S Mohinuddin

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.

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.

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.

G482(P) Neurological assessment in infants referred for therapeutic hypothermia: Quality of documentation and match with cooling criteria

Aims Therapeutic hypothermia (TH) has become the standard of care for term newborns with hypoxic ischaemic encephalopathy (HIE). The major cooling trials had specific criteria to select infants with moderate-severe encephalopathyand the BAPM guidance recommends approaches compatible with those trials. Our objectives were: 1. To assess the completeness of neurological assessment documentation used for referring the infant for TH. 2. To compare the examination findings with published criteria for encephalopathy, as used by the two major cooling trials. Methods Two cohorts of infants referred to the London Neonatal Transfer Service for TH between July 2011–June 2013 and July 2014–June 2015 respectively were included. Case records were reviewed. Results Data were available on 266 infants transferred to the cooling centres, 145 in the first period and 121 in the second respectively. Baseline and clinical characteristics were comparable between the two groups. During the second period, active servocontrolled hypothermia in transport became the standard of care and a neurological assessment tool was introduced. Neurological assessment was documented by the referring hospital in 83/117 babies (70.9%), whereas the Neonatal Encephalopathy Assessment Sheet was completed by NTS in 64/116 babies (56.1%). Tone was the most common neurological feature assessed in both groups [97% vs 97.5%]. Assessment was sufficiently complete to allow the matching with TOBY and NICHHDcriteria only in 62/145 (42.7%) infants in the first period and 42/121 (34.7%) and 49/121 (40.4%) respectively in the second period. When measured against the TOBY encephalopathy assessment criteria, 31/62 (50%) infants in the first group and 20/42 (47.6%) fulfilled the criteria. When reviewed for encephalopathy assessment criteria as published by the Shankaran et al, 18/42 (42.8%) in the first group and 21/49 (42.9%) in the second group did meet the minimum three of the six categories required. Conclusion The documentation of neurological assessment was not sufficiently complete in 40% referrals, in spite of a neurological examination assessment form. Also, the majority of the babies with complete documentation did not fulfil the criteria for encephalopathy according to published trials. There was no significant improvement over the years. This can have important clinical, resource and medico-legal implications.

Donor human milk for Muslim infants in the UK

Donor human milk (DHM) is currently used in neonatal units (NNUs) for feeding preterm infants when own mothers milk is not available or insufficient. In 2014, the latest Cochrane review1 showed that in preterm and low birthweight infants, feeding with formula compared with DHM results in a higher risk of developing necrotising enterocolitis (NEC). As the incidence of NEC increases in relation to the other complications of preterm birth,2 there is growing interest in the use of DHM, as evidenced by an expansion in the number of milk banks worldwide (currently >500 in 44 countries).3 In the UK, it is estimated that 75% of neonatal intensive care units4 use DHM for the feeding of infants, most commonly for those at high risk of NEC. However, one part of the world where the use of DHM is not growing is in countries with predominantly Muslim population. Here, the introduction of anonymised DHM has been challenged by the Islamic concept of milk kinship. The sharing of human milk, historically in the form of a wet nurse, creates kinship ties and thus marriage prohibitions between the family of the donor and recipient.5 Surveys have shown that these beliefs may also affect the acceptability of DHM to Muslim parents …

Infants with suspected intestinal malrotation or volvulus are not prioritised for transfer

Intestinal malrotation and volvulus in infants can be easily missed. The authors highlight the substantial risk of mortality and morbidity and recommend immediate surgical referral.1 In our experience as a regional neonatal transfer service for London, despite recognition of risks in infants with bilious vomiting, they are not prioritised for transfer to surgical centres. We recently audited 163 term infants with bilious vomiting transferred at ≤7 days of …

PC.83 Evaluating a Network Based Multi-Professional Neonatal Emergencies Simulation Course

Objective To evaluate the usefulness of a network based multi-professional neonatal emergencies team training simulation course on participant’s self-perceived level of confidence in dealing with neonatal emergencies. Background The development of networks and centralisation of services has decreased the exposure of staff to neonatal emergencies. Following an analysis of patient safety incidents by the London NTS, a neonatal emergencies team training simulation (NETS) course was developed in collaboration with tertiary network centres. Simulation scenarios were designed to use clinical, organisational and communication skills. Methods Feedback was collected during the course to encourage participant reflection and allow the faculty to evaluate effectiveness and improve future experiences. A self-assessment questionnaire was completed before and after the training using a 5 point scale. Other questions requested open responses which have been categorised. Data from the last five courses has been evaluated in this study. Results Over the 5 courses, feedback was collected from 95 participants. The results show a positive trend with an increase in the modal value from 3 to 4 (out of 5) for most categories (Figure 1). Candidates were asked to reflect on their key learning outcomes (Figure 2). 92% participants felt that they could apply what they had learnt in their clinical capacity. Abstract PC.83 Figure 1 Participant self assessment of knowledge and skills before and after course Abstract PC.83 Figure 2 Participant reflection on positive learning outcomes of course Discussion We have demonstrated that a network based multi-professional education programme on neonatal emergencies can be delivered using simulation technology. We are currently reviewing our patient safety data to observe any changes in trends and aim to perform a delayer re-evaluation by the participants.