The neonatal transfer process through the lens of neonatologists at public hospitals in South Africa

Background: Neonatal care is provided by various levels of healthcare facilities in South Africa. Intensive care for neonates is only provided at the higher levels, hence the need for transfers from lower-level to higher-level facilities (e.g. primary hospitals to tertiary hospitals) or across levels of facilities, particularly when life-threatening situations arise (e.g. cardiac deterioration, respiratory deterioration and desaturation). Aim: The aim of the study was to explore neonatologists' views regarding the neonatal transfer process and to describe the preparedness of advanced life support (ALS) paramedics to undertake such transfers. Setting: The setting consisted of neonatologists from three provinces i.e. KwaZulu-Natal, Gauteng and Western cape. Method: A qualitative descriptive design was utilised in this study. Semistructured interviews were conducted on the public health hospitals in three provinces (N = 9; n = 3) with neonatologists (N = 7; n = 7) who were involved in the transfers of critically ill neonates. The process of thematic analysis was used. Results: The themes that emerged in this study were: an awareness of local contextual realities related to neonatal transfers, challenges evident within the context of neonatal transfers, decision-making around the transfer of ill neonates, ALS paramedic preparedness for transfers and good clinical governance Conclusion: The study found that there was a need to be aware of local contextual realities confronting neonatal transfers, a need for greater preparedness for paramedics to undertake these transfers, a need for a sound referral processes and a need for coordinated transfer effort between paramedics, hospital staff and transport team members for the successful transfer of critically ill neonates. Contribution: The findings highlight the challenges confronting the neonatal transfer process in South Africa through the lens of neonatologist at public hospitals. Hence, the study reinforces the preparedness and coordination of the transfer process, along with more efficient communication between paramedics, hospital staff and the transfer team.

Functional echocardiography training in the neonatal intensive care unit: comparing measurements and results with the pediatric cardiologist / Treinamento em ecocardiografia funcional na unidade de terapia intensiva neonatal: comparando as medidas e resultados com o cardiologista pediátrico

Abstract Objectives: Functional echocardiography is a valuable tool in the neonatal intensive care unit, but training programs are not standardized. The aim was to report an functional echocardiography training program for neonatologists and to describe the agreement of their measurements with the pediatric cardiologist. Methods: Functional echocardiography training lasted 32 h. After training program, the neonatologists performed functional echocardiography in the neonatal intensive care unit and were required to measure left cardiac chambers dimensions, left ventricle systolic function, right and left ventricular output, ductus arteriosus diameter, and flow pattern. Images were recorded by the equipment and reviewed offline by the pediatric cardiologist. The Bland-Altman test was used for quantitative variables and the kappa test, for qualitative variables. Results: Twenty-two trained neonatologists performed 100 functional echocardiography exams. Ductus arteriosus identification and flow pattern had substantial agreement (kappa = 0.91 and 0.88, respectively), as well as its diameter (mean difference = 0.04 mm). The mean difference for the aortic root was −1.2 mm; left atrium, 0.60 mm; left ventricle diastolic diameter, −0.90 mm; left ventricle systolic diameter, −0.30 mm. Shortening fraction and ejection fraction correlated well with broad limits of agreement, −2.96% (14.88; −20.82%) and −-3.43% (15.54; −22.40%), respectively. Right and left ventricular output had broad limits of agreement, 16.69 mL/kg/min (222.76; −189.37) and 23.57 mL/kg/min (157.88; −110), respectively. There was good agreement between interpretations of normal or low cardiac output (76.7% for right ventricular output; 75.7% for left ventricular output). Conclusion: This functional echocardiography training program enabled neonatologists to obtain adequate skills in performing the images, obtaining good agreement with the cardiologist in simple hemodynamic measurements and ductus arteriosus evaluation.

Resumo Objetivos: A ecocardiografia funcional é uma ferramenta valiosa na unidade de terapia intensiva neonatal, mas os programas de treinamento não são padronizados. Nosso objetivo foi relatar um programa de treinamento em ecocardiografia funcional para neonatologistas e descrever a concordância de suas medidas com o cardiologista pediátrico. Métodos: O treinamento em ecocardiografia funcional durou 32 horas. Após o programa de treinamento, os neonatologistas faziam ecocardiografia funcional na unidade de terapia intensiva neonatal e mediam as dimensões das câmaras cardíacas esquerdas, função sistólica do ventrículo esquerdo, débito cardíaco do ventrículo direito e débito cardíaco do ventrículo esquerdo, diâmetro do canal arterial e o padrão de fluxo. As imagens foram registradas no equipamento e revisadas offline pelo cardiologista pediátrico. O teste de Bland-Altman foi usado para variáveis quantitativas e o teste Kappa para variáveis qualitativas. Resultados: Foram feitas por 22 neonatologistas treinados 100 ecocardiografias funcionais. A identificação do canal arterial e o padrão de fluxo apresentaram concordância substancial (Kappa = 0,91 e 0,88, respectivamente), bem como seu diâmetro (diferença média = 0,04 mm). A diferença média foi de -1,2 mm para a raiz da aorta, 0,60 mm para o átrio esquerdo, -0,90 mm para o diâmetro diastólico do ventrículo esquerdo e de -0,30 mm para o diâmetro sistólico do ventrículo esquerdo. A fração de encurtamento e a fração de ejeção apresentaram boas correlações, com amplos limites de concordância, respectivamente -2,96% (14,88; -20,82%) e -3,43% (15,54; -22,40%). Os débitos cardíacos do ventrículo direito e do ventrículo esquerdo apresentaram amplos limites de concordância, 16,69 mL/kg/min (222,76; -189,37) e 23,57 mL/kg/min (157,88; -110), respectivamente. Houve boa concordância entre a interpretação de débito cardíaco normal ou baixo (76,7% de débito ventricular direito; 75,7% de débito ventricular esquerdo). Conclusão: Esse programa de treinamento em ecocardiografia funcional permitiu aos neonatologistas obter habilidades adequadas na realização das imagens, com boa concordância com o cardiologista em medidas hemodinâmicas simples e avaliação do canal arterial.

Calidad de la atención en el Servicio de Neonatología del Hospital General Docente "Dr. Juan Bruno Zayas Alfonso" / Quality of care in the Neonatology Service of "Dr. Juan Bruno Zayas Alfonso" Teaching General Hospital

Se realizó un estudio descriptivo y transversal con vistas a evaluar la calidad de la atención en el Servicio de Neonatología del Hospital General Docente "Dr. Juan Bruno Zayas Alfonso", de septiembre de 2013 a marzo de 2014, para lo cual fue dividida la investigación en 3 dimensiones: estructura, proceso y resultados; y se establecieron diferentes criterios, indicadores y estándares. De forma general, se identificaron deficiencias en la calidad de la atención respecto a la estructura del Servicio, en el que no se contaba con ningún pediatra y de los 12 neonatólogos que debían estar laborando, solo lo hacían 7. En cuanto al equipamiento, se detectó que de las 2 cunas térmicas existentes, una se encontraba en mal estado, para 50,0 %, de manera que este indicador resultó inadecuado; de los 5 perfusores disponibles, 1 de ellos estaba en mal estado y 4 aptos, para 80,0 %, lo cual se consideró como inadecuado. Por su parte, de las 3 pesas convencionales, 2 de ellas estaban en mal estado, para 67,0 % del estándar establecido, de modo que este indicador fue inadecuado. Por último, no se detectaron deficiencias ni en el proceso ni en los resultados, por lo que todo el personal fue evaluado como adecuado.

A descriptive and cross-sectional study was carried out with the aim of evaluating the quality of care in the Neonatology Service of "Dr. Juan Bruno Zayas Alfonso" Teaching General Hospital from September, 2013 to March, 2014, for which the investigation was divided in 3 dimensions: structure, process and results; equally, approaches, indicators and standards were established. Generally, deficiencies were identified in the quality of care related to the structure of the Service, in which there was no pediatrician and of the 12 neonatologists who should have been working, there were only 7. Regarding the equipments, it was detected that of the 2 existing thermal cradles, one was not functioning well, for 50.0%, so that this indicator was inadequate; of the 5 available infusion pumps, 1 of them was in bad conditions and 4 were functioning, for 80.0 %, which was inadequate. On the other hand, of the 3 conventional weights, 2 of them were not right, for 67.0% of the established standard, so the indicator was inadequate. Lastly, deficiencies were detected neither in the process nor in the results, so that the whole staff was evaluated as competen.