Neonatal inter-hospital transfer: clinical information sharing and condition of neonates referred to tertiary hospitals in Kigali, Rwanda

Abstract

ABSTRACT 1 – Delphi study Background: Effective communication between healthcare providers is essential for patient safety. Standardized neonatal referral forms (NRFs) ensure continuity of care between facilities.

Objective: We sought to determine the key data items, Core Clinical Information (CCI), that should be conveyed for neonatal inter-hospital transfer in resource-limited settings.

Methods: We conducted an international, three-round, modified Delphi consensus study. Round-1 was a literature and internet search to identify existing NRFs. In rounds two and three, participants evaluated the items generated from this search and proposed additional items to be included in an NRF through an online questionnaire. Participants were Rwandan and international pediatric healthcare practitioners who had worked in Rwanda in the five years prior to the study.

Results: We identified 16 pre-existing NRFs containing 125 individual items. Ninety-one items met the pre-defined consensus criteria for inclusion in Round-2. Only 33 items were present in more than 50% of the 16 NRFs, confirming the need for this consensus study. In Round-2, participants proposed 12 new items, six of which met the pre-defined consensus criteria. In Round3, participants scored items for importance, and 57 items met the final consensus criteria.

Conclusions: By converging diverse opinions from neonatal clinicians, we have generated a 57 items CCI list that can be used to generate an NRF for any centres that refer neonates to institutions that provide a higher level of care in resource-limited settings. The language would need to be modified where appropriate and the items assessed for local suitability. However, how the use of these CCI list/NRF affect the outcomes of neonatal transfer between health facilities in Rwanda is yet to be determined and would make an interesting piece of future research work too. ABSTRACT 2 – Cross-sectional study Background: When transporting sick neonates in resource-limited settings there needs to be adequate information-sharing to ensure optimal transfer of care. Currently there is no data on the adequacy of data-sharing for transported neonates in Rwanda. Objective: We sought to evaluate the quality of the existing information sharing practice and determine the baseline outcome of neonates referred to tertiary hospitals in Rwanda. Methods: This was a cross-sectional, longitudinal study conducted at CHUK and RMH for a sixmonth period. We analyzed the completeness of the referral letters using the previously designed CCI list as standard. Prevalence of morbidities, mortality and its timing in seven days from admission were determined using SPSS version 22. The level of documentation for these referral letters was compared with mortality, described odds ratios, and gained p-values. Results: 158 neonates were enrolled. 67%, had surgical condition as primary diagnosis and 68% presented within their first week of life. The completeness of the analyzed referral letters ranged from 10 to 60%; and 33.3% was determined as median. The overall seven-days mortality was 19% and, one fifth died within the first day of admission. More than a third of neonates were admitted hypoxic, and they were three times more likely to die (OR=2.96 (CI: 1.11 to 7.9), p=0.025). Low birth weight was associated to mortality, (OR= 2.37, p=0.034, 95% CI: 1.05 to 5.32). There was a trend but no statistical association between low documentation (< 33.3%) and mortality, OR=1.58, (p=0.262 95% CI: 0.71 to 3.52). Conclusion: Transfer of neonates in resource limited settings poses an additional risk to mortality and morbidities. Need of an organized transfer system with focus to more vulnerable population, neonates. There is a gap in communication during neonatal transfer that needs a harmonized referral letter and improved documentation.