Authored by Tongo Olukemi*
Abstract
Aim: Only a third of deliveries in Nigeria occur in health facilities and a number of sick neonates have to be referred for advanced care. We sought to assess the morbidity and mortality within 24 and 48 hours of arrival among neonates presenting at the University College Hospital, (UCH) Ibadan in relation to the prevailing neonatal transport care practices.
Methods: The pretransport and intratransport care available to 401 neonates presenting in UCH were determined and their respiratory rate, heart rate, SpO2, serum bicarbonate, temperature and blood pressure were checked on arrival. TRIPS (Transport Risk Index of Physiologic Stability) scores were determined and same parameters were reassessed 24 and 48 hours after presentation.
Results: Nineteen babies (4.7%) were brought in dead. The morbidities present on admission were hypothermia (35.1%), hypoxia (28.4%), hypoglycaemia (12.5%), apnoea (9%), acidosis (8.2%), unrecordable blood pressure (16.5%). The median TRIP score on arrival was 17 with 23% having very severe score (>30), severe 19.4%, moderate 24.6% and low 33%. Babies who received oxygen, IVF/breastmilk during transport were more in the low and moderate scores. By 48 hours of admission, 22% had died and those who did not receive IVF/breastmilk had the highest risk of dying (OR 4.67 CI 1.81,12.05).
Conclusion: Neonates presenting at the UCH had significant morbidity and mortality in the first 48 hours of presentation, which was associated with poor pre and intratransport care. It is crucial to emphasize pretransport stabilization and suitable intratransport care in the training of peripheral healthcare workers in resource limited settings in order to improve newborn outcomes.
Keywords: Outcomes; Neonatal; Transport; TRIPS; Nigeria
Abbreviations: CHILD: Child Intervention for Living Drug-Free; WHO: World Health Organization; INL: International Narcotics and Law Enforcement Affairs, US Department of States; GLMM: General Linear Mixed Model; ASSIST: Alcohol, Smoking and Substance Involvement Screening Test; ASSIST-Y: Alcohol, Smoking and Substance Involvement Screening Test-Youth
Introduction
Neonatal morbidity and mortality continue to be major public health burden in developing countries despite the availability of proven cost-effective interventions for addressing it [1]. By the end of 2015, global neonatal mortality rates (NMR) had not reduced as much as under-five mortality rates and the need for 13 nations including Nigeria to accelerate the reduction in neonatal mortality rate in order to achieve 12 per 1000 live births by 2030 in line with the SDGs has been identified [2]. The need to strengthen community and facility newborn care services to achieve this cannot be overemphasized.
It has been shown that poor pre-transport and intra-transport care is associated with early neonatal morbidity and mortality [3]. Serious neonatal morbidity such as hypothermia, hyperthermia and hypoglycaemia may result from poor transportation and inadequate care resulting in increased risk of neonatal mortality [4,5]. Furthermore, only about 36% of births take place in health facilities in Nigeria [6], which implies that many of the neonates are delivered in settings without adequate resources for newborn care and they would require immediate transportation to betterequipped facilities should they require further care. Sick neonates in developing countries including Nigeria often require to be transported from places of birth to other health facilities for better care in conditions that are often suboptimal and capable of compromising survival even if they get to such centers alive [7]. The conditions of most transported neonates on arrival at the neonatal care centers can be poor because of inadequate attention given to pre- and intra-transport stabilization. Many of the babies thus transported are cold, blue, and hypoglycemic, and as many as 75% of the babies transferred this way have been reported to have serious clinical complications [8-10]. One of the critical requirements for neonatal referral is optimal transportation from the place of delivery to neonatal care centers, as well as the clinical state of the child being transported. In many developed countries, this aspect of neonatal care is well documented and there are established guidelines as well as written polices, but there is dearth of data on neonatal transportation and its immediate outcomes in Nigeria or other sub-Saharan countries. The only available data from Nigeria was published over 40 years ago, which may not be a true reflection of the current practice [11].
The TRIPS score has been used as a tool to evaluate the effect of transport on illness severity in newborns even in some developing countries [12]. The TRIPS score is not being used in Nigeria and many other developing countries however, it would be a useful tool in such settings as it would allow health care workers assess the impact of transport practices on outcomes of these sick newborns and make necessary adjustments. Although some information is available on the clinical state of referred and inborn neonates at point of admission in Nigeria [13-15], not much is known about the effect of transportation on these morbidity in the first few hours of admission. This study was conducted during a study to evaluate neonatal transport practices in Ibadan, South West Nigeria which has been previously published [7]. It sought to determine the association between pre-transport and intra-transport care and immediate (first 48 hours) morbidity using the TRIPS score and mortality of neonates presenting to UCH a tertiary hospital in South West Nigeria.
Materials and Methods
This was a cross-sectional study of newborns presenting at the emergency unit of the University College Hospital (UCH), Ibadan from August 2012 to February 2013. Ethical approval was obtained from the University of Ibadan/University College Hospital ethics review committee. Newborns with lethal congenital anomalies such as anencephaly were excluded from the study. The UCH receives referral from other hospitals/clinics in Ibadan and neighboring villages, towns, and states. Newborns accounted for about 30% of the annual pediatric emergencies seen. The newborns were resuscitated and stabilized at the emergency unit, and subsequently transferred to neonatal wards within 48 hours of presentation.
Four hundred and one consecutive newborns out of 411 presenting to the children’s emergency room, UCH were recruited. Information on resuscitation and the care given before referral, during transport and on admission was obtained with a structured case record form. Resuscitation for this purpose was at least clearing of the airway usually by suctioning using manual suction, bulb syringe or suctioning machine and bag and mask ventilation if indicated.
On admission, detailed clinical assessment of each baby was carried out and the following parameters documented; the rectal temperature, random plasma glucose, respiratory rate, heart rate, oxygen saturation, blood pressure and serum bicarbonate. The Transport Risk Index of Physiologic Stability (TRIPS) score was calculated for each of the neonates and classified as low (0-10), moderate (11-20), severe (21-30), and very severe (>30) [16-19]. The TRIPS comprise four empirically weighted items (temperature, blood pressure, respiratory status, and response to noxious stimuli) is validated for infant transport assessment [20]. Each neonate was reassessed after 48 hours of presentation to determine the outcome in terms of normalization of above parameters and/or mortality. Mortality within 24 hours was also noted. All neonates that were brought in dead were also recruited and the pre- and intra-transport information were obtained.
The rectal temperatures were measured by the attending nurse using digital thermometers (Omron® Digital Thermometer, made in Germany). Oxygen saturation was recorded using the pulse oximeter (Massimo® Rad 5 Pulse Oximeter, made in U.S.A). The random plasma glucose was determined using the glucometer (Accu-Chek® Glucometer, made in Germany). The serum bicarbonate was also determined in the laboratory. All the above procedures were done following the written protocol in-use at the emergency unit during the study. The neonates were weighed using an infant digital weighing scale (SECA Model 354, SECA Medical Systems, made in Germany) to the nearest 10g. General examination was performed and standard protocol of care of newborns as practiced in the department was followed.
Hypothermia was defined as temperatures <36.5 °C (WHO) [20]. Hypoglycaemia was taken as blood glucose <2.2mmol/l, using American Academy of Pediatrics (AAP) recommendation [21], SpO2 values less than <90% was considered as hypoxaemia [22] and bicarbonate <16mmol/L as metabolic acidosis [23]. The expected pretransport care was as defined by STABLE, an acronym for “Sugar control, Temperature control, Airway maintenance, Blood pressure, Laboratory work, and Emotional support for the family” [24]. Emotional support could not be quantified, hence, for this study, emotional support was taken as all actions taken at the sources of referral or during transportation to ameliorate the emotional distress the caregivers were undergoing immediately the decision to refer the neonate was taken. It included empathy, counselling regarding explanation of the diagnosis and hope given to the caregivers of the patients from referring centers.
Data analysis
The main outcome (dependent) variables were the immediate morbidity on arrival in the emergency unit (core temperature, oxygen saturation, random plasma glucose, respiratory rate, heart rate, blood pressure, resuscitation requirements as well as serum bicarbonate) and whether patient survived the first 24 hours and 48 hours or not. Independent variables were pre-transport and intratransport care given to neonates such intravenous fluid, oxygen administration, incubator care, administration of drugs, methods of resuscitation and means of providing warmth. Categorical variables were compared using the Chi square test while continuous variables were compared by the student t-test. Logistic regression analysis was used to determine predictors of survival for 48 hours. Only variables found to be significantly associated with outcome (survived or died) were included in the logistic regression model. The data were entered and analyzed using SPSS 17.0 statistical software (SPSS Inc. USA). Statistical significance level was set at P = 0.05.
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