Comparing Three Methods of Therapeutic Hypothermia Among Transported Neonates with Hypoxic-Ischemic Encephalopathy.

Hypoxic-ischemic encephalopathy (HIE) and associated multiorgan injury are significant causes of morbidity and mortality in term and near-term neonates. Therapeutic hypothermia (TH) is the current standard of care for neuroprotection in neonates with HIE. In our experience, the majority of babies born with HIE were found in nontertiary care facilities in our region, where effective methods of cooling during transport to tertiary care centers are desirable. Most centers initiate passive TH at referral hospitals, while active cooling is typically initiated during transport. The objective of this study was to evaluate the effectiveness of three methods of cooling during transport of neonates with HIE in southern Alberta. In this prospective cohort study, 186 neonates with HIE were transported between January 2013 and December 2021. Among the 186 neonates, 47 were passively cooled, 36 actively cooled with gel packs, and 103 cooled with a servo-controlled cooling device. The clinical characteristics were comparable for the three groups, with no difference in adverse events. Fifteen neonates (8%) died and 54 neonates (29%) suffered radiologically determined brain injury. Servo-controlled cooling was found to be superior to other methods in maintaining a target temperature without significant fluctuation during transport and with temperature in the target range on arrival at tertiary care facilities. The rate of overcooling was also lower in the servo-controlled group compared with other groups. There were no statistically significant differences between the groups in relation to mortality and brain MRI changes associated with HIE. Adjusting for GA, 10-minute Apgar score, base excess, HIE stage, and need for intubation during transport, passive cooling increased the odds of temperature fluctuation outside the range by 12-fold and gel pack cooling by 13-fold compared with servo-controlled cooling. The use of servo-controlled TH devices should be the preferred practice wherever feasible. (REB17-1334_REN3).

Impact of quality improvement outreach education on the incidence of acute brain injury in transported neonates born premature.

OBJECTIVE: To evaluate impact of a quality improvement (QI) outreach education on incidence of acute brain injury in transported premature neonates. STUDY DESIGN: Neonates born at <33 weeks gestation outside the tertiary center were included. The QI intervention was a combination of neuroprotection care bundle, in-person visits, and communication system improvement. Descriptive and regression (adjusting for Gestational Age, Birth Weight, Gender, and antenatal steroids, Mode of delivery, Apgars at 5 minutes, Prophylactic indomethacin, PDA, and Inotropes use) analyses were performed. The primary outcome was a composite of death and/or severe brain injury on cranial ultrasound using a validated classification. RESULTS: 181 neonates studied (93 before and 88 after). The rate and adjusted odds of death and/or severe brain injury reduced significantly post intervention (30% vs 15%) and (AOR 0.36, 95%CI, 0.15-0.85, P = 0.02) respectively. CONCLUSION: Implementation of outreach education targeting neuroprotection can reduce acute brain injury in transported premature neonates.

Impact of outreach education program on outcomes of neonates with hypoxic ischemic encephalopathy.

AIM: To evaluate the impact of outreach education targeting neuroprotection on outcomes of outborn infants with moderate-to-severe hypoxic ischemic encephalopathy (HIE). METHODS: A retrospective cohort study of infants admitted with moderate-to-severe HIE was conducted following the implementation of outreach education in January 2016. Key interventions were early identification and referral of infants with encephalopathy utilizing telemedicine and a centralized communication system, hands-on simulation, and interactive case discussion and dissemination of clinical management guidelines and educational resources. The association between the intervention and a composite outcome of death and/or severe brain injury on brain magnetic resonance imaging (MRI) was tested controlling for the confounding factors. RESULTS: Of 165 neonates, 37 (22.4%) died and/or had a severe brain injury. This outcome decreased from 35% (27/77) to 11% (10/88) following the implementation of outreach education (P<0.001). Eligible infants not undergoing therapeutic hypothermia within 6 hours from birth decreased from 19.5% (15/77) to 4.5% (4/88). The use of inotropes decreased from 49.3% (38/77) to 19.6% (13/88). Any core temperature below 33°C was recorded for 20/53 (38%) before and 16/78 (21%) after, while those within the target range of 33°C to 34°C at admission to a tertiary care facility increased from (15/53) 28% to (51/88) 58%. Outreach education was independently associated with decreased composite outcome of death and/or severe brain injury on MRI (adjusted odds ratio 0.2; 95% confidence interval 0.07 to 0.52). CONCLUSION: Outreach education targeting neuroprotection for infants with moderate-to-severe HIE was associated with a reduction in death and/or severe brain injury.

Neonatal transport services, a cross-sectional study.

Objective: To understand the process and challenges facing neonatal transport in Canada and to delineate their composition and working.Subjects and methodology: An online questionnaire was sent to all neonatal transport team directors/coordinators in Canada. The questionnaire covered different aspects of transport and was pilot tested prior to finalization. The responses were anonymous to the investigators.Results: All sixteen neonatal transport teams in Canada surveyed. Fifteen teams responded. Dedicated team as a model was adopted by 12 teams (80%). A combined Neonatal/pediatrics team, where the team could be assembled by either neonatal or pediatrics intensive care staff, adopted by two (13%). Team members were cross-trained in about quarter of the teams (four teams out of 15) with respiratory therapists and registered nurses performing each other's roles. Neonatal Resuscitation Program was mandatory for all teams that responded (15 teams) to become certified as a neonatal transport team member. Nine teams use a central dispatch phone call system.Conclusion: As the first to comprehensively describe the status of neonatal transport in Canada, our study shows that neonatal transport teams have similarities as well as differences. Regionalization and differences in referral practices, geography, provincial laws, and manpower are the main reasons why teams may have their individual variations in policies, protocols, and logistics. Our data can be utilized by health professionals and policy makers to improve neonatal transport logistics within their health care systems resulting in better outcomes of transported neonates.

Neonatal Transport Clinician Performed Ultrasound Evaluation of Cardiac Function.

BACKGROUND: Limited point-of-care ultrasound skills for ultrasound-naïve neonatal transport clinicians could enhance clinical evaluation and decision making. Teaching Respiratory Therapists and Nurses to assess cardiac filling and contractility may be feasible. METHODS: Prospective educational study using educational materials, didactic theoretical, and hands-on practical sessions, followed by assessment of practical and theoretical skills. RESULTS: A total of 18 participants completed the study meeting the predefined standard, proving feasibility. Nine (50%) participants had ≤ 10 years of NICU experience. The mean time required for complete training was 8.6 ±â€¯2.1 hours. Time was spent on average on 269 ±â€¯104 minutes for hands-on practice, 171 ±â€¯96 minutes on didactic training, and 76 ±â€¯16 minutes on testing sessions. The median number of hands-on sessions per participant was 5 [Interquartile range (IQR) 5, 7]. The median number of infants required to complete training was 9 infants (IQR 7, 11). RRTs required less time than RNs. Evaluations and feedback from participants on the training program was positive. CONCLUSION: Neonatal RNs and RTs can be trained to perform focused cardiac ultrasound examinations with average time of 8.6 hours. This skill could enhance clinical care on neonatal transport with appropriate interventions to manage suspected hypotension or shock.

Elective transfers of preterm neonates to regional centres on non-invasive respiratory support is cost effective and increases tertiary care bed capacity.

AIM: Managing capacity at regional facilities caring for sick neonates is increasingly challenging. This study estimated the clinical and economic impact of the elective transfer of stable infants requiring nasal continuous positive airway pressure (NCPAP) from level three to level two neonatal intensive care units (NICUs) within an established clinical network of five NICUs. METHODS: We retrospectively analysed the records of 99 stable infants transferred on NCPAP between two level three NICUs and three level two NICUs in Calgary, Canada, between June 2014 and May 2016. RESULTS: The median gestational age and weight at birth were 28 weeks and 955 g, and the median corrected gestational age and weight at transfer were 33 weeks and 1597 g, respectively. This resulted in cost savings of $2.65 million Canadian dollars during the two-year study period, and 848 level three NICU days were freed up for potentially sick neonates. There were no adverse events associated with the transfers. CONCLUSION: The elective transfer of stable neonates on NCPAP from level three to level two NICUs within an established clinical network led to substantial cost savings, was safe and increased the bed capacity at the two level three NICUs.