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Adverse events during neonatal transfers: What have we learnt?

Presented at the Neonatal Society 2006 Summer Meeting (programme).

Swamy R, Venkataraman A, Lal M

Neonatal Unit, The James Cook University Hospital, Middlesbrough TS4 3BW, UK

Introduction: Our neonatal transport team is responsible for over a third of the transfers in the Northern Region. Adverse events during such transfers are known to occur despite all precautions. It is our practice to monitor such events and to bring about change in practice to improve standards of clinical care.

Objective: To evaluate the incidence of adverse events during neonatal transfers after recent change in practice.

Methods: Prospectively collected data on all transfers at James Cook university hospital over a period of 12 months (April 2005 to March 2006) were analysed.

Results: Total numbers of transfers were 141 of which 5 were consultant led, 112 were Registrar led, 22 were transport nurse led and 2 by ANNPs. (88 ventilated babies and 53 unventilated). There were 27 adverse events which included 1 dislodged ET tube, 2 dislodged lines, 18 babies with low temperature (<35.5C) and 6 babies with high temperature (>37.6C). In addition, there were 3 mechanical problems relating to the ambulance. The following figures show changes in blood gas taken before and after the transfer.

Conclusions: In our practice, thermoregulation and mechanical problems with ambulance appear to be significant. These issues are being addressed in order to improve clinical outcome in future.

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