An analysis of inter-healthcare facility transfer of neonates within the eThekwini Health District of KwaZulu-Natal

Abstract

Introduction The safe transfer of neonates from one healthcare facility to another is an integral component in the process of neonatal care. Neonates, a term applying specifically to infants during the first 28 days of life, are transferred from medical healthcare facilities which do not have specialist care or intensive care management to more specialised facilities in order to improve their clinical outcome and chance of survival. The transfer system is thus an important aspect of the overall care provided to neonates. The transfer process, however, poses a threat of aggravating the clinical condition of the neonate. Inter-healthcare facility transfer of a neonate requires careful planning, skilled personnel and specialised equipment to maintain the continuum of care, as this directly impacts on the morbidity and mortality of the neonate. Purpose of the study The purpose of the study was to undertake a descriptive analysis of the current neonatal inter-healthcare facility transfer system in the eThekwini Health District of KwaZulu-Natal (KZN). This service is provided by the public sector ambulance service known as the Emergency Medical Rescue Service (EMRS). The study, based on 120 consecutive transfers, assessed the clinical demographics of the neonates, the time taken to complete the transfers, including time sub-intervals, the equipment that was necessary for the transfers and the qualifications and procedures performed by the transfer team. The study also identified any adverse events that were encountered during the transfers. Methodology The study was conducted from 19 December 2011 to 30 January 2012. It used quantitative methodology and a non-experimental prospective design to undertake a descriptive analysis of 120 inter-healthcare facility transfers of neonates within the eThekwini Health District of KwaZulu-Natal. Data collection relied upon two types of questionnaires. A descriptive survey method incorporated logistic and deductive reasoning to evaluate the objectives of this study. Frequency distributions were generated to describe data categories. Bivariate analysis was conducted using chi- square. Results During the study period there were a total of 120 neonatal inter-healthcare facility transfers. All referrals were undertaken by road ambulances. Eighty-three (62.2%), transfers were undertaken by the operational ambulance units, 35 (29.2%) by the obstetric unit and 2 (1.7%) by the planned patient transport units. Thirty one (28.5%) transfers were on Fridays, followed by 24 (20.8%) on Mondays and 20 (16.6%) on weekends. Ninety seven (80.8%) were during the hours of dayshift (07h00-19h00) and 23 (19.2%) were during nightshift (19h00-07h00). Of the 120 neonatal transfers, 29 (24.2%) were specialised transfers, of which 22 (75.9%) were ventilated. With reference to the gestational ages of the neonates being transferred 90 (76.7%), were pre-term, 26 (21.7%) were term and 2 (1.7%) were post-term. There were 11 (9.2%) newborns (from birth to 4 hours), 56 (46.7%) early neonates (from 4 hours to 7 days) and 53 (44.2%) late neonates (from 7 days to 28 days). Of the 120 neonatal transfers, 90 (75.0%) were pre-term having associated co-morbidities and 49 (40.8%) had respiratory problems. The mean time ± standard deviation (SD), taken by EMRS eThekwini to complete an inter-healthcare facility transfer was 3h 49min ± 1h 57min. The minimum time to complete a transfer was 55min and the maximum time was 10h 34min. The mean time ± SD from requests to dispatch was 1h 20min ± 1h 36min. The delays in dispatch were associated with no ambulances being available 70 (58.3%), no ALS personnel available 48 (40.0%), no equipment available 23 (19.2%) and no ILS personnel available 7 (5.8%) to undertake the transfers. Junior or inexperienced personnel in the communication centre also contributed to the time delays by dispatching ALS personnel for non-specialised transfers and requesting neonatal equipment when it had not been requested by the referring personnel for the transfer. The mean time ± SD from the referring hospital to the time mobile to the receiving hospital was 43min ± 26min. Six (5.0%) neonates were clinically unstable at the referring facility for transfer. For 15 (12.5%) transfers, neonates had been inappropriately packaged for transport by the hospital staff, which added to the delays, p. value = 0.018. The necessary equipment was unavailable for 37 (30.8%) of the transfers. The lack of equipment was due to problems such as poor resource allocation, and malfunctioning, inappropriate, insufficient and unsterile equipment. The pre- departure checklist had not been completed in 50 (41.67%) of the transfers. The study identified 10 (8.3%) adverse events related to the physiological state of the neonate and included 1 (0.8%) mortality. Nine (7.5%) neonates suffered serious life threating complications during transportation, 8 (6.7%) of which were due to desaturation, 6 (5.0%) due to respiratory deterioration, 3 (2.5%) due to cardiac deterioration and 1 (0.8%) due to temperature related problems. Eighteen (15.0%) of 120 transfers experienced equipment related adverse events of which 9 (7.5%) were associated with ventilators, 9 (7.5%) with incubators, 3 (2.5%) with the ambulance, 2 (1.7%) with the oxygen supply and 1 (0.8%) with arterial cannulation. Five (33.3%) of the 15 equipment related adverse events contributed directly to life threatening physiologically related adverse events, p. value = 0.007. Conclusion and recommendation The Emergency Medical Rescue Service (EMRS) is involved in the transportation of a significant number of neonates between various healthcare facilities in the eThekwini Health District, some requiring intensive care and some not. This descriptive, prospective study has identified numerous shortfalls in the service provided by the EMRS in the eThekwini District. Inter-healthcare facility transfer of neonates can be safely performed by the transport services if the operations are well co-ordinated and there are dedicated, specialised and trained transport teams armed with appropriate equipment and medication, together with the guidance of policies and quality assurance. Transport teams must be trained to provide this specialised care in various environments, including ground and air ambulances and understand the multiphase neonatal transfer processes. There must be good communication and co-ordination by all role players, which is underpinned by good team work to improve the standards of neonatal care and monitoring. Only then can clinical excellence be achieved when transporting neonates between healthcare facilities.