Neonatal Retrieval Experience from the pilot project Dr. Ramya - - PowerPoint PPT Presentation

13th Annual Scientific Sessions Perinatal Society of Sri Lanka

Neonatal Retrieval Experience from the pilot project

• Dr. Ramya Savithri de Silva

MBBS(Col), DCH, MD(Paed), DPD FSLCPaed, FRCP(Glasg), FRCPCH(UK)

Consultant Paediatrician/Neonatologist

Lady Ridgeway Children’s Hospital Colombo 08

14th August 2014

Sri Lanka over time

5 10 15 20 Infant Neonatal Under 5 2008 2012

Source: WHO World Health Statistics 2010 and 2014

Share of neonatal mortality in under five mortality has risen over time Distribution of mortality under 5 in 2008 by mortality category

Neonatal 29 day to 365 1 year to 5 years Neonatal 29 day to 365 1 year to 5 years

Distribution of mortality under 5 in 2012 by mortality category

Source: Calculations based on WHO World Health Statistics 2010 and 2014

Addressing the Millennium Goals

Reduce child mortality - Where we are?

From the UNDP MDG website “…. the IMR is lower than that achieved by countries considerably wealthier than Sri Lanka” “the MDG child mortality targets are well within reach.” “Future reductions in infant mortality in Sri Lanka will be driven largely by reductions in neonatal mortality, which is considerably more difficult and expensive to attain”

Post–Millennium Development Goals

• Disability-free survival
• Human capital
• Sustainable development

Case for a neonatal Transport Service

• Regular audits expressed concern about poor

condition of newborns following inter- hospital transfer

• Hypothermia and hypoglycemia being

common problems on admission

• Some incidents of major catastrophes
• No organized/protocol driven/safe methods

prescribed for transfer

Why was back transfer identified as important?

• Patients are referred to the LRH from all round

the country.

• LRH only has 5 ventilated cots. Often referrals

have to be refused due to lack of cots.

• If facilities exist for safely transferring back

babies when the acute phase is over, then NICU cots can be released to accommodate more neonates for specialized care.

• Feeding mothers have more family support at

the local hospital.

Birth of the Neonatal Transport Service

• The Perinatal Society of Sri Lanka identified the formulation of a

comprehensive neonatal transport system a key priority area in 2013

• Collaboration with Oxford University NHS Trust
• Funding from the WHO and UNICEF
• Supported by the FHB
• Based at the NICU, Lady Ridgeway Hospital
• A pilot project for Western Province

Service

• Training workshop on the 8th May 2013
• Transport team - 4 medical officers &

20 nurses trained in house

• Dedicated ambulance with a named driver
• 8 am to 4pm service

1st retrieval on 26 June 2013 from Kethumathi Maternity Hospital Panadura

Kethumathi Maternity Hospital, Panadura

Base Hospital Wathupitiwala

Transfers

• 60 retrievals
• 37 back transfers
• Total number of admissions to the unit 267

The First year

• June 26th 2013 to June 26th 2014
• Total - 267 infants transferred into LRH

– Retrieved – 60 infants – Non retrieved – 207 infants – Back transfer - 37

• 60 infants from the non-retrieved group

admitted sequentially -selected for analysis

Demographics

Retrieved Non retrieved Gestation Mean 32.5 (4.6) 34.4 (4.9)* Birth Weight 1.7 (0.8) 2.1 (0.9)*

Values – mean (SD), *p<0.05

• : strong presumption against null hypothesis
• : low presumption against null hypothesis
• : no presumption against the null hypothesis

The retrieved babies are ‘more at risk’ compared to the non-retrieved group – significant differences in gestational mean and birth weight

Transfer modes prior to Retrieval (In 2012)

160 63 84 78 20 40 60 80 100 120 140 160 180 Incubator cot Trolley Hand Incubator cot Trolley Hand

Temperature on admission prior to retrieval pilot project

118 64 1 20 40 60 80 100 120 140 Temp <37 37 or above Unrecordable Temp <37 37 or above Unrecordable

10 20 30 40 50 60 Non-retrieved Retrieved

Below 36.5 Above 36.5

Temperature on admission comparison of retrieved and non-retrieved neonates

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Non-retrieved Retrieved

37.5 to 39 36.5-37.5 36-36.5 35.5-36 35-35.5 34.5-35 34-34.5 33.5-34

Temperature on admission detailed comparison

• f retrieved and non-retrieved neonates

Capillary blood sugar on arrival

Retrieved infants Non retrieved infants Blood sugar (average) 104.0 91.4 Number of infants with blood sugars <45 mg/dL 6

Retrieved group

• Smaller and more immature neonates

(selection bias)

• Excellent temperature control
• No episodes of hypoglycemia on arrival
• No ‘major’ incidents

Peripheral Hospitals

• Staff happy -no stress
• Less hassle – saves their manpower
• Delays minimized
• Parents happy – better care for their baby

Challenges

• Geographically restricted
• Back transfers – not undertaken as yet fully
• 60 transfers – long way to go!

Difficulties encountered

• Shortage of trained staff – Medical / Nursing
• Limited no. of NICU cots
• Only from 0800 – 1600 hours
• Strained relationships when unstable

neonates are not retrieved

• Limited to the Western Province

Future

• A precedence has been set
• Needs to be expanded
• Data collection
• National Roll out!