Transport of sick neonates to a tertiary care hospital,south India: condition at arrival and outcome

Introduction

Reducing under-five mortality rate by two-thirds is the World Health Organization (WHO) target as per Millennium Development Goal (MDG) 4 and timely treatment of complications for newborns is one of the key strategies for achieving the same.^1,2 The phenomenal number of deliveries and poorly organised system of neonatal transport in developing countries are definite hurdles for the achievement of MDG 4. It is not uncommon to see hypothermic, hypoglycaemic, hypoxic or apnoeic neonates arriving at the paediatric emergency room owing to delayed and improper transport.^3–5 In utero transfer is the safest transfer, but unfortunately preterm delivery, perinatal illness and congenital malformations cannot always be anticipated, resulting in a continuing need for transfer of these neonates after delivery. These babies are often critically ill and the outcome is partly dependent on the effectiveness of the transport system. There is also paucity of data on neonatal transport in India. This study was done to describe the transport of sick neonates to a tertiary care hospital and evaluate their condition at arrival and outcome.

Methods

This descriptive study on neonatal transport was conducted in the Division of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry from February 2012 to January 2013. The study was approved by the Institute’s ethical committee and informed consent was obtained from parents. All extramural neonates (<28 days) transported to the JIPMER Neonatal Intensive Care Unit during the study period were included. Neonates with major congenital or surgical anomalies were excluded. Data including demographic parameters and transport details were recorded in a structured pro forma. Antenatal details including maternal morbidities, natal and postnatal details including mode of delivery, liquor quality, resuscitation particulars and Apgar score were recorded. Gestational age was assessed for all neonates using the modified Ballards scoring. Clinical details including respiratory distress, lethargy, vomiting, abdominal distension, bleeding, jaundice and seizures if present were noted. All neonates were uniformly managed as per National Neonatology Forum (NNF) guidelines and were followed up till discharge or death. Statistical analysis was done using SPSS version (IBM, New York, USA) and Graphpad insat 3. Categorical data were presented as frequencies and percentages and normal distributed continuous data were presented as mean with standard deviation. To determine the association of clinical factors with outcome χ² and Fisher’s exact tests were used. Statistical analysis was carried out at 5% level of significance and a P value <0.05 was considered significant.

Results

Among the target population of 339 neonates, 303 satisfied the inclusion criteria while 36 were excluded. Their baseline characteristics are depicted in Table 1. Most of the neonates were transported by private ambulance (36%) followed by taxi (29%), bus (15%), ‘108 ambulance’ (a free government service) (11%), two-wheeler (6%) and private car (3%). The most common indication for transport was sepsis (30.7%) followed by birth asphyxia (17.5%) and respiratory distress (15.2%). Only 24.8% of neonates arrived before 6 h of life and the majority of neonates were referred after 24 h of life. Forty-five percent of the neonates were referred from hospitals less than 50 km away from JIPMER and the distance travelled did not correlate with the outcome. At admission, 50% had cold stress and 30% had hypothermia. Out of the 60 neonates who died, 27 (45%) died within 24 h of arrival to our hospital. Among the neonates who died, 76% were hypothermic and 10% hypoglycaemic at admission. Blood culture was positive in 24% of all the neonates and the common organisms isolated were E. coli and Staphylococcus aureus. The transport variables and clinical features affecting the outcome are depicted in Tables 2 and 3, respectively.

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Table 1

Baseline characteristics of neonates included.

Characteristics	n = 303	%
Maturity
Term	228	78.5
Preterm	65	21.5
Post term	10	3.3
Mode of delivery
Spontaneous vaginal delivery (SVD)	237	78.2
Lower segment caesarean section (LSCS)	47	15.5
Delivered by forceps/vacuum	19	6.3
Significant obstetric problems
Pregnancy induced hypertension (PIH)	64	21
Premature rupture of membranes (PROM)	65	21.5
Meconium stained liquor	17	5.6
Foul-smelling liquor	9	3
APGAR score at 5 min
0–3	7	2.3
4–6	41	13.5
7–10	211	69.6
Not available	44	14.5
Clinical features
Lethargy	186	61.4
Seizures	87	28.7
Grunting	60	19.8
Vomiting	41	13.5
Abdominal distension	37	12.2
Bleeding	20	6.6
Outcome
Discharged	231	76.2
Expired	60	19.8
Against medical advice (AMA)	12	3.9

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Table 2.

Transport characteristics versus outcome.

Variable	Discharged	Expired	P value
	(n = 231)	(n = 60)
Mother transported along with neonate
Yes	185	48	<0.0003
No	46	12
Transport personnel
Doctor	8	4	<0.0001
Nurse	18	7
Attender/Parent	189	32
Trained emergency technician	16	17
Oxygen administered during transport
Yes	66	30	<0.001
No	165	30
Intubated prior to transport
Yes	4	7	<0.002
No	227	53
IV fluids administered during transport
Yes	80	39	<0.0001
No	151	21
IV inotropes administered during transport
Yes	7	6	<0.01
No	224	54

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Table 3.

Clinical features versus outcome.

Variables	Discharged (n = 231)	Expired (n = 60)	P value
Maturity
Term	180	38	<0.012
Preterm	43	21
Post term	9	1
Pregnancy induced hypertension (PIH) in mother
Present	42	20	<0.001
Absent	189	40
Prolonged rupture of membranes (PROM)
Present	38	24	<0.0001
Absent	193	36
Respiratory distress
Present	125	56	<0.0001
Absent	106	4
Grunting
Present	26	32	<0.0001
Absent	205	28
Bleeding manifestations
Present	11	9	<0.01
Absent	220	51
Abdominal distension
Present	23	13	<0.04
Absent	208	47
Blood culture
Positive	62	7	<0.03
Negative	169	53

Discussion

Though neonatal transport is an important determinant of clinical outcome among sick neonates, it is often neglected in resource restricted settings such as India.^6,7 A study by Narang et al. revealed that road transport was mostly used with limited use of ambulances and a general lack of trained health personnel. ⁸ In our study, the common mode of neonatal transport was by private ambulances while 108 services (government) were used in only 11% of cases. Private ambulances were often lacking adequate facilities and trained personnel. Neonates transported by dedicated neonatal emergency services amounted to only 3%. Though the country has witnessed mammoth growth in telecommunication and space science, it is a paradox that still most sick neonates are transported to hospitals by auto, two-wheeler or taxi. In remote villages, a bullock cart or even a physical lift maybe used. Most of the transfers in India are carried out by semi-trained or ill-trained personnel whose presence may even increase the risk of adverse events during transport. ‘108 Emergency service’ – a free service by GVK Emergency Management and Research Institute with state-of-the-art emergency call response centres and over 5,306 ambulances – is available in most states and on an average their ambulance reaches a client in 14 min in urban areas and 22 min in rural areas. However, dedicated neonatal ambulances are few. ⁶ The existing healthcare system with reference to maternal and child care in south India is neither uniform nor streamlined as in developed countries. Deliveries are conducted in various settings (both government and private) with varied availability of resources and skilled personnel. However, not all are equipped to manage sick neonates and thus these critically ill patients are referred to the nearest larger government hospital/medical college for expert management (especially for mechanical ventilation). Those referring to JIPMER include private nursing homes, government primary health centres and district hospitals from Pondicherry and neighbouring districts of Tamil Nadu. Most of these units have paediatricians and staff nurses but lack facilities for level II or III neonatal care. With the introduction of facility-based Integrated Management of Neonatal and Childhood Illness (IMNCI), a few special care newborn units (SCNU) are being set up in the government sector but they are very few in number and do not meet the growing demand.

Oxygen support during transport was lacking in 43% of the neonates transported by private and 55% of those by public services. Oxygen is mandatory during transport of sick term babies who are either hypoxic or in respiratory distress. However for preterm babies overzealous oxygen treatment may cause retinopathy of prematurity and lung injury.

In a study by Kumar et al. stabilisation of the neonate before and during transport has been shown to improve the condition of the neonate in terms of temperature, oxygenation, blood glucose and blood pressure. ⁴ In our study data regarding endotracheal intubation and inotropes showed that most of the babies were transported without prior stabilisation and hence the poor outcome of these neonates. Our data showed that distance covered was unimportant compared with stabilisation prior to transport which is vital. Neonates accompanied by health personnel (doctors and nurses) had a poorer outcome compared to those accompanied by a parent. This may be related to the observation that trained personnel were involved only when the neonate was critical and relatively stable neonates were transported by their parents alone. Kangaroo mother care during transport is likely to reduce hypothermia and hypoglycaemia among stable neonates, and especially preterm babies. However, this practice was not observed in our study.

Among 60 neonates who died, 76% were hypothermic at admission and many of them died within the first 24 h. This implies that hypothermia is a major factor contributing to the poor outcome in sick neonates. Similar results highlighting the significance of hypothermia prevention during neonatal transport have been documented in studies from African countries.^9–11 Hypothermia during transport can be avoided using one or more of the following: skin-to-skin care, radiant warmers, plastic coverings and caps and exothermic mattresses.^12,13 A Delhi-based study revealed that birth weight <1 kg and transportation time >1 h were significant predictors for mortality among transported neonates. ⁸ According to Njokanma et al. from Nigeria, suboptimal condition of neonatal resuscitation, thermoregulation and transfer were associated with poor immediate outcome. ¹⁰ Our study showed that prematurity, pregnancy induced hypertension (PIH), prolonged rupture of membranes (PROM), respiratory distress, grunting, bleeding, abdominal distension and a positive blood culture correlated with a poor outcome. The presence of one or more of these parameters in a transported neonate should alert the attending physician and warrant vigilant monitoring. A specialised neonatal transport service can improve the survival and decrease the temperature and biochemical abnormalities in referred neonates. A sustained and coordinated effort to augment resources for neonatal transport as well as educating transfer personnel is the need of the hour. The public should also be educated that neonates can become hypothermic in apparently warm climates and the preventive strategies for hypothermia should be emphasised.