Inequalities in birth before arrival at hospital in South West England: a multimethods study of neonatal hypothermia and emergency medical services call-handler advice.

OBJECTIVES: To examine inequalities in birth before arrival (BBA) at hospitals in South West England, understand which groups are most likely to experience BBA and how this relates to hypothermia and outcomes (phase A). To investigate opportunities to improve temperature management advice given by emergency medical services (EMS) call-handlers during emergency calls regarding BBA in the UK (phase B). DESIGN: A two-phase multimethod study. Phase A analysed anonymised data from hospital neonatal records between January 2018 and January 2021. Phase B analysed anonymised EMS call transcripts, followed by focus groups with National Health Service (NHS) staff and patients. SETTING: Six Hospital Trusts in South West England and two EMS providers (ambulance services) in South West and North East England. PARTICIPANTS: 18 multidisciplinary NHS staff and 22 members of the public who had experienced BBA in the UK. RESULTS: 35% (64/184) of babies conveyed to hospital were hypothermic on arrival. When compared with national data on all births in the South West, we found higher percentages of women with documented safeguarding concerns at booking, previous live births and 'late bookers' (booking their pregnancy >13 weeks gestation). These women may, therefore, be more likely to experience BBA. Preterm babies, babies to first-time mothers and babies born to mothers with disability or safeguarding concerns at booking were more likely to be hypothermic following BBA. Five main themes emerged from qualitative data on call-handler advice: (1) importance placed on neonatal temperature; (2) advice on where the baby should be placed following birth; (3) advice on how to keep the baby warm; (4) timing of temperature management advice and (5) clarity and priority of instructions. CONCLUSIONS: Findings identified factors associated with BBA and neonatal hypothermia following BBA. Improvements to EMS call-handler advice could reduce the number of babies arriving at hospital hypothermic.

Epidemiology, Management, and Outcomes of Accidental Hypothermia: A Multicenter Study of Regional Care.

BACKGROUND: Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. METHODS: Trauma patients with temperatures <35°C at 4 ACS-verified trauma centers in Wisconsin and Minnesota from 2006 to 2016 were reviewed. Statistical analysis included chi-square and Fisher's exact tests. A P value < .05 was considered significant. RESULTS: 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) (P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity (P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia (P = .44). CONCLUSION: Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.

Assessment of rewarming methods in unplanned out-of-hospital births from a prospective cohort.

BACKGROUND: Mobile intensive care units frequently manage unplanned out-of-hospital births (UOHB). Rewarming methods during pre-hospital management of UOHB have not yet been compared. The aim was to compare rewarming methods used during pre-hospital management in a large prospective cohort of UOHB in France. METHODS: We analysed UOHB from the prospective AIE cohort from 25 prehospital emergency medical services in France. The primary outcome was the change in body temperature from arrival at scene to arrival at hospital. RESULTS: From 2011 to 2018, 1854 UOHB were recorded, of whom 520 were analysed. We found that using incubator care was the most effective rewarming method (+ 0.8 °C during transport), followed by the combination of plastic bag, skin-to-skin and cap (+ 0.2 °C). The associations plastic bag + cap and skin-to-skin + cap did not allow the newborn to be warmed up but rather to maintain initial temperature (+ 0.0 °C). The results of the multivariate model were consistent with these observations, with better rewarming with the use of an incubator. We also identified circumstances of increased risk of hypothermia according to classification and regression tree, like premature birth (< 37 weeks of gestation) and/or low outside temperature (< 8.4 °C). CONCLUSIONS: Using an incubator was the most effective rewarming method during pre-hospital management of UOHB in our French prospective cohort. Based on our model, in cases of term less than 37 weeks of gestation or between 37 and 40 weeks with a low outside temperature or initial hypothermia, using such a method would be preferred.

Implementing a thermal care bundle for inadvertent perioperative hypothermia: A cost-effectiveness analysis.

BACKGROUND: Active warming reduces risk of surgical complications. Implementation of a perioperative thermal care bundle increased use of active warming for surgical patients. OBJECTIVE: This study aimed to determine if implementing a thermal care bundle to prevent inadvertent perioperative hypothermia is cost-effective. DESIGN: A model-based cost-effectiveness analysis was undertaken using Monte Carlo simulations from input distributions to estimate costs and effects. SETTING: Hospitals undertaking between 5,000 and 40,000 surgeries per year, which either implemented or did not implement the thermal care bundle, were modelled. PARTICIPANTS: The decision tree guiding the structure of the model was populated with clinical outcomes (surgical site infection, blood transfusion requirement and morbid cardiac events) of a hypothetical cohort of surgical patients. INTERVENTIONS: Implementation or non-implementation of the thermal care bundle. MAIN OUTCOME MEASURES: Net monetary benefit was calculated by multiplying the health benefits (quality-adjusted life years) by the willingness-to-pay threshold minus the cost. We tested a range of values for willingness to pay per quality-adjusted life year thresholds and plotted results for expected incremental benefits and probability of cost-effectiveness. The incremental cost-effectiveness ratio was also calculated. RESULTS: Thermal care bundle implementation simultaneously reduced costs and increased quality-adjusted life years in the majority of simulations (88.1%). The average cost reduction was $689,659 (95% credible intervals spanned from a $2,718,364 decrease in costs to $379,826 increase in costs) and average difference in quality-adjusted life years was 54 (95% CI = 0.4 less to 176 more). This equated to an incremental cost-effectiveness ratio of $12747 saved per quality-adjusted life year gained. CONCLUSIONS: It is likely that increasing use of active warming by implementing the thermal care bundle would generate cost-savings and improve the quality of life for surgical patients. It would be good value for hospitals with similar characteristics to those included in our model to allocate the extra resources required for implementation.

"Cold Card" to Guide Responders in the Assessment and Care of Cold-Exposed Patients.

INTRODUCTION: A concise, easy-to-use decision aid "Cold Card" that can be carried in the field by wilderness search and rescue teams or medical responders to advise on assessment and care of cold-exposed patients was created. METHODS: A 2-sided card was designed to summarize the important principles established by the Wilderness Medical Society practice guidelines for hypothermia. The card was continually updated through feedback from several content experts. The card was then distributed for further feedback from members of the Search and Rescue Volunteer Association of Canada and enrollees of the Baby It's Cold Outside web-based educational program. This additional feedback was used to create the final iteration of the card. RESULTS: On the front "ASSESS COLD PATIENT" side, the level of cold exposure or hypothermia is accomplished by evaluating (as either normal or impaired function) consciousness, movement, shivering, and alertness on a series of concentric rings. The important treatment actions are provided for each cold-exposure level. The back "CARE FOR COLD PATIENT" side provides the required elements and principles of use for a hypothermia wrap. The Cold Card is available for free download and unlimited use for education or in-field instruction by any individual or group. The card should be printed on heavy, waterproof stock (13×18 cm) for use in all weather conditions. CONCLUSIONS: Key elements of hypothermia evaluation and field care have been summarized on a small portable card for laypersons, trained rescuers, and first responders.

Comparison of the performance of battery-operated fluid warmers.

OBJECTIVES: Warming intravenous fluids is essential to prevent hypothermia in patients with trauma, especially when large volumes are administered. Prehospital and transport settings require fluid warmers to be small, energy efficient and independent of external power supply. We compared the warming properties and resistance to flow of currently available battery-operated fluid warmers. METHODS: Fluid warming was evaluated at 50, 100 and 200 mL/min at a constant input temperature of 20°C and 10°C using a cardiopulmonary bypass roller pump and cooler. Output temperature was continuously recorded. RESULTS: Performance of fluid warmers varied with flows and input temperatures. At an input temperature of 20°C and flow of 50 mL/min, the Buddy Lite, enFlow, Thermal Angel and Warrior warmed 3.4, 2.4, 1 and 3.6 L to over 35°C, respectively. However, at an input temperature of 10°C and flow of 200 mL/min, the Buddy Lite failed to warm, the enFlow warmed 3.3 L to 25.7°C, the Thermal Angel warmed 1.5 L to 20.9°C and the Warrior warmed 3.4 L to 34.4°C (p<0.0001). CONCLUSION: We found significant differences between the fluid warmers: the use of the Buddy Lite should be limited to moderate input temperature and low flow rates. The use of the Thermal Angel is limited to low volumes due to battery capacity and low output temperature at extreme conditions. The Warrior provides the best warming performance at high infusion rates, as well as low input temperatures, and was able to warm the largest volumes in these conditions.

The health economic benefits of perioperative patient warming for prevention of blood loss and transfusion requirements as a consequence of inadvertent perioperative hypothermia.

Active warming of patients is recommended by The National Institute for Health and Care Excellence (NICE) to prevent inadvertent perioperative hypothermia (IPH). This paper examines the cost effectiveness of one consequence of IPH, an increase in blood loss and the resulting transfusion risk. We quantified the risk and modelled two patient pathways, one with and one without warming, across two different surgery types. We were able to demonstrate the cost effectiveness of active warming based on one consequence even allowing for uncertainties in the model.

[Assessment of knowledge about hypothermia among the medical personnel of polish medical air rescue].

Polish Medical Air Rescue is tasked to deal with the most serious incidents associated with life threatening situations, in multiple circumstances. As a consequence, medical personnel have to meet high standards of education and show a continuous theoretical and practical development of the skills which are necessary during medical treatment. Thanks to the introduction of ECMO treatment for accidental hypothermia patients, new clinical and operational possibilities have arisen, so more patients can be saved with a very good neurological outcome. AIM: To analyze the data on hypothermia collected by the personnel of Polish Medical Air Rescue and to assess the e-learning platform as an educational tool. MATERIALS AND METHODS: 123 persons were involved. The subject of analysis were the e-learning platform results of the Polish Medical Air Rescue medical personnel. The e-learning consisted of a pre-test, 8 lessons followed by MCQ's (multi choice questions) and a post-test. RESULTS AND CONCLUSIONS: We could not prove a statistically significant difference in the knowledge about hypothermia between doctors and other medical professionals. Post-traumatic hypothermia and associated coagulation disturbances are two important topics requiring particular focus during the design of further educational and training projects. As a consequence of the training, both groups significantly improved their knowledge: i.e. a statistically significant improvement of knowledge about hypothermia between pre-test and post-test results in both groups was shown. The hypothermia e-learning platform for medical personnel is an effective educational tool.

Difficulties in funding of VA-ECMO therapy for patients with severe accidental hypothermia.

BACKGROUND: Severe accidental hypothermia is defined as a core temperature below 28 Celsius degrees. Within the last years, the issue of accidental hypothermia and accompanying cardiac arrest has been broadly discussed and European Resuscitation Council (ERC) Guidelines underline the importance of Extracorporeal Rewarming (ECR) in treatment of severely hypothermic victims. The study aimed to evaluate the actual costs of ECR with VA-ECMO and of further management in the Intensive Care Unit of patients admitted to the Severe Accidental Hypothermia Centre in Cracow, Poland. METHODS: We carried out the economic analysis of 31 hypothermic adults in stage III-IV (Swiss Staging) treated with VA ECMO. Twenty-nine individuals were further managed in the Intensive Care Unit. The actual treatment costs were evaluated based on current medication, equipment, and dressing pricing. The costs incurred by the John Paul II Hospital were then collated with the National Health Service (NHS) funding, assessed based on current financial contract. RESULTS: In most of the cases, the actual treatment cost was greater than the funding received by around 10000 PLN per patient. The positive financial balance was achieved in only 4 (14%) individuals; other 25 cases (86%) showed a financial loss. CONCLUSION: Performed analysis clearly shows that hospitals undertaking ECR may experience financial loss due to implementation of effective treatment recommended by international guidelines. Thanks to new NHS funding policy since January 2017 such loss can be avoided, what shall encourage hospitals to perform this expensive, yet effective method of treatment.

Developing sustainable global health technologies: insight from an initiative to address neonatal hypothermia.

Relative to drugs, diagnostics, and vaccines, efforts to develop other global health technologies, such as medical devices, are limited and often focus on the short-term goal of prototype development instead of the long-term goal of a sustainable business model. To develop a medical device to address neonatal hypothermia for use in resource-limited settings, we turned to principles of design theory: (1) define the problem with consideration of appropriate integration into relevant health policies, (2) identify the users of the technology and the scenarios in which the technology would be used, and (3) use a highly iterative product design and development process that incorporates the perspective of the user of the technology at the outset and addresses scalability. In contrast to our initial idea, to create a single device, the process guided us to create two separate devices, both strikingly different from current solutions. We offer insights from our initial experience that may be helpful to others engaging in global health technology development.

Web-based hypothermia information: a critical assessment of Internet resources and a comparison to peer-reviewed literature.

AIMS: Hypothermia is a medical condition characterized by a drop in core body temperature, and it is a considerable source of winter weather-related vulnerability in mid-/high-latitude areas. Heat vulnerability research, including assessments of internet-based resources, is more thoroughly represented in the peer-reviewed literature than cold-related vulnerability research. This study was undertaken to summarize available web-based hypothermia information, and then determine its scientific validity compared to the peer-reviewed literature. METHODS: This research takes a similar approach used by Hajat et al. for web-based heat vulnerability research, and utilizes this framework to assess hypothermia information found on the internet. Hypothermia-related search terms were used to obtain websites containing hypothermia information, and PubMed (medical literature search engine) and Google Scholar were used to identify peer-reviewed hypothermia literature. The internet information was aggregated into categories (vulnerable populations, symptoms, prevention), which were then compared to the hypothermia literature to determine the scientific validity of the web-based guidance. The internet information was assigned a Strength of Recommendation Taxonomy (SORT) grade (developed by the American Academy of Family Practitioners) of A, B, or C based on the peer-reviewed evidence. RESULTS: Overall, 25 different pieces of guidance within the three categories were identified on 49 websites. Guidance concerning hypothermia symptoms most frequently appeared on websites, with six symptoms appearing on 50% or greater of websites. No piece of guidance within the vulnerable population categories appeared on greater than 60% of the websites, and prevention-related guidance was characterized by varied SORT grades. CONCLUSIONS: Hypothermia information on the internet was not entirely congruent with the information within the peer-reviewed medical literature. Several suggestions for improving web-based hypothermia resources include clearly listing sources for users to see and eliminating guidance with lower SORT grades and replacing with evidence-based information.

Late preterm birth: a new nursing issue.

Late preterm infants are those born between 34 and 36 6/7 completed weeks' gestation. In the last decade, late preterm infants have become the fastest growing subset of preterm infants and now account for 74% of all preterm births. They are at greater risk for feeding problems, dehydration, hypothermia, jaundice, and hypoglycemia and are more likely to be readmitted to the hospital in the first weeks after birth and accrue greater healthcare costs as a result. Despite the alarming growth of this population and the acknowledgment of increased risk in the literature, there is limited information available to the clinical nurse and few evidence-based guidelines to direct the care of these infants specifically. This article describes what is known to date about this issue and what nurses need to do to appropriately care for late preterm infants.

Increased energy expenditure after dilutional exchange transfusion for neonatal polycythemia.

OBJECTIVE: Hypothermia is a known symptom of neonatal polycythemia (NP) and its pathophysiology is unclear. The effect of partial dilutional exchange transfusion (PET) upon resting energy expenditure (REE) is unknown. We aimed to test the hypothesis that PET leads to an increase in REE. STUDY DESIGN: 11 patients with NP who underwent PET and 10 controls without polycythemia were studied. NP was defined as a venous HCT >/=0.65. Per protocol, symptomatic infants and/or those with venous HCT > or =0.70 underwent PET. REE was measured just prior and 23 hours after PET in patients with NP and at identical ages in the control group. Infants were studied in a skin servo controlled radiant warmer, while clinically and thermally stable, prone and asleep. Measurements were stopped during body movements (less than 5% of the time of measurement). Metabolic measurements were performed by indirect calorimetry, using the Deltatrac II Metabolic monitor (Datex-Ohmeda, Helsinki, Finland). This instrument uses the principle of the open circuit system that allows continuous measurements of oxygen consumption (Vo(2)) and carbon dioxide production (Vco(2)) using a constant flow generator. REE measurements were corrected for the infant weight (Kcal/kg/d). Comparison of REE values between groups was performed using paired Wilcoxon ranked test. RESULTS: Patients with and without NP had nearly identical baseline REE. In patients with NP, REE increased from 44.0 +/- 6.6 Kcal/Kg/d to 48.3 +/- 5.1 Kcal/Kg/d after PET (P<0.05). Furthermore, the increase in REE following PET correlated inversely with the decrease in hematocrit. There was no significant change in REE over time in the control group. In the NP group, symptomatic infants (n=5) had a significantly greater increase in REE following PET than non-symptomatic ones (1.4 +/- 6.3 vs. 7.8 +/- 4.9 Kcal/Kg/d, p<0.05). CONCLUSIONS: Energy expenditure of polycythemic infants increases following PET, in a manner proportional to the decrease in hematocrit. Symptomatic polycythemic infants have a greater rise in REE following PET than non-symptomatic ones. We speculate that polycythemia leads to a decreased REE that might be remedied by PET.

[Perioperative thermal management]. / Perioperatives Wärmemanagement.

Perioperative hypothermia can influence clinical outcome negatively. It triples the incidence of adverse myocardial outcomes, significantly increases perioperative blood loss, significantly augments allogenic transfusion requirements, and increases the incidence of surgical wound infections. The major causes are redistribution of heat from the core of the body to the peripheral tissues and a negative heat balance. Adequate thermal management includes preoperative and intraoperative measures. Preoperative measures, e.g., prewarming, enhance heat content of the peripheral tissues, thereby reducing redistribution of heat from the core to the peripheral tissues after induction of anesthesia. Intraoperative measures are active skin surface warming of a large body surface area with conductive or convective warming systems. Intravenous fluids should be warmed when large volumes of more than 500-1000 ml/h are required. The body surfaces that cannot be actively warmed should be insulated. Airway humidification and conductive warming of the back are less efficient.

Hypothermia: assessment, treatment and prevention.

Hypothermia is a condition that can have serious consequences, yet its symptoms are often unrecognised in older people because they can be easily confused with symptoms of other age-related illnesses. Nurses should know how to treat the condition, as well as be able to offer health promotion and health education advice about keeping warm.

Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India.

BACKGROUND: Neonatal care is not available to most neonates in developing countries because hospitals are inaccessible and costly. We developed a package of home-based neonatal care, including management of sepsis (septicaemia, meningitis, pneumonia), and tested it in the field, with the hypothesis that it would reduce the neonatal mortality rate by at least 25% in 3 years. METHODS: We chose 39 intervention and 47 control villages in the Gadchiroli district in India, collected baseline data for 2 years (1993-95), and then introduced neonatal care in the intervention villages (1995-98). Village health workers trained in neonatal care made home visits and managed birth asphyxia, premature birth or low birthweight, hypothermia, and breast-feeding problems. They diagnosed and treated neonatal sepsis. Assistance by trained traditional birth attendants, health education, and fortnightly supervisory visits were also provided. Other workers recorded all births and deaths in the intervention and the control area (1993-98) to estimate mortality rates. FINDINGS: Population characteristics in the intervention and control areas, and the baseline mortality rates (1993-95) were similar. Baseline (1993-95) neonatal mortality rate in the intervention and the control areas was 62 and 58 per 1000 live births, respectively. In the third year of intervention 93% of neonates received home-based care. Neonatal, infant, and perinatal mortality rates in the intervention area (net percentage reduction) compared with the control area, were 25.5 (62.2%), 38.8 (45.7%), and 47.8 (71.0%), respectively (p<0.001). Case fatality in neonatal sepsis declined from 16.6% (163 cases) before treatment, to 2.8% (71 cases) after treatment by village health workers (p<0.01). Home-based neonatal care cost US$5.3 per neonate, and in 1997-98 such care averted one death (fetal or neonatal) per 18 neonates cared for. INTERPRETATION: Home-based neonatal care, including management of sepsis, is acceptable, feasible, and reduced neonatal and infant mortality by nearly 50% among our malnourished, illiterate, rural study population. Our approach could reduce neonatal mortality substantially in developing countries.

PIP: The article presents the effect of home-based neonatal care and management of sepsis on neonatal mortality in the Gadchiroli district of India. The study responds to the growing need for the reduction of neonatal mortality rate in developing countries. Sample population involved 39 intervention and 47 control villages in the Gadchiroli district. Baseline data for 2 years (1993-95) were collected from these districts. Neonatal care was introduced in the intervention villages in 1995-98, wherein village health workers trained in neonatal care made home visits and managed sepsis and other neonatal problems. Other workers recorded all births and deaths in the intervention and the control area (1993-98) to estimate mortality rates. Findings showed that the net percentage reduction in the third year of intervention for the neonatal mortality rate was 25.5 (62.2%); for the infant mortality rate, 38.8 (45.7%); and for the perinatal mortality rate, 47.8 (71.0%). Case fatality in neonatal sepsis declined from 16.6% before treatment to 2.8% after treatment by village workers (p 0.01). The article concludes that home-based neonatal care, including management of sepsis could reduce neonatal mortality substantially in developing countries.

In-line blood/solution warmers.

In-line blood/solution warmers are used in many clinical procedures to warm refrigerated and room temperature fluids as they are infused into the patient. Warming fluids such as whole blood, blood products, intravenous (IV) solutions, and irrigation solutions helps to maintain the patient's core body temperature, thus minimizing adverse thermal reactions (e.g., hypothermia). In this study, we evaluated nine in-line blood/solution warmers from seven manufacturers. We tested these systems' performance and safety, human factors design, and quality of construction, focusing on how well the devices warm fluids over a variety of infusion rates common in clinical use. We rated each system according to the clinical application base for which it is primarily intended-routine-flow procedures (i.e., those that require low or moderate flow rates) or high-flow procedures. Of the six systems in the routine-flow category, we rated only two units Acceptable; the remaining four were rated Acceptable-Not Recommended because they could not warm fluids to the same temperature level as the Acceptable units. We rated all three of the systems in the high-flow category Acceptable. Within each of these rating groups, we ranked units according to the results of our testing, as well as the results of a life-cycle cost analysis that we performed. In the Technology Overview, we discuss the clinical need for blood/solution warming and outline the debate over whether and when in-line warming devices should be used. Also, we describe the technologies used in these devices, as well as the safety issues associated with their use. The Selection, Purchasing, and Use Guide at the end of the Evaluation provides guidance to help facilities (1) assess their blood/solution warming needs, (2) choose the systems that will best meet their needs, and (3) use these systems effectively. This study also includes the supplementary article, "Maximum Blood Warming Temperature-How Hot Is Too Hot?"