A Leslie

Optimising neonatal transfer.

Services for neonatal intensive care in the United Kingdom have evolved in a largely unplanned fashion. Units of different sizes provide various amounts of intensive care, and, with a few exceptions, there is little or no formal regional or subregional organisation. Chronic underresourcing and the salvaging of ever more complex infants have resulted in tertiary neonatal intensive care units operating at full capacity most of the time, a situation compounded by a chronic national shortage of nursing staff. These factors have in turn resulted in an increase in requirements for emergency perinatal transfers.

Neonatal transfers by advanced neonatal nurse practitioners and paediatric registrars

Objective: To evaluate the safety and practicality of using advanced neonatal nurse practitioners (ANNPs) to lead acute neonatal transfers. Design: Comparison of transport times, transport interventions, and physiological variables, covering the first four complete years of operating a transport service that uses ANNPs and specialist paediatric registrars (SpRs) interchangeably. Setting: Tertiary neonatal transport service. Patients: The first 51 transfers of sick infants under 28 days of age by an ANNP led transport team into Nottingham compared with the next consecutive SpR led transfer after each ANNP led one. Main outcome measures: Transport times; interventions and support given during stabilisation for transfer and during transfer; condition on completion of transfer, assessed from blood glucose, systolic blood pressure, pH, oxygenation, and temperature. Results: The ANNP led team responded more rapidly to requests for transfer and took longer to stabilise babies. The groups undertook similar numbers of procedures during stabilisation, and there were no differences in the ventilatory and other support that infants needed in transit. The infants transferred by the doctor led group had worse values for pH (doctor led, 7.31 (6.50–7.46); ANNP led, 7.35 (7.04–7.50), p = 0.02) and Pao2 (doctor led, 6.7 (2.4–13.1); ANNP led, 8.7 (3.5–17.0); p = 0.008) before transfer (all values median (range)). Comparisons of the infant’s condition before and after transfer showed a significant improvement in temperature for the infants transferred by ANNP led teams (36.8°C (34.0–37.8) v 37.0°C (34.6–38.0), p = 0.001) and in oxygen saturation (96% (88–100) v 98% (92–100), p = 0.01). There were no differences between the ANNP and doctor led groups in the values obtained for any variable after transfer. Conclusions: Clinical condition on completion of transport is similar for babies transferred by ANNP and doctor led teams. ANNP led transport appears to be practical and safe.

Audit of neonatal intensive care transport–closing the loop

To audit the effectiveness of changes in transport arrangements, data on babies ventilated during transfer into a neonatal unit were compared between two periods. During the first period, August 1991 ‐February 1993, an ad hoc transport team operated. Transport practice was changed in 1993 by forming a nine‐person nursing transport team, improving training and upgrading monitoring. The second audit period was January 1994‐July 1995. The groups were not significantly different for birth weight, gestation or levels of ventilation. Physiological variables were assessed with a “transport score”. Improved scores for temperature and pH were achieved on completion of transfer in 1994–95 compared to 1991–93. Stabilizing prior to transfer took longer in the 1994–95 period. No serious deteriorations occurred in transit in the 1994–95 period, three in 1991–93. Audit facilitates identification of problems in transport. Staff, education and equipment changes were associated with improved audited outcomes.

Who should staff neonatal transport teams

Neonatal transport is variously staffed by diverse combinations of nurses, doctors and paramedical staff. There is no evidence that neonatal transport undertaken with staff from any particular professional background results in improved outcomes for infants; instead, it appears that beneficial outcomes result from using staff who are specifically trained in transport practice, regardless of their professional background. Core transport competencies that are transferrable should be a routine part of the training of transport team members.

The state of neonatal transport services in the UK

Neonatal transfer services across the UK have evolved at different rates, using a variety of approaches. Scotland, Northern Ireland and most recently Wales have adopted a more centralised approach than in England, where due to comparative population size transport services have developed alongside neonatal network boundaries. Despite considerable investment, transport provision remains variable in some areas and there are continuing issues common to most regions, including service provision and configuration, training, competencies and audit. Further development is required to optimise the use of available resources and develop benchmarking to ensure a high quality sustainable service.

PB.09 A Feasibility Study of Active Manuka Honey Dressings on Babies Requiring Admission to NICU

Objective Honey Dressings have been demonstrated to have important anti-infective and wound healing properties in adults and children. Mechanisms of action include an osmotic effect on bacteria and anti-inflammatory properties. They have yet to be adequately studied in newborn infants and this study aimed to determine if honey dressings are safe and acceptable to staff and parents. In this abstract we present the themes obtained from asking parents and staff what they thought of the dressings. Methods Questionnaires were distributed to parents of babies who had Active Manuka Honey Dressings applied to their wounds in a feasibility study. Similar questionnaires were given to staff that had used the dressings. Responses were grouped into themes reflecting similar comments. Results 12 parents responded, giving responses grouped into the themes of ‘natural product’ and the ‘effect on healing’. 46 staff commented and their responses were grouped into three themes: ‘ease of application’, ‘smell’ and ‘effect on healing’. Some negative comments were also received covering 5 areas: ‘properties of the dressings’, ‘wastage’, ‘inappropriate use’, ‘appearance’ and ‘lack of adhesion’ under certain conditions. Conclusion Honey Dressings appear to be acceptable to parents and staff with both groups saying that they felt the dressings helped the wounds heal more quickly. More research is required to fully assess the effectiveness and role of honey dressings in newborn infants.

Neonatal head and torso vibration exposure during inter-hospital transfer.

Inter-hospital transport of premature infants is increasingly common, given the centralisation of neonatal intensive care. However, it is known to be associated with anomalously increased morbidity, most notably brain injury, and with increased mortality from multifactorial causes. Surprisingly, there have been relatively few previous studies investigating the levels of mechanical shock and vibration hazard present during this vehicular transport pathway. Using a custom inertial datalogger, and analysis software, we quantify vibration and linear head acceleration. Mounting multiple inertial sensing units on the forehead and torso of neonatal patients and a preterm manikin, and on the chassis of transport incubators over the duration of inter-site transfers, we find that the resonant frequency of the mattress and harness system currently used to secure neonates inside incubators is ~ 9 H z . This couples to vehicle chassis vibration, increasing vibration exposure to the neonate. The vibration exposure per journey (A(8) using the ISO 2631 standard) was at least 20% of the action point value of current European Union regulations over all 12 neonatal transports studied, reaching 70% in two cases. Direct injury risk from linear head acceleration (HIC15) was negligible. Although the overall hazard was similar, vibration isolation differed substantially between sponge and air mattresses, with a manikin. Using a Global Positioning System datalogger alongside inertial sensors, vibration increased with vehicle speed only above 60 km/h. These preliminary findings suggest there is scope to engineer better systems for transferring sick infants, thus potentially improving their outcomes.

Newborn infants with bilious vomiting: a national audit of neonatal transport services

Objective The precautionary approach to urgently investigate infants with bilious vomiting has increased the numbers referred to transport teams and tertiary surgical centres. The aim of this national UK audit was to quantify referrals and determine the frequency of surgical diagnoses with the purpose to inform the consequent inclusion of these referrals in the national ‘time-critical’ data set. Methods A prospective, multicentre UK-wide audit was conducted between 1 August, 2015 and 31 October, 2015. Term infants aged ≤7 days referred for transfer due to bilious vomiting were included. Data at the time of transport and outcomes at 7 days after transfer were collected by the local teams and transferred anonymously for analysis. Results Sixteen teams contributed data on 165 cases. Teams that consider such transfers as ‘time-critical’ responded significantly faster than those that do not classify bilious vomiting as time-critical. There was a surgical diagnosis in 22% cases, and 7% had a condition where delayed treatment may have caused bowel loss. Most surgical problems could be predicted by clinical and/or X-ray findings, but two infants with normal X-ray features were found to have a surgical problem. Conclusion The results support the need for infants with bilious vomiting to be investigated for potential surgical pathologies, but the data do not provide evidence for the default designation of such referrals as ‘time-critical.’ Decisions should be made by clinical collaboration between the teams and, where appropriate, swift transfer provided.

Categorising neonatal transports

The UK is now covered by separately commissioned neonatal transport services. This has required significant investment and it is essential that meaningful comparisons of activity levels, outcomes and value for money be made. The UK Neonatal Transport Interest Group devised a dataset in 2005 to compare transport teams. The major problem encountered was defining mutually exclusive categories of transfer. The terms ‘planned’ and ‘unplanned’ were agreed, with ‘time-critical’ added following publication of the Neonatal Toolkit.1 Unplanned/time-critical transfers are subject to scrutiny as part of the Neonatal Quality Standards.2 There is a wide …

PO-0532 Active Manuka Honey Dressings In Babies Requiring Admission To Nicu; Assessing The Feasibility Of A Randomised Trial

Honey dressings have important anti-infective and wound healing properties in adults but have not been adequately studied in newborns. Osmotic and antinflammatory effects are believed to be important mechanisms of action. We carried out a pre-trial feasibility study and assessed safety and acceptability to staff and parents. Methods Following informed parental consent, babies were recruited to an observational study of Active Manuka Honey Dressings (Advancis Activon Tulle). Parents completed a questionnaire examining the acceptability and performance of the dressings and staff members who used the dressings filled out a similar questionnaire. The study was fully approved by the Nottingham 2 Research Ethics Committee and funded by Bliss. Results 28 wounds (8 different types) were dressed using the Active Manuka Honey dressings. Median gestational age at birth was 25 weeks (range 166–284 days), median age at entry into the study was 6 days (2–64 days). Median birth weight, 770 g, (500- 5305 g). Other parents declined to take part due to not wishing to disturb the dressing applied whilst considering taking part. Surgeons expressed strong preferences for other dressings. Analysis of predictive variables for time to wound healing did not identify any associations Conclusions Honey Dressings were easy to apply, well tolerated, with little pain on application or removal but there were fewer wounds than expected. No infant required escalation of pain relief or developed hyperglycaemia felt to be due to the dressings. These results suggest that Honey dressings are safe but that a trial may be challenging.