In this prospective observational study of 404 sick newborns referred to the pediatric emergency of a tertiary care institution of North India. We found that referrals from government hospitals brought in National Ambulance Service contribute to the majority of cases. This service has definitely improved the access and equity for a large proportion of the poor. However, important gaps in the quality of the whole process were found. After the introduction of NAS and establishment of SNCUs under NHM, objective data about the quality of referral and transport has been scanty barring few studies from South India. 1, 4 – 5
Though a referral note accompanied majority of referred neonates, a large proportion of them were very sketchy and failed to provide complete information about the neonate. Data regarding pre-transport status like temperature, oxygen saturation, ventilatory and hemodynamic status and stabilization measures could not be retrieved in most of the cases. In a similar study from Saudi Arabia, quality of referral slip was found to be poor in 23% of cases. 5 Proper referral note is a major means of communication between physicians at different levels of the healthcare system. 6,7 It is well accepted that stabilization of neonate before and during transport improves the condition of the neonate in terms of temperature, oxygenation, blood glucose and blood pressure. 8 Similar to the observations of Rathod et al4 and others, we did not find any prior communication between referring and receiving teams. The importance and impact of prior communication between referring and receiving centers is well described. 12 The most likely reason for this is lack of dedicated and publicized contact numbers by the referral centers.
As expected, we found a significant correlation between increasing TOPS score and mortality. A study done at Ahmedabad, India from July 2010 to July 2012 found that those newborns who did not have improvement in TOPS score after 1 hour had a poor outcome. They found the most altered parameter at admission to be hypothermia (55% incidence). A study done in Tamilnadu, India found hypothermia in 26% of babies at admission. 9 In our study, only 8% were hypothermic with almost universal usage of blanket and towels for thermal support. This was in contrast to the study by Rathod et al from Southern India which found 80% of referred neonates to be hypothermic or in cold stress at arrival. 4 The reasons for this difference could be related to temporal improvements as well as seasonal variations. Though mother accompanied more than half of the infants in our study, Kangaroo mother care (KMC) or skin to skin care with any other adult was not practiced. Skin to skin contact during transport is likely to be of great benefit in our country where the ambulances may not have adequate mechanisms for thermal support of the newborn.
We found poor circulation (27%), hypoxia (15%) and hypoglycemia (9%) to be more common derangements than hypothermia. The use of ambulances as a mode of transport was little higher in our study (58%) as compared to study done in Ahmedabad, India (47%).10 Narang et al reported limited use of ambulances and a general lack of accompanying trained healthcare personnel for road transport of sick neonates.11 A previous observation of 2012-13 from Southern India reported that private ambulances or vehicles without emergency transport personnel were the main modalities, with government ambulances contributing to only 11% of transports.4 Our study found a substantial increase in uptake of government ambulance in 58% of transports and majority accompanied by a EMT. Even though, government ambulances were accompanied by dedicated emergency transport team (EMT), quality of transport was not optimal. The increasing usage of NAS is an indicator of easy access made available by the government’s program. The easy access to NAS is also brought out by the fact that the time taken for transport was less than 6 hours in the majority, though this is also a reflection of the geography and road network.
We found that admission blood culture grew an organism in one-fifth of study neonates. Though most common organisms were as expected, the growth of multi-drug resistant Klebsiella and Acinetobacter, is of major concern and creates worries about the practices in the referring hospitals. Rathod et al found 24% blood culture positivity with commonest organisms being Escherichia coli and Staphylococcus aureus. 4 A study from Tamilnadu, India had found 12% rate of septicemia among referred morbid neonates. 9
Ambulance services to transport sick newborns remain a challenge in our country. 13 No doubt, the ready availability of a free ambulance service on dialing of a common nationwide number is a revolution in itself. However, it needs to be realized that ambulance in itself is only one component of a coordinated, efficient, safe referral and transport system. The development of a ‘system’ of safe referral and transport requires urgent attention of policy makers and planners.