NEONATAL TRANSPORT IN TEHRAN: A CAUSE FOR MUCH ...

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M. Kazemian, S. H. Fakhraee, F. Zonouzi• well-functioning equipment (e.g. transportincubator, ventilator...);• trained personnel skilled in neonatalresuscitation and stabilization;• well-functioning and well-equipped vehicles;• good roads and highways; and• good communication between primary andreferral hospital.In Tehran there are few NICUs where thetrained personnel and necessary equipment areavailable for the care of high-risk neonates.Because of shortage of these facilities, many ofthe sick neonates who need to be transported cannot obtain admission. Even when they can obtainadmission, their transport is delayed and veryinefficient due to lack of good communication,transport vehicle, and trained personnel, etc. Inthis study, we attempt to clarify some of theinadequacies in regard to neonatal transport inTehran and to give some suggestions topolicymakers in order to improve neonataltransport and reduce neonatal morbidity andmortality.Patients and MethodsIn this study, 16 maternity hospitals withoutNICU facilities in different geographical locationsof Tehran were selected randomly forparticipation during the month of November 2002.All infants born at these hospitals during thatperiod who were candidates for transport toNICUs according to the universal standards wereincluded in this study. 6 By reviewing severaltransport protocols we prepared a questionnaireand distributed it to the head nurses of theneonatal units of the participating hospitals. Thepediatricians of these hospitals determined theeligibility of the neonates for transport accordingto the above-mentioned criteria.All of the information regarding the transportof these babies were extracted from thequestionnaires and analyzed using SPSS software.ResultsIn the participating hospitals, 3,125 infantswere born during the study period. Of these, 320(10.24%) needed admission to a special care unitdue to complications such as respiratory distressand surgical problems. Of the 320 patients whorequired transport and admission, only 22 infants(6.87%) from 13 centers were able to obtainadmission.Fifteen (68.18%) of the infants who receivedtransport were premature while seven (31.82%)were born full-term. The mean ± SD age of theinfants at the time of request for transport was 3.8± 3.07 hours and the mean ± SD birth weight was1.92 ± 0.28 kg. The reason for transport in 17cases (77.27%) was respiratory distress and in fiveothers (22.73%) transport was desired for surgicalproblems. Three of the fifteen premature infants(13.63% of all the infants requiring transport) diedbefore they could obtain admission.The mean ± SD waiting time for admissionwas 110 ± 50 min and the mean ± SD elapsedinterval between receiving confirmation ofadmission acceptance, and exiting the primaryhospital was 50 ± 26 min. The mean ± SD intervalbetween leaving the referring hospital and arrivingat referral hospital was 46 ± 17 min. In 16 cases(84.21%) the father accompanied the infant, whilein 3 cases (15.79%) another relative accompaniedthe infant. Health care professionals also oftenaccompanied the patient; in 15 cases (78.9%) anurse and in 4 cases (21.1%) interns accompaniedthe patient.Out of these 19 health care personnel whoaccompanied the patients, only 8 (42.1%) hadparticipated in neonatal resuscitation workshops.None of the transported infants was intubated butall of them had intravenous lines.In 11 cases (57.9%) the transport vehicle was ahospital ambulance while in rest of the cases, itwas a private ambulance. None of the ambulanceshad optimal equipment such as proper-sized bagand mask, transport incubators, monitors,equipment for temperature regulation, or transportventilators. In seven cases, (36.84%) a transportincubator was used and in 12 cases (63.16%)blankets were used to warm the baby duringtransport. Cardiopulmonary resuscitation (CPR)was performed on one premature infant duringtransport. It was unsuccessful and the patient diedbefore reaching the referral hospital. Three otherpremature infants had mechanical ventilationintermittently with bag and mask during transportbut none was intubated. None of the health careprofessionals who accompanied the babies hadexperience with neonatal tracheal intubation.DiscussionIn most developed countries, critically illArchives of Iranian Medicine, Volume 7, Number 4, October 2004 257
Neonatal transport in Tehranneonates are often born in specialized centerseither because the referral center routinely deliverscare to at-risk perinatal populations, or due toprenatal detection of a problem. These babies arecalled "inborn." A large number of outbornneonates, however, require emergent transfer to atertiary care center, often due to medical, surgical,2, 3, 4or rapidly emerging postpartum problems.Since the outcome of an outborn neonate withmajor medical or surgical problems remains worsethan an inborn infant, primary emphasis shouldalways remain on prenatal diagnosis andsubsequent maternal transfer whenever possible.Despite advanced training and technology,mothers usually make the best transport incubators2, 3, 4(i.e.: in utero transport).In 1976, the Committee on Perinatal Health,sponsored by the March of Dimes, of the UnitedStates proposed a system for regionalizedperinatal care and defined three levels of hospitalcare, as a national model for the rapiddevelopment of neonatal referral centers. Thismodel required the development of a neonataltransport system, which was associated with asignificant reduction in the neonatal mortalityrate. 1 According to the regionalization programswhich were established during the early 1970s inmost of Europe and North America, three levels ofperinatal and neonatal care are defined andexpectant mothers are assigned to these levelsearly in pregnancy according to their needs. 2 – 4Despite the fact that intrauterine transport isthe best mode of transporting premature and highriskfetuses to specialized centers, this procedureis still not practiced in Tehran. The reasons for notpracticing this method in Tehran are several,including:• many obstetricians invest a majority of theirtime working in private hospitals. Comparedto public hospitals, private hospitals lack manyof the necessary hospitals for care of high-riskneonates. Those high-risk neonates born inprivate facilities must be transferred to publichospitals to receive the required care;• lack of a regionalization program for perinataland neonatal care;• inadequate number of specialized centers forcare of high-risk deliveries (care of mother andneonate);• lack of adequate communication betweenprimary and referral hospitals;• the few available NICU facilities are located inpediatric hospitals, which are far away frommaternity units;• lack of good transport resources; and• lack of a centralized transport unit to arrangetransports to specialized centers.According to the present study, less than 7% ofthe high-risk neonates delivered in Tehran couldget admission to specialized care centers. Theoutcome of more than 90% of these deliveries isnot known by us and is a subject for anotherstudy. The present study shows that the referringhospitals spend a considerable amount of time toget admission from the referral hospitals. Thislapsed time sometimes causes significantmorbidity and mortality in the sick newborns. Oneof the most important factors in this delay is thelack of a centralized transport unit in Tehran forarranging all neonatal transports.To achieve safe and rapid transport, thereshould be a centralized unit in each region thatreceives all requests for the transport of sickinfants and arranges their transport to differentreferral hospitals in the region according to theirneeds and levels of required care. 1 Unfortunately,there is currently not such a center in Tehran andthe referring hospitals and families have to checkmany hospitals hoping that they may be able tofind a place to which they can transport their sickinfant. Unfortunately, families and staff spend avaluable amount of time in this process and thistime is very critical and important in neonatalcare.Another important problem in neonataltransport in Tehran is the lack of adequatecommunication between referring and admittingphysicians. The information given to the referralhospitals is, in most cases, insufficient and givenby a nurse or paramedical personnel rather than aphysician. One of the main factors in successfultransport is the stabilization of the neonate beforetransport . 2 – 7 This is not often practiced in Tehranand sick infants are transported before they arestabilized. This is one of the main factors thatincreases the morbidity and mortality of theseinfants.Equipment such as transport incubators,monitors, and tools for mechanical ventilation areinadequate and malfunction in many cases duringtransport. Even when equipment are available, thetransport team often can not use them effectivelydue to lack of training.In summary, the present study shows that all258Archives of Iranian Medicine, Volume 7, Number 4, October 2004
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