The quality of neonatal inter-facility transport systems within the Johannesburg Metropolitan Region

Abstract

Little is known about the clinical outcomes of neonates who are transported from one health facility to another in resource-poor settings. In resource-rich settings dedicated retrieval teams undertake most, if not all, of the neonatal transfers between different health institutions. Outcomes are often closely monitored and improvements made on a regular basis. The aim of this study was to ascertain the clinical physiological stability of sick neonates on arrival at the receiving hospital following transport from another health facility, as a measure of the quality of transport facilities available to sick infants within the Johannesburg Metropolitan region. Infants aged less than 28 days at the time of enrolment and referred to any of the three University of Witwatersrand academic complex paediatric hospitals were studied from October to December 2007. They were transported by either a private or public medical transport unit. Clinical physiological parameters such as oxygen saturation, heart rate, blood pressure, body temperature, blood glucose and muscle tone, amongst others, were documented on arrival of the infant at the receiving hospital, as part of their routine clinical assessment. A total of 104 retrievals were done during this period of which 96 of them are reported in our audit. The majority (92%) of the 96 infant retrievals were made by a paramedic-led team. Common adverse clinical events noted on arrival at the receiving hospital included hypotonia (32%), hypoxia (22%), hypothermia (21%) and acidosis (in 21/52 [40%]). The mortality at 48 hours after transfer was 7%. Statistically significant predictors of mortality at 48 hours for transported infants were: bradycardia (OR 38.2, 95% CI 4.4-421, p-value 0.003), hypoxia (OR 29.6, 95% CI 3.31 - 264, p-value < 0.001), hypotension (OR 14.6, 95% CI 1.6 -165, p-value 0.008), poor rating of the transfer process by the receiving clinician (OR 10.59, 95% CI 1.60 - 87.3, p-value 0.006) and hypothermia (OR 6.08, 95% CI 1.01 - 39, p-value 0.03). The study confirms that many infants arrive in a poor clinical condition following transfer to a referral hospital, with a relatively high mortality in the 48 hours after transfer.