Risk Assessment of Morbidity and Mortality in the Neonatal Transport

1 Nurse. Esp. In Neonatal Intensivism. Federal University of Rio Grande do Norte. Natal/RN, Brazil. 2 Nurse. PhD in Health Sciences, Federal University of Rio Grande do Norte. Natal/RN, Brazil. 3 Nurse. PhD student in Nursing by the Graduate Program in Nursing, Federal University of Rio Grande do Norte. Natal/RN, Brazil. 4 Nurse. Master in Nursing from the Federal University of Rio Grande do Norte. Natal/RN, Brazil.


Introduction
The profile of neonatal morbidity and mortality is related to the birth of a newborn (NB), in particular those at high risk who are born under unfavorable conditions need care in tertiary centers with human resources and specialized materials.This NB is characterized by presen-ting: severe perinatal asphyxia (from <7 to 5 min); premature birth weight <2,000g; gestational age <35 weeks or other serious diseases [1,2].
In this context, it is performed the neonatal transport, which is classified as inter-hospital and in-hospital.The first case where the patient requires intensive and intermediate care, and was initiated after adequate stabilization of the patient in the hospital of origin, discussed in agreement with the destination hospital staff and assured vacancy in the referred hospital.The second is that what happens between the delivery room and the Neonatal Intensive Care Unit (NICU) or Intermediate care unit, as well as between the Neonatal Unit and Diagnostic and/or Surgical Center [2,3].
Neonatal transport risks may compromise the patient's physiologic stability.Therefore, we need to consider some essential elements for neonatal transfer system: organization, communication, human resources, equipment and transport units as well as regionalized and hierarchical system of perinatal care [4,5].
Reflecting the issue of quality and safety in the transport neonatal procedure, the need to meet the safety conditions of the transports.For this it developed a registration form of the transports, considering the variables of risk score for the Intra-Hospital Neonatal transport (ERTIH-Neo) and the patient's risk calculation during the Inter-hospital transport -Transport Risk Index of Physiologic Stability [5,6].
From this, formulated the following research question: Terrestrial neonatal transport and interhospital confers risk of morbidity and mortality for newborns?The hypothesis tested in this research question implies that this type of transport sets risks of morbidity and mortality in this population.
It is expected that the application of these indexes identify the risks that generate impacts on neonatal morbidity and mortality, and assist in the development of measures to reduce damage during this event.Thus, the present study aims at assessing the risk of morbidity and mortality of infants during the inter-and intra-hospital ground transportation in accordance with the TRIPS and the ERTIH-Neo scores.

Methods
A cross-sectional study, descriptive and retrospective nature, performed in a maternity reference School in maternal and neonatal care, located in Rio Grande do Norte, held in December 2014 period, using data corresponding to the months from September to November of the same year.
The data were from transport registration form conducted with RNs NICU, based on the guidelines of the Brazilian Society of Pediatrics on the Transport High Risk Newborn [2].This form consists of data into three categories, initially presented information regarding the labor and birth, were later described the path data, travel time, type of procedure to be performed and equipment used to transport and finally the tables of scores used.This instrument was used for the monitoring of intra and inter-hospital transportation, characterizing the transport and describing the possible complications.
Inclusion criteria was considered the RNs from the NICU, indicating perform inter-or intra-hospital transport.The study excluded the RNs who had severe hemodynamic instability hindering the performance of the transport.From these criteria the population totaled 34 RNs from a non-probabilistic sample, which required to make use of transport in the analyzed period.
All data collected were organized into databases built on Excel Software and submitted to descriptive statistical analysis through absolute and relative frequencies, being subsequently discussed in the light of the relevant literature.
To calculate the index of morbidity TRIPS, the following variables were used: axillary temperature, respiratory pattern, systolic blood pressure and the neurological State.And for the ERTIH-Neo, variables were evaluated relating to gestational age, axillary temperature, underlying disease, destination and respiratory support.The scores were calculated before and after all ot the transports.
All ethical principles were respected and the study received the approval of the Ethics Committee and research of the University Hospital Onofre Lopes, under Opinion No. 874,423, no.874.423,CAEE Nº 36065814.2.0000.5292.

Results
A total of 57 transports, involving 34 NBs, where more than one transport per NB.There was a profile of mostly premature neonates, with an average of 32.3 weeks gestational age (SD ± 4.5 weeks).Much of the studied population presented an APGAR score less than seven at the first moment of life.Predominated RNs with very low birth weight, with an average of 1,575 g (SD ± 938g) and current weight below 2,500 g.The results are shown in Table 1.
Of the transports, predominated those conducted in the intra-hospital environment.Those who require transfers to other institutions or admissions in the same service were verbally regulated in 26% of the cases.With regard to the statement, 63% were in support diagnostic tests, such as ultrasound of the abdomen and transfontanellar, echocardiograms and CT scans.In relation to the knowledge of parents or guardians about the need of neonatal transport, homogeneity of the data, both for those who were aware how much the others that were not reported.(Table 2) According to the data obtained, the team involved in shipping in most procedures, were composed by professional doctors and nurses.As for the route, For the calculation of the score variables were considered complete TRIPS just for 26% of the studied population.Since it was not possible to verify PAS, for lack of necessary equipment in service, which made the actual measurement of the risk assessment of these NBs, featuring a limitation of the study.Considering this fact, most obtained a score greater than ten, indicating changes that interfere with the clinical morbidity and mortality of the population studied.
The incomplete data found on record were also analyzed, whose scores have referred to changes in the condition of NBs during the inter-hospital trans-port, such as temperature, standard respiratory and neurological state.
The temperature prevalent values below 36.5ºC,corresponding to a point on the scale TRIPS, which portrays a hypothermia condition.In the analysis of the breath, it was observed that the higher percentage was related to a standard considered normal for the age group, although most require supplemental oxygen.The variable neurological State, presented evidence to those who were hypoactive before transport, however, after the procedure, this same variable highlighted the reactivity of newborns.(Table 4)   With regard to the results of the calculations relating to the intra-hospital transport, there was a predominance of newborns who have obtained a score between 16 and 20 on the scale used, reflecting a 38% risk for developing complications during transport.(Figure 1)

Discussion
Neonatal transport-related studies usually involve the investigation of many aspects related to indications of this procedure, conditions of transport offered and its repercussions on health care of the newborn, multidisciplinary team work, discuss the risks and benefits, the most important pathologies that require this service, report about the possible complications and complications and emphasize the essential care in this care, among others [5,6,7,8].
In the study proposed the majority of the population was characterized by newborns at high risk, since they had defining criteria for this classification under the Ministry of Health [1], such as prematurity, Apgar score <7 in the fifth minute of life and low birth weight.
Among the types of transport, there was predominance in in-hospital, which involved the conduct of examinations and diagnostic support admissions in the NICU.The inter-hospitals understood the Imaging exams that were not available in the institution, as well as surgeries, specialized queries and transfers.Other studies corroborate with these findings regarding the frequency and referral [2].
Although there is no institutional protocol for the implementation of the neonatal transport in NICU searched, the hospital routine was surely adopted by professional executioners of the process, as far as the regulation of slots and communication to parents about the accuracy of the transports.According to the authors, these conducts are essential in follow-up the steps to a proper planning [2].This investigation has been found to claim the team offer a safe transportation for the patient, in that most of the calls were made by a professional doctor and a nurse are enabled by means of a training about the transport of high-risk NBs.However, this conduct is not pointed to other studies, for example, Dinizi et al [9], evaluated the clinical conditions and transport of infants admitted to neonatal intensive therapy units, in which the data revealed that only 2.8% of transport were accompanied by a complete team.
The responsibility to indicate the completion of the neonatal transport is the health team working in the NICU, which assesses the need and the risk of carrying out such assistance.In the case of human resources, the neonatal transport is carried out by a doctor and a nurse, both with proven ability to the urgent and emergency care of the newborn at risk [10,11,12].
The complications that occurred were classified as equipment failures, NB clinical changes, accidents and transport timeout, among which stand out those physiological instability related to the NB.This result is confirmed by other research that address these implications during and after transport, for example, hypothermia, hypoxia, hypoglycemia, and metabolic disorders.Associated with this fact the increased risk of brain damage and death [5,13,14,15,16].
As for the TRIPS was detected a score progression in value considered risk before and after transport.This elevation for the score > 10 was registered due to clinical instability exposed by most newborns converging on the increased risk of neonatal morbidity and mortality.In a study conducted in California analyzed data collected in transport 21,279 2007 period to 2009, which used TRIPS range and confirmed that this validation instrument for predicting death among children transported after seven days [14,15].
A large portion of the NBs presented hypothermia during all the way, which favors the acid/base imbalance, respiratory distress, Necrotizing Enterocolitis and intraperiventricular hemorrhage at a very low birth weight NBS, characterizing this variable as a risk factor for mortality.In severe hypothermia, bradycardia, hypotension may occur, irregular breathing, decreased activity, weak suction, decreased reflexes, nausea and vomiting, metabolic acidosis, hypoglycemia, hypercalcemia, azotemia, oliguria and, sometimes, widespread bleeding, pulmonary hemorrhage and death [1].
The prevalence of the score found in this investigation in 16-20 range reflecting a 38% risk of developing complications in shipping, is founded by authors responsible for the validation of ERTIH-Neo [6].This score is predictive and allows the identification of newborns susceptible to multiple risks of complications during transport-hospital clinics, therefore, considers that the neonates undergoing transport in the study institution showed a risk of morbidity.Based on that one should think about the risks and benefits of transport in order to minimize the implications that involve the NBs who are exposed in the context of the neonatal transport [17,18].
On the exposed, the people need to promote the stabilization of the clinical picture of the newborn, before transporting it to any procedure in intrahospital environment or inter-hospital; evaluating the risks and benefits in developing this assistance.Since an inadequate transportation may not only affect associated morbidities, but also leads to severe and irreversible conditions such as neonatal death [19,20].

Conclusion
The analysis of the TRIPS and ERTIH-Neo indexes relating to land transport inter and in-hospital enabled the understanding of neonatal morbidity and mortality risks.Which were present in most neonates undergoing the procedure, on the grounds of point scores above the normal range proposed by rating scales.
The limitations of the study involved the verification of systolic blood pressure not because of a lack of available equipment for all NBs, the information were sketchy on the charts and the record sheets that were not filled after the transport.This factor was an impediment to the actual calculation of most indexes related to the inter-hospital type.
This research is expected to encourage an orderly implementation of these scores in NB assistance during transport, allowing you to assess the risks of this procedure through the identification of factors that influence neonatal morbidity and mortality.Thus, the nurse may prepare measures aimed at reducing damage during this event and to ensure improved thermal control.

Table 2 .
Characterization of Neonatal Transport.Natal/RN, Brazil, 2014.Research data the most prevalent was transport carried out in time less than an hour, with an average of 46 minutes and average of 20 minutes.It should be mentioned that the shortest time occurred in only five minutes and the longest four hours.With regard to complications triggered by newborns, were mainly related to changes of the clinical State such as Hypothermia, drop in oxygen saturation, skin paleness and hypotonia.(