Acta Pædiatrica ISSN 0803-5253
REGULAR ARTICLE
Delivery room management of extremely low birthweight infants shows marked geographical variations in Italy Daniele Trevisanuto ([email protected])1, Irene Satariano1, Nicoletta Doglioni1, Giulio Criscoli2, Francesco Cavallin3, Camilla Gizzi4, Claudio Martano5, Fabrizio Ciralli6, Flaminia Torielli7, Paolo E. Villani8, Sandra Di Fabio9, Lorenzo Quartulli10, Luigi Giannini11, On Behalf of Neonatal Resuscitation Study Group, Italian Society of Neonatology 1.Children and Women’s Health Department, Medical School University of Padua Azienda, Padua, Italy 2.Italian Army - Signals and Information Technology HQ - C4 Systems Integration Development, Treviso, Italy 3.Independent Statistician, Padua, Italy 4.Neonatal Intensive Care Unit Pediatric, Neonatal Department ‘S.Giovanni Calibita’, Fatebenefratelli Hospital, Rome, Italy 5.Neonatal Intensive Care Unit, Pediatric Department, Medical School University of Turin, Azienda Ospedaliera OIRM-S, Torino, Italy 6.Neonatal Intensive Care Unit, Department of Mother and Infant Science Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy 7.Neonatology Unit, University of Genova, Azienda Ospedaliera San Martino IRCCS – IST National Institute on Cancer Research, Genova, Italy 8.Neonatal Intensive Care Unit, Maternal and Pediatric Department, Carlo Poma Hospital, Mantova, Italy 9.Neonatal Intensive Care Unit, Department of Mother and Infant Science, ‘San Salvatore’ Hospital, L’Aquila, Italy 10.Neonatology Unit, ‘A. Perrino’ Hospital, Brindisi, Italy 11.Pediatric Department, Medical School University ‘La Sapienza’ Rome Azienda Ospedaliera Policlinico Umberto, Rome, Italy
Keywords Delivery room, Guidelines, Preterm infant, Resuscitation, Survey Correspondence D Trevisanuto, MD, Children and Women’s Health Department, Medical School, University of Padua, Azienda Ospedaliera di Padova, Via Giustiniani, 3 35128 Padua, Italy. Tel: 39 049 8213545 | Fax: 39 049 8213502 | Email: [email protected] Received 21 November 2013; revised 6 February 2014; accepted 20 February 2014. DOI:10.1111/apa.12612
ABSTRACT Aim: To evaluate any geographical variations in practice and adherence to international guidelines for early delivery room management of extremely low birthweight (ELBW) infants in the North, Centre and South of Italy. Methods: A questionnaire was sent to all 107 directors of Italian level III centres between April and August 2012. Results: There was a 92% (n = 98) response rate. A polyethylene bag/wrap was used by 54 centres (55.1%), with the highest rate in Northern Italy (77.5%) and the lowest rate in Southern (37.7%) areas. In Northern regions, one centre (2.5%) said it used oxygen concentrations >40% to initiate positive pressure ventilation in ELBW infants. These proportions were higher in the Central (14.3%) and Southern (16.2%) areas. A T-piece device for positive pressure ventilation was more frequently available in the Northern (95%) units than in those in the Central (66.7%) and Southern (69.4%) regions. A median of 13% (IQR: 5%–30%) of ELBW infants received chest compressions at birth in Italy: 5%, 18% and 22% in Northern, Central and Southern units, respectively. Conclusion: In Italy, delivery room management of ELBW infants showed marked geographical variations. Implementation of national training programmes could increase adherence to the guidelines and reduce such discordance.
INTRODUCTION Approximately 5 to 10% of newborns require some assistance to begin breathing at birth. About 3% are managed with positive pressure ventilation and 40% to initiate resuscitation. Of these 10 centres, five said they used a 100% oxygen concentration. Almost all of these centres belonged to the Central and Southern groups. Most centres had a pulse oxymeter (91/98, 92.9%) available in delivery room and used saturation targets (82/98, 83.7%), with the highest rates in the Northern group (97.5% and 90.0%, respectively) (Table 2). Ventilatory support Data on the approach to ventilation are shown in Table 3. The T-piece device was widely used (77/97, 79.4%), with the highest rates in Northern centres (95.0%). Almost all centres used a facial mask as initial interface for positive pressure ventilation (95/98, 96.9%), with a homogeneous rate among the geographical subgroups (North 97.5%, Centre 95.2%, South 97.3%). The use of positive end expiratory pressure (PEEP) during positive pressure ventilation was reported by 88 centres (89.8%): the highest rate was found in Northern group (95.0%). Initial PEEP showed similar levels among subgroups, whereas median peak inspiratory pressure (PIP) was higher in the Northern group (Table 3). Only three centres (all in the North area) stated that they monitored the delivered tidal volume during positive pressure ventilation. Continuous positive airway pressure (CPAP) was widely used to avoid intubation (85.4%), and similar rates were observed in geographical subgroups (North 85.0%, Centre 82.4%, South 87.5%). The oral route of intubation was chosen by most centres (61.2%), but there was a large difference in geographical subgroups. Northern centres preferred the nasal route
Table 2 Thermal control and oxygenation Geographical area
Participating centres, n DR temperature (°C) DR temperature ≥26°C Use polyethylene bags/wrap Use cap to cover head Initiate resuscitation with FiO2 = 1.0 Initiate resuscitation with FiO2 >0.40 Use pulse oxymeter Use of saturation targets
All
North
Centre
South
98
40
21
37
24 (22–25)
24 (22–25)
23 (22–24)
24 (23–26)
18 (20.2)
7 (20.6)
2 (10.5)
9 (25.0)
54 (55.1)
31 (77.5)
9 (42.9)
14 (37.8)
59 (60.2)
25 (62.5)
14 (66.7)
20 (54.1)
0
2 (9.5)
3 (8.1)
10 (10.2)
1 (2.5)
3 (14.3)
6 (16.2)
91 (92.9)
39 (97.5)
19 (90.5)
33 (89.2)
82 (83.7)
36 (90.0)
17 (81.0)
29 (78.4)
5 (5.1)
DR = Delivery room, FiO2 = Fraction of inspiratory oxygen. Data expressed as n (%) or median (IQR).
(82.5%), whereas Central and Southern centres used the oral route (81.0% and 97.3%, respectively). The percentage of ELBW infants intubated at birth had a median of 60% (IQR: 40%–80%), with the highest values in Central group (median 66%, IQR: 50%–75%). The percentage of ELBW infants receiving only nasal-CPAP at birth had a median of 22% (IQR: 10%–40%), with the highest values in Northern group (median 25%, IQR: 8%–45%). The percentage of ELBW infants managed without any respiratory support at birth had a median of 3% (IQR: 0%–10%), with quite similar values in all subgroups (Table 3). Chest compressions and medications A median of 13% (IQR: 5%–30%) of ELBW infants received chest compressions at birth, mostly in Central (median 18%) and Southern (median 22%) centres. Chest compression techniques are presented in Table 4. Medication was given at birth to 6% of ELBW infants (IQR: 0–17%), and small differences were observed among the subgroups (Table 4).
DISCUSSION This study reflects the early delivery room management of ELBW infants in Italy in relation to the different geographical areas.
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 605–611
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Table 3 Respiratory support
Table 4 Chest compressions, medications and fluid management Geographical area
All Participating 98 centres, n PPV administered through* Self-inflating 20 (20.6) bag T-Piece 77 (79.4) Initial interface for PPV Facial mask 95 (96.9) Endotracheal 3 (3.1) tube Use PEEP 88 (89.8) with PPV PEEP value 5 (4–5) PIP value 18 (17–20) Use CPAP 76 (85.4) to avoid intubation Route of intubation Nasal 38 (38.8) Oral 60 (61.2) 60 (40–80) Percentage of ELBW infants intubated at birth 22 (10–40) Percentage of ELBW infants receiving only nasal-CPAP at birth 3 (0–10) Percentage of ELBW infants managed without any respiratory support
Geographical area
North
Centre
South
40
21
37
2 (5.0)
7 (33.3)
11 (30.6)
38 (95.0)
14 (66.7)
25 (69.4)
39 (97.5) 1 (2.5)
20 (95.2) 1 (4.8)
36 (97.3) 1 (2.7)
38 (95.0)
17 (81.0)
33 (89.2)
5 (5–5) 20 (18–20) 34 (85.0)
5 (4–5) 18 (16–20) 14 (82.4)
4 (4–5) 18 (18–20) 28 (87.5)
33 (82.5) 7 (17.5) 60 (40–82)
4 (19.0) 17 (81.0) 66 (50–75)
1 (2.7) 36 (97.3) 58 (30–75)
North
Centre
South
98
40
21
37
38 (41.3)
17 (50.0)
7 (33.3)
14 (37.8)
31 (33.7)
13 (38.2)
6 (28.6)
12 (32.4)
23 (25.0)
4 (11.8)
8 (38.1)
11 (29.7)
13 (5–30)
5 (0–17)
18 (6–30)
22 (11–38)
6 (0–17)
5 (0–13)
10 (1–16)
7 (0–23)
Data expressed as n (%) or median (IQR). *Data not available in 6 centres. 25 (8–45)
1 (0–10)
22 (5–30)
3 (0–10)
20 (10–45)
4 (0–10)
PPV = Positive pressure ventilation. Data expressed as n (%) or median (IQR). *Data not available in 1 centre.
There were relevant differences among geographical areas in delivery room management of ELBW infants in Italy. Regional differences were also reported for neonatal mortality rates that were 2.5 per 1000 live births in the whole country, 2.1 per 1000 in Northern, 2.3 per 1000 in central and 3.1 per 1000 in Southern areas, respectively (14). Unlikely, national and/or regional data on mortality and morbidity of Italian ELBW infants are not available, but the Italian Neonatal Network reported similar geographical differences in mortality rate of VLBW infants (15). In a previous study, Corchia and Orzalesi showed an important gradient in mortality of VLBW infants between the Northern and Southern Italian regions, with an intermediate position of the Central regions. They stated that ‘the reasons for these disparities are numerous, complex
608
Participating centres, n Chest compressions* Both techniques Two-thumb technique Two-finger (TF) technique Percentage of ELBW infants who received chest compressions at birth Percentage ELBW infants who received medications at birth
All
and partially interrelated among them and include socioeconomic, political-administrative, cultural-historical, organisational-professional aspects’ (11). Our data provide additional evidence that the approach to the care of ELBW infants at birth shows geographical variations. As the delivery room management of ELBW infants may have a direct influence on the immediate survival and also on long-term morbidity (3–6), the results of this study suggest that further efforts are needed to improve this area of care. Previous studies have reported important differences in mortality rates among neonatal units and geographical regions, irrespective of the infant’s characteristics, suggesting variable degrees of effectiveness of medical care (16,17). The strength of this study is the high response rate (92%). In the latest official data in 2009, there were 568,857 births in Italy, and of these, 1% were VLBW infants births (13). Based on these data, it means that about 35% of all births and about 87% of VLBW infant births in Italy occurred in the surveyed centres. Nine centres (six in the South region) did not participate to the survey. As the epidemiological characteristics of these hospitals, such as number of births and ELBW infants admitted each year, were similar to the surveyed centres, we believe that their self-exclusion has not affected the results. In comparison with the Northern and Central units, those in the Southern area had lower patient volumes (births/centre and admitted ELBW infants). However, the relationship between mortality rate and patient volume of NICUs is controversial (18–20).
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 605–611
Italian management of very preterm infants
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In addition to the staff workload, other aspects seem to play an important role in the patients’ outcomes. The American Nurses Credentialing Center developed the Magnet Recognition Program to recognise healthcare organisations for quality patient care, nursing excellence and innovations in professional nursing practice (21,22). A recent study compared VLBW infants born in hospitals that had received a recognition for nursing excellence to those that did not. It showed that there was a significantly lower risk-adjusted rate of seven-day mortality, nosocomial infection and severe intraventricular haemorrhage (23). Unfortunately in this study, we did not monitor the educational profiles of nurses and doctors in depth. This aspect should be a considered in future surveys. Some interventions, such as the use of polyethylene/ polyurethane wrapping (4), titrating inspiratory fraction of oxygen (5) and the use of noninvasive ventilation have been recently evaluated in prospective randomised clinical trials (6). In the latest versions of the International Liaison Committee on Resuscitation, the body of recommendations devoted to neonatal resuscitation of ELBW infants has been progressively increasing (1). These include strategies to prevent thermal losses, oxygen administration and ventilation. Our data show a different adherence to the guidelines in relation to the geographical area with the highest rates in Northern regions and lowest in the Southern areas. For example, the implementation of a simple practice to prevent hypothermia such as the use of polyethylene bag/wrap was limited to 37.8% of the centres in the South, in comparison with 77.5% in the Northern regions. A very similar picture was documented for other important interventions (initial fraction of oxygen, use of pulse oximetry, saturation targets). Furthermore, ventilation through a T-piece was more frequently adopted by the centres in the Northern regions in comparison with those in the Central and Southern areas. The reasons for such discordance could be due to different organisational and educational programmes among the country’s regions. Although the role of continuous medical education is well-recognised, effective training programmes, benchmarking and quality improvement initiatives should be further implemented and monitored. A national neonatal network including all level III Italian hospitals should be also sustained for continuous monitoring and comparison of short and long-term outcomes (15). Increasing delivery room temperature significantly influences the temperature of preterm infants on NICU admission (24,25). Despite the limitations of these studies, their results highlight the importance of aiming for, and achieving, delivery room temperatures that are ≥25°C. World Health Organization Guidelines, updated in 2003, state that environmental temperatures should be ≥25°C (26). Despite this guidance, delivery room temperatures are consistently reported to be lower than this in all healthcare settings (27,28). Also our study showed a low adherence to international guidelines that does not appear to be influenced by geographical area. The reasons that impede a
widespread adoption of higher environmental temperatures (at least 25°C) remain unexplained, but perinatal teams have to consider this to be one of the greatest challenges in improving thermal care for newborn infants. The latest version of guidelines for neonatal resuscitation states that ‘. . . the 2 thumb-encircling hands technique is recommended for performing chest compressions in newly born infants (Class IIb, LOE C)’ (1). About one-third of the units in the Central and Southern regions declared to choose instead the two-finger technique for chest compressions. This not recommended approach was limited to 11.8% of the centres in the Northern area. In addition, the percentages of ELBW infants who received chest compressions at birth were markedly different among the surveyed regions (median: North 5%; Centre 18%; South 22%). In the North American Vermont Oxford Network registry, which collected data on infants with birthweight of 501 to 1500 g, the proportion of those who received chest compressions was about 6% (29). Overall, the results of this study are very similar to those reported in a recent survey conducted in UK. The authors found many areas of good evidence-based delivery room practice, but they identified also significant variation in delivery room resuscitation practices among neonatal services (30). A different approach to chest compressions among geographical areas does not represent the only reason for the differences found in our study. Other factors can play a role, such as the babies’ conditions at birth, which in turn can be connected with obstetrical and other aspects of care. For example, it is interesting to notice that a recent cohort study of the Italian Neonatal Network including VLBW infants from 56 NICUs showed that antenatal care standards (antenatal visits and antenatal steroids administration) were lower in the Southern areas than in the Northern regions (15). There are some limitations to this study. As we only involved the directors of the participating centres, the actual practices of individual providers may not be represented. However, a consistent part of the information obtained in this survey is related to available equipment and intent to use different practices. This study involved only tertiary units, and the approach to delivery room management of ELBW infants can be different in level I and II Italian centres. However, the majority of ELBW infants in Italy were born at tertiary units. The data on ELBW infants who were resuscitated in the centres were retrospectively collected limiting the quality of this information. Unfortunately, our questionnaire did not include questions regarding the survival rates in the surveyed centres. For this reason, we could not correlate the delivery room management with neonatal mortality. However, the North– South difference found in our study mirrors the figure of the mortality rate reported by previous authors for VLBW infants (11,15) and by the National Institute of Statistics for the whole neonatal population (14).
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 605–611
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CONCLUSIONS Our study shows good compliance with the International Guidelines for Neonatal Resuscitation in Italian tertiary Centres. However, there were marked geographical differences in delivery room management of ELBW infants. Consistency of practice and adherence to international guidelines were higher in units located in the North of the country in comparison with those in the Southern regions, with an intermediate position of centres in the Central regions. Although factors contributing to such discordance remain unclear, implementation of national networks for effective training programmes could help to increase the adherence to the guidelines and reduce these geographical variations. Along with political, administrative, financial and organisational efforts, effective educational interventions focused on the practice of neonatal resuscitation have to be supported in the future.
ACKNOWLEDGEMENTS We are grateful to Dr Matteo Parotto for revising the manuscript and the heads of the participating centres for their assistance with this survey.
COMPETING INTERESTS We declare that we have no conflict of interests.
FUNDING No specific funding.
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9. Trevisanuto D, Gizzi C, Martano C, Dal Cengio V, Ciralli F, Torielli F, et al. Neonatal Resuscitation Study Group, Italian Society of Neonatology. Oxygen administration for the resuscitation of term and preterm infants. J Matern Fetal Neonatal Med 2012; 25 Suppl 3: 26–31. 10. Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R, et al. European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants – 2010 Update. Neonatology 2010; 97: 402–17. 11. Corchia C, Orzalesi M. Geographic variations in outcome of very low birth weight infants in Italy. Acta Paediatr 2007; 96: 35–8. nel primo anno di vita e le differenze 12. Corchia C. La mortalita regionali. Quaderni ACP 2006; 13: 58–61. 13. Ministero della Salute. Certificato di assistenza al parto (CeDAP). Analisi dell’evento nascita - Anno 2009. http://www. salute.gov.it/imgs/C_17_pubblicazioni_1731_allegato.pdf (accessed on January 7, 2014) 14. Istat, Decessi: caratteristiche demografiche e sociali - Anno 2009, Tavole di dati, 2 aprile 2012. http://www.istat.it/it/ archivio/58350 (accessed on January 7, 2014). R, Gagliardi L, Mosca F, Zanini R, 15. Ronconi A, Corchia C, Bellu et al. Esiti dei neonati di basso peso nelle Terapie Intensive Neonatali partecipanti all’Italian Neonatal Network nel 2008. . 2011, iii, 74 p. Rapporti ISTISAN Istituto Superiore di Sanita 11/44. 16. de Vonderweid U, Spagnolo A, Corchia C, Chiandotto V, Chiappe S, Chiappe F, et al. Italian multicentre study on very low-birth-weight babies. Neonatal mortality and two-year outcome. Acta Paediatr 1994; 83: 391–6. 17. Horbar JD, Badger GJ, Lewit EM, Rogowski J, Shiono PH. Hospital and patient characteristics associated with variation in 28-day mortality rates for very low birth weight infants. Pediatrics 1997; 99: 149–56. 18. Hamilton KE, Redshaw ME, Tarnow-Mordi W. Nurse staffing in relation to risk adjusted mortality in neonatal care. Arch Dis Child Fetal Neonatal Ed 2007; 92: F99–103. 19. Tucker J. UK Neonatal Staffing Study Group. Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation. Lancet 2002; 359: 99–107. 20. Callaghan LA, Cartwright DW, O’Rourke P, Davies MW. Infant to staff ratios and risk of mortality in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 2003; 88: F94–7. 21. American Nurses Credentialing Center. Magnet recognition program overview. 2011. http://www.nursecredentialing.org/ Magnet/ProgramOverview.aspx (accessed on January 7, 2014). 22. American Nurses Credentialing Center. Application manual: magnet recognition programâ. Silver Spring, MD: American Nurses Credentialing Center, 2011: 142–56. 23. Lake ET, Staiger D, Horbar J, Cheung R, Kenny M, Patrick T, et al. Association between hospital recognition for nursing excellence and outcomes of very low birth weight infants. JAMA 2012; 307: 1709–16. 24. Jia Y-S, Lin Z-L, Lv H, Li Y-M, Green R, Lin J. Effect of delivery room temperature on the admission temperature of premature infants: a randomized controlled trial. J Perinatol 2013; 33: 264–7. 25. Demauro SB, Douglas E, Karp K, Schmidt B, Patel J, Kronberger A, et al. Improving delivery room management for very preterm infants. Pediatrics 2013; 132: e1018–25. 26. World Health Organization. Managing newborn problems: a guide for doctors, nurses and midwives. WHO Library Cataloguing-in-Publication Data; 2003: C1–9.
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27. McCarthy LK, Molloy EJ, Twomey AR, Murphy JF, O’Donnell CP. A randomized trial of exothermic mattresses for preterm newborns in polyethylene bags. Pediatrics 2013; 132: e135–41. 28. Lunze K, Bloom DE, Jamison DT, Hamer DH. The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival. BMC Medicine 2013; 11: 24.
29. Soll RF, Edwards EM, Badger GJ, Kenny MJ, Morrow KA, Buzas JS, et al. Obstetric and neonatal care practices for infants 501 to 1500 g from 2000 to 2009. Pediatrics 2013; 132: 222–8. 30. Mann C, Ward C, Grubb M, Hayes-Gill B, Crowe J, Marlow N, et al. Marked variation in newborn resuscitation practice: A national survey in the UK. Resuscitation 2012; 83: 607–11.
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 605–611
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REGULAR ARTICLE
Delivery room management of extremely low birthweight infants shows marked geographical variations in Italy Daniele Trevisanuto ([email protected])1, Irene Satariano1, Nicoletta Doglioni1, Giulio Criscoli2, Francesco Cavallin3, Camilla Gizzi4, Claudio Martano5, Fabrizio Ciralli6, Flaminia Torielli7, Paolo E. Villani8, Sandra Di Fabio9, Lorenzo Quartulli10, Luigi Giannini11, On Behalf of Neonatal Resuscitation Study Group, Italian Society of Neonatology 1.Children and Women’s Health Department, Medical School University of Padua Azienda, Padua, Italy 2.Italian Army - Signals and Information Technology HQ - C4 Systems Integration Development, Treviso, Italy 3.Independent Statistician, Padua, Italy 4.Neonatal Intensive Care Unit Pediatric, Neonatal Department ‘S.Giovanni Calibita’, Fatebenefratelli Hospital, Rome, Italy 5.Neonatal Intensive Care Unit, Pediatric Department, Medical School University of Turin, Azienda Ospedaliera OIRM-S, Torino, Italy 6.Neonatal Intensive Care Unit, Department of Mother and Infant Science Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy 7.Neonatology Unit, University of Genova, Azienda Ospedaliera San Martino IRCCS – IST National Institute on Cancer Research, Genova, Italy 8.Neonatal Intensive Care Unit, Maternal and Pediatric Department, Carlo Poma Hospital, Mantova, Italy 9.Neonatal Intensive Care Unit, Department of Mother and Infant Science, ‘San Salvatore’ Hospital, L’Aquila, Italy 10.Neonatology Unit, ‘A. Perrino’ Hospital, Brindisi, Italy 11.Pediatric Department, Medical School University ‘La Sapienza’ Rome Azienda Ospedaliera Policlinico Umberto, Rome, Italy
Keywords Delivery room, Guidelines, Preterm infant, Resuscitation, Survey Correspondence D Trevisanuto, MD, Children and Women’s Health Department, Medical School, University of Padua, Azienda Ospedaliera di Padova, Via Giustiniani, 3 35128 Padua, Italy. Tel: 39 049 8213545 | Fax: 39 049 8213502 | Email: [email protected] Received 21 November 2013; revised 6 February 2014; accepted 20 February 2014. DOI:10.1111/apa.12612
ABSTRACT Aim: To evaluate any geographical variations in practice and adherence to international guidelines for early delivery room management of extremely low birthweight (ELBW) infants in the North, Centre and South of Italy. Methods: A questionnaire was sent to all 107 directors of Italian level III centres between April and August 2012. Results: There was a 92% (n = 98) response rate. A polyethylene bag/wrap was used by 54 centres (55.1%), with the highest rate in Northern Italy (77.5%) and the lowest rate in Southern (37.7%) areas. In Northern regions, one centre (2.5%) said it used oxygen concentrations >40% to initiate positive pressure ventilation in ELBW infants. These proportions were higher in the Central (14.3%) and Southern (16.2%) areas. A T-piece device for positive pressure ventilation was more frequently available in the Northern (95%) units than in those in the Central (66.7%) and Southern (69.4%) regions. A median of 13% (IQR: 5%–30%) of ELBW infants received chest compressions at birth in Italy: 5%, 18% and 22% in Northern, Central and Southern units, respectively. Conclusion: In Italy, delivery room management of ELBW infants showed marked geographical variations. Implementation of national training programmes could increase adherence to the guidelines and reduce such discordance.
INTRODUCTION Approximately 5 to 10% of newborns require some assistance to begin breathing at birth. About 3% are managed with positive pressure ventilation and 40% to initiate resuscitation. Of these 10 centres, five said they used a 100% oxygen concentration. Almost all of these centres belonged to the Central and Southern groups. Most centres had a pulse oxymeter (91/98, 92.9%) available in delivery room and used saturation targets (82/98, 83.7%), with the highest rates in the Northern group (97.5% and 90.0%, respectively) (Table 2). Ventilatory support Data on the approach to ventilation are shown in Table 3. The T-piece device was widely used (77/97, 79.4%), with the highest rates in Northern centres (95.0%). Almost all centres used a facial mask as initial interface for positive pressure ventilation (95/98, 96.9%), with a homogeneous rate among the geographical subgroups (North 97.5%, Centre 95.2%, South 97.3%). The use of positive end expiratory pressure (PEEP) during positive pressure ventilation was reported by 88 centres (89.8%): the highest rate was found in Northern group (95.0%). Initial PEEP showed similar levels among subgroups, whereas median peak inspiratory pressure (PIP) was higher in the Northern group (Table 3). Only three centres (all in the North area) stated that they monitored the delivered tidal volume during positive pressure ventilation. Continuous positive airway pressure (CPAP) was widely used to avoid intubation (85.4%), and similar rates were observed in geographical subgroups (North 85.0%, Centre 82.4%, South 87.5%). The oral route of intubation was chosen by most centres (61.2%), but there was a large difference in geographical subgroups. Northern centres preferred the nasal route
Table 2 Thermal control and oxygenation Geographical area
Participating centres, n DR temperature (°C) DR temperature ≥26°C Use polyethylene bags/wrap Use cap to cover head Initiate resuscitation with FiO2 = 1.0 Initiate resuscitation with FiO2 >0.40 Use pulse oxymeter Use of saturation targets
All
North
Centre
South
98
40
21
37
24 (22–25)
24 (22–25)
23 (22–24)
24 (23–26)
18 (20.2)
7 (20.6)
2 (10.5)
9 (25.0)
54 (55.1)
31 (77.5)
9 (42.9)
14 (37.8)
59 (60.2)
25 (62.5)
14 (66.7)
20 (54.1)
0
2 (9.5)
3 (8.1)
10 (10.2)
1 (2.5)
3 (14.3)
6 (16.2)
91 (92.9)
39 (97.5)
19 (90.5)
33 (89.2)
82 (83.7)
36 (90.0)
17 (81.0)
29 (78.4)
5 (5.1)
DR = Delivery room, FiO2 = Fraction of inspiratory oxygen. Data expressed as n (%) or median (IQR).
(82.5%), whereas Central and Southern centres used the oral route (81.0% and 97.3%, respectively). The percentage of ELBW infants intubated at birth had a median of 60% (IQR: 40%–80%), with the highest values in Central group (median 66%, IQR: 50%–75%). The percentage of ELBW infants receiving only nasal-CPAP at birth had a median of 22% (IQR: 10%–40%), with the highest values in Northern group (median 25%, IQR: 8%–45%). The percentage of ELBW infants managed without any respiratory support at birth had a median of 3% (IQR: 0%–10%), with quite similar values in all subgroups (Table 3). Chest compressions and medications A median of 13% (IQR: 5%–30%) of ELBW infants received chest compressions at birth, mostly in Central (median 18%) and Southern (median 22%) centres. Chest compression techniques are presented in Table 4. Medication was given at birth to 6% of ELBW infants (IQR: 0–17%), and small differences were observed among the subgroups (Table 4).
DISCUSSION This study reflects the early delivery room management of ELBW infants in Italy in relation to the different geographical areas.
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Table 3 Respiratory support
Table 4 Chest compressions, medications and fluid management Geographical area
All Participating 98 centres, n PPV administered through* Self-inflating 20 (20.6) bag T-Piece 77 (79.4) Initial interface for PPV Facial mask 95 (96.9) Endotracheal 3 (3.1) tube Use PEEP 88 (89.8) with PPV PEEP value 5 (4–5) PIP value 18 (17–20) Use CPAP 76 (85.4) to avoid intubation Route of intubation Nasal 38 (38.8) Oral 60 (61.2) 60 (40–80) Percentage of ELBW infants intubated at birth 22 (10–40) Percentage of ELBW infants receiving only nasal-CPAP at birth 3 (0–10) Percentage of ELBW infants managed without any respiratory support
Geographical area
North
Centre
South
40
21
37
2 (5.0)
7 (33.3)
11 (30.6)
38 (95.0)
14 (66.7)
25 (69.4)
39 (97.5) 1 (2.5)
20 (95.2) 1 (4.8)
36 (97.3) 1 (2.7)
38 (95.0)
17 (81.0)
33 (89.2)
5 (5–5) 20 (18–20) 34 (85.0)
5 (4–5) 18 (16–20) 14 (82.4)
4 (4–5) 18 (18–20) 28 (87.5)
33 (82.5) 7 (17.5) 60 (40–82)
4 (19.0) 17 (81.0) 66 (50–75)
1 (2.7) 36 (97.3) 58 (30–75)
North
Centre
South
98
40
21
37
38 (41.3)
17 (50.0)
7 (33.3)
14 (37.8)
31 (33.7)
13 (38.2)
6 (28.6)
12 (32.4)
23 (25.0)
4 (11.8)
8 (38.1)
11 (29.7)
13 (5–30)
5 (0–17)
18 (6–30)
22 (11–38)
6 (0–17)
5 (0–13)
10 (1–16)
7 (0–23)
Data expressed as n (%) or median (IQR). *Data not available in 6 centres. 25 (8–45)
1 (0–10)
22 (5–30)
3 (0–10)
20 (10–45)
4 (0–10)
PPV = Positive pressure ventilation. Data expressed as n (%) or median (IQR). *Data not available in 1 centre.
There were relevant differences among geographical areas in delivery room management of ELBW infants in Italy. Regional differences were also reported for neonatal mortality rates that were 2.5 per 1000 live births in the whole country, 2.1 per 1000 in Northern, 2.3 per 1000 in central and 3.1 per 1000 in Southern areas, respectively (14). Unlikely, national and/or regional data on mortality and morbidity of Italian ELBW infants are not available, but the Italian Neonatal Network reported similar geographical differences in mortality rate of VLBW infants (15). In a previous study, Corchia and Orzalesi showed an important gradient in mortality of VLBW infants between the Northern and Southern Italian regions, with an intermediate position of the Central regions. They stated that ‘the reasons for these disparities are numerous, complex
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Participating centres, n Chest compressions* Both techniques Two-thumb technique Two-finger (TF) technique Percentage of ELBW infants who received chest compressions at birth Percentage ELBW infants who received medications at birth
All
and partially interrelated among them and include socioeconomic, political-administrative, cultural-historical, organisational-professional aspects’ (11). Our data provide additional evidence that the approach to the care of ELBW infants at birth shows geographical variations. As the delivery room management of ELBW infants may have a direct influence on the immediate survival and also on long-term morbidity (3–6), the results of this study suggest that further efforts are needed to improve this area of care. Previous studies have reported important differences in mortality rates among neonatal units and geographical regions, irrespective of the infant’s characteristics, suggesting variable degrees of effectiveness of medical care (16,17). The strength of this study is the high response rate (92%). In the latest official data in 2009, there were 568,857 births in Italy, and of these, 1% were VLBW infants births (13). Based on these data, it means that about 35% of all births and about 87% of VLBW infant births in Italy occurred in the surveyed centres. Nine centres (six in the South region) did not participate to the survey. As the epidemiological characteristics of these hospitals, such as number of births and ELBW infants admitted each year, were similar to the surveyed centres, we believe that their self-exclusion has not affected the results. In comparison with the Northern and Central units, those in the Southern area had lower patient volumes (births/centre and admitted ELBW infants). However, the relationship between mortality rate and patient volume of NICUs is controversial (18–20).
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In addition to the staff workload, other aspects seem to play an important role in the patients’ outcomes. The American Nurses Credentialing Center developed the Magnet Recognition Program to recognise healthcare organisations for quality patient care, nursing excellence and innovations in professional nursing practice (21,22). A recent study compared VLBW infants born in hospitals that had received a recognition for nursing excellence to those that did not. It showed that there was a significantly lower risk-adjusted rate of seven-day mortality, nosocomial infection and severe intraventricular haemorrhage (23). Unfortunately in this study, we did not monitor the educational profiles of nurses and doctors in depth. This aspect should be a considered in future surveys. Some interventions, such as the use of polyethylene/ polyurethane wrapping (4), titrating inspiratory fraction of oxygen (5) and the use of noninvasive ventilation have been recently evaluated in prospective randomised clinical trials (6). In the latest versions of the International Liaison Committee on Resuscitation, the body of recommendations devoted to neonatal resuscitation of ELBW infants has been progressively increasing (1). These include strategies to prevent thermal losses, oxygen administration and ventilation. Our data show a different adherence to the guidelines in relation to the geographical area with the highest rates in Northern regions and lowest in the Southern areas. For example, the implementation of a simple practice to prevent hypothermia such as the use of polyethylene bag/wrap was limited to 37.8% of the centres in the South, in comparison with 77.5% in the Northern regions. A very similar picture was documented for other important interventions (initial fraction of oxygen, use of pulse oximetry, saturation targets). Furthermore, ventilation through a T-piece was more frequently adopted by the centres in the Northern regions in comparison with those in the Central and Southern areas. The reasons for such discordance could be due to different organisational and educational programmes among the country’s regions. Although the role of continuous medical education is well-recognised, effective training programmes, benchmarking and quality improvement initiatives should be further implemented and monitored. A national neonatal network including all level III Italian hospitals should be also sustained for continuous monitoring and comparison of short and long-term outcomes (15). Increasing delivery room temperature significantly influences the temperature of preterm infants on NICU admission (24,25). Despite the limitations of these studies, their results highlight the importance of aiming for, and achieving, delivery room temperatures that are ≥25°C. World Health Organization Guidelines, updated in 2003, state that environmental temperatures should be ≥25°C (26). Despite this guidance, delivery room temperatures are consistently reported to be lower than this in all healthcare settings (27,28). Also our study showed a low adherence to international guidelines that does not appear to be influenced by geographical area. The reasons that impede a
widespread adoption of higher environmental temperatures (at least 25°C) remain unexplained, but perinatal teams have to consider this to be one of the greatest challenges in improving thermal care for newborn infants. The latest version of guidelines for neonatal resuscitation states that ‘. . . the 2 thumb-encircling hands technique is recommended for performing chest compressions in newly born infants (Class IIb, LOE C)’ (1). About one-third of the units in the Central and Southern regions declared to choose instead the two-finger technique for chest compressions. This not recommended approach was limited to 11.8% of the centres in the Northern area. In addition, the percentages of ELBW infants who received chest compressions at birth were markedly different among the surveyed regions (median: North 5%; Centre 18%; South 22%). In the North American Vermont Oxford Network registry, which collected data on infants with birthweight of 501 to 1500 g, the proportion of those who received chest compressions was about 6% (29). Overall, the results of this study are very similar to those reported in a recent survey conducted in UK. The authors found many areas of good evidence-based delivery room practice, but they identified also significant variation in delivery room resuscitation practices among neonatal services (30). A different approach to chest compressions among geographical areas does not represent the only reason for the differences found in our study. Other factors can play a role, such as the babies’ conditions at birth, which in turn can be connected with obstetrical and other aspects of care. For example, it is interesting to notice that a recent cohort study of the Italian Neonatal Network including VLBW infants from 56 NICUs showed that antenatal care standards (antenatal visits and antenatal steroids administration) were lower in the Southern areas than in the Northern regions (15). There are some limitations to this study. As we only involved the directors of the participating centres, the actual practices of individual providers may not be represented. However, a consistent part of the information obtained in this survey is related to available equipment and intent to use different practices. This study involved only tertiary units, and the approach to delivery room management of ELBW infants can be different in level I and II Italian centres. However, the majority of ELBW infants in Italy were born at tertiary units. The data on ELBW infants who were resuscitated in the centres were retrospectively collected limiting the quality of this information. Unfortunately, our questionnaire did not include questions regarding the survival rates in the surveyed centres. For this reason, we could not correlate the delivery room management with neonatal mortality. However, the North– South difference found in our study mirrors the figure of the mortality rate reported by previous authors for VLBW infants (11,15) and by the National Institute of Statistics for the whole neonatal population (14).
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CONCLUSIONS Our study shows good compliance with the International Guidelines for Neonatal Resuscitation in Italian tertiary Centres. However, there were marked geographical differences in delivery room management of ELBW infants. Consistency of practice and adherence to international guidelines were higher in units located in the North of the country in comparison with those in the Southern regions, with an intermediate position of centres in the Central regions. Although factors contributing to such discordance remain unclear, implementation of national networks for effective training programmes could help to increase the adherence to the guidelines and reduce these geographical variations. Along with political, administrative, financial and organisational efforts, effective educational interventions focused on the practice of neonatal resuscitation have to be supported in the future.
ACKNOWLEDGEMENTS We are grateful to Dr Matteo Parotto for revising the manuscript and the heads of the participating centres for their assistance with this survey.
COMPETING INTERESTS We declare that we have no conflict of interests.
FUNDING No specific funding.
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