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Title: An analysis of inter-healthcare facility transfer of neonates within the eThekwini Health District of KwaZulu-Natal
Authors: Ashokcoomar, Pradeep 
Issue Date: 18-Jan-2013
The safe transfer of neonates from one healthcare facility to another is an integral
component in the process of neonatal care. Neonates, a term applying specifically to
infants during the first 28 days of life, are transferred from medical healthcare
facilities which do not have specialist care or intensive care management to more
specialised facilities in order to improve their clinical outcome and chance of survival.
The transfer system is thus an important aspect of the overall care provided to
neonates. The transfer process, however, poses a threat of aggravating the clinical
condition of the neonate. Inter-healthcare facility transfer of a neonate requires
careful planning, skilled personnel and specialised equipment to maintain the
continuum of care, as this directly impacts on the morbidity and mortality of the
Purpose of the study
The purpose of the study was to undertake a descriptive analysis of the current
neonatal inter-healthcare facility transfer system in the eThekwini Health District of
KwaZulu-Natal (KZN). This service is provided by the public sector ambulance
service known as the Emergency Medical Rescue Service (EMRS). The study,
based on 120 consecutive transfers, assessed the clinical demographics of the
neonates, the time taken to complete the transfers, including time sub-intervals, the
equipment that was necessary for the transfers and the qualifications and
procedures performed by the transfer team. The study also identified any adverse
events that were encountered during the transfers.
The study was conducted from 19 December 2011 to 30 January 2012. It used
quantitative methodology and a non-experimental prospective design to undertake a
descriptive analysis of 120 inter-healthcare facility transfers of neonates within the
eThekwini Health District of KwaZulu-Natal. Data collection relied upon two types of
questionnaires. A descriptive survey method incorporated logistic and deductive
reasoning to evaluate the objectives of this study. Frequency distributions were
generated to describe data categories. Bivariate analysis was conducted using chi-
During the study period there were a total of 120 neonatal inter-healthcare facility
transfers. All referrals were undertaken by road ambulances. Eighty-three (62.2%),
transfers were undertaken by the operational ambulance units, 35 (29.2%) by the
obstetric unit and 2 (1.7%) by the planned patient transport units. Thirty one (28.5%)
transfers were on Fridays, followed by 24 (20.8%) on Mondays and 20 (16.6%) on
weekends. Ninety seven (80.8%) were during the hours of dayshift (07h00-19h00)
and 23 (19.2%) were during nightshift (19h00-07h00). Of the 120 neonatal transfers,
29 (24.2%) were specialised transfers, of which 22 (75.9%) were ventilated.
With reference to the gestational ages of the neonates being transferred 90 (76.7%),
were pre-term, 26 (21.7%) were term and 2 (1.7%) were post-term. There were 11
(9.2%) newborns (from birth to 4 hours), 56 (46.7%) early neonates (from 4 hours to
7 days) and 53 (44.2%) late neonates (from 7 days to 28 days). Of the 120 neonatal
transfers, 90 (75.0%) were pre-term having associated co-morbidities and 49
(40.8%) had respiratory problems.
The mean time ± standard deviation (SD), taken by EMRS eThekwini to complete an
inter-healthcare facility transfer was 3h 49min ± 1h 57min. The minimum time to
complete a transfer was 55min and the maximum time was 10h 34min. The mean
time ± SD from requests to dispatch was 1h 20min ± 1h 36min. The delays in
dispatch were associated with no ambulances being available 70 (58.3%), no ALS
personnel available 48 (40.0%), no equipment available 23 (19.2%) and no ILS
personnel available 7 (5.8%) to undertake the transfers. Junior or inexperienced
personnel in the communication centre also contributed to the time delays by
dispatching ALS personnel for non-specialised transfers and requesting neonatal
equipment when it had not been requested by the referring personnel for the
transfer. The mean time ± SD from the referring hospital to the time mobile to the
receiving hospital was 43min ± 26min. Six (5.0%) neonates were clinically unstable
at the referring facility for transfer. For 15 (12.5%) transfers, neonates had been
inappropriately packaged for transport by the hospital staff, which added to the
delays, p. value = 0.018.
The necessary equipment was unavailable for 37 (30.8%) of the transfers. The lack
of equipment was due to problems such as poor resource allocation, and
malfunctioning, inappropriate, insufficient and unsterile equipment. The pre-
departure checklist had not been completed in 50 (41.67%) of the transfers.
The study identified 10 (8.3%) adverse events related to the physiological state of
the neonate and included 1 (0.8%) mortality. Nine (7.5%) neonates suffered serious
life threating complications during transportation, 8 (6.7%) of which were due to
desaturation, 6 (5.0%) due to respiratory deterioration, 3 (2.5%) due to cardiac
deterioration and 1 (0.8%) due to temperature related problems. Eighteen (15.0%) of
120 transfers experienced equipment related adverse events of which 9 (7.5%) were
associated with ventilators, 9 (7.5%) with incubators, 3 (2.5%) with the ambulance, 2
(1.7%) with the oxygen supply and 1 (0.8%) with arterial cannulation. Five (33.3%) of
the 15 equipment related adverse events contributed directly to life threatening
physiologically related adverse events, p. value = 0.007.
Conclusion and recommendation
The Emergency Medical Rescue Service (EMRS) is involved in the transportation of
a significant number of neonates between various healthcare facilities in the
eThekwini Health District, some requiring intensive care and some not. This
descriptive, prospective study has identified numerous shortfalls in the service
provided by the EMRS in the eThekwini District.
Inter-healthcare facility transfer of neonates can be safely performed by the transport
services if the operations are well co-ordinated and there are dedicated, specialised
and trained transport teams armed with appropriate equipment and medication,
together with the guidance of policies and quality assurance. Transport teams must
be trained to provide this specialised care in various environments, including ground
and air ambulances and understand the multiphase neonatal transfer processes.
There must be good communication and co-ordination by all role players, which is
underpinned by good team work to improve the standards of neonatal care and
monitoring. Only then can clinical excellence be achieved when transporting
neonates between healthcare facilities.
Dissertation submitted in fulfillment of the requirements for the Degree of Master of
Technology: Emergency Medical Care, Durban University of Technology, Durban, South Africa, 2012.
Appears in Collections:Theses and dissertations (Health Sciences)

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