省级医院帮扶提升基层新生儿危重症救治能力的实践与研究

BackgroundIncreased survival of preterm infants in developing countries has often been accompanied by increased morbidity. A previous study found rates of severe retinopathy of prematurity varied widely between different neonatal units in Rio de Janeiro. Nurses have a key role in the care of high-risk infants but often do not have access to ongoing education programmes. We set out to design a quality improvement project that would provide nurses with the training and tools to decrease neonatal mortality and morbidity. The purpose of this report is to describe the methods and make the teaching package (POINTS of care--six modules addressing P ain control; optimal O xygenation; I nfection control; N utrition interventions; T emperature control; S upportive care) available to others.Methods/DesignSix neonatal units, caring for 40% of preterm infants in Rio de Janeiro were invited to participate. In Phase 1 of the study multidisciplinary workshops were held in each neonatal unit to identify the neonatal morbidities of interest and to plan for data collection. In Phase 2 the teaching package was developed and tested. Phase 3 consisted of 12 months data collection utilizing a simple tick-sheet for recording. In Phase 4 (the Intervention) all nurses were asked to complete all six modules of the POINTS of care package, which was supplemented by practical demonstrations. Phase 5 consisted of a further 12 months data collection. In Phase 1 it was agreed to include inborn infants with birthweight ≤ 1500 g or gestational age of ≤ 34 weeks. The primary outcome was death before discharge and secondary outcomes included retinopathy of prematurity and bronchopulmonary dysplasia. Assuming 400-450 infants in both pre- and post-intervention periods the study had 80% power at p = < 0.05 to detect an increase in survival from 68% to 80%; a reduction in need for supplementary oxygen at 36 weeks post menstrual age from 11% to 5.5% and a reduction in retinopathy of prematurity requiring treatment from 7% to 2.5%.DiscussionThe results of the POINTS of Care intervention will be presented in a separate publication.Trial registrationCurrent Controlled Trials: ISRCTN83110114

* Abbreviations: HBB — : Helping Babies Breathe HRH — : human resources for health LMICs — : low-income and lower-middle–income countries QI — : quality improvement SDG — : Sustainable Development Goal WHO — : World Health Organization On the eve of the 10th anniversary of Helping Babies Breathe (HBB), we are clearly on the precipice of a new era. Currently, the coronavirus disease 2019 pandemic has made in-person gatherings challenging, if not impossible. Health systems are stretched far beyond the typical limits. We see innovation in infection control approaches, personal protective equipment, and communication with health care professionals and families. Crisis can be the stimulus for innovation, and this will surely spur a new approach to preparation of health care workers. This preparation will go far beyond traditional concepts of training and is best conceptualized as supporting the success of health care workers as measured by their impact within a health system on the population it serves. After all, if the health of a population is not supported or improving, the health care worker is not achieving his or her goal. HBB was launched in 2010 during the Millennium Development Goals era, in which the world set 8 measurable goals that ranged from halving extreme poverty and hunger to reducing child mortality by the target date of 2015. At this time, there was a critical need to develop training materials that could be used at a local level in resource-limited settings without relying on sophisticated technology. HBB materials are available for free online and are easily downloadable so that they can be used by those with intermittent Internet access. Hard copies of the materials can be purchased or printed locally in-country. Countless labor and delivery units have the action plan hanging on the wall near the site of resuscitation, and thousands of flip charts for training … Address correspondence to Janna Patterson, MD, MPH, Global Child Health and Life Support, American Academy of Pediatrics, 345 Park Blvd, Itasca, IL 60613. E-mail: jpatterson{at}aap.org

… the evidence of effective capacity building for essential obstetric and newborn care in a rural … inequities in health care (Figure 1).21, 22 Our focus on capacity building incorporates our …

There is a high burden of critical illness in low-income countries (LICs), adding pressure to already strained health systems. Over the next decade, the need for critical care is expected to grow due to ageing populations with increasing medical complexity; limited access to primary care; climate change; natural disasters; and conflict. In 2019, the 72nd World Health Assembly emphasised that an essential part of universal health coverage is improved access to effective emergency and critical care and to “ensure the timely and effective delivery of life-saving health care services to those in need”. In this narrative review, we examine critical care capacity building in LICs from a health systems perspective. We conducted a systematic literature search, using the World Heath Organisation (WHO) health systems framework to structure findings within six core components or “building blocks”: (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines and equipment; (5) financing; and (6) leadership and governance. We provide recommendations using this framework, derived from the literature identified in our review. These recommendations are useful for policy makers, health service researchers and healthcare workers to inform critical care capacity building in low-resource settings.

Strengthening leadership and management is important for building an effective and efficient health system. This paper presents the findings from a L&M capacity building initiative which was implemented as part of a larger study aimed at improving maternal and newborn outcomes within primary health facilities in the Morogoro, Tanzania. The initiative, involving 30 stakeholders from 20 primary health facilities, 4 council health management teams and the regional health management team in the Morogoro region, provided leadership and managerial training through two 5-day in-person workshops, onsite mentoring, and e-learning modules. The initiative was evaluated using a pre-post design. Quantitative instruments included the ‘Big Results Now’ star-rating assessments and a team-developed survey for health providers/managers. The ‘Big Results Now’ star-rating assessments, conducted in 2018 (19 facilities) and 2021 (20 facilities), measured overall facility leadership and management capability, with comparisons of star-ratings from the two time-points providing indication of improvement. The survey was used to measure 3 key leadership indicators - team climate, role clarity/conflict and job satisfaction. The survey was completed by 97 respondents at baseline and 100 at follow up. Paired t-tests were used to examine mean score differences for each indicator. Triangulated findings from focus groups with 99 health providers and health management team members provided support and context for quantitative findings. Star-ratings increased in 15 (79%) of 19 facilities, with the number of facilities achieving the target of 3 plus stars increasing from 2 (10%) in 2018 to 10 (50%) in 2021, indicating improved organizational performance. From the survey, team climate, job satisfaction and role clarity improved across the facilities over the 3 project years. Focus group discussions related this improvement to the leadership and managerial capacity-building. Improved leadership and managerial capacity in the participating health facilities and enhanced communication between the health facility, council and regional health management teams created a more supportive workplace environment, leading to enhanced teamwork, job satisfaction, productivity, and improved services for mothers and newborns. Leadership and managerial training at all levels is important for ensuring efficient and effective health service provision.

Extensive neonatal resuscitation is a high acuity, low-frequency event accounting for approximately 1% of births. Neonatal resuscitation requires an interprofessional healthcare team to communicate and carry out tasks efficiently and effectively in a high adrenaline state. Implementing a neonatal patient safety simulation and debriefing program can help teams improve the behavioral, cognitive, and technical skills necessary to reduce morbidity and mortality. In Simulating Success, a 15-month quality improvement (QI) project, the Center for Advanced Pediatric and Perinatal Education (CAPE) and California Perinatal Quality Care Collaborative (CPQCC) provided outreach and training on neonatal simulation and debriefing fundamentals to individual teams, including community hospital settings, and assisted in implementing a sustainable program at each site. The primary Aim was to conduct two simulations a month, with a goal of 80% neonatal intensive care unit (NICU) staff participation in two simulations during the implementation phase. While the primary Aim was not achieved, in-situ simulations led to the identification of latent safety threats and improvement in system processes. This paper describes one unit’s QI collaborative experience implementing an in-situ neonatal simulation and debriefing program.

… neonatal intensive care (NIC) no longer has an independent status, but was incorporated into paediatric intensive care or … changed structure is that neonatal intensive care nursing is not …

… They also believed that building educational capacity would have a wider impact: ‘I think we really need to build capacity of the African woman. Africa is a unique problem, a unique …

Nurses and midwives are at the forefront of the provision of Emergency Obstetric and Neonatal Care (EmONC) and Continuous Professional Development (CPD) is crucial to provide them with competencies they need to provide quality services. This research aimed to assess uptake and accessibility of midwives and nurses to CPD and determine their knowledge and skills gaps in key competencies of EmONC to inform the CPD programming. The study applied a quantitative, cross-sectional, and descriptive research methodology. Using a random selection, forty (40) health facilities (HFs) were selected out of 445 HFs that performed at least 20 deliveries per month from July 1st, 2020 to June 30th, 2021 in Rwanda. Questionnaires were used to collect data on updates of CPD, knowledge on EmONC and delivery methods to accessCPD. Data was analyzed using IBM SPSS statistics 27 software. Nurses and midwives are required by the Rwandan midwifery regulatory body to complete at least 60 CPD credits before license renewal. However, the study findings revealed that most health care providers (HCPs) have not been trained on EmONC after graduation from their formal education. Results indicated that HCPs who had acquired less than 60 CPD credits related to EmONC training were 79.9% overall, 56.3% in hospitals, 82.2% at health centres and 100% at the health post levels. This resulted in skills and knowledge gaps in management of Pre/Eclampsia, Postpartum Hemorrhage and essential newborn care. The most common method to access CPD credits included workshops (43.6%) and online training (34.5%). Majority of HCPs noted that it was difficult to achieve the required CPD credits (57.0%). The findings from this study revealed a low uptake of critical EmONC training by nurses and midwives in the form of CPD. The study suggests a need to integrate EmONC into the health workforce capacity building plan at all levels and to make such training systematic and available in multiple and easily accessible formats. Findings will inform the revision of policies and strategies to improve CPD towards accelerating capacity for the reduction of preventable maternal and perinatal deaths as well as reducing maternal disabilities in Rwanda.

Background: Simulation-based training (SBT) and debriefing have increased in healthcare as a method to conduct interprofessional team training in a realistic environment. Purpose: This qualitative study aimed to describe the experiences of neonatal healthcare professionals when implementing a patient safety simulation and debriefing program in a neonatal intensive care unit (NICU). Methods: Fourteen NICUs in California and Oregon participated in a 15-month quality improvement collaborative with the California Perinatal Quality Care Collaborative. Participating sites completed 3 months of preimplementation work, followed by 12 months of active implementation of the simulation and debriefing program. Focus group interviews were conducted with each site 2 times during the collaborative. Content analysis found emerging implementation themes. Results: There were 234 participants in the 2 focus group interviews. Six implementation themes emerged: (1) receptive context; (2) leadership support; (3) culture change; (4) simulation scenarios; (5) debriefing methodology; and (6) sustainability. Primary barriers and facilitators with implementation of SBT centered around having a receptive context at the unit level (eg, availability of resources and time) and multidisciplinary leadership support. Implications for Practice and Research: NICUs have varying environmental (context) factors and consideration of unit-level context factors and support from leadership are integral aspects of enhancing the successful implementation of a simulation and debriefing program for neonatal resuscitation. Additional research regarding implementation methods for overcoming barriers for both leaders and participants, as well as determining the optimal frequency of SBT for clinicians, is needed. A knowledge gap remains regarding improvements in patient outcomes with SBT.

… referrals of high-risk patients to regional centers, was associated with a decrease in … neonatal care only occurring in level II and III hospitals, respectively, and establish referral networks …

Regionalized care reduces neonatal morbidity and mortality. This study evaluated the association of patient characteristics with quantitative differences in neonatal transport networks. We retrospectively analyzed prospectively collected data for infants <28 days of age acutely transported within California from 2008 to 2012. We generated graphs representing bidirectional transfers between hospitals, stratified by patient attribute, and compared standard network analysis metrics. We analyzed 34,708 acute transfers, representing 1594 unique transfer routes between 271 hospitals. Density, centralization, efficiency, and modularity differed significantly among networks drawn based on different infant attributes. Compared to term infants and to those transported for medical reasons, network metrics identify greater degrees of regionalization for preterm and surgical patients (more centralized and less dense, respectively [p < 0.001]). Neonatal interhospital transport networks differ by patient attributes as reflected by differences in network metrics, suggesting that regionalization should be considered in the context of a multidimensional system.

… regional neonatal network guideline within the United Kingdom. The purpose of the guideline is to: (a) help referring hospitals with neonatal … neonatal clinical practice across the region, …

AIM During humanitarian emergencies, women and children are particularly vulnerable to health complications and neonatal mortality rates have been shown to rise. Additionally, health cluster partners face challenges in coordinating referrals, both between communities and camps to health facilities and across different levels of health facilities. The purpose of this review was to identify the primary referral needs of neonates during humanitarian emergencies, current gaps and barriers, and effective mechanisms for overcoming these barriers. METHODS A systematic review was performed using four electronic databases (CINAHL, EMBASE, Medline, and Scopus) between June and August 2019 (PROSPERO registration number CRD42019127705). Title, abstract, and full text screening were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The target population was neonates born during humanitarian emergencies. Studies from high-income countries and prior to 1991 were excluded. The STROBE checklist was used to assess for risk of bias. RESULTS A total of 11 articles were included in the analysis; these were mainly cross-sectional, field-based studies. The primary needs identified were referrals from homes to health facilities before and during labour, and inter-facility referrals after labour to more specialised services. Some of the main barriers included a lack of roads and infrastructure for transport, staff shortages-especially among more specialised services, and a lack of knowledge among patients for self-referral. Mechanisms for addressing these needs and gaps included providing training for community healthcare workers (CHWs) or traditional birth attendants to identify and address antenatal and post-natal complications; education programmes for pregnant women during the antenatal period; and establishing ambulance services in partnership with local Non-Governmental Organizations. CONCLUSION This review benefited from a strong consensus among selected studies but was limited in the quality of data and types of data that were reported. Based on the above findings, the following recommendations were compiled: Focus on local capacity-building programmes to address programmes acutely. Recruit CHWs to raise awareness of neonatal complications among pregnant women. Upskill CHWs to provide timely, appropriate and quality care during humanitarian emergencies.

… network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions … of neonatal referral networks could be …

… the referral hospitals in their referral area. The perinatal/neonatal clinical nurse specialist working in regional … to improve the care of neonates and pregnant women in the referral area. …

The Networks of Care approach has the potential to harmonize existing strategies and optimize health systems functions for maternal and newborn health, thereby strengthening the quality of care and ultimately improving outcomes. Key Messages Networks of Care (NOCs) can improve quality of care, continuity of care, and maternal and newborn outcomes. They focus on relational elements that are key to health system functioning and are context specific. NOCs focus on creating intentional connections between people and services and strengthening the functional aspects of health systems while incorporating and emphasizing core relational aspects. They can also be used to strengthen referral systems, thus promoting continuity of care. With momentum and interest gathering around the NOC approach, it could be an essential tool for meeting the Sustainable Development Goals for maternal and newborn health.

BackgroundAn estimated 2.8 million neonatal deaths occur annually worldwide. The vulnerability of newborns makes the timeliness of seeking and receiving care critical for neonatal survival and prevention of long-term sequelae. To better understand the role active referrals by community health workers play in neonatal careseeking, we synthesize data on referral completion rates for neonates with danger signs predictive of mortality or major morbidity in low- and middle-income countries.MethodsA systematic review was conducted in May 2014 of the following databases: Medline-PubMed, Embase, and WHO databases. We also searched grey literature. In addition, an investigator group was established to identify unpublished data on newborn referral and completion rates. Inquiries were made to the network of research groups supported by Save the Children’s Saving Newborn Lives project and other relevant research groups.ResultsThree Sub-Saharan African and five South Asian studies reported data on community-to-facility referral completion rates. The studies varied on factors such as referral rates, the assessed danger signs, frequency of home visits in the neonatal period, and what was done to facilitate referrals. Neonatal referral completion rates ranged from 34 to 97 %, with the median rate of 74 %. Four studies reported data on the early neonatal period; early neonatal completion rates ranged from 46 to 97 %, with a median of 70 %. The definition of referral completion differed by studies, in aspects such as where the newborns were referred to and what was considered timely completion.ConclusionsExisting literature reports a wide range of neonatal referral completion rates in Sub-Saharan Africa and South Asia following active illness surveillance. Interpreting these referral completion rates is challenging due to the great variation in study design and context. Often, what qualifies as referral and/or referral completion is poorly defined, which makes it difficult to aggregate existing data to draw appropriate conclusions that can inform programs. Further research is necessary to continue highlighting ways for programs, governments, and policymakers to best aid families in low-resource settings in protecting their newborns from major health consequences.

… important aspects of the tertiary care regional center, and one that … to the particular needs of the referral network it seeks to serve; … system in support of its regional referral network. …

Background Functional referral system including pre referral care, access to emergency transport and ensuring continuity of care between facilities is critical for improved newborn health outcome. The neonatal transport system is quite undervalued in many sub Saharan countries, Tanzania included. This study assessed the pre referral care, transport process, ambulance characteristics, admission clinical status and outcomes of referred neonates at Muhimbili National Hospital Upanga, a tertiary facility in Dar es Salaam, Tanzania. Methods A descriptive cross sectional study with a longitudinal follow up was conducted from September 2020 to February 2021 including neonates referred to Muhimbili National Hospital. A structured questionnaire was used to collect demographic characteristics and transport factors including pre referral care extracted from the referral documents and through interviewing caregivers or escorting person/nurse. Ambulances were directly observed using a structured checklist on presence, absence and functionality of supportive equipment. All enrolled neonates had a clinical assessment at admission and 48 hours post admission to determine admission clinical status and 48 hours’ clinical outcome as either survived/died. Results Out of the 348 neonates assessed during the study period, the median gestation age was 38 weeks (IQR 32, 39) with the mean birth weight of 2455 ± 938 g. Pre referral documentation showed that temperature was measured in 176 (57.1%), oxygen saturation and random blood glucose in only 143 (46.6%) and 116 (36.2%) neonates respectively. Ambulance was used as a means of transportation in 308 (88.5%) neonates. While no ambulance had an incubator only 7 (2.0%) neonates were kept on a Kangaroo Mother Care position. Monitoring enroute was done to only 94 (27%) of the transferred neonates with 169 (54.9%) of health care professionals escorting the neonates lacking training on essential newborn care. On arrival, 115 (33%) were hypothermic, 74 (21.3%) hypoxic, 30 (8.6%) with poor perfusion and 49 (14.1%) hypoglycemic. Hypothermic neonates had an increased chance of dying compared to those who were normothermic (OR = 2.09, 95% CI (1.05–4.20), p = 0.037). The chance of dying among those presenting with hypoxia was almost three times (OR = 2.88, 95%CI (1.44–5.74), p = 0.003) while those with poor perfusion was almost five times (OR = 4.76, 95%CI (1.80–12.58), p = 0.002). Additionally, neonates who had hyperglycemia (RBG > 8.3mmol/l) on arrival had a higher probability of dying compared to those who were euglycemic [(OR = 3.10, 95% CI (1.19–8.09) p = 0.021]. Overall mortality was 22.4% within 48 hours of admission and risk of dying increased as the presence of poor clinical status added on. Conclusion Neonatal transportation in Dar es Salaam, Tanzania was observed to be challenging. Pre transfer care and monitoring during transportation was inadequate and this contributed to poor clinical status on admission. Hypothermia, hypoglycemia, hyperglycemia, hypoxia and poor perfusion on admission were associated with increased mortality. Effective referral network is needed for improved neonatal health outcomes. Pre referral supportive care, training of health care professionals, transportation with improved monitoring, clear communication protocol and referral documentation should be invested and effectively utilized.

A reliable referral system is the key to handling emergency cases, for this reason, it is necessary to conduct an in-depth study of the description of the referral system that is in force and implemented in North Lampung, considering that most maternal deaths are caused by cases that require fast and integrated treatment. The aim of the research is to provide an overview of the readiness of the maternal neonatal referral system in terms of four aspects: i) infrastructure, ii) human resources readiness, iii) community readiness, and iv) policy readiness. The research is using qualitative analysis. Data collection uses in-depth interviews, documentation studies, observations, and Focus Group Discussions (FGDs). The Maternal Mortality Rate (MMR) is impacted by the quality of maternal and neonatal services, including handling pregnancy complications. The percentage of rural North Lampung who gained coverage for focusing on pregnancy issues throughout 2021 was a miserable 52.66%. Rural North Lampung's pregnancy-related issues procedures do not adhere to the operational guidelines for maternal-neonatal referral procedures. The fundamental reference, Educate Basic Emergency Neonatal Obstetric (BEmONC), is no longer in operation, as is Comprehensive Emergency Neonatal Obstetric Services (CEmONC). The readiness of all stakeholders for the neonatal and maternal referral system needs to be improved, including the readiness of infrastructure, human resources, and family-community readiness, and needs to be supported by regional government policies.

Abstract There is a lack of studies concerning the maternal and neonatal referral system in troubled contexts, and the number of maternal and neonatal mortality deaths is considered high in developing countries. This study aims to understand the current conditions of the maternal and neonatal referral system in developing countries, in the context of barriers and technologies. We conducted a narrative literature review based on journals and conference papers in the last five years (2014–2018) from selected databases (MEDLINE, CINAHL, Science Direct, Scopus, Wiley Online, PMC, and ProQuest). The results of the study selection show that 40 studies identified barriers or challenges in maternal or neonatal referral systems, and eight studies discussed technology to support referral. Based on the results, barriers in maternal and neonatal referral systems can be divided into two main factors: 1. the healthcare system and 2. the patient. Some technologies are used in developing countries to support maternal and neonatal referral. However, these technologies still do not address all of the barriers described in the referral system. A study from different perspectives is needed, such as community involvement or government programs, to improve the current conditions of the maternal and neonatal referral system.

Purpose: Assessments of neonatal regionalization to date have relied on identification of hospital characteristics and the distances between them. Such an approach fails to take into account the overall linkage of hospitals in a coordinated system of communication, learning and response. In contrast, network analysis provides a set of analytic techniques that consider not only individual patients and hospitals, but can also quantify the relationships between them at the system level. The objective of the current study is to use quantitative network analysis to describe the pattern of neonatal transfers in the state of California, …

Background Referral and clinical decision-making support are important for reducing delays in reaching and receiving appropriate and quality care. This paper presents analysis of the use of a pilot referral and decision making support call center for mothers and newborns in the Greater Accra region of Ghana, and challenges encountered in implementing such an intervention. Methods We analyzed longitudinal time series data from routine records of the call center over the first 33 months of its operation in Excel. Results During the first seventeen months of operation, the Information Communication Technology (ICT) platform was provided by the private telecommunication network MTN. The focus of the referral system was on maternal and newborn care. In this first phase, a total of 372 calls were handled by the center. 93% of the calls were requests for referral assistance (87% obstetric and 6% neonatal). The most frequent clinical reasons for maternal referral were prolonged labor (25%), hypertensive diseases in pregnancy (17%) and post-partum hemorrhage (7%). Birth asphyxia (58%) was the most common reason for neonatal referral. Inadequate bed space in referral facilities resulted in only 81% of referrals securing beds. The national ambulance service was able to handle only 61% of the requests for assistance with transportation because of its resource challenges. Resources could only be mobilized for the recurrent cost of running the center for 12 h (8.00 pm – 8.00 am) daily. During the second phase of the intervention we switched the use of the ICT platform to a free government platform operated by the National Security. In the next sixteen-month period when the focus was expanded to include all clinical cases, 390 calls were received with 51% being for medical emergency referrals and 30% for obstetrics and gynaecology emergencies. Request for bed space was honoured in 69% of cases. Conclusions The call center is a potentially useful and viable M-Health intervention to support referral and clinical decision making in the LMIC context of this study. However, health systems challenges such inadequacy of human resources, unavailability of referral beds, poor health infrastructure, lack of recurrent financing and emergency transportation need to be addressed for optimal functioning.

Neonatal transport is an essential part of regionalization for highly specialized neonatal intensive care. This retrospective analysis of prospectively collected data on neonatal transport activity in a large Swiss perinatal network more than 1 year, aimed to quantify this activity, to identify the needs for staff, and the demands regarding know-how and equipment. Of the 565 admissions to the tertiary neonatology clinic, 176 (31.2%) were outborn patients, transported as emergencies to the level III unit. In 71.6% of cases, respiratory insufficiency was one of the reasons for transfer. Circadian and weekly distribution showed increased transport activity on workdays between 8 am and 10 pm, but regular demands for emergency transports regardless of the time frame require a neonatal transport team available 24/7. This study highlights the importance of neonatal transport and unveils several functional and infrastructural insufficiencies, which led to suggestions for improvement.

… road network data, were used to model referral networks and catchment areas across 2 regions of … With these tools we modeled the current referral networks of facilities, calculated the …

BACKGROUND As a rule, newborns do not require special medical care. If unexpected complications occur peripartum or postpartum, support from and transport to specialised neonatal hospitals might be needed. METHODS In a retrospective study, all transport protocols of a supraregional paediatric‑neonatological maximum care hospital in northwestern Germany from 01.10.2018 through 30.09.2021 were analysed. The particular focus was on transports of newborns (<7 days) and the leading symptoms that led to contact. RESULTS A total of 299 patients were included (average age of 15.4 h, 61.6 % males). The average complete transport time was approximately 2 h. Five leading neonatal diseases (respiratory, infectious, asphyxia, cardiac, haematological) were found to represent the causes of >80 % of transfers. Respiratory adaptation disorders are the main reason for transferring a newborn to a centre, whereas asphyxia is the most severe condition. The various symptoms differ in their time of onset, a factor which must be taken into account in practice. Differences were also found between different types of hospitals: while a large proportion of transports were carried out from maternity hospitals (80.6 %), children transported from children's hospitals were generally more severely ill. DISCUSSION Transfers of neonates, especially from maternity hospitals to neonatal intensive care units due to special neonatal diseases, are not rare. In times of increasingly scarce resources, the effective care of sick or at-risk neonates is essential. For low-population regions, this means professional cooperation between maximum care providers and smaller children's hospitals and maternity-only hospitals.

… of these through education, training and risk management. In … of the pros and cons of emergency driving and for ambulance … and emergency medical technicians in neonatal …

… Participation in a 1-day course on neonatal transport and a 2-day course on neonatal … the neonatal transport team. In the last 2 decades, principles and contents of the training programs …

… neonatal emergency transport network, and discusses the human resources required for safe transport, … for maternal and paediatric transports is complementary to the neonatal training. …

… Increasingly, transport teams are comprised of health … Simulation-based training supplements and reinforces … use of simulation in the training of neonatal transport teams and critically …

Background : In Japan, 44.3% of neonates are delivered in private clinics without an attending pediatrician. Obstetricians in the clinics must resuscitate asphyxiated neonates in unstable condition, such as respiratory failure, and they are frequently transferred to tertiary perinatal medical centers. There has been no study comparing the physiological status and prognosis of neonates transported by ambulance with those transported by helicopter.

… to address means by which pediatric and neonatal transport nurses can acquire and maintain … of an approach to airway training. Part 2 will address training for other critical procedures …

Specialized paediatric and neonatal transport is a useful and essential resource in the interhospital transfer of these patients. It allows bringing the material and personal resources of an intensive care unit closer to the regional hospitals where the patient can be found. The benefits of these teams are very well demonstrated in the literature. These units should be part of the emergency systems, while it would be recommended that they be staff integrated in the tertiary hospitals, in order to maintain the necessary skills and competencies. The team, made up of physicians, nurses and emergency medical technicians, must master both the pathophysiology of transport and that of the critical patient in this age range. A high quality of both human and care is important, so continuous training and periodic recycling will be essential to be compliant with the quality indicators in transport. Likewise, it is essential to have specific vehicles adapted to this function, which allow carrying the wide variety of necessary material, as well as the electromedicine that is required. However, in Spain this paediatric and neonatal transport model is not standardized and therefore is not homogeneous: there are different models that do not always provide adequate quality, making it necessary to implement specialized units throughout the country to guarantee sanitary transport quality to any critical child or neonate.

… in neonatal transport team composition, training, or competency evaluation, this article will demonstrate how the utilization of simulation-based training … to the emergency department of a …

Neonatal deaths contribute significantly to under‐5 mortality worldwide with Sub‐Saharan Africa (SSA) alone accounting for 43% of global newborn deaths. Significant challenges in the region's health systems evidenced by huge disparities in health facility deliveries and poor planning for preterm births are major contributors to the high neonatal mortality. Many neonates in the region are delivered in suboptimal conditions and require transportation to facilities equipped for specialized care. This review describes neonatal transport across the subregion, focusing on low‐cost interventions employed.

… respondents reported receiving any training in the transportation of neonates, either in the … 10 or fewer neonatal transfers. The self‐perceived confidence for transporting neonates was …

… Most transport utilises road vehicles but helicopter emergency medical … training has become the major format for many aspects of neonatal sub-specialty training and transport training …

… transport services, (2) guiding necessary changes in training or services, and (3) aiding programs that seek to develop a neonatal transport … on transport, emergency safety training, team …

<ns7:p> Background Quality of neonatal transport services may impact outcomes. We assessed the effect of skill-based education of ambulance personnel (AP) on outcomes of transported neonates. Methods We conducted a single-arm intervention study (pre and post) over 18 months. We assessed the perceptions and practices of AP on neonatal transport along with ambulance equipment availability/usage. We compared neonatal clinical vital parameters at arrival and clinical outcomes from Neonatal Intensive Care Unit (NICU) pre versus post intervention. We analysed data using SPSS version 25. Results Of 77 AP receiving education, there was significant <ns7:italic>(</ns7:italic> p &lt; 0.001) improvement in the perceptions/practices towards temperature regulation (44.55 ± 23.94 <ns7:italic>vs</ns7:italic> . 25.94 ± 21.36), glucose homeostasis (46.27 ± 18.83 <ns7:italic>vs.</ns7:italic> 18.60 ± 17.50), maintaining asepsis (67.05 ± 17.53 <ns7:italic>vs.</ns7:italic> 39.35 ± 16.85), supporting airway (47.73 ± 25.39), circulation (85.26 ± 23.27 <ns7:italic>vs.</ns7:italic> 48.45 ± 25.10), along with ambulance equipment availability/usage postintervention. Of 53 neonates studied post intervention, there was a significant reduction in hypothermia (17% <ns7:italic>vs.</ns7:italic> 48.4%, p &lt; 0.001), hypoglycemia (16.9% <ns7:italic>vs.</ns7:italic> 38.7%, p=0.010), and prolonged capillary refill time (71.7% <ns7:italic>vs.</ns7:italic> 46.8%, p=0.042), improvement in the use of intravenous fluids (69.8% <ns7:italic>vs.</ns7:italic> 29%, p &lt;0.001), a reduction in growth from umbilical swabs (15.1% <ns7:italic>vs.</ns7:italic> 42%, p=0.002) and duration of NICU stay (p = 0.001). Conclusions After educational intervention there was significant improvement in the perceptions and practices of ‘108’ ambulance personnel towards transporting neonates and a significant decrease in hypothermia, hypoglycemia, and duration of NICU stay with improvement in maintenance of circulation and asepsis in neonates. </ns7:p>

… with on-site training during neonatal stabilization at the community hospital. … during transport of a high-risk parturient or a sick neonate. In certain emergency situations, the emergency …

Abstract Objective This study aimed to identify the neonatal training needs of levels I and II community health centers (CHCs). Study Design We conducted a mixed-methods study involving a questionnaire, focus groups (FG), and an audit of neonatal transport data. The questionnaire assessed the felt needs of CHC staff, FGs identified normative needs with an expert neonatal transport team, and the audit captured expressed needs using data from the Canadian neonatal transport network. Results A total of 158 respondents from 12 CHCs completed the questionnaire (98% completeness rate). Key findings indicated significant challenges in human resources, procedural training, management of critical situations including neonatal resuscitation, nutrition, and neurodevelopmental care (NDC), and crisis resource management. Simulation emerged as the preferred training modality. FGs (three sessions, 17 participants) emphasized the importance of regular, multidisciplinary simulation-based training and stress management. The audit (947 means of transport, 2017–2020) revealed frequent respiratory, neurological, and surgical diagnoses, reinforcing the need for advanced training in respiratory support, neonatal resuscitation, and select high-acuity-specific pathologies. Conclusion Targeted outreach education is essential to address the identified training needs in neonatal care at CHCs. Key components should include simulation-based training, comprehensive procedural modules, and specialized modules on extreme prematurity, pneumothorax, hypoxic-ischemic encephalopathy/seizures, and surgical conditions. Enhanced training in nutrition and NDC is also critical for community health practitioners. Key Points CHC lack neonatal care training. In situ simulation training is the preferred modality of CHC. Key training gaps include resuscitation and ventilation. Crisis resource management and stress management are key team training components. Training must cover prematurity, respiratory, neurological, and surgical conditions.

BackgroundIn India, the neonatal mortality rate is nearly double the Sustainable Development Goal target with more than half of neonatal deaths occurring in only four states, one of which is Bihar. Evaluations of immediate neonatal care and neonatal resuscitation skills in Bihar have demonstrated a need for significant improvement. However, barriers to evidence based practices in clinical care remain incompletely characterized.MethodsTo better understand such barriers, semi-structured interviews were conducted with 18 nurses who participated as mentors in the AMANAT maternal and child health quality improvement project, implemented by CARE India and the Government of Bihar. Nurse-mentors worked in primary health centers throughout Bihar facilitating PRONTO International emergency obstetric and neonatal simulations for nurse-mentees in addition to providing direct supervision of clinical care. Interviews focused on mentors’ perceptions of barriers to evidence based practices in immediate neonatal care and neonatal resuscitation faced by mentees employed at Bihar’s rural primary health centers. Data was analyzed using the thematic content approach.ResultsMentors identified numerous interacting logistical, cultural, and structural barriers to care. Logistical barriers included poor facility layout, supply issues, human resource shortages, and problems with the local referral system. Cultural barriers included norms such as male infant preference, traditional clinical practices, hierarchy in the labor room, and interpersonal relations amongst staff as well as with patients’ relatives. Poverty was described as an overarching structural barrier.ConclusionInteracting logistical, cultural and structural barriers affect all aspects of immediate neonatal care and resuscitation in Bihar. These barriers must be addressed in any intervention focused on improving providers’ clinical skills. Strategic local partnerships are vital to addressing such barriers and to contextualizing skills-based trainings developed in Western contexts to achieve the desired impact of reducing neonatal mortality.

Background Evidence based interventions (EBIs) can improve patient care and outcomes. Understanding the process for successfully introducing and implementing EBIs can inform effective roll-out and scale up. The Promoting Action on Research Implementation in Health Services (PARIHS) framework can be used to evaluate and guide the introduction and implementation of EBIs. In this study, we used kangaroo mother care (KMC) as an example of an evidence-based neonatal intervention recently introduced in selected Chinese hospitals, to identify the factors that influenced its successful implementation. We also explored the utility of the PARIHS framework in China and investigated how important each of its constructs (evidence, context and facilitation) and sub-elements were perceived to be to successful implementation of EBIs in a Chinese setting. Method We conducted clinical observations and semi-structured interviews with 10 physicians and 18 nurses in five tertiary hospitals implementing KMC. Interview questions were organized around issues including knowledge and beliefs, resources, culture, implementation readiness and climate. We used directed content analysis to analyze the interview transcript, amending the PARIHS framework to incorporate emerging sub-themes. We also rated the constructs and sub-elements on a continuum from “low (weak)”, “moderate” or “high (strong)” highlighting the ones considered most influential for hospital level implementation by study participants. Results Using KMC as an example, our finding suggest that clinical experience, culture, leadership, evaluation, and facilitation are highly influential elements for EBI implementation in China. External evidence had a moderate impact, especially in the initial awareness raising stages of implementation and resources were also considered to be of moderate importance, although this may change as implementation progresses. Patient experience was not seen as a driver for implementation at hospital level. Conclusion Based on our findings examining KMC implementation as a case example, the PARIHS framework can be a useful tool for planning and evaluating EBI implementation in China. However, it’s sub-elements should be assessed and adapted to the implementation setting.

… transfusion guidelines for our division and neonatal intensive care network, including 19 hospitals, … Our neonatal care network provides irradiated and leukoreduced products to all those …

… learning through a network of providers, the performance of health care systems and neonatal outcomes can be improved. We use examples of successful neonatal networks from …

… neonatal intensive care unit rates for death and serious morbidities from 2005 to 2014 at US Vermont Oxford Network member neonatal intensive care … % of neonatal intensive care units …

… Network and sought to make measurable improvements in the quality and cost of neonatal intensive care … costs at the 10 participating neonatal intensive care units (NICUs) over the …

… In the early days of neonatal intensive care, scarce resources led to regionalized systems of neonatal and, later, perinatal services, generally based on voluntary agreements but …

… that neonates are at higher risk of morbidity and mortality if they are born in hospitals with lowerlevel neonatal … in which a neonatologist may assist local providers with their resuscitative …

… of references for most of the information, the lack of precise and scientific methodologies for their design and evaluation, the absence or inconsistency of specialized consultations by …

Neonatal tele-resuscitation programs use synchronous audio-video telemedicine systems to connect neonatologists with community hospital care teams during high risk resuscitations. Using tele-resuscitation, remote neonatologists can visualize and actively guide the resuscitation and stabilization of at-risk neonates. The feasibility of tele-resuscitation has been proven, and early evidence suggests that tele-resuscitation improves the quality of care, reduces unnecessary medical transports, and may generate a net savings to the health system. Community hospital staff and remote neonatologists are highly satisfied with tele-resuscitation programs. Tele-resuscitation presents an opportunity to improve healthcare delivery for neonates regardless of their birth location. The neonatology community should work to identify and rigorously study the value tele-resuscitation can bring to neonates, their families, and care teams.

… Approximately 10% of newborns will require some assistance … calls that requested a neonatal telemedicine consult. In addition, … If the remote neonatologist had not been able to visually …

Moderately ill preterm infants residing in medically underserved areas are frequently transferred to tertiary care NICUs that are mostly located in urban areas, resulting in mother-infant separation, high transportation costs, and the emotional costs of limited infant visitation. In 2012, The American Academy of Pediatrics revised neonatal care guidelines, adding in-house neonatal services to the scope of Level II NICUs. Limited availability of neonatologists in medically underserved areas has prompted innovative solutions like telemedicine to meet this requirement. Telemedicine consultations for pediatric transports have demonstrated improved patient outcomes compared with phone consultation, but evidence regarding telemedicine use for neonatal transport is mostly limited to simulation settings. Also, there are limited data on telemedicine use as a primary means to provide intensive care to neonates in Level I/II NICUs. Recently, two groups demonstrated the feasibility and safety of synchronous telemedicine to guide care for premature infants at lower level NICUs. This approach prevented unnecessary transfer and appeared to provide the same quality of care that the baby would have received at the tertiary care facility. As current evidence regarding the use of telemedicine to extend intensive care is based on single-center experiences, additional research and evaluation of the effectiveness of telemedicine for this application is required. This chapter describes the use of telemedicine to support physicians at lower level nurseries and the transport team with management of critical neonates, utility as primary means to provide care at lower level NICUs, barriers for implementation, and future opportunities to enhance telemedicine's impact in NICU settings.

a Division of Neonatology, Department of Pediatrics, University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, PA, USA b Division of Newborn Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center; Oklahoma City, Oklahoma, USA c Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA d Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital of Colorado, Aurora, CO, USA e Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA f Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA

OBJECTIVE To determine whether accurate remote echocardiographic diagnosis of congenital heart disease could be achieved using a low cost telemedicine system. DESIGN Echocardiographic images obtained by a paediatrician from neonates suspected of having congenital heart disease were transmitted by a telemedicine link across two integrated service digital network (ISDN) lines to a regional paediatric cardiology unit for interpretation by a consultant paediatric cardiologist. The “tele-echo” diagnosis was verified by the paediatric cardiologist on direct consultation and echocardiography. SETTING Neonatal unit of Altnagelvin Hospital, Londonderry (a district general hospital) and the regional paediatric cardiology department, Royal Belfast Hospital for Sick Children. MAIN OUTCOME MEASURES Accuracy of the diagnosis made using the telemedicine link; impact on patient management. RESULTS Between September 1995 and September 1997 echocardiographic images were transmitted on 63 patients. A diagnosis was made in 61 (97%) (transmitted images were unsatisfactory in two). Congenital heart disease was diagnosed in 42 patients. Fourteen patients with major congenital heart disease were accurately diagnosed within 24 hours of admission using the telemedicine link and were transferred to the regional paediatric cardiology unit. A further 28 with less serious congenital heart disease continued to be managed at the district general hospital. Congenital heart disease was excluded in 19. Follow up consultation confirmed accurate diagnosis or exclusion of congenital heart disease in 57 (93%). There were four inaccurate diagnoses (6.3%; three undetected small ventricular septal defects and one pulmonary stenosis). CONCLUSIONS Transmitted images were of sufficient quality to allow confirmation or exclusion of major congenital heart disease. The telemedicine link facilitated early diagnosis and initiation of appropriate management in patients with complex congenital heart disease and avoided the need for transfer in those where significant congenital heart disease was excluded.

… innovative approach that will assist in the provision of Neonatal services to rural and … consultation’ to ‘virtual consultation’ may reduce the need to conduct high risk moves of neonates …

… 13 we designed a remote teleconsultation system for neonatal examination and … neonatal teleconsultation in the controlled environment of the NICU before deployment for trial in remote …

The telemedicine approach is a very much relevant and effective strategy for the Mongolian context of a huge geographical area with a sparse population and huge disparities in quality and access to health services. Through this initiative, it was possible to strengthen the capacity of service providers to provide timely and appropriate care, especially to mothers with pregnancy and childbirth complications. All the way through this network, health staff had easy access to information and support from experts; this improved access to knowledge is a positive benefit of the program. The early detection of pregnancy complications and timely management with the distance consultation of an expert team had contributed significantly to the reduction of maternal and newborn morbidity and mortality in project-selected provinces compared to non-project areas. The effective use of a modern telemedicine approach has been demonstrated as being effective in addressing the remoteness and rural-urban discrepancy in the quality of health care in Mongolia.

… assist in the earlier diagnosis of neonates with congenital heart disease (CHD) in an area hospital remote … -cost telemedicine link between the neonatal unit of a district general hospital …

The regionalization of neonatal care was implemented with an overarching goal to improve neonatal outcomes.1 This led to centralized neonatal care in urban settings that jeopardized the sustainability of the community level 2 and level 3 Neonatal Intensive Care Units (NICU) in medically underserved areas.2 Coupled with pediatric subspecialist and allied health professional workforce shortages, regionalization resulted in disparate and limited access to subspecialty care.3-6 Innovative telemedicine technologies may offer an alternative and powerful care model for infants in geographically isolated and underserved areas. This chapter describes how telemedicine offerings of remote pediatric subspecialty and specialized programs may bridge gaps of access to specialized care and maintain the clinical services in community NICUs.

Most newborn infants do well at birth; however, some require immediate attention by a team with advanced resuscitation skills. Providers at rural or community hospitals do not have as much opportunity for practice of their resuscitation skills as providers at larger centers and are, therefore, often unable to provide the high level of care needed in an emergency. Education through telemedicine can bring additional training opportunities to these rural sites in a low-resource model in order to better prepare them for advanced neonatal resuscitation. Telemedicine also offers the opportunity to immediately bring a more experienced team to newborns to provide support or even lead the resuscitation. Telemedicine can also be used to train and assist in the performance of emergent procedures occasionally required during a neonatal resuscitation including airway management, needle thoracentesis, and umbilical line placement. Telemedicine can provide unique opportunities to significantly increase the quality of neonatal resuscitation and stabilization in rural or community hospitals.

We examined records of all admissions to an isolated community neonatal intensive care unit (NICU) in California between 2001 and 2006. We also reviewed the echocardiograms for …

Neonatal neurocritical care (NNCC) has emerged as an important specialty to address neurological conditions affecting newborns including a wide spectrum of brain injuries and developmental impairment. Despite the discipline's growth, variability in NNCC service delivery, patient care, and clinical training poses significant challenges and potentially adversely impacts patient outcomes. Variations in neuroprotective strategies, postnatal care, and training methodologies highlight the urgent need for a unified approach to optimize both short- and long-term neurodevelopmental outcomes for these vulnerable population. This paper presents strategic blueprints for establishing standardized NNCC clinical care and training programs focusing on collaborative effort across medical and allied health professions. By addressing these inconsistencies, the paper proposes that standardizing NNCC practices can significantly enhance the quality of care, streamline healthcare resource utilization, and improve neurodevelopmental outcome, thus paving the way for a new era of neonatal neurological care.