An evaluation of intra-hospital transport outcomes from tertiary neonatal intensive care unit

An analysis of a new rapid difficult airway response team in a vertically built children's hospital

BACKGROUND

Intrahospital transport is associated with adverse events. This challenge is amplified during airway management. Although difficult airway response teams have been described, little attention has been paid to patient transport during difficult airway management versus the alternative of managing patient airways without moving the patient. This is especially needed in a 22-floor vertical hospital.

HYPOTHESIS

Development of a rapid difficult airway response team and an associated difficult airway cart will allow for the ability to manage difficult airways in the patient's primary location.

METHODS

A retrospective chart review of all rapid difficult airway response activations from December 18, 2019 to December 31, 2021 was performed to determine the number of airways secured in the patient's primary location (primary outcome). Secondary outcomes included length of time until airway securement, airway device used, number of attempts, complications, use of front of neck access, and mortality.

RESULTS

There were 96 rapid difficult airway response activations in a 2-year period, with 18 activations deemed inappropriate. Of the 78 indicated rapid difficult airway response deployments, all activations resulted in a secure airway, and 76 (97.4%) of cases had an airway secured in the patient's primary location. The mean time to airway securement was 17.1 min (standard deviation 18.8 min). The most common methods of airway securement were direct laryngoscopy (42.3%, 33/78) and video laryngoscopy (29.5%, 23/78). The mean number of attempts by the rapid difficult airway response team was 1.4. There were no documented cases requiring front of neck access. The Cormack-Lehane airway grade at time of intubation was I-II in 83.3% (65/78) of activations. Rapid difficult airway response activation resulted in 16 cases of cardiac arrest and 4 patient deaths within 48 h.

CONCLUSIONS

A rapid difficult airway response team allows a large majority of patients' airways to be managed and secured in the patient's primary hospital location. Future directions include reducing time to airway securement and identifying factors associated with cardiac arrest.

A Quality Improvement Initiative to Provide Timely Central Vascular Access in a Neonatal Intensive Care Unit

BACKGROUND

Timely central venous access is essential in the care of critically ill neonates. Peripherally inserted central catheters (PICCs) are the preferred form of central venous access when umbilical venous catheters cannot be placed or are discontinued. However, time delays increase risk for injury from peripheral intravenous lines and may contribute to inconsistent delivery of necessary fluids and medications.

PURPOSE

The aim of this quality improvement project was to decrease wait times for PICC placement in the neonatal intensive care unit (NICU).

METHODS

A unit-based PICC team was developed consisting of NICU nurses and attending neonatologists and implemented in 2 phases. Data were collected from chart reviews before, during, and after implementation of the team. We tracked time between PICC order and placement and number of attempts. Hospital metrics on peripheral intravenous line infiltrations and central line-associated blood stream infection were also monitored. At the end of the project, we continued tracking outcomes to determine whether gains would be sustained past the project period.

RESULTS

Implementation of a unit-based interdisciplinary specialty team led to a 50% reduction in mean PICC wait times from 1.2 days to 0.58 days. Benefits of the initiative were sustained past the initial project period.

IMPLICATIONS FOR PRACTICE

The development of a dedicated, local team played a key role in improving vascular access in the NICU.

IMPLICATIONS FOR RESEARCH

Proximity of specialized teams provides a solution to address gaps in care in the NICU.

Experience of Mass Intrahospital Neonatal Transport: Impact on Vitals

Background

Mass transport of neonates is required in cases of disasters and calamities such as fire. It may also be required when there is a need for the upgradation of infrastructure. Neonatal transport even for a short period is a period of stress for the neonate. Mass transport of neonates needs much planning, and even after diligent planning, may result in the destabilization of neonates.

Objectives

The objectives of this study were to assess the impact of mass intrahospital neonatal transport on the vital parameters of neonates, the occurrence of any adverse event during transport. To study the frequency of adverse events in mass intrahospital neonatal transport and factors related to it.

Materials and methods

This was a retrospective observational study on a cohort of 16 neonates who were transported to an alternate site in the hospital so that renovation and upscaling of the infrastructure of the newborn intensive care unit (NICU) could be undertaken. Site selection, preparation, and transport details were observed. Vital parameters pre and post-transport were noted, and the occurrence of adverse events during transport was documented and analyzed.

Results

Sixteen neonates were transported over a span of 90 minutes with a mean travel time of 5.62±3.03 minutes. There was a statistically significant rise in the heart rate of the neonates post transport (137.7±8.51vs 141.3±9.01, p-value .00769) though not clinically significant. Six point two-five percent (6.25%) of neonates deteriorated post transport and needed extra efforts for stabilization. Equipment malfunction was responsible for deterioration.

Conclusion

Unforeseen events can occur during neonatal transport. Despite adequate planning, preparation, and care during transport, it remains a period of stress for a neonate.

Adverse Events and Associated Factors During Intrahospital Transport of Newborn Infants

OBJECTIVE

To determine the frequency, type, and severity of adverse events (AEs) during intrahospital transport of newborn infants and to identify associated factors.

STUDY DESIGN

We conducted a prospective observational study in a tertiary care academic neonatal unit. All patients hospitalized in the neonatal unit and undergoing intrahospital transport between June 1, 2015, and May 31, 2017 were included. Transports from other hospitals and the delivery room were not included.

RESULTS

Data from 990 intrahospital transports performed in 293 newborn infants were analyzed. The median postnatal age at transport was 13 days (Q1-Q3, 5-44). Adverse events occurred in 25% of transports (248/990) and were mainly related to instability of cardiovascular and respiratory systems, agitation, and temperature control. Adverse events were associated with no harm in 207 transports (207/990, 21%), mild harm in 37 transports (37/990, 4%), and moderate harm in 4 transports (4/990, 0.4%). There was no severe or lethal adverse event. Hemodynamic support with catecholamines, the presence of a central venous catheter, and a longer duration of transport were independent predictors for the occurrence of adverse events during transport.

CONCLUSIONS

Intrahospital transports of newborns are associated with a substantial proportion of adverse events of low-to-moderate severity. Our data have implications to inform clinical practice, for benchmarking and quality improvement initiatives, and for the development of specific guidelines.

The bedside practice of sonographic guided internal jugular vein access in critically ill premature infants

BACKGROUND

Intrahospital transport, general anesthesia, and the prolonged duration of the central venous catheterization (CVC) in unfavorable conditions pose a significant risk to a critically-ill premature infant. We aimed to demonstrate a minimalized and safe manner of CVC in this patient population.

METHODS

We worked on a prospective study in 51 critically-ill premature infants in which a 22 Gauge catheter was put in one of the central thoracic veins with the guidance of sonography as a bedside procedure. Of the patients, 27 (53%) were extremely premature, and 21 (41%) were extremely low birth weight infants (ELBW). The mean gestational age was 29 ± 5 weeks, and the mean weight at the time of the procedure was 1655 ± 1028 grams. While no anesthetic and sedative drugs were administered to ELBW infants during procedures, in the remainder of the cohort, procedures were carried out only under sedoanalgesia.

RESULTS

Vascular access was achieved in 48 (94%) of the patients after a mean number of 1.47 ± 0.75 attempts. Body heat loss of the patients at the end of the procedures was not statistically significant (p=0.164). However, ELBW infants lost their body heat significantly more than the rest of the cohort (p=0.032). We experienced clinically insignificant common carotid artery puncture in three patients and hemothorax in one patient.

CONCLUSIONS

CVC of critically ill premature infants can be safely and successfully achieved in incubators using sonography guidance, protecting them from hypothermia and anesthetic drugs.

Neonatal Air Medical Transportation Practices in Italy: A Nationwide Survey

The present article shows the current neonatal air transport organization and activity in Italy. The results were obtained on the basis of a recent 2019 survey (year of activity 2018) performed by the Neonatal Transport Study Group of the Italian Society of Neonatology. The total number of newborn transports during the year 2018 was 6,464. The air-suitable transports were 512 of 5,852 (8.74%), and among them, 101 of 512 (19.72%) were performed by helicopter and 34 by airplane. Besides the availability of air transport, the interfacility distance, weather and traffic conditions, and rural mountainous roads were the main factors in determining the vehicle choice. Neonatal air transport in Italy is not homogeneously distributed and needs organizational corrections. The high density of neonatal emergency transport services on the national territory indicates the need to overcome the limits imposed by regional administrative borders, thus expanding the geographic area of competence.

Adverse Events During Intrahospital Transport of Critically Ill Children: A Systematic Review

Intrahospital transport of a critically ill patient is often required to achieve a diagnostic and/or therapeutic objective. However, clinicians who recommend a procedure that requires transport are often not fully aware of the risks of transport. Clinicians involved in the care of critically ill children may therefore benefit from a clear enumeration of adverse events that have occurred during transport, risk factors for those events, and guidance for event prevention. The objective of this review was to collect all published harm and adverse events that occurred in critically ill children in the context of transport within a medical center, as well as the incidence of each type of event. A secondary objective was to identify what interventions have been previously studied that reduce events and to collect recommendations for harm prevention from study authors. Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and CINAHL were searched in January 2018 and again in December 2018. Terms indicating pediatric patients, intrahospital transport, critical illness, and adverse events were used. Titles and abstracts were screened and full text was reviewed for any article meeting inclusion criteria. If articles included both children and adults, incidence data were collected only if the number of pediatric patients could be ascertained. Of 471 full-text articles reviewed, 40 met inclusion criteria, of which 24 included only children, totaling 4104 patient transports. Heterogeneity was high, owing to a wide range of populations, settings, data collection methods, and outcomes. The incidence of adverse events varied widely between studies. Examples of harm included emergent tracheostomy, pneumothorax, and cardiac arrest requiring chest compressions. Respiratory and airway events were the most common type of adverse event. Hypothermia was common in infants. One transport-associated death was reported. When causation was assessed, most events were judged to have been preventable or potentially mitigated by improved double-checks and usage of checklists. Prospective studies demonstrated the superiority of mechanical ventilation over manual ventilation for intubated patients. Risk of adverse events during critical care transport appears to relate to the patient's underlying illness and degree of respiratory support. Recommendations for reducing these adverse events have frequently included the use of checklists. Other recommendations include optimization of the patient's physiological status before transport, training with transport equipment, double-checking of equipment before transport, and having experienced clinicians accompany the patient. All available recommendations for reducing transport-associated adverse events in included articles were collated and included.

Neonatal Transport in the Practice of the Crews of the Polish Medical Air Rescue: A Retrospective Analysis

The aim of the study was to present characteristics of patients transported in incubators by crews of Helicopter Emergency Medical Service (HEMS) and Emergency Medical Service (EMS) of the Polish Medical Air Rescue as well as the character of their missions. The study was based on the method of retrospective analysis of neonatal transports with the use of transport incubators by the crews of HEMS and EMS of the Polish Medical Air Rescue. The study covered 436 medical and rescue transports of premature babies and full-term newborns in the period between January 2012 and December 2018. The study group consisted mainly of male patients (55.05%) who, on the basis of the date of delivery, were qualified as full-term newborns (54.59%). During the transport their average age was 37.53 (standard deviation, SD 43.53) days, and their average body weight was 3121.18 (SD 802.64) grams. A vast majority of neonatal transports were provided with the use of a plane (84.63%), and these were medical transports (79.36%). The average transport time was 49.92 (SD 27.70) minutes with the average distance of 304.27 km (SD 93.05). Significant differences between premature babies and full-term newborns were noticed in terms of age and body weight at the moment of transport, diagnosis based on the International Statistical Classification of Diseases and Related Health Problems (ICD-10), the most commonly used medications (prostaglandin E1, glucose, furosemide, vitamins), National Advisory Committee for Aeronautics (NACA) scale rate as well as the mission type and the presence of an accompanying person.

Neonatal Transport: Current Trends and Practices

Since the inception of organized neonatal transport in the 1940s, advances in clinical care and technology have made the neonatal intensive care unit even more mobile in terms of care delivery. There currently exists an emphasis on quality metrics and simulation-based training for transport team members to achieve high levels of individual and team competence. Emerging therapies such as active cooling for neuroprotective hypothermia and high-frequency ventilation provide evidence-based care in the transport environment to enhance clinical outcomes. Accreditation of neonatal transport programs is now embraced as an indicator of competency and compliance with transport standards.

The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: A 10-year experience

Whether critically ill neonates needing a surgical intervention should be transferred to an operating room (OR) or receive the intervention in a neonatal intensive care unit (NICU) is controversial. In this study, we report our experience in performing surgical procedures in a NICU including air cleanliness.This was a retrospective study performed at a metropolitan hospital. The charts of all neonates undergoing surgical procedures in the NICU and OR were retrospectively reviewed from January 2007 to June 2017. Data on baseline characteristics, procedure and duration of surgery, ventilator use, hypothermia, instrument dislocations, surgery-related infections and complications, and outcomes were analyzed.Ninety-two neonates were enrolled in this study, including 44 in the NICU group and 48 in the OR group. The air cleanliness was International Organization for Standardization (ISO) 14644-1 class 7 in the NICU and class 5-6 in the OR. The NICU group had a younger gestational age and lower birth body weight than the OR group. The OR group had a higher incidence of hypothermia than in the NICU group (56.3% vs 9.1%, P < .001). However, there were no significant differences in surgical site related infections or mortality between the 2 groups.This study suggests that performing surgical procedures in a NICU with air cleanliness class 7 is as safe as in an OR, as least in part, when performing patent ductus arteriosus ligation and exploratory laparotomy.

Surgery and magnetic resonance imaging increase the risk of hypothermia in infants

AIM

Maintaining normothermia is a tenet of neonatal care. However, neonatal thermal care guidelines applicable to intra-hospital transport beyond the neonatal intensive care unit (NICU) and during surgery or magnetic resonance imaging (MRI) are lacking. The aim of this study is to determine the proportion of infants normothermic (36.5-37.5°C) on return to NICU after management during surgery and MRI, and during standard clinical care in both environments.

METHODS

Sixty-two newborns requiring either surgery in the operating theatre (OT) (n = 41) or an MRI scan (n = 21) at the Royal Children's Hospital (Melbourne) NICU were prospectively studied. Core temperature, along with cardiorespiratory parameters, was continuously measured from 15 min prior to leaving the NICU until 60 min after returning. Passive and active warming (intra-operatively) was at clinician discretion.

RESULTS

The study reported 90% of infants were normothermic before leaving NICU: 86% (MRI) and 93% (OT). Only 52% of infants were normothermic on return to NICU (relative risk (RR) 1.75; 95% confidence interval (CI) 1.39-2.31; number needed to harm (NNH) 2.6). Between departure from the NICU and commencement of surgery, core temperature decreased by mean 0.81°C (95% CI 0.30-1.33; P = 0.0001, analysis of variance), with only 24% of infants normothermic when surgery began (P < 0.0001; RR 3.80 (95% CI 2.33-6.74); NNH 1.5). After an MRI, infants were a mean 0.41°C (95% CI 0.16-0.67) colder than immediately before entering the scanner (P = 0.001, analysis of variance), with only 43% being normothermic (P = 0.003; RR 2.11 (95% CI 1.35-3.74); NNH 2.1).

CONCLUSION

Unintentional hypothermia is a common occurrence during surgery in the OT and MRI in neonates, indicating that evidence-based warming strategies to prevent hypothermia should be developed.