Nandiran Ratnavel

Passive cooling for initiation of therapeutic hypothermia in neonatal encephalopathy

Objective To determine the feasibility of passive cooling to initiate therapeutic hypothermia before and during transport. Methods Consensus guidelines were developed for passive cooling at the referring hospital and on transport by the London Neonatal Transfer Service. These were evaluated in a prospective study. Results Between January and October 2009, 39 infants were referred for therapeutic hypothermia; passive cooling was initiated at the referring hospital in all the cases. Despite guidance, no rectal temperature measurements were taken before arrival of the transfer team. Cooling below target temperature (33°C–34°C) occurred in five babies before the arrival of the transfer team. In two of these infants, active cooling was performed, rectal temperature was not recorded and their temperature was lower than 32°C. Of the remaining 37 babies, 33 (89%) demonstrated a reduction in core temperature with passive cooling alone. The percentage of the babies within the temperature range at referral, arrival of the transfer team and arrival at the cooling centre were 0%, 15% and 67%, respectively. On arrival at the cooling centre, four babies had cooled to lower than 33°C by passive cooling alone (32.7°C, 32.6°C, 32.2°C and 32.1°C). Initiation of passive cooling before and during transfer resulted in the therapy starting 4.6 (1.8) h earlier than if initiated on arrival at the cooling centre. Conclusions Passive cooling is a simple and effective technique if portable cooling equipment is unavailable. Rectal temperature monitoring is essential; active cooling methods without core temperature monitoring may lead to overcooling.

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.

Effect of a centralised transfer service on characteristics of inter-hospital neonatal transfers

Objective: To determine the effect of a centralised neonatal transfer service on numbers of neonatal transfers and the time taken for teams to reach the baby. Design: Prospective census of neonatal inter-hospital transfers between May and July 2004. Comparison with a previous census undertaken before introduction of the service. Analysis of requests for antenatal in-utero transfer to the regional emergency bed service. Setting: Geographically defined area in London and southeast England. Patients: Babies transferred to or from a neonatal unit. Interventions: Introduction of a centralised neonatal transfer service. Main outcome measures: Numbers of transfers, time taken for teams to arrive to the baby (response time). Results: During the census there were 835 transfers with an increase of 34% from the previous census (n = 619). Most of the increase was in urgent transfers for neonatal intensive care. There was a mean of 4.4 urgent transfers a day, with 3.9 elective and 0.8 short-term transfers. Over the same period in-utero transfers decreased. Response times improved from a median of 2 h in 2001 to 1.45 h in 2004 (p<0.05). The 90th centile fell from 6 h to 4.9 h. Conclusion: Following the introduction of a centralised neonatal transfer service, response times improved significantly. An increase in the numbers of transfers for medical intensive care was associated with a reduced number of in-utero transfers. To balance the improved safety and accessibility of neonatal transfer, similar developments may be needed to facilitate in-utero transfer.

Safety and governance issues for neonatal transport services

Neonatal transport is a subspecialty within the field of neonatology. Transport services are developing rapidly in the United Kingdom (UK) with network demographics and funding patterns leading to a broad spectrum of service provision. Applying principles of clinical governance and safety to such a diverse landscape of transport services is challenging but finally receiving much needed attention. To understand issues of risk management associated with this branch of retrieval medicine one needs to look at the infrastructure of transport teams, arrangements for governance, risk identification, incident reporting, feedback and learning from experience. One also needs to look at audit processes, training, communication and ways of team working. Adherence to current recommendations for equipment and vehicle design are vital. The national picture for neonatal transport is evolving. This is an excellent time to start benchmarking and sharing best practice with a view to optimising safety and reducing risk.

Outcomes of full-term infants with bilious vomiting: observational study of a retrieved cohort

Bilious vomiting in a neonate may be a sign of intestinal obstruction often resulting in transfer requests to surgical centres. The aim of this study was to assess the use of clinical findings at referral in predicting outcomes and to determine how often such patients have a time-critical surgical condition (eg, volvulus, where a delay in treatment is likely to compromise gut viability). Methods 4-year data and outcomes of all term newborns aged ≤7 days with bilious vomiting transferred by a regional transfer service were analysed. Specificity, sensitivity, likelihood ratios, correlations, prior and posterior probability of clinical findings in predicting newborns with surgical diagnosis were calculated. Results Of 163 neonates with bilious vomiting, 75 (46%) had a surgical diagnosis and 23 (14.1%) had a time-critical surgical condition. The diagnosis of a surgical condition in neonates with bilious vomiting was significantly associated with abdominal distension (χ2=5.17, p=0.023), abdominal tenderness (χ2=5.90, p=0.015) and abnormal abdominal X-ray findings (χ2=5.68, p=0.017) but not with palpation findings of a soft as compared with a tense abdomen (χ2=3.21, p=0.073). Abnormal abdominal X-ray, abdominal distension and tenderness had 97%, 74% and 62% sensitivity, respectively, with regard to association with an underlying surgical diagnosis. Normal abdominal X-ray reduced the posterior probability of surgical diagnosis from 50% to 16%. Overall, clinical findings at referral did not differentiate between infants with or without surgical or time-critical condition. Conclusions We recommend that term neonates with bilious vomiting referred for transfer are prioritised as time critical.

In-utero transfer is too difficult: Results from a prospective study

BACKGROUND Perinatal transfer is an unavoidable part of neonatal care. In-utero as opposed to postnatal transfer is recommended whenever possible. AIMS To quantify prevalence of in-utero transfers, determine the duration of time spent arranging in-utero transfers and whether failures in the organisation of potential in-utero transfers were occurring. STUDY DESIGN Prospective study of in-utero transfers referred and completed, and questionnaire study of failed potential in-utero transfers. SUBJECTS Women referred to the Emergency Bed Service (EBS), women undergoing in-utero transfer by London Ambulance Service (LAS), and preterm infants undergoing postnatal transfer where in-utero transfer had been potentially achievable, in the London area, over a six month period in 2009. OUTCOME MEASURES Number of in-utero transfers being undertaken, duration of time spent arranging in-utero transfer, and number of failed in-utero transfers. RESULTS Over the study period LAS undertook 438 in-utero transfers and there were 338 referrals for in-utero transfer to EBS, of which 180 (53%) were successful. Of 69 emergency postnatal transfers of preterm infants (<29 weeks gestational age), 11 were classified as failed in-utero transfers. Median (IQR) duration of EBS involvement in in-utero referrals was 340 (200-696)min. A median (IQR) of 240 (150-308)min was spent contacting a median (IQR) of 7 (6-8)units when attempting to arrange in-utero transfer in the failed in-utero transfer group. CONCLUSIONS Arranging in-utero transfer consumes considerable clinical time; an important number of in-utero transfer attempts fail for non-clinical reasons; establishment of a centralised in-utero transfer planning service will save clinical time and may improve outcomes.

Comparison of Passive and Servo-Controlled Active Cooling for Infants with Hypoxic-Ischemic Encephalopathy during Neonatal Transfers

Objective The recent availability of servo‐controlled cooling equipment on transport makes it possible to commence active cooling at the referral unit for infants with hypoxic‐ischemic encephalopathy. This study aimed to compare the temperature and transfer variables in passively and actively cooled babies. Study Design This is a retrospective cohort study comparing two groups—passively cooled (July 2011 to August 2012) versus actively cooled group (September 2012 to June 2013), following introduction of active hypothermia using servo‐controlled cooling mattress by the London Neonatal Transfer Service (NTS). Results Seventy‐six infants were passively cooled and 69 were actively cooled. There was a significant difference between the temperatures of the two groups at each point in the transfer episode: on arrival of NTS, during stabilization, during transfer, and at the receiving hospital. Median time to achieve target temperature was 30 (95% confidence interval [CI]: 23‐37) minutes in actively cooled, significantly shorter in comparison to 130 (95% CI: 83‐177) minutes in passively cooled babies. Of the 69 newborns, 62 (90%) had temperature within target range at receiving center in actively cooled group as compared with 30/76 (40%) in passively cooled group. Conclusion The use of active cooling during neonatal transfer achieves target temperature in a shorter period and maintains better temperature stability.

Evaluating and improving neonatal transport services

Interfacility transport is a necessary part of hospital care. Neonates often need to access specialist input at different sites necessitating a reliable transfer process. Services have evolved significantly over the last ten years to meet this need. This followed the recognition that ad hoc arrangements were unreliable and often unsafe. Services have significantly improved during this time. Attention has been paid to training, clinical governance, disseminating best practice, setting standards, ring fenced funding and supporting parents. Transport teams have become integral to neonatal network function and quality and performance of transport services needs to be evaluated. National audit creates useful team comparisons and identifies outlier status allowing closer inspection of variations between services. Work is needed in the form of external appraisal in order to maintain service standards.

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.

799 Factors Influencing Early Neonatal Mortality in Retrieved Extreme Preterm Neonates

Background and Aims Neonatal care is increasingly delivered within regionalised networks, often necessitating transfer of vulnerable preterm babies from local neonatal units to neonatal intensive care units (NICU). Extreme preterm infants (gestation < 28 weeks) born in hospitals without a NICU have a relatively higher mortality rate than those inborn in hospitals with NICU. In this study we aim to investigate the factors that impact on early (7-day) neonatal mortality in retrieved extreme preterm infants. Methods Inclusion criteria (< 28 weeks gestation, transfer < 24 hours of birth, complete data entry) were applied to all entries in a regional transfer service database between January 2005 and December 2011 (n=7669) leaving 621. Early mortality was analysed against gestational age, birth weight, lowest pH, temperatures on NTS arrival at referring unit (T1), departure from referring unit (T2) and arrival at the receiving unit (T3). Statistical analysis was carried out using SPSS v18. Results 7-day mortality was 88 (14.17%). Mean (Range) for gestational age was 25.35 weeks (22.0–27.86), birth weight 794g (440–1650) and lowest pH (prior to transfer) was 7.28 (6.90–7.53). Only gestational age (< 0.001), birth weight (p<0.001) and lowest pH affected mortality individually (p<0.001). Mortality was not significantly affected by T1 (p=0.152), T2 (p=0.265) and T3 (p=0.065). To control for confounding, we performed logistic regression, after which gestational age (p<0.001) and lowest pH (p=0.001) remained significant. Conclusion Gestational age and lowest pH significantly influence 7-day mortality within retrieved extreme preterm infants.