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Comparison of the Outcome of Transported Neonates Between Two Study Periods in Tainan

Cheng-Chien Lu, Chyi-Her Lin,1 Te-Jen Chen, Yuh-Jyh Lin,1 Shr-Ting Ho,2 Shu-Lin Chen,3 Un-Shr Hong4

Neonatal transport is an integral part of perinatal regionalization and the pattern could be affected by the policy of payment. This study evaluated the impact of National Health Insurance on the results of neonatal transport in the Tainan area. We collected regional data on the transported neonates obtained over two time periods. The first group (n=260) was collected between July 1991 and May 1992, and the second group (n=473) was collected between August 1997 and March 1999, three years after the implementation of National Health Insurance. The percentage of low-birth weight neonates transported was not different between the two periods (59.6% vs 59.1%). The frequency of endotracheal tube intubation performed by the transport team (41.3% vs 21%, p<0.01) was lower in the latter group. The incidence of hypothermia was similar between the two groups (20.7% vs 19.8%). The incidence of hypoglycemia (26.8% vs 13%, p<0.01), acidemia (35.3% vs 26%, p<0.01), infant mortality (19.7% vs 9.3%, p<0.01) and incidence of discharge against medical advise (4.2% vs 0.4%, p<0.01) decreased in the latter period. We conclude that the outcome of neonatal transport has improved and may be due to the establishment of a network of transportation and the implementation of National Health Insurance. Key words: regionalization, neonatal transport, National Health Insurance Regionalization of perinatal care has been recognized as a potential means of reducing perinatal mortality and morbidity [1-4]. Antenatal transport, in comparison with postnatal transport, is associated with decreased mortality [5-7] and morbidity [8]. However, postnatal transport is unavoidable in certain situations, such as advanced labor, intrapartum complications, or undiagnosed prenatal conditions [9]. The outcome of transported neonates may be adversely affected when infants are transported by unqualified personnel [10]. In addition, early recognition of neonatal problems and adequate stabilization in advance may also affect the outcome [10]. Wang et al [11], pointed out that the outcome of transported neonates may vary according to the level of the receiving hospital. It has also been reported that the pattern of medical care has changed since the implementation of wide nation coverage by National Health Insurance in Taiwan [12]. According to Braveman et al, uninsured neonates had poor outcomes [13]. We speculated that the morbidity and mortality of transported neonates would decrease after implementation of universal insurance. The main purpose Department of Pediatrics, Chi-Mei Foundation Hospital; National Cheng Kung University Hospital1; Sin Lau Hospital2; Municipal Tainan Hospital3; Tainan Hospital of Department of Health4 Received: January 10, 2000 Accepted: January 27, 2000 of this study is to compare the morbidity, mortality and the other outcomes of transported neonates in two defined time periods in the Tainan area.

Materials and Methods

In 1991, a neonatal transport team was established in Tainan City and County in southern Taiwan. It consisted of an experienced nurse, a senior pediatric resident, and a ground ambulance, which was equipped with instruments for stabilization and maintenance of patients' conditions. The transport team operated 24 hours a day and was part of the regionalization of neonatal care which included three hospital levels. The level of care in perinatal medicine was defined as follows: level I units were obstetric clinics providing care for normal neonates only.Level II units were district or regional hospitals providing intermediate and/or intensive care for high risk neonates. A level III unit was a medical center providing comprehensive neonatal care. Among all medical service providers in the Tainan area, those were 51 level I units, Reprint requests to: Dr. Chyi-Her Lin, Department of Pediatrics, NCKUH 138, Sheng-Li Rd., Tainan, Taiwan

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CC Lu, CH Lin, JJ Chen, et al 8 level II units and 1 level III unit in the first period; and 75 level I units, 4 level II units and 1 level III unit in the second period. Guidelines [14] for transfer were provided, and the direction and destination were suggested by the network. Basically, referrals were decided at the discretion of the referring physicians in level I units. The transport team took no active part in decision making. Data from the first group were collected from July 1991 to May 1992, and from the second group from August 1997 to March 1999. Standardized transport records with patient's name, birth weight, date of birth, and reason for referral were used. Whenever necessary, stabilization measures such as oxygen supply, nasal continuous positive airway pressure, or endotracheal intubation were performed before transfer. Data obtained before and at admission at the receiving hospital included hypothermia (rectal temperature < 35.5 ), hypoglycemia (dextrostix < 40 mg/dL) and acidemia (Ph < 7.25). Diagnoses of the transported neonates were made by the attending physicians in the receiving neonatal intensive care units (NICU) and their outcomes at discharge were recorded on standardized NICU registry forms by circling one of the following categories: (1) home discharge, (2) deceased, (3) discharge against medical advice (AAD), and (4) retransfer. All comparisons were made using the Pearson chisquare test or Fisher's exact test when the expected frequency in a cell was less than five. P < 0.05 was considered statistically significant. the level III unit was higher in the second group compared with the first group (21.6% vs 32.3%, p < 0.01). The mean birth weight was 2,224 g (range, 370 g to 5,800 g), and 2,312 g (range, 322 g to 5,000 g) in the first group and second group, respectively. The birth weight profile of the transported neonates is shown in Figure 1. Although there was a tendency of fewer very low birth weight (VLBW) infants transported in the second group, there was no statistical difference between the groups in each birth weight category. In the first and second group, the mean gestational age was 34 weeks (range, 20 to 42 weeks) and 35 weeks (range, 20 to 40 weeks), respectively. The frequency of endotracheal tube intubation performed by the transport team was lower in the second group compared with the first group (21% vs 41.3%, p<0.01). The incidence of complications in the transported neonates before and at admission is shown in the Table. Approximately one fifth of the transported neonates had hypothermia, and its incidence (21.3% vs 18%; 20.7% vs 19.8%, respectively) did not differ significantly between the groups. The incidence of hypoglycemia was significantly lower in the second group both before and at admission compared with the first group (16% vs 26.5%, p<0.01; 13% vs 26.8%, p<0.01, respectively). The inci50 40 FREQUENCY 30 (% TRANSPORT) 20 10 0 <1,500 1,500-2,500 BIRTH-WEIGHT (g) >2,500 45.9 40 40 18.8 41.2

Results

Two hundred and sixty infants (first group) were transported over 11 months in the first period. Five were excluded due to unknown origin of transfer. Of the remaining infants 200 (78.4%) were tranferred to level II units and 55 (21.6%) to the level III unit. Of the 473 infants (second group) transported over 20 months, 320 (67.7%) were transferred to level II units, and 153 (32.3%) to the level III unit. The percentage of neonates transported to

1st group lst group

14.1

2nd group

2nd group

Fig. 1. Birthweight profile of transported neonates.

There is no significant difference in frequency between each category of the two groups.

Table . Frequency of Hypothermia, Hypoglycemia and Acidemia before and at Admission 1st group (n=260) before admission at admission 21.3 26.5 20.7 26.8 35.3 2nd group (n=473) before admission at admission 18.0 16.0 19.8 13.0 26.0

Complications Hypothermia (%) Hypoglycemia* (%) Acidemia+ (%)

*p<0.01, 1st group vs 2nd group before and at admission, respectively + p<0.01, 1st group vs 2nd group at admission

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Outcome of the Transported Neonates dence of acidemia at admission was significantly lower in the second group compared with the first group (35.3% vs 26%, p < 0.01). Of the 255 infants transported in the first group, 51 (19.7%) died during hospitalization, 16 (6.2%) were retransferred to either the hospital of origin or another medical facility, and 11 (4.2%) were discharged against medical advice. Of the 473 infants transported in the second group, only 44 (9.3%) died during hospitalization, 20 (4%) were re-transferred to either the hospital of origin or another medical facility, and 2 (0.4%) were discharged against medical advice. The neonatal mortality in the second group was significantly lower than that in the first group (9.3% vs 19.7%, p < 0.01). Furthermore, the number of neonates discharged against medical advice was also significantly lower in the second group compared with the first group (0.4% vs 4.2%, p < 0.01). transport accounted for their better condition on arrival at the receiving hospitals. Better communication and early consultation with pediatricians, on-site education by transport personnel, and post-transport review have been shown to improve the clinical condition of transported neonates [15-19]. The morbidity in the second group and mortality in the first and second groups of the transported neonates in Tainan were compared with that in Tennessee in 1975 [21], the first year of regionalization there and in 1986, the 12th year after regionalization (Fig. 2 & Fig. 3). The percentage of transported neonates with hypothermia and acidemia significantly decreased in 1986 compared with 1975 in Tennessee but the incidence of hypoglycemia did not vary in two periods. As in Taiwan, the mortality of transported infants was significantly lower in 1986 than in 1975 in Tennessee [22]. The mortality of transported neonates did not vary between 1998 in Tainan and 1986 in Tennessee. Many factors have been associated with mortality in neonatal care such as level of the hospital, patient volume [20] and pattern of regionalization [21] . Implementation of regionalized perinatal care results in early identification and antenatal referral of high risk neonates, and also improves stabilization before and during transport of those transferred postnatally [21].

m o rtality 2 5% 2 0% 1 5% 1 0% 5% 0%

Discussion

Antenatal transfer of high risk pregnant women to tertiary care centers has proved to be better than neonatal transport in improving perinatal outcome [5-8]. However, we observed that the percentages of low birth weight (LBW) and very low birth weight (VLBW) infants among transported patients did not decrease in the latter period in the Tainan area. The annual birth rate in this area has not changed much in the past seven years. Our observations suggest that there was no increase in antenatal transfer in this area, which may be due to late detection of high-risk fetus, or maternal condition unsuitable for transfer [11]. Although the percentages of LBW and VLBW were not reduced, the frequency of endotracheal tube intubation decreased in the latter period. We did not score the severity of illness for the transported neonates. Possible explanation for the lower endotracheal intubation rate may be related to the better antenatal care in the high risk pregnancy and higher standards of stabilization skills of the transport team. The frequency of hypothermic neonates did not decrease in the second group compared with the first group. A possible explanation may be the lack of warmers or heating lamps at obstetric clinics. In addition, the incidence of AAD decreased in the second period. AAD may be related to family factors, economic situation or the poor general condition of the babies. The possible explanations for fewer AAD cases include improved quality of care in the NICU and less economic burden on the family after the implementation of health insurance. Moreover, the mortality rate of the transported neonates decreased significantly in the second group. It is likely that early diagnosis and improved technique in the management of these infants either before transport or during

17 %

19 .70 % 9.30 %

1 97 5 T en n esse e 1 98 6 T en n esse e 1 99 2 T ain an 1 99 8 T ain an

7%

Fig. 2. Comparison of morbidity at admission at receiv-

ing hospitals between Tainan and Tennessee. *axillary/rectal temperature <36; +arerial/ venous/capillary pH< 7.25 .

mortality 25% 19.70% 17% 20% 15% 9.30% 7% 10% 5% 0%

1975 Tennessee 1986 Tennessee 1992 Tainan 1998 Tainan

Fig. 3. Comparison of mortality of transported neonates

between Tainan and Tennessee in two time periods. The mortality of transported infants was significantly lower in the latter years in both locations. The mortality did not vary between Tainan, 1998 and in Tennessee, 1986.

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CC Lu, CH Lin, JJ Chen, et al Tennessee had successful regionalization during its first decade as indicated by favorable changes in referral pattern and improved outcome of transported neonates [22]. In Taiwan, we speculate that the improved outcome of transported neonates in the latter period was related to the establishment of a network of perinatal services in the Tainan area, which included educating physicians and nurses on how to identify high risk neonates and perform neonatal resuscitation, consultation and communication, and training of transport teams. The difference between Tainan and Tennessee was that there was no increase in antenatal transport in the Tainan area. Further efforts such as a policy of reimbursement or guidelines for referral provided by the Society of Perinatalogy or the Bureau of National Health Insurance are necessary or the Bureau of National Health Insurance are necessary to facilitate antenatal transfer. 9. Jayant P. Shenai. Neonatal transport: 1Outreach educational program. Pediatric Clin North Am 1993; 40: 275-84. 10. Jerry L. Hood, Alan Cross, Barbara Hulka, et al. Effectiveness of the neonatal transport team. Crit Care Med 1983; 11: 419-23. 11. Wang ST, Lin CH, Wang JN, et al. A study of the referral patterns of obstetric clinics and the performance of receiving neonatal intensive care units in Taiwan. Public Health 1997; 111: 149-52. 12. Cheng SH, Chiang TL. The effect of universal health insurance on health care utilization in Taiwan. Results from a natural experiment. JAMA 1997; 278: 89-93. 13. Braveman P, Oliva G, Miller MG, et al. Adverse outcomes and lack of health insurance among newborns in an eight-county area of California, 1982 to 1986. N Engl J Med 1989; 321: 508-13. 14. American Academy of Pediatrics and American College of Obstericians and Gynecologists. Chapter 2: Interhospital Care of the Perinatal Patient. In: Guidelines for perinatal care. Evanston IL, American Academy of Pediatrics. 3rd ed. 1992; 35-47. 15. Oh W, Cowett RM, Clark S, et al. Role of education program in the regionalization of perinatal health care. Semin Perinatol 1977; 1: 279-82. 16. Chance GW, Matthew JD, Gash J, et al. Neonatal transport: a controlled study of skilled assistance. J Pediatr 1978; 93: 662-6. 17. Skelton MA, Perkett EA, Major CW, et al. Transport of the neonate. South Med J 1979; 72: 144-8. 18. Perlstein PH, Edwards NK, Sutherland JM. Neonatal hotline telephone network. Pediatrics 1979; 64: 41924. 19. Lazzara A, Kanto WP, Dykes FD, et al. Continuing education in the community and reduction in the incidence of intracerebral hemorrhage in the transported preterm infant. J Pediatr 1982; 101: 757-61. 20. Phibbs CS, Bronstein JM, Buxton E, et al. The effects of patient volume and level of care at the hospital of birth on neonatal mortality. JAMA 1996; 276: 1054-9. 21. Yeast JD, Poskin M, Stockbauer JW, et al. Changing patterns in regionalization of perinatal care and the impact on neonatal mortality. Am J Obstet Gynecol 1998; 178: 131-5. 22. Jayant P. Shenai, Cheryl W. Major, Mark S. Gaylord, et al. A successful decade of regionalized perinatal care in Tennessee: The neonatal experience. J Perinatol 1991; 11: 137-43.

Acknowledgements

This study was supported by grants for the Promotion of Perinatal Care, Department of Health, R.O.C.

References

1. Lucey JF. Why we should regionalize perinatal care. Pediatrics 1973; 52: 488-91. 2. Johnson KG. The promise of regional perinatal care as a national strategy for improved maternal and infant care. Public Health Rep 1982; 97: 134-9. 3. McCormick MC, Shapiro S, Starfield BH. The regionalization of perinatal services: summary of the evaluation of a national demonstration program. JAMA 1985; 253:799-804. 4. Killam AP, Barrett JM, Cotton RB. The impact of a tertiary perinatal center on survival of the very low birth weight infant. J Tenn Med Assoc 1981; 74: 8702. 5. Harris BA, Wirtschafter DD, Huddleston JF, et al. In utero versus neonatal transportation of high risk perinates: A comparison. Obstet Gynecol 1981; 57: 496-9. 6. Harris TR, Isaman J, Giles HR. Improved neonatal survival through maternal transport. Obstet Gynecol 1978; 52: 294-300. 7. Lamont RF, Dunlop PDM, Crowley P, et al. Comparative mortality and morbidity of infants transferred in utero or postnatally. J Perinat Med 1983; 11: 2003. 8. Modanlou HD, Dorchester WL, Thorosian A, et al. Antenatal versus neonatal transport to a regional perinatal center: A comparison between matched pairs. Obstet Gynecol 1979; 53: 725-9.

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