Referral challenges and outcomes of neonates received at Muhimbili National Hospital, Dar es Salaam, Tanzania

Background Functional referral system including pre referral care, access to emergency transport and ensuring continuity of care between facilities is critical for improved newborn health outcome. The neonatal transport system is quite undervalued in many sub Saharan countries, Tanzania included. This study assessed the pre referral care, transport process, ambulance characteristics, admission clinical status and outcomes of referred neonates at Muhimbili National Hospital Upanga, a tertiary facility in Dar es Salaam, Tanzania. Methods A descriptive cross sectional study with a longitudinal follow up was conducted from September 2020 to February 2021 including neonates referred to Muhimbili National Hospital. A structured questionnaire was used to collect demographic characteristics and transport factors including pre referral care extracted from the referral documents and through interviewing caregivers or escorting person/nurse. Ambulances were directly observed using a structured checklist on presence, absence and functionality of supportive equipment. All enrolled neonates had a clinical assessment at admission and 48 hours post admission to determine admission clinical status and 48 hours’ clinical outcome as either survived/died. Results Out of the 348 neonates assessed during the study period, the median gestation age was 38 weeks (IQR 32, 39) with the mean birth weight of 2455 ± 938 g. Pre referral documentation showed that temperature was measured in 176 (57.1%), oxygen saturation and random blood glucose in only 143 (46.6%) and 116 (36.2%) neonates respectively. Ambulance was used as a means of transportation in 308 (88.5%) neonates. While no ambulance had an incubator only 7 (2.0%) neonates were kept on a Kangaroo Mother Care position. Monitoring enroute was done to only 94 (27%) of the transferred neonates with 169 (54.9%) of health care professionals escorting the neonates lacking training on essential newborn care. On arrival, 115 (33%) were hypothermic, 74 (21.3%) hypoxic, 30 (8.6%) with poor perfusion and 49 (14.1%) hypoglycemic. Hypothermic neonates had an increased chance of dying compared to those who were normothermic (OR = 2.09, 95% CI (1.05–4.20), p = 0.037). The chance of dying among those presenting with hypoxia was almost three times (OR = 2.88, 95%CI (1.44–5.74), p = 0.003) while those with poor perfusion was almost five times (OR = 4.76, 95%CI (1.80–12.58), p = 0.002). Additionally, neonates who had hyperglycemia (RBG > 8.3mmol/l) on arrival had a higher probability of dying compared to those who were euglycemic [(OR = 3.10, 95% CI (1.19–8.09) p = 0.021]. Overall mortality was 22.4% within 48 hours of admission and risk of dying increased as the presence of poor clinical status added on. Conclusion Neonatal transportation in Dar es Salaam, Tanzania was observed to be challenging. Pre transfer care and monitoring during transportation was inadequate and this contributed to poor clinical status on admission. Hypothermia, hypoglycemia, hyperglycemia, hypoxia and poor perfusion on admission were associated with increased mortality. Effective referral network is needed for improved neonatal health outcomes. Pre referral supportive care, training of health care professionals, transportation with improved monitoring, clear communication protocol and referral documentation should be invested and effectively utilized.


Abstract: Background
Functional referral system including pre referral care, access to emergency transport and ensuring continuity of care between facilities is critical for improved newborn health outcome. This study assessed the admission clinical status, transportation factors and outcomes of referred neonates at Muhimbili National Hospital (MNH), a tertiary facility in Dar es Salaam, Tanzania.

Methods
A descriptive cross sectional study with a longitudinal follow up was conducted from September 2020 to February 2021, including all neonates received at MNH. A structured questionnaire was used to collect demographic characteristics and transport factors were extracted from the referral documents and by interviewing caregivers or escorting person/nurse. Ambulances were directly observed using a structured checklist on presence, absence and functionality of supportive care during transportation. All enrolled neonates had a clinical assessment at admission and 48 hours post admission to determine 48 hours' clinical outcome as either survived/died.

Results
Out of the 348 neonates assessed during the study period, the median gestation age was 38 weeks (IQR 32, 39) with the mean birth weight of 2461 ± 936 g. Pre referral documentation showed that temperature was measured in 176 (57.1%), oxygen saturation and random blood glucose in only 143 (46.6%) and 116 (36.2%) neonates respectively. Ambulance was used as a means of transportation among 308 (88.5%) neonates. While no ambulance had an incubator only 7 (2.0%) neonates were kept on a Kangaroo Mother Care (KMC) position. Monitoring      There is enough evidence to support that the transport by a skilled organized team reduces neonatal 87 morbidity and mortality (6,10,11). The goal of all neonatal transport teams should be transporting 88 a well-stabilized neonate. Pre transport stabilization is crucial; this entails securing the patency of 89 the airway, breathing and circulation. Pre-transport procedures such as establishing an intravenous 90 access should be carried out before arrival of the transport team (12)(13). Continuous monitoring 91 need to be maintained on the way to a higher facility.

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This study aimed at describing the transport characteristics (i.e. mode of transport, equipment, 93 communication, accompanying personnel and monitoring enroute) used for the referred neonates.   conducted at MNH prior to this, and was found to be 35%. A sample size of 349 was achieved 124 using the Kish Leslie formula with 95% confidence level and 5% margin of error.

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Data was collected day and night using a pretested structured questionnaire designed for the study 126 (S1). Data on demographic characteristics of the study participants were obtained from the referral 127 documents and by interviewing the caregiver or escorting personnel/nurse. The accompanying 128 personnel was enquired about the transport process including pre transport care and monitoring 129 during transport. All escorts were asked on whether they received a training on essential newborn  Multiple logistic regressions (odds ratio) was used to determine association with clinical outcome.

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A p-value ≤ 0.05 was considered statistically significant at 95% confidence interval.

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Baseline characteristics of the study participants 156 A total of 349 referred neonates were screened during the study period, one was excluded from 157 the study due to a congenital anomaly which was incompatible with life (anencephaly).       In our study, eighteen percent of the neonates were referred due to lack of a newborn unit in their 226 facilities while almost half of others were referred for specialized medical or surgical care.

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Improving level of care in these referring institutions including establishment of well-equipped 228 neonatal units will reduce a need for transfer. Having a dedicated neonatal transport team is also 229 of paramount importance to ensure smooth transfer for those in need.

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Pre transport stabilization and care is pivotal before transfer to a higher facility. It is generally 231 agreeable that for a quality transport and desirable outcome, stabilization prior to transfer is   prolonged capillary refill time on admission had an overall poor outcome compared to their 266 counterparts (15). This is similar to our study which attested to the same. Additionally, we found 267 a number of neonates who were hyperglycemic, with significant higher odds of mortality. These 268 were the neonates whose blood sugar levels were not monitored and some were given continuous 269 infusion of glucose without any blood glucose check.  Overall, this study demonstrates inadequate pre transport care, documentation and stabilization, 287 plus lack of monitoring enroute contributing to poor conditions of neonates on admission.

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Emphasis has to be placed on having well equipped ambulances dedicated to neonatal 289 transportation. Additionally, ensuring continuous training on health care workers on neonatal 290 resuscitation and essential newborn care is key. Strengthening the referral system network remains 291 a challenge to be tackled.

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The study may have been exposed to recall bias as some of the information relied on the escorting      The % contribution were as follows: Public hospital 89.4% Private hospital 9.2% Home 1.4%

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