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Outcomes of Sick Neonates Transported to a Tertiary Care Hospital by a Trained Team, in Northern India |
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Bijaylaxmi Behera, Babu Lal Meena 1. Consultant, Department of Paediatrics and Neonatology, Chaitanya Hospital, Chandigarh, India. 2. DM Student, Department of Hepatology, PGIMER, Chandigarh, India. |
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Correspondence Address : Dr. Bijaylaxmi Behera, Chaitanya Hospital, Sector 44, Chandigarh, India. E-mail: jollybubu2008@gmail.com |
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ABSTRACT | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
: Introduction: In developing countries, like ours, the major causes of neonatal mortality are Prematurity, Birth asphyxia and Sepsis. Although institutional delivery and in utero transport of newborn is the safest way to transport but it is difficult to anticipate preterm deliveries and perinatal illnesses. Moreover, transport with a well equipped and manned team improves neonatal outcomes than self transport. Hence, with the above hypothesis this study was conducted to analyse the profile of newborn babies transported to our unit by our team. Aim: To study the outcome of the sick neonates transported by a well equipped and manned neonatal transport to a Tertiary Care Hospital, indications of transport and also evaluate their condition at arrival. Materials and Methods: This was a retrospective longitudinal descriptive study, including 101 extramural neonates who were transported by a well equipped and manned team, to a Tertiary Care Hospital in Northern India. Transport details along with demographic parameters and clinical features prior to transport and at arrival were recorded. Follow-up was done for all neonates till discharge or death. Transport, clinical variables and Score for Neonatal Acute Physiology-Perinatal Extension ll (SNAPPE-II) were correlated with outcome using logistic regression analysis. Results: Total 101 newborn infants were transported. Fifty-eight babies were term and 43 were preterm. Birth asphyxia, Meconium Aspiration Syndrome, Hyaline Membrane Disease, Transient Tachypnea of Newborn, Congenital Cyanotic Heart Disease, Neonatal Jaundice, Pneumonia, Hypoglycaemia, Preterm, Fever, Feed intolerance were the major indications for transport. Total 16 neonates died. Out of all babies at admission, 14.8% of babies were still hypothermic, 10.8% were still hypoxic, 4.9% were still hypoglycemic and 14.8% were still in shock. SNAPPE score >40, hypoglycaemia, hypothermia, hypoxia and shock correlated with poor outcome. Distance did not correlate with the outcome. Conclusion: Stabilising newborns prior to transport is crucial and neonatal transport is not dependent on distance. Hypothermia, hypoglycaemia, hypoxia and shock should be managed in neonates before and during transport as they affect their outcomes. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Keywords : Ambulance, Hypothermia, Mortality, Neonatal, Score for neonatal acute physiology-perinatal extension score-II, Transport | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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DOI and Others :
DOI: 10.7860/IJNMR/2021/46275.2286
Date of Submission: Aug 14, 2020 Date of Peer Review: Sep 29, 2020 Date of Acceptance: Dec 07, 2020 Date of Publishing: Jan 01, 2021 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was Ethics Committee Approval obtained for this study? Yes • Was informed consent obtained from the subjects involved in the study? Yes • For any images presented appropriate consent has been obtained from the subjects. No PLAGIARISM CHECKIN |
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INTRODUCTION | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Neonatal transport is an evolving concept in the Indian scenario. Although the safest method of transport is in utero transfer but unfortunately, it is difficult to anticipate preterm delivery, perinatal illness and congenital malformations, thus resulting in transfer of babies postnatally (1),(2),(3). Although treatment of sick neonates in Tertiary Care Units has been associated with decrease in mortality and morbidity, having an organised and developed emergency neonatal transport system is an important component in the regionalisation of perinatal care (1),(2),(3). According to the target of World Health Organisation (WHO), as per Millennium Development Goal (MDG), timely treatment of complications for newborns is one Indiaof the key strategies is to reduce under-five mortality rate by two-thirds (4),(5). Increased number of deliveries and poorly organised system of neonatal transport in developing countries are definite hurdles for achievement of the same. Most neonatal transport in India is done by self in private vehicles or the source hospital by utilising private ambulances and semi-trained or ill-trained personnel. The risk can increase in case of less experienced staff, than with well-equipped and trained staff (6),(7),(8). Navjat Shishu Suraksha Karyakram (NSSK) launched by Government of India also emphasises the role of safe neonatal transport (9). Few studies done earlier have shown that mortality almost doubles as the transport time increases and most of the children arriving after a prolonged transport were cold, hypoglycaemic or hypoxic (10). Short-term outcomes such as the clinical condition of the newborns at admission to the NICU and within 24 hour of admission are important indicators of the effectiveness of specialised transport teams (10),(11). To the best of our knowledge there is only one published data about the efficacy of a well equipped neonatal transport of a Tertiary Care Centre in India, by the index hospital itself and all other studies have depicted the outcomes of newborns who are self transported (12). The aim of the present study was to identify the various indications of referral, look at the effectiveness of a well equipped and manned neonatal transport on the neonatal outcomes and complications present at the time of admission in our unit. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Material and Methods | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Study Design A retrospective descriptive cohort study was conducted, from July 2017 till December 2018, enrolling 101 consecutive extramural neonates who were transported by our own team to Neonatal Intensive Care Unit (NICU) of our hospital. Babies with major congenital anomalies were excluded. Ethical committee approval was taken for the study {llH-lEC Approval for the Protocol No.EC/llH-lEC/SPl (RETRO)}. The objective was to study the outcome of the neonates transported by our well-equipped and manned neonatal transport team, indications of transport and also to evaluate their condition at arrival. Sample Size Calculation If the resulting estimate fall within 10% points of the true proportion with 95% confidence was 81, based on the formula for descriptive studies, sample size=z21-a/2 p(1-p)/d2, where p=70%, d=10%. Total 101 consecutive patients were enrolled and all the babies were transported by our well-equipped hospital ambulance, with the facility of transport incubator, transport ventilator, infusion pumps, pulse oximeter, defibrillator, well trained staff and doctors. Patient’s relatives and parents were properly counselled and informed consent was taken prior to transport. Data were collected regarding the maternal morbidities, natal and postnatal details including mode of delivery, liquor quality, APGAR score, indication of referral, gestational age, sex, birth weight, age at admission, distance travelled, in a structured proforma. SNAPPE-II scoring was done to assess the clinical severity and relation with outcome; the parameters of the same are given on (Table/Fig 1) (13). Less than 20 kilometer (km) transport was considered as short distance and ≥20 km was long distance. Data was taken from the transport sheets, the case sheets and ambulance records. All neonates were uniformly managed as per National Neonatology Forum (NNF) guidelines (14) and were followed-up till discharge or death. STATISTICAL ANALYSIS Data was analysed using Statistical Package for the Social Sciences (SPSS) statistics. Baseline characteristics were given in number (N) and percentages. Descriptive statistics are expressed as mean and SD for variables that show normal distribution in continuous data and as percentages {% (n)} for categorical variables. Binary logistic regression analysis was used to analyse the effect of independent variables on two outcome dependent variables. The differences between groups were analysed using Independent t-test for parametric data. Statistical analysis was carried out at 5% level of significance and the p-value <0.05 was considered significant. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Results | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
A total of 101 newborn infants were transported to NICU during the study period in which 58 babies were term and 43 were preterm. Mean gestational age was 35 (±SD 3.7) weeks and mean birth weight was 2246.60 (±SD 913.9) grams. Sixty five babies were male and 36 were female. The mortality rate for all patients was 15.8% (n=16). Most common causes of transport are mentioned in (Table/Fig 2) and amongst the miscellaneous causes of transport, Neonatal Jaundice (NNJ) 5 (4.9%) was the commonest one. The baseline characteristics of the babies are given in (Table/Fig 2). SNAPPE II scores of admitted babies are given in (Table/Fig 3). SNAPPE II was calculated in 91 babies as in 10 babies APGAR was not known. Physiological instability at receiving the baby from other hospital and at admission in NICU and outcome are given in (Table/Fig 4). Total 16 babies died. Five out of 10 babies were received with moderate hypothermia (50%), 10 out of 11 babies were still having saturation <90%, 10 out of 15 babies with deranged perfusion and all the 5 babies with hypoglycaemic records at the time of receiving at our centre died. Twenty-two babies stayed for nearly one day, 28 babies stayed for one week, 29 babies for one to three weeks and 22 babies for more than 3 weeks. Eleven babies expired within first 48 hours of admission. Amongst causes of mortality, four babies were with Hypoxic Ischemic Encephalopathy (HIE), four with sepsis with pneumonia, four due to prematurity and three Meconium Aspiration Syndrome (MAS) with Persistent Pulmonary Hypertension (PPHN), 1 Congenital Diaphragmatic Hernia (CDH) (Table/Fig 5). On univariate analysis, hypoxic, hypoglycaemic, hypothermic, babies with poor perfusion, low APGARs and babies having SNAPPE score more than 40 were significant risk factors for mortality. On multiple logistic regression analysis, hypothermia, hypoperfusion, hypoglycaemia and SNAPPE II score have effects on outcome with sensitivity of 70% and specificity of 93%. (Table/Fig 6) represents the results of regression analysis. Less than 20 kilometer (km) transport was considered as short distance and ≥20 km as long distance, which didn’t have any effect on outcomes of babies. There was no CPR during transport or at arrival to our hospital. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Discussion | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Neonatal transport from level I and II to level III units are common for improving neonatal outcomes and for this a well equipped ambulance with well trained staff and doctors are the need of the hour. In the current study, babies who had deranged Temperature, Oxygenation, Perfusion and Sugar levels (TOPS) and higher SNAPPE-II score had poor outcomes. Studies have shown that babies who were self-transported had poor outcome compared to babies transported by equipped and trained team (12),(15). In present study 42.6% babies were premature, which was nearly similar to studies by Sehgal A et al., and Singh H et al., and Mir NA et al., (15),(16),(17). Male to female ratio was 1.2:1 and indications of transport were almost similar to previous studies (18). Hypothermia was observed in 14.8% babies in present study however, it ranged from 23.18% to 54% in previously published studies(18),(19),(20). Hypoxia and hypoglycaemia were10.8% and 4.9% respectively in present study however, in previously published studies it was 18.6% and 7.27% respectively (18). This suggests that with a well trained and equipped transport system the physiological instability of babies can be decreased to a large extent. A 66.3% babies received ventilation compared to 44.3% as reported in literature (12). Studies by Sehgal A et al., and Kumar PP et al., have shown that stabilisation of neonates temperature, oxygenation, perfusion, sugar, prior to and during transport improves neonatal outcome (15),(21). There was no CPR recorded during or receiving baby in our NICU compared to 28% as reported by Henry S and Trotman H (19). Nearly 15.8% of babies expired compared to 19.8 to 32% as published by Rathod D et al., and Buch Pankaj M et al., (22),(23). Eleven (68.7%) babies expired within first 48 hours of admission compared to 33.3% to 55.2% reported in other studies (12),(15) which was justified by the severity of clinical condition of the transported patients with high SNAPPE II scores (13). Mortality was high in babies with SNAPPE II score more than 40. In present study there was no effect of duration of transport on the outcome, as seen in Buch Pankaj M et al., might be explained by the fact that babies physiological parameters were stabilised by our well trained team prior and during transport, but those babies with severe deranged parameters succumbed (23). But other studies have shown significant effect of the same (20),(22). Usually the transportation team should devote time in stabilisation of the baby prior to starting transport, without which, clinical deterioration of baby’s condition during transport is expected. Limitation(s) It was a retrospective study. A prospective study needs to be planned for more definitive recommendations. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Original article / research
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