babies were male. The sensitivity of MINT score for predicting mortality was higher than SNAP-PE-II and TREMS. However, specificity was higher in TREMS score. The negative predictive value was highest in MINT score, whereas TREMS has the highest positive predictive value.

CONCLUSIONS

The TREMS scoring system is a simple scoring system with a high specificity for predicting mortality. Further studies with larger sample size including more centers and newborn infants with diverse clinical problems are needed to assess the validity and reliability of the TREMS scoring system.

[Utility of a physiologic stability index based on Transport Risk Index of Physiologic Stability (TRIPS) for the evaluation of infants transferred to a specialized hospital]

BACKGROUND

Neonatal mortality is a public health priority. We review the physiological instability of the newborn after a transfer, which contributes to increased neonatal mortality. The objective of this work was to determine whether the Transport Risk Index of Physiologic Stability (TRIPS) in newborns transferred to the Neonatal Intensive Care Unit of a secondary hospital serves as a predictor of early neonatal mortality.

METHODS

We use the TRIPS to predict neonatal death in the first 7 days after patients' admission.

RESULTS

Neonatal mortality at 7 days after admission is related to the TRIPS rating. The score of the survivors and neonatal deaths show a significant difference (p: 0.009). For a score of 16, a sensitivity of 62% and a specificity of 84%; area under the curve of 0.757 was determined.

CONCLUSIONS

Physiological index weighting using TRIPS is a good predictor of neonatal mortality. It is important to establish measures to improve physiological stability of the newborn before, during and after the transfer in order to reduce neonatal mortality.

Time-to-delivery after maternal transfer to a tertiary perinatal centre

Objectives. To determine, in women transferred antenatally for acute admission with high risk pregnancies, the numbers who deliver, the average time from transfer to delivery, and whether the reason for transfer influences the time-to-delivery. Methods. A retrospective analysis of time-to-delivery was performed in a population of women transferred to the Royal Brisbane and Women's Hospital, QLD. Data were obtained from the hospital obstetric, neonatal, and admission databases. Results. A total of 941 women were transferred antenatally with high risk pregnancies where delivery was deemed potentially imminent. Of these 821 (87%) delivered at RBWH. The remaining 120 women (13%) were discharged prior to delivery and then delivered elsewhere. Of the 821 maternal transfers that delivered, the median time to delivery was 24.4 hrs. There were 43% who delivered within 24 hours of admission and 29% who either delivered after 7 days or delivered elsewhere. Most transfers for fetal abnormality delivered in the first 24 hours while most transfers for antepartum haemorrhage and preterm prelabour membrane rupture delivered beyond 24 hours. Conclusion. There are significant differences in time-to-delivery following transfer depending on the reason for transfer and many infants transferred in utero will not deliver imminently.

Bedside neonatal intensive care unit surgery- myth or reality!

Neonatal transport is associated with complications, more so in sick and unstable neonates who need immediate emergency surgery. To circumvent these problems, surgery in Neonatal intensive care unit (NICU) is proposed for these neonates. This article reviews the literature regarding feasibility of this novel concept and based on the generated evidence, suggest the NICU planners to always include infrastructure for this. Also neonatal surgical team can be developed that could be transported.

Factors associated with clinical complications during intra-hospital transports in a neonatal unit in Brazil

OBJECTIVE

Analyze factors associated with clinical complications during intra-hospital transport of neonatal intensive care unit (NICU) patients.

METHODS

Prospective study of 641 infants submitted to 1197 intra-hospital transports at a public university NICU. Factors associated with clinical complications during intra-hospital transports were studied by multiple logistic regression analysis.

RESULTS

Included infants had a mean gestational age of 35.1 ± 3.8 weeks and a birth weight of 2328 ± 906 g. Underline diseases were: malformations (71.9%), infections (7.6%), respiratory distress (4.1%) and others (16.4%). Patients were transported for surgical procedures (22.6%), magnetic resonance (10.6%), tomography imaging (20.9%), contrasted exams (18.2%), ultrasound (10.4%) and others (17.3%). Clinical complications occurred in 327 (27.3%) transports and were associated (odds ratio; 95% CI) with: central nervous system malformations (1.6; 95% CI 1.0-2.0); use of supplemental oxygen (4.0; 95% CI 2.8-5.6); mechanical ventilation (5.0; 95% CI 3.5-7.5); transport for surgeries (4.0; 95% CI 1.1-14.0) and duration of the transport longer than 120 min (1.6; 95% CI 1.1-2.4).

CONCLUSIONS

Intra-hospital transports are associated with increased risk of clinical complications.

A retrospective evaluation of the impact of a dedicated obstetric and neonatal transport service on transport times within an urban setting

Objective

To determine whether the establishment of a dedicated obstetric and neonatal flying squad resulted in improved performance within the setting of a major metropolitan area.

Design and Setting

The Cape Town metropolitan service of the Emergency Medical Services was selected for a retrospective review of the transit times for the newly implemented Flying Squad programme. Data were imported from the Computer Aided Dispatch programme. Dispatch, Response, Mean Transit and Total Pre-hospital times relating to the obstetric and neonatal incidents was analysed for 2005 and 2008.

Results

There was a significant improvement between 2005 and 2008 in all incidents evaluated. Flying Squad dispatch performance improved from 11.7% to 46.6% of all incidents dispatched within 4 min (p < 0.0001). Response time performance at the 15-min threshold did not demonstrate a statistically significant improvement (p = 0.4), although the improvement in the 30-min performance category was statistically significant in both maternity and neonatal incidents. Maternity incidents displayed the greatest improvement with the 30-min performance increasing from 30.3% to 72.9%. The analysis of the mean transit times demonstrated that neonatal transfers displayed the longest status time in all but one of the categories. Even so, the introduction of the Flying Squad programme resulted in a reduction in a total pre-hospital time from 177 to 128 min.

Conclusion

The introduction of the Flying Squad programme has resulted in significant improvement in the transit times of both neonatal and obstetric patients. In spite of the severe resource constraints facing developing nations, the model employed offers significant gains.

Fatores associados à hipotermia durante o transporte intra-hospitalar em pacientes internados em Unidade de Terapia Intensiva Neonatal

OBJETIVO: Determinar a frequência e os fatores associados à ocorrência de hipotermia em transportes intra-hospitalares de pacientes internados em uma unidade neonatal de cuidados intensivos. MÉTODOS: Estudo transversal aninhado em uma coorte prospectiva de crianças submetidas a transportes intra-hospitalares realizados por uma equipe treinada de janeiro de 1997 a dezembro de 2008 na unidade de cuidados intensivos de um hospital público universitário. Foram excluídos os transportes de pacientes com mais de um ano e/ou com peso na data do transporte superior a 10kg. Os fatores associados à hipotermia durante o transporte foram estudados por regressão logística. RESULTADOS: Dos 1.197 transportes realizados no período do estudo, 1.191 (99,5%) atenderam aos critérios de inclusão. As doenças de base das 640 crianças estudadas (idade gestacional: 35,0±3,8 semanas; peso ao nascer: 2341±888g) foram: malformações únicas ou múltiplas (71,0%), infecções (7,7%), hemorragia peri/intraventricular (5,5%), desconforto respiratório (4,0%) e outros (11,8%). Os pacientes foram transportados para realização de cirurgias (22,6%), ressonância magnética (10,6%), tomografia (20,9%), exames contrastados (18,2%) e outros procedimentos (27,7%). A hipotermia ocorreu em 182 (15,3%) transportes e se associou ao (OR; IC95%): peso ao transporte <1000g (3,7; 1,4-9,9); peso ao transporte 1000-2500g (1,5; 1,0-2,2); temperatura axilar pré-transporte <36,5°C (2,0; 1,4-2,9); presença de malformações do sistema nervoso (2,8; 1,8-4,4); uso de oxigênio inalatório (1,6; 1,0-2,5); ventilação mecânica antes do transporte (2,5; 1,5-4,0); cirurgias (1,7; 1,0-2,7) e anos de 2001, 2003 e 2006 (protetores). CONCLUSÕES: Os transportes intra-hospitalares apresentaram risco elevado de hipotermia, mostrando que devem ser realizados por equipe habilitada e com equipamentos adequados.

Impact of introducing binasal continuous positive airway pressure for acute respiratory distress in newborns during retrieval: Experience from Western Australia

AIM

We aimed to review the impact of introducing binasal continuous positive airway pressure (CPAP) for acute respiratory distress in newborns ≥32 weeks gestation during retrieval in Western Australia.

METHODS

Retrospective review of newborns ≥32 weeks gestation with acute respiratory distress, transported by the Western Australian Neonatal Transport Service between February 2002 and December 2004.

RESULTS

Respiratory management of 369 newborns was examined. CPAP use increased significantly during the study period from 33% in 2002 to 59% in 2004. Overall, endotracheal tube (ETT) ventilation was required in 108 (29%), nasal CPAP in 166 (45%) and cot oxygen in 95 (26%) patients. Twenty-two (13%) newborns in the CPAP group subsequently required ETT ventilation within 24 h: these babies had higher initial oxygen requirements than those successfully transported on CPAP alone. There was no significant morbidity or mortality in patients retrieved on CPAP.

CONCLUSION

CPAP was increasingly utilised as an alternative to ETT ventilation for the management of most cases of less severe acute respiratory distress in near-term neonates on retrieval. This review demonstrated that newborns requiring more than 45-50% oxygen at the time of retrieval were more likely to require intubation at a later time, and hence may benefit from intubation at the time of retrieval. A prospective randomised trial would assist in ascertaining the true benefit of CPAP during retrieval in the newborn period.

Prolonged neonatal interhospital transport on road: relevance for developing countries

OBJECTIVE

To compare prolonged inter hospital long distance transports on road undertaken by a qualified transport team vs those done by the same team from shorter distances and time.

METHODS

Retrospective descriptive comparative study of the neonatal transports done during a period of 48 mo. All neonates transferred on road to a tertiary level pediatric hospital from various maternity and pediatric centers. The biochemical characteristics, adverse effects during transport and 24 hr survival after the transport in both the groups were compared.

RESULTS

The babies were comparable in their gestational age and ventilatory requirements (46% vs 39%). The biochemical and metabolic characteristics and 24 hr mortality rates for babies who were transported for longer times and distances were comparable (p value =0.75) to those transported for shorter times.

CONCLUSION

Long distance neonatal transport on road is feasible and with a qualified team results can be comparable to those transported from shorter distances.

Setting up a neonatal transport service: air transport

Air transport is an integral part of any system that provides neonatal care in the developed world. To ensure that this is developed in an efficient and appropriate manner a prospective analysis is required to allow a multidisciplinary team to progress a project aimed at providing appropriate staff with adequate training using equipment that has satisfied all regulatory bodies. This article highlights the difficulties in achieving this, reflecting on the way in which established air transport teams have overcome many of the difficulties. The commonalities with land based transport are emphasised along with those issues which are specific to teams providing such a service who aspire to become "air capable".

A prospective review of adverse events during interhospital transfers of neonates by a dedicated neonatal transfer service

OBJECTIVES

To categorize and quantify adverse events occurring during emergency interhospital transfers performed by a specialized neonatal retrieval team and to assign levels of associated risk.

DESIGN

Prospective review of adverse events during emergency interhospital transfers of neonates by the London Neonatal Transfer Service over a 6-month period. The events were categorized based on an adapted retrieval team model from the Paediatric & Neonatal Safe Transfer and Retrieval Course (PANSTAR). Risk levels were measured using a modified risk assessment score.

SETTING

Emergency interhospital transfers by a specialized neonatal retrieval team.

PATIENTS

Patients were 346 emergency neonatal transfers over 6 months.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We found that 125 transfers (36.1%) had at least one adverse event. There were 205 adverse events in total; 139 events (67%) were perceived as being due to avoidable human errors. Almost a third of events (30%) occurred even before the retrieval team arrived at the referring hospital and made contact with the patient. The largest group of events occurred due to problems in preparation (n = 69) and communication (n = 49). Most events (n = 143) had insignificant impacts on patients, but six events could have potentially caused major harm.

CONCLUSIONS

Adverse events commonly occur during neonatal transfers, even if performed by a dedicated transfer service. Early identification of potentially harmful episodes is important. Human error is likely to be a factor in the majority of adverse events; hence, opportunities should be taken to reduce the number of these through education, training, and risk management.

A population based 10-year study of neonatal air transport in North Norway

AIM

This study audits the activity of the neonatal air transport team in Norway's two northernmost counties.

METHODS

Data on all air transports to or from the regional Neonatal Intensive Care (NICU) Unit within a 10-year period were collected.

RESULTS

Two hundred and thirty-eight acute transports were conducted during the study period; 169 referrals to the NICU and 69 transfers to national surgical and cardiac centres. Only 13 very low birth weight infants were transported; the in utero transport rate was 95% for this patient population. The adjusted risk of death and/or intracranial haemorrhage for outborn very low birth weight infants was five-fold increased compared to those not transported postnatally. Babies with congenital heart disease comprised the one-fourth of all transports. The long-term mortality was 14% for the whole study population, and 29% for infants with congenital heart disease. Only seven deaths (3.2%) were defined as being transport-related; death during or within 24 h after transport. However, preventable complications like temperature instability, hypoglycaemia and hypo-/hypercapnia occurred in 10-20% of all transports.

CONCLUSION

The transport related mortality was low in this study, however very low birth weight infants and infants with major congenital heart disease showed a relatively poor outcome.

Impact of service changes on neonatal transfer patterns over 10 years

INTRODUCTION

Many changes have been made to the staffing and organisation of neonatal care in the UK in the past 10 years. This study assessed the extent to which these changes had affected the transfer of babies between different parts of the service.

METHODS

Data from the Trent Neonatal Survey, an ongoing study of neonatal intensive care activity in the former Trent Health Region of the UK, were used to evaluate neonatal inter-hospital transfers over a 10-year period, from 1 January 1995 to 31 December 2004. The number of transfers and the types of transfer were analysed and trends in gestation and disease severity over the study period were assessed. Rates of "inappropriate transfer" were also identified.

RESULTS

8105 babies were transferred over the period; 2294 babies underwent urgent postnatal transfer and this equates to approximately two such transfers every three days. The maximum number of journeys by any one baby was eight. Intensive care activity rose during the 10 years but the number of inappropriate transfers remained persistently high.

CONCLUSIONS

Organisational changes in neonatal care during the 10-year period have been insufficient to deal with the rising demand, as reflected by the persistently high rate of inappropriate transfers.

Critical dependence of acetate thermal mattress on gel activation temperature

BACKGROUND

Sodium acetate gel mattresses provide an active method of warming patients through release of latent heat of crystallisation. They can be used as an adjunct to incubator care or as an exclusive heat source.

OBJECTIVE

To determine activation temperatures of the Transwarmer mattress needed to achieve plateau temperatures of 38-42 degrees C.

DESIGN AND SETTING

In vitro testing of mattress temperature.

METHODS AND OUTCOME MEASURES

Transwarmer mattresses were activated at initial temperatures ranging from 5 to 40 degrees C. Mattress temperature was recorded up to 4 h to determine peak and plateau temperatures. Peak and plateau temperatures achieved by the mattress were related to the initial starting temperature.

RESULTS

The starting temperature of the mattress was strongly correlated with peak and plateau temperature (r = 0.99, p<0.001). To achieve the target temperature of 38-42 degrees C, the Transwarmer mattress requires activation between 19.2 degrees C and 28.3 degrees C. A temperature of 37 degrees C could be generated by activation at 17 degrees C.

CONCLUSIONS

Safe use of this device is critically dependent on gel temperature at the point of activation. To ensure warming of a hypothermic neonatal patient without running any risk of burns, the mattress should be activated with a gel temperature between 19 degrees C and 28 degrees C.

Perinatal care in Portugal: effects of 15 years of a regionalized system

AIM

To share information on the organization of perinatal care in Portugal.

METHODS

Data were derived from the Programme of the National Committee for Mother and Child Health 1989, National Institute for Statistics, and Eurostat.

RESULTS

In 1989, perinatal care in Portugal was reformed: the closure was proposed of maternity units with less than 1500 deliveries per year; hospitals were classified as level I (no deliveries), II (low-risk deliveries, intermediate care units) or III (high-risk deliveries, intensive care units), and functional coordinating units responsible for liaison between local health centres and hospitals were established. A nationwide system of neonatal transport began in 1987, and in 1990 postgraduate courses on neonatology were initiated. With this reform, in-hospital deliveries increased from 74% before the reform to 99% after. Maternal death rate decreased from 9.2/100,000 deliveries in 1989 to 5.3 in 2003 and, in the same period, the perinatal mortality rate decreased from 16.4 to 6.6/1000 (live births + stillborn with > or = 22 wk gestational age), the neonatal mortality rate decreased from 8.1 to 2.7/1000 live births, and the infant mortality rate from 12.2/1000 live births to 4/1000.

CONCLUSION

Regionalization of perinatal care and neonatal transport are key factors for a successful perinatal health system.

Use of nasal continuous positive airway pressure during neonatal transfers

OBJECTIVE

To review all cases in which nasal continuous positive airway pressure (CPAP) was used as a means of respiratory support during land based ambulance transfers by a regional neonatal transport service.

DESIGN

Retrospective study based on review of transport records.

RESULTS

A total of 1175 transfer requests were received over the 21 month period. The infant in 163 of these cases was receiving nasal CPAP. Ninety two referrals were accepted by the doctor/nurse practitioner led team. Of these, 84 were transported while receiving nasal CPAP. Intervention during transport was required in three of these cases. Fifty five referrals were accepted by the nurse led team. Of these, 16 were transported while receiving nasal CPAP. Intervention was required in two cases.

CONCLUSION

There is a small but significant demand for transferring infants who are receiving nasal CPAP. Nasal CPAP appears to be a safe method of respiratory support for a carefully selected group of infants during land based ambulance transfers.

Neonatal pneumothorax: comparison between neonatal transfers and inborn infants

OBJECTIVE

To assess the differences in clinical characteristics, management and outcome between the neonatal transfers and inborn neonates with pneumothorax.

METHODS

The records of 36 neonatal transfers (Group A) and 25 inborn (Group B) neonates with symptomatic pneumothorax were retrospectively analyzed.

RESULTS

In Group A, gestational age (36+/-2 vs. 31+/-4 weeks; P<0.01), birth weight (2720+/-537 vs. 1736+/-1028 g; P<0.01), exclusive oxygen-therapy before the event (47% vs. 20%; P<0.05) and tube thoracostomy (78% vs. 44%; P<0.05) were significantly higher than in Group B. The need of resuscitation at birth (19% vs. 44%; P<0.05), conventional mechanical ventilation (20% vs. 56%; P<0.05), presence of associated major congenital malformations (0% vs. 20%; P<0.01), length of hospital stay (9+/-6 vs. 32+/-32 days; P=0.01) and mortality (0% vs. 16%; P=0.01) were significantly lower in Group A than in Group B.

CONCLUSIONS

Neonatal transfers and inborn neonates with pneumothorax have different clinical characteristics and outcome. This information could be useful for all persons involved in the interhospital care of perinatal patients.

Fit to fly: practical challenges in neonatal transfers by air

Air transport of infants in incubators should be undertaken in a manner that is safe for both staff and infant and satisfies all directives by appropriate regulatory bodies. In Scotland during the last two years, certification of an infant incubator system for use in both rotary and fixed wing aircraft has been accomplished. This is a report of the issues addressed during this project, which will be common to all neonatal transport services intending to develop air transport capability.

Towards safer neonatal transfer: the importance of critical incident review

BACKGROUND

Critical incidents are common during the inter-hospital transfer of sick patients, and infants are an especially vulnerable group.

AIMS

To examine the effect of critical incident review on the number of adverse events during inter-hospital transfer of sick infants.

METHODS

Critical incidents over an eight year period are reported from a single neonatal transfer service before and after major service changes were made. The changes were instigated as part of ongoing critical incident reviews.

RESULTS

Changes made as a result of critical incident review significantly reduced the number of incidents contributed to by poor preparation, transport equipment or clinical problems, ambulance delays, and ambulance equipment failure.

CONCLUSIONS

The continuous process of critical incident reporting and review can reduce the number of adverse events during the transfer of critically ill infants.