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Pediatrics and Neonatology (2014) xx, 1e6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.pediatr-neonatol.com
ORIGINAL ARTICLE
Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan Ya-Lei Wang a,b, Suh-Fang Jeng c, Po-Nien Tsao a, Hung-Chieh Chou a, Chien-Yi Chen a, Wu-Shiun Hsieh a,* a Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan b Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan c School and Graduate Institute of Physical Therapy, National Taiwan University College of Medicine, Taipei, Taiwan
Received Apr 16, 2014; received in revised form Jul 17, 2014; accepted Oct 8, 2014
Key Words neonatal intensive care unit; operating room; operation
Background: Most neonates who reside in the neonatal intensive care unit (NICU) and require surgery are transferred to the operating room (OR) or undergo bedside surgery. However, critically ill neonates who are transferred often encounter the risk of complications. An OR in our NICU was therefore launched in 2009. This study was to appraise the surgeries performed in the NICU OR and compare results with the traditional main OR outside the NICU. Methods: This was a retrospective study in the NICU of a tertiary center. Retrospective chart review was conducted for all neonates who underwent surgical procedures in the NICU OR and the main OR. The information regarding baseline characteristics, surgical procedures and duration, ventilator use, hypothermia, hyperglycemia, instrument dislocations, surgically related infection or complications, and outcomes was obtained. Results: There were a total of 65 patients in this study, 37 in the NCIU OR group and 28 in the main OR group. The presurgical mean airway pressure and the fraction of inspired oxygen (FiO2) were comparable between the two groups, but the postsurgical FiO2 was significantly lower in the NICU OR group (31.0%) than in the main OR group (40.9%; p Z 0.027). Furthermore, the NICU OR group required a significantly shorter preoperation waiting time (34.4 minutes vs. 63.6 minutes, p Z 0.001) and had a lower incidence of hypothermia than the main OR group (8.1% vs. 39.3%, p Z 0.008). However, surgically related complications were similar between groups.
* Corresponding author. Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Number 7, Chung San South Road, Taipei, Taiwan. E-mail address: [email protected] (W.-S. Hsieh). http://dx.doi.org/10.1016/j.pedneo.2014.10.003 1875-9572/Copyright ª 2014, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Wang Y-L, et al., Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan, Pediatrics and Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2014.10.003
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Y.-L. Wang et al Conclusion: The OR within the NICU may reduce the risk of complications during transportation and provide continuity of care to critically ill neonates. It also decreases the disturbance to other NICU patients during operation. Copyright ª 2014, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
high-frequency oscillatory ventilation, inhaled nitric oxide therapy, and even extracorporeal membrane oxygenation (ECMO).8,9 Furthermore, performing the surgery in the NICU provides continuity of care by the same intensive care team.7 However, there are doubts about increasing the risk of infection when performing bedside surgery.10,11 To solve this problem, we opened an operating room in our NICU (NICU OR) in 2009. The aim of this study was to compare the benefits and risks of performing surgery on critically ill newborns in the OR within the NICU with those of conducting surgery outside the NICU.
1. Introduction Critically ill neonates in the neonatal intensive care unit (NICU) often require surgical procedures. Neonates in need of surgery are traditionally transferred to the main operation room outside the NICU. However, transferring the critically ill neonates to the OR outside the NICU risks complications. In critical patients, previous studies have shown that clinical complications may occur in up to 70% of intrahospital transports.1e4 The possible events include hypothermia, change in variations in heart rate and blood pressure, and dislocation of vascular accesses or endotracheal tubes.2,5 The incidence of complications may relate to the duration of transportation and the severity of the patients’ symptoms.2,4,5 For example, Vieira et al5 demonstrated that in intrahospital NICU transports, hypothermia events developed in up to 17% of patients, and these hypothermia events were associated with prolonged transports.5 To avoid the adverse events during transportation, some surgical procedures, such as patent ductus arteriosus (PDA) ligation, are done at the NICU bedside, with similar results to those done in the main OR.6,7 Surgery at the NICU bedside avoids the accident during transport, especially for critical and unstable neonates who are in use of
2. Methods There are 25 beds in the NICU in the National Taiwan University Hospital, Taipei, Taiwan. The OR is located in the central area of the ward (Figure 1). The room area in the NCIU OR is 25 m2, which is similar to the main OR (15e25 m2). The NICU OR has a laminar air flow system with 15 fresh filtered air changes per hour, which is similar to that of the main OR of our hospital. Prior to surgery, the patient was transferred directly from his/her bed to the NICU OR with an overhead radiant warmer. The theater staff brought equipment to the NICU OR. The surgical team consisted of surgeons, a neonatologist, an anesthetist, an
Gas Room
Main Door
Lounge Staff Room Storehouse Elevator
Ward-01
Operating Room
Soiled Linens Room
Station Ward-02
Isolation Ward
Staff Room
Ward-06
Ward-05
Figure 1
Ward-04
Nursing Room
Ward-03
Floor plan of the NICU in NTUH.
Please cite this article in press as: Wang Y-L, et al., Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan, Pediatrics and Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2014.10.003
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Operating room within the neonatal intensive care unit anesthesia nurse, a scrub nurse, and a circulating nurse. Continued monitoring was provided during the surgery. The neonatologist attended the surgery for adjustment of the ventilator. After the surgery was performed, the primary care nurse and pediatrician looked after the neonate. The patient then stayed in the NICU OR until physiologically stable, and then the patient was transferred back to his/ her bedside. Regular activity in the NICU was not disturbed during the surgery. A retrospective chart review was undertaken for all neonates undergoing surgical procedures in the NICU OR from February 2009 to April 2011. The interim analysis of these data showed that the majority of the patients required PDA ligation or repair of congenital diaphragmatic hernia (CDH; Table 1). Thus, the data of those undergoing PDA ligation or CDH repair in the NICU OR were selected as the NICU OR group. Historical comparison was made by retrospective collection of the medical data of residents in our NICU who received PDA ligation or CDH repair in the main OR outside the NICU from 2001 to 2011, as the main OR group. The following data were collected from the medical chart: sex, gestational age, birth weight, age at the time of surgery, surgical procedures and duration, preoperation waiting time from on call to the commencement of the operation (defined as the time for transfer and preoperative preparation), ventilator information, hypothermia, hyperglycemia, instrument dislocations, incidence of surgically related infection, complications, and outcome. The mean airway pressure (MAP) and the fraction of inspired oxygen (FiO2) were used to measure respiratory support. Hypothermia was defined as temperature < 35.5 C, and hyperglycemia was defined as blood sugar > 200 mg/dL. Surgically related infection was recorded as culture-proved wound or surgical drainage sites infection within 1 week of surgery. Statistical analyses were performed using the SPSS version 12.0 (SPSS Inc., Chicago, IL, USA). Means were calculated for baseline demographic characteristics, FiO2, MAP, temperature, and duration. Frequencies were calculated for the rate of hypothermia, hyperglycemia, and other complications. The comparisons between the NICU OR group and main OR group were performed by Wilcoxon rank sum test for continuous variables, and Chi-square test
Table 1 Procedures and surgical duration performed in the Neonatal Intensive Care Unit operating room. Surgical procedure Bronchopleural fistula repair Congenital diaphragm hernia repair Bowel resection PDA ligation Exploratory thoracotomy Total PDA Z patent ductus arteriosus.
Number
Surgical duration (min)
1
130
9
140 (80e165)
1 28 1 39
155 46 (15e100) 90 59
3 for categorical variables. A p value 0.05 was considered to be statistically significant for all analyses.
3. Results There were 37 patients in the NCIU OR group, and 28 patients in the main OR group. In the NICU OR group, 28 patients received PDA ligation and nine patients received CDH repair, whereas in the main OR group, 12 patients received PDA ligation and 16 patients received CDH repair. We compared the two groups with respect to birth weight, gestational age, age at the time of operation, and preoperative FiO2 and MAP in an effort to compare the baseline characteristics and severity prior to the operation. The comparison of the baseline characteristics in these two groups is listed in Table 2. The mean gestational age and birth weight for the NICU OR group were 30.5 4.5 weeks (range 25e39 weeks) and 1387 759 g (range 590e3335g), respectively; the mean gestational age and birth weight for the main OR group were 35.2 3.0 weeks (range 29e40 weeks) and 2512 745 g (range 1160e3906 g), respectively. The postnatal age of operation was 13.1 9.9 days in the NICU OR group and 11.8 11.4 days in the main OR group. Prior to the surgery, the percentage of patients requiring mechanical ventilation showed no significant difference (81.1% in the NICU OR group vs. 53.5% in the main OR group, p Z 0.307). The baseline mean FiO2 and the mean MAP in the NICU OR group were 30.2% and 8.85 cmH2O, respectively, whereas in the main OR group they were 27.4% (p Z 0.735) and 8.39 cmH2O (p Z 0.654), respectively. The preoperative body temperature was 36.8 C and 36.9 C in the NICU OR and the main OR group (p Z 0.929), respectively (Table 3). Table 3 demonstrates the postoperative characteristics and surgically related events in both groups. The preoperation waiting time was significantly shorter in the NICU OR group than in the main OR group (34.4 minutes vs. 63.6 minutes, p < 0.001). The duration of surgery in the main OR group was longer than the NICU OR group (101.1 minutes in the main OR group versus 70.4 minutes in the NICU OR group, p Z 0.001). However, the subgroup analysis of the duration of surgery according to different procedures showed no significant difference. For PDA ligation, the mean operating duration was 64.4 minutes in the main OR group versus 48.0 minutes in the NICU OR group. For CDH repair, the mean operating duration was 140 minutes in the NICU OR group versus 129 minutes in the main OR group. The difference of the operation duration might come from a greater proportion of patients receiving PDA ligation in the NICU OR group, because PDA ligation generally takes less time than the CDH repair procedure. Although the body temperature prior to the operation was similar in the two groups, the lowest body temperature during the operation and transfer was significantly different (36.2 C in the NICU OR group versus 35.2 C in the main OR group, p < 0.001). Three patients (8.1%) in the NICU OR showed hypothermia during the operation and transfer, whereas 11 patients (39.3%) had hypothermia in the main OR group (p Z 0.008). The presurgical MAP and FiO2 were not significantly different between groups, but the
Please cite this article in press as: Wang Y-L, et al., Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan, Pediatrics and Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2014.10.003
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Y.-L. Wang et al Table 2 Demographic characteristics among infants who received PDA ligation and CDH repair in the Neonatal Intensive Care Unit operating room (NICU OR) group versus the main operating room (OR) group. NICU OR
Male Female Gestational age (wk) Birth weight (gm) Age of operation (d)
Main OR
PDA
CDH
PDA
CDH
N Z 28
NZ9
N Z 12
N Z 16
54 46 28.7 3.3 1070 472 16.3 9.1
67 33 36.1 2.8 2375 628 2.9 2.5
50 50 33.0 2.0 1939 636 23.6 7.1
56 44 36.9 2.5 2941 494 3.0 1.5
Data are presented as % or mean standard deviation. CDH Z congenital diaphragmatic hernia; PDA, Z patent ductus arteriosus.
postsurgical FiO2 was significantly different (31.0% in the NICU OR group vs. 40.9% in the main OR group, p Z 0.027). For the surgically related events, the hyperglycemia incidence was higher in the main OR group than in the NICU OR group (29.7% vs. 42.9%, p Z 0.311). In the NICU OR group, there were no cases with endotracheal tube or vascular lines dislocation during transportation. However, two episodes of endotracheal dislocation occurred when the patients were transported to the main OR. For the surgically related infection, one infant undergoing surgery for PDA in the NICU OR had chest tube wound infection by Methicillin-resistant Staphylococcus aureus. By contrast, four cases had wound infection or abscess, and one infant had Streptococcus mitis bacteremia after the operation in the main OR group. The rate of surgically related wound infection was comparable between groups.
Table 3 Preoperative and postoperative characteristics and surgical related events among infants who received PDA ligation and CDH repair in the Neonatal Intensive Care Unit operating room (NICU OR) group versus the main operating room (OR) group.
Pre-OP ventilator use FiO2 pre-OP FiO2 post-OP MAP pre-OP (cmH2O) MAP post-OP (cmH2O) Waiting time (min) OP duration (min) BT pre-OP ( C) Lowest BT ( C) Hypothermia IVF during OP (mL/kg/h) Hyperglycemia ET dislocation Surgical related infection
NICU OR (n Z 37)
Main OR (n Z 28)
p
30 (81.1) 30.2 31.0 8.85 9.43 34.4 70.4 36.8 36.2 3 (8.1) 11.6 11 (29.7) 0 (0) 1 (2.7)
16 (53.5) 27.4 40.9 8.39 8.83 63.6 101.1 36.9 35.2 11 (39.3) 18.8 12 (42.9) 1 (3.5) 4 (14.3)
0.307 0.735 0.027 0.654 0.594 0.001 0.001 0.929 0.001 0.008 0.067 0.311 0.422 0.104
Data are presented as n (%), unless otherwise indicated. BT Z body temperature; CDH Z congenital diaphragmatic hernia; ET Z endotracheal tube; IVF Z intravenous fluid; MAP Z main airway pressure; OP Z operation; PDA Z patent ductus arteriosus.
Mortality rate was higher for neonates operated in the NICU OR that including three extremely low birth weight preterm infants. One female infant with a birth weight of 735 g underwent CDH repair and died 129 days after surgery due to massive intracranial hemorrhage after several days of ECMO support. The second was a male preterm infant with a birth weight of 850 g who underwent PDA ligation at the age of 22 days. He died 150 days after surgery due to bowel perforation. The third was a female preterm infant with a birth weight of 616 g who underwent PDA ligation at the age of 21 days and died due to chronic lung disease 133 days after surgery.
4. Discussion In most hospitals, neonates are transported to the OR outside the NICU for surgery. Those neonates who are transported for surgery may encounter an increased risk of complications.5 Despite improvements in intrahospital transportation equipment and experience, significant risks still exist.4 Previous studies discussed mishaps during transport of ill patients. Most patients may have change in at least one physiologic variable during transportation, such as hypothermia, or changes in heart rate, blood pressure, or respiratory rate. Equipment-related mishaps are also not uncommon.2 Preterm infants frequently experience respiratory compromise and require additional respiratory support.12 Such patients with mechanical ventilators or required high ventilator settings are at an increased risk of transportation-related adverse events.13 Furthermore, the duration of transport was associated with equipmentrelated events.2 Complications during transport may aggravate the clinical status of ill neonates; however, many events are potentially preventable.14,15 There are guidelines for the transfer of critically ill patients that emphasize a comprehensive and effective interfacility transfer plan.16 The transfer plan should comprise the coordination and communication of a multidisciplinary team, the assessment of the facility including the transport personnel and equipment, and the continuous quality improvement process to refine the plan. Although the guideline is not designed for neonates, the principle can also be applied to the intrahospital transfer of NICU patients. In our unit, no matter where the surgeries are to be carried out, the
Please cite this article in press as: Wang Y-L, et al., Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan, Pediatrics and Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2014.10.003
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Operating room within the neonatal intensive care unit surgeon and the anesthesiologist visit the patient before the surgical procedure is performed. The neonatologist may discuss the specific condition of the patient with the surgeon and the anesthesiologist. After the surgical time is booked, the neonatologist and the NICU nurses make preparations for the proper vascular accesses, elective intubation, and equipment for transfer. Prior to and after the surgery, the NICU nurses and the surgical nurses will communicate to each other detailed information about the patient. If the surgery is performed in the NICU OR, the neonatologist will attend throughout the surgery. In addition, some studies provided suggestions to improve safety for transportation in pediatric or neonatal population. For example, good pretransport planning, transport team training, and use of checklists may reduce transportation-related mishaps.17e19 Transport conducted by specialized pediatric staff is also suggested to reduce the related risk.20,21 However, it often takes three or more staff for transportation to and from the main OR. Time taken and personnel costs would be increased by the long duration of transportations.22 Thus, for the critically ill neonates, avoiding transportation of long duration is a cornerstone of safety. There are numerous studies about the bedside operation in the NICU.23 However, no study has focused on an operating room within the NICU. In our study, we compared the transportation and surgically related events between the main OR and NICU OR. The NICU OR group infants in this study were much smaller and more immature than the infants in the main OR group. Furthermore, these two groups were from different cohorts. However, the data still demonstrate some essential differences. The significantly shorter waiting time prior to surgery in the NICU OR group reflects the shorter journey of transportation. This also suggests that the number of staff and time spent for transportation can be reduced. The incidence of hypothermia after transportation was significantly lower in the NICU OR group than in the main OR group. This indicates that the heat loss during transportation could be reduced. In the NICU OR, we kept the room temperature in the range of 24e26oC during the operation, whereas the room temperature was approximately 23e25oC in the main OR. There is a slight difference of the setting of room temperature at these two sites. This might be a factor for the lower hypothermia rate in the NICU OR group. The literature has demonstrated many complications that are encountered during transportation. In our study, we compared the rate of instrument dislocations during transportation. There was no case of intravenous line or arterial line dislocation in the two groups. However, two episodes of endotracheal dislocation occurred when the patient was being transported to the main OR, whereas no case showed endotracheal tube dislocation in the NICU OR group. We consider the endotracheal tube dislocation as a major adverse event that could cause harm to the patient. Thus, even though the difference does not reach statistical significance, it should be emphasized. Other than the shorter transportation distance and the lower risk of associate complication, surgery in the NICU provided additional benefits. One example is the continuity of care.24 The neonatologist attended during the surgery
5 with the cooperation of the anesthetist to adjust the ventilation setting. According to our data, the preoperation ventilation settings were not significantly different; however, the postoperation FiO2 was significantly higher in the main OR group. This finding was not discussed in previous literature. According to our experience, the attention of the neonatologist in the operation can avoid the inappropriate goal of high saturation during and after the operation. The average intravenous fluid given during the operation was also slightly more in the main OR group, and the incidence of hyperglycemia was also higher in this group. Nosocomial infection could further deteriorate the critically ill neonate.25,26 The infection rates are particularly high for neonates with mechanical ventilation or central venous catheter, such as in our study population. Some literature claimed that the rate of surgical infection is slightly higher when patients underwent bedside surgery in the NICU.11 In our study, surgery in the NICU OR, which had similar settings as the main OR, did not increase the rate of surgical infection. The surgical duration after adjustment to the procedure was the same in the NICU OR and the main OR. The mortality rate in the NICU OR group was higher than the main OR group. However, the NICU OR group infants were much smaller and more immature than those of the main OR group. There were three mortality cases in the NICU OR group. However, these deaths were not related to the surgery itself but to the severity of the underlying diseases: one patient died due to severe CDH with ECMO complication long after surgery and the others due to longterm complications of extreme prematurity. There are limitations of this study, such as small sample size, retrospective design, and the different baseline characteristics including gestational age and birth weight in the two groups. However, since the construction of our NICU OR, nearly all suitable operating procedures have been undertaken at the NICU OR. A prospective, randomized design may entail ethical issues and may not collect the comparable procedures between the main OR and the NICU OR groups. In the future, more surgical procedures may be performed in the NICU OR. The complexity of the diverse surgical procedures is a challenge to NICU and the surgical teams. The formal and comprehensive perioperative plan including a checklist will be amended. Simulation practice for transportation may also be introduced. For better infection control, the aims are to decrease unnecessary traffic into the OR during surgery, to separate the cleaning schedule for the OR, and to avoid unnecessary equipment in the OR.27,28 Many previous studies demonstrated that it was safe for some surgical procedures to take place at the bedside in the NICU. However, bedside surgery may disturb nearby patients and also increase the risk of infection.11,29 In our observation, the surgery in the NICU OR brought fewer disturbances to other NICU patients in comparison with bedside surgery. We further designed an independent space that was similar to the main OR. This may prevent some possible surgical infection and also provide sufficient space for the surgical team. Our study showed that this setting is safe and convenient for critically ill neonates. The NICU OR
Please cite this article in press as: Wang Y-L, et al., Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan, Pediatrics and Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2014.10.003
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6 is currently only for selected procedures such as PDA ligation and CDH repair or bowel perforation. We will attempt other procedures in cooperation with the surgical and anesthesia teams in future.
Conflicts of interest The authors declare that they have no financial or nonfinancial conflicts of interest related to the subject matter or materials discussed in the manuscript.
References 1. Szem JW, Hydo LJ, Fischer E, Kapur S, Klemperer J, Barie PS. High-risk intrahospital transport of critically ill patients: safety and outcome of the necessary “road trip”. Crit Care Med 1995; 23:1660e6. 2. Wallen E, Venkataraman ST, Grosso MJ, Kiene K, Orr RA. Intrahospital transport of critically ill pediatric patients. Crit Care Med 1995;23:1588e95. 3. Schwebel C, Clec’h C, Magne S, Minet C, Garrouste-Orgeas M, Bonadona A, et al. Safety of intrahospital transport in ventilated critically ill patients: a multicenter cohort study. Crit Care Med 2013;41:1919e28. 4. Waydhas C. Intrahospital transport of critically ill patients. Crit Care 1999;3:R83e9. 5. Vieira AL, dos Santos AM, Okuyama MK, Miyoshi MH, de Almeida MF, Guinsburg R. Factors associated with clinical complications during intra-hospital transports in a neonatal unit in Brazil. J Trop Pediatr 2011;57:368e74. 6. Shenassa H, Sankaran K, Duncan W, Tyrrell M, Bharadwaj B. Surgical ligation of patent ductus arteriosus in a neonatal intensive care setting is safe and cost effective. Can J Cardiol 1986;2:353e5. 7. Mallick MS, Jado AM, Al-Bassam AR. Surgical procedures performed in the neonatal intensive care unit on critically ill neonates: feasibility and safety. Ann Saudi Med 2008;28:105e8. 8. Ko YC, Chang CI, Chiu IS, Chen YS, Huang SC, Hsieh WS. Surgical ligation of patent ductus arteriosus in very-low-birth-weight premature infants in the neonatal intensive care unit. J Formos Med Assoc 2009;108:69e71. 9. Lin CT, Liu WH, Cheng BC, Wang LY, Chen TJ. Surgical closure of patent ductus arteriosus in preterm infants at neonatal intensive care unit. Acta Paediatr Taiwan 2003;44:287e91. 10. Ku ¨ster A, Jouvet P, Bonnet D, Flandin C, Lenclein R, Hubert P, et al. Feasibility of surgery for patent ductus arteriosus of premature babies in a neonatal intensive care unit. Eur J Pediatr Surg 2003;13:294e7. 11. Lago P, Meneghini L, Chiandetti L, Tormena F, Metrangolo S, Gamba P. Congenital diaphragmatic hernia: intensive care unit or operating room? Am J Perinatol 2005;22:189e97. 12. Kirkby S, Greenspan JS, Kornhauser M, Schneiderman R. Clinical outcomes and cost of the moderately preterm infant. Adv Neonatal Care 2007;7:80e7.
Y.-L. Wang et al 13. Vieira AL, Santos AM, Okuyama MK, Miyoshi MH, Almeida MF, Guinsburg R. Predictive score for clinical complications during intra-hospital transports of infants treated in a neonatal unit. Clinics (Sao Paulo) 2011;66:573e7. 14. Moss SJ, Embleton ND, Fenton AC. Towards safer neonatal transfer: the importance of critical incident review. Arch Dis Child 2005;90:729e32. 15. Bowen SL. Transport of the mechanically ventilated neonate. Respir Care Clin N Am 2002;8:67e82. 16. Warren J, Fromm Jr RE, Orr RA, Rotello LC, Horst HM, American College of Critical Care Medicine. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004;32:256e62. 17. Chance GW, Matthew JD, Gash J, Williams G, Cunningham K. Neonatal transport: a controlled study of skilled assistance. Mortality and morbidity of neonates less than 1.5 kg birth weight. J Pediatr 1978;93:662e6. 18. Leppa ¨la ¨ K. Whether near or far...Transporting the neonate. J Perinat Neonatal Nurs 2010;24:167e71. 19. Fanara B, Manzon C, Barbot O, Desmettre T, Capellier G. Recommendations for the intra-hospital transport of critically ill patients. Crit Care 2010;14:R87. 20. Edge WE, Kanter RK, Weigle CG, Walsh RF. Reduction of morbidity in interhospital transport by specialized pediatric staff. Crit Care Med 1994;22:1186e91. 21. Orr RA, Felmet KA, Han Y, McCloskey KA, Dragotta MA, Bills DM, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics 2009;124:40e8. 22. Hatherill M, Waggie Z, Reynolds L, Argent A. Transport of critically ill children in a resource-limited setting. Intensive Care Med 2003;29:1547e54. 23. Finer NN, Woo BC, Hayashi A, Hayes B. Neonatal surgery: intensive care unit versus operating room. J Pediatr Surg 1993; 28:645e9. 24. Gavilanes AW, Heineman E, Herpers MJ, Blanco CE. Use of neonatal intensive care unit as a safe place for neonatal surgery. Arch Dis Child Fetal Neonatal Ed 1997;76:F51e3. 25. Kawagoe JY, Segre CA, Pereira CR, Cardoso MF, Silva CV, Fukushima JT. Risk factors for nosocomial infections in critically ill newborns: a 5-year prospective cohort study. Am J Infect Control 2001;29:109e14. 26. Won SP, Chou HC, Hsieh WS, Chen CY, Huang SM, Tsou KI, et al. Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2004;25:742e6. 27. Ayliffe GA. Role of the environment of the operating suite in surgical wound infection. Rev Infect Dis 1991;13:S800e4. 28. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97e132. 29. John T, Colvin R, Ferrall B. Improving the management and delivery of bedside patent ductus arteriosus ligation. AORN J 2007;86:231e8.
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Pediatrics and Neonatology (2014) xx, 1e6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.pediatr-neonatol.com
ORIGINAL ARTICLE
Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan Ya-Lei Wang a,b, Suh-Fang Jeng c, Po-Nien Tsao a, Hung-Chieh Chou a, Chien-Yi Chen a, Wu-Shiun Hsieh a,* a Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan b Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan c School and Graduate Institute of Physical Therapy, National Taiwan University College of Medicine, Taipei, Taiwan
Received Apr 16, 2014; received in revised form Jul 17, 2014; accepted Oct 8, 2014
Key Words neonatal intensive care unit; operating room; operation
Background: Most neonates who reside in the neonatal intensive care unit (NICU) and require surgery are transferred to the operating room (OR) or undergo bedside surgery. However, critically ill neonates who are transferred often encounter the risk of complications. An OR in our NICU was therefore launched in 2009. This study was to appraise the surgeries performed in the NICU OR and compare results with the traditional main OR outside the NICU. Methods: This was a retrospective study in the NICU of a tertiary center. Retrospective chart review was conducted for all neonates who underwent surgical procedures in the NICU OR and the main OR. The information regarding baseline characteristics, surgical procedures and duration, ventilator use, hypothermia, hyperglycemia, instrument dislocations, surgically related infection or complications, and outcomes was obtained. Results: There were a total of 65 patients in this study, 37 in the NCIU OR group and 28 in the main OR group. The presurgical mean airway pressure and the fraction of inspired oxygen (FiO2) were comparable between the two groups, but the postsurgical FiO2 was significantly lower in the NICU OR group (31.0%) than in the main OR group (40.9%; p Z 0.027). Furthermore, the NICU OR group required a significantly shorter preoperation waiting time (34.4 minutes vs. 63.6 minutes, p Z 0.001) and had a lower incidence of hypothermia than the main OR group (8.1% vs. 39.3%, p Z 0.008). However, surgically related complications were similar between groups.
* Corresponding author. Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Number 7, Chung San South Road, Taipei, Taiwan. E-mail address: [email protected] (W.-S. Hsieh). http://dx.doi.org/10.1016/j.pedneo.2014.10.003 1875-9572/Copyright ª 2014, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Wang Y-L, et al., Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan, Pediatrics and Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2014.10.003
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Y.-L. Wang et al Conclusion: The OR within the NICU may reduce the risk of complications during transportation and provide continuity of care to critically ill neonates. It also decreases the disturbance to other NICU patients during operation. Copyright ª 2014, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
high-frequency oscillatory ventilation, inhaled nitric oxide therapy, and even extracorporeal membrane oxygenation (ECMO).8,9 Furthermore, performing the surgery in the NICU provides continuity of care by the same intensive care team.7 However, there are doubts about increasing the risk of infection when performing bedside surgery.10,11 To solve this problem, we opened an operating room in our NICU (NICU OR) in 2009. The aim of this study was to compare the benefits and risks of performing surgery on critically ill newborns in the OR within the NICU with those of conducting surgery outside the NICU.
1. Introduction Critically ill neonates in the neonatal intensive care unit (NICU) often require surgical procedures. Neonates in need of surgery are traditionally transferred to the main operation room outside the NICU. However, transferring the critically ill neonates to the OR outside the NICU risks complications. In critical patients, previous studies have shown that clinical complications may occur in up to 70% of intrahospital transports.1e4 The possible events include hypothermia, change in variations in heart rate and blood pressure, and dislocation of vascular accesses or endotracheal tubes.2,5 The incidence of complications may relate to the duration of transportation and the severity of the patients’ symptoms.2,4,5 For example, Vieira et al5 demonstrated that in intrahospital NICU transports, hypothermia events developed in up to 17% of patients, and these hypothermia events were associated with prolonged transports.5 To avoid the adverse events during transportation, some surgical procedures, such as patent ductus arteriosus (PDA) ligation, are done at the NICU bedside, with similar results to those done in the main OR.6,7 Surgery at the NICU bedside avoids the accident during transport, especially for critical and unstable neonates who are in use of
2. Methods There are 25 beds in the NICU in the National Taiwan University Hospital, Taipei, Taiwan. The OR is located in the central area of the ward (Figure 1). The room area in the NCIU OR is 25 m2, which is similar to the main OR (15e25 m2). The NICU OR has a laminar air flow system with 15 fresh filtered air changes per hour, which is similar to that of the main OR of our hospital. Prior to surgery, the patient was transferred directly from his/her bed to the NICU OR with an overhead radiant warmer. The theater staff brought equipment to the NICU OR. The surgical team consisted of surgeons, a neonatologist, an anesthetist, an
Gas Room
Main Door
Lounge Staff Room Storehouse Elevator
Ward-01
Operating Room
Soiled Linens Room
Station Ward-02
Isolation Ward
Staff Room
Ward-06
Ward-05
Figure 1
Ward-04
Nursing Room
Ward-03
Floor plan of the NICU in NTUH.
Please cite this article in press as: Wang Y-L, et al., Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan, Pediatrics and Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2014.10.003
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Operating room within the neonatal intensive care unit anesthesia nurse, a scrub nurse, and a circulating nurse. Continued monitoring was provided during the surgery. The neonatologist attended the surgery for adjustment of the ventilator. After the surgery was performed, the primary care nurse and pediatrician looked after the neonate. The patient then stayed in the NICU OR until physiologically stable, and then the patient was transferred back to his/ her bedside. Regular activity in the NICU was not disturbed during the surgery. A retrospective chart review was undertaken for all neonates undergoing surgical procedures in the NICU OR from February 2009 to April 2011. The interim analysis of these data showed that the majority of the patients required PDA ligation or repair of congenital diaphragmatic hernia (CDH; Table 1). Thus, the data of those undergoing PDA ligation or CDH repair in the NICU OR were selected as the NICU OR group. Historical comparison was made by retrospective collection of the medical data of residents in our NICU who received PDA ligation or CDH repair in the main OR outside the NICU from 2001 to 2011, as the main OR group. The following data were collected from the medical chart: sex, gestational age, birth weight, age at the time of surgery, surgical procedures and duration, preoperation waiting time from on call to the commencement of the operation (defined as the time for transfer and preoperative preparation), ventilator information, hypothermia, hyperglycemia, instrument dislocations, incidence of surgically related infection, complications, and outcome. The mean airway pressure (MAP) and the fraction of inspired oxygen (FiO2) were used to measure respiratory support. Hypothermia was defined as temperature < 35.5 C, and hyperglycemia was defined as blood sugar > 200 mg/dL. Surgically related infection was recorded as culture-proved wound or surgical drainage sites infection within 1 week of surgery. Statistical analyses were performed using the SPSS version 12.0 (SPSS Inc., Chicago, IL, USA). Means were calculated for baseline demographic characteristics, FiO2, MAP, temperature, and duration. Frequencies were calculated for the rate of hypothermia, hyperglycemia, and other complications. The comparisons between the NICU OR group and main OR group were performed by Wilcoxon rank sum test for continuous variables, and Chi-square test
Table 1 Procedures and surgical duration performed in the Neonatal Intensive Care Unit operating room. Surgical procedure Bronchopleural fistula repair Congenital diaphragm hernia repair Bowel resection PDA ligation Exploratory thoracotomy Total PDA Z patent ductus arteriosus.
Number
Surgical duration (min)
1
130
9
140 (80e165)
1 28 1 39
155 46 (15e100) 90 59
3 for categorical variables. A p value 0.05 was considered to be statistically significant for all analyses.
3. Results There were 37 patients in the NCIU OR group, and 28 patients in the main OR group. In the NICU OR group, 28 patients received PDA ligation and nine patients received CDH repair, whereas in the main OR group, 12 patients received PDA ligation and 16 patients received CDH repair. We compared the two groups with respect to birth weight, gestational age, age at the time of operation, and preoperative FiO2 and MAP in an effort to compare the baseline characteristics and severity prior to the operation. The comparison of the baseline characteristics in these two groups is listed in Table 2. The mean gestational age and birth weight for the NICU OR group were 30.5 4.5 weeks (range 25e39 weeks) and 1387 759 g (range 590e3335g), respectively; the mean gestational age and birth weight for the main OR group were 35.2 3.0 weeks (range 29e40 weeks) and 2512 745 g (range 1160e3906 g), respectively. The postnatal age of operation was 13.1 9.9 days in the NICU OR group and 11.8 11.4 days in the main OR group. Prior to the surgery, the percentage of patients requiring mechanical ventilation showed no significant difference (81.1% in the NICU OR group vs. 53.5% in the main OR group, p Z 0.307). The baseline mean FiO2 and the mean MAP in the NICU OR group were 30.2% and 8.85 cmH2O, respectively, whereas in the main OR group they were 27.4% (p Z 0.735) and 8.39 cmH2O (p Z 0.654), respectively. The preoperative body temperature was 36.8 C and 36.9 C in the NICU OR and the main OR group (p Z 0.929), respectively (Table 3). Table 3 demonstrates the postoperative characteristics and surgically related events in both groups. The preoperation waiting time was significantly shorter in the NICU OR group than in the main OR group (34.4 minutes vs. 63.6 minutes, p < 0.001). The duration of surgery in the main OR group was longer than the NICU OR group (101.1 minutes in the main OR group versus 70.4 minutes in the NICU OR group, p Z 0.001). However, the subgroup analysis of the duration of surgery according to different procedures showed no significant difference. For PDA ligation, the mean operating duration was 64.4 minutes in the main OR group versus 48.0 minutes in the NICU OR group. For CDH repair, the mean operating duration was 140 minutes in the NICU OR group versus 129 minutes in the main OR group. The difference of the operation duration might come from a greater proportion of patients receiving PDA ligation in the NICU OR group, because PDA ligation generally takes less time than the CDH repair procedure. Although the body temperature prior to the operation was similar in the two groups, the lowest body temperature during the operation and transfer was significantly different (36.2 C in the NICU OR group versus 35.2 C in the main OR group, p < 0.001). Three patients (8.1%) in the NICU OR showed hypothermia during the operation and transfer, whereas 11 patients (39.3%) had hypothermia in the main OR group (p Z 0.008). The presurgical MAP and FiO2 were not significantly different between groups, but the
Please cite this article in press as: Wang Y-L, et al., Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan, Pediatrics and Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2014.10.003
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Y.-L. Wang et al Table 2 Demographic characteristics among infants who received PDA ligation and CDH repair in the Neonatal Intensive Care Unit operating room (NICU OR) group versus the main operating room (OR) group. NICU OR
Male Female Gestational age (wk) Birth weight (gm) Age of operation (d)
Main OR
PDA
CDH
PDA
CDH
N Z 28
NZ9
N Z 12
N Z 16
54 46 28.7 3.3 1070 472 16.3 9.1
67 33 36.1 2.8 2375 628 2.9 2.5
50 50 33.0 2.0 1939 636 23.6 7.1
56 44 36.9 2.5 2941 494 3.0 1.5
Data are presented as % or mean standard deviation. CDH Z congenital diaphragmatic hernia; PDA, Z patent ductus arteriosus.
postsurgical FiO2 was significantly different (31.0% in the NICU OR group vs. 40.9% in the main OR group, p Z 0.027). For the surgically related events, the hyperglycemia incidence was higher in the main OR group than in the NICU OR group (29.7% vs. 42.9%, p Z 0.311). In the NICU OR group, there were no cases with endotracheal tube or vascular lines dislocation during transportation. However, two episodes of endotracheal dislocation occurred when the patients were transported to the main OR. For the surgically related infection, one infant undergoing surgery for PDA in the NICU OR had chest tube wound infection by Methicillin-resistant Staphylococcus aureus. By contrast, four cases had wound infection or abscess, and one infant had Streptococcus mitis bacteremia after the operation in the main OR group. The rate of surgically related wound infection was comparable between groups.
Table 3 Preoperative and postoperative characteristics and surgical related events among infants who received PDA ligation and CDH repair in the Neonatal Intensive Care Unit operating room (NICU OR) group versus the main operating room (OR) group.
Pre-OP ventilator use FiO2 pre-OP FiO2 post-OP MAP pre-OP (cmH2O) MAP post-OP (cmH2O) Waiting time (min) OP duration (min) BT pre-OP ( C) Lowest BT ( C) Hypothermia IVF during OP (mL/kg/h) Hyperglycemia ET dislocation Surgical related infection
NICU OR (n Z 37)
Main OR (n Z 28)
p
30 (81.1) 30.2 31.0 8.85 9.43 34.4 70.4 36.8 36.2 3 (8.1) 11.6 11 (29.7) 0 (0) 1 (2.7)
16 (53.5) 27.4 40.9 8.39 8.83 63.6 101.1 36.9 35.2 11 (39.3) 18.8 12 (42.9) 1 (3.5) 4 (14.3)
0.307 0.735 0.027 0.654 0.594 0.001 0.001 0.929 0.001 0.008 0.067 0.311 0.422 0.104
Data are presented as n (%), unless otherwise indicated. BT Z body temperature; CDH Z congenital diaphragmatic hernia; ET Z endotracheal tube; IVF Z intravenous fluid; MAP Z main airway pressure; OP Z operation; PDA Z patent ductus arteriosus.
Mortality rate was higher for neonates operated in the NICU OR that including three extremely low birth weight preterm infants. One female infant with a birth weight of 735 g underwent CDH repair and died 129 days after surgery due to massive intracranial hemorrhage after several days of ECMO support. The second was a male preterm infant with a birth weight of 850 g who underwent PDA ligation at the age of 22 days. He died 150 days after surgery due to bowel perforation. The third was a female preterm infant with a birth weight of 616 g who underwent PDA ligation at the age of 21 days and died due to chronic lung disease 133 days after surgery.
4. Discussion In most hospitals, neonates are transported to the OR outside the NICU for surgery. Those neonates who are transported for surgery may encounter an increased risk of complications.5 Despite improvements in intrahospital transportation equipment and experience, significant risks still exist.4 Previous studies discussed mishaps during transport of ill patients. Most patients may have change in at least one physiologic variable during transportation, such as hypothermia, or changes in heart rate, blood pressure, or respiratory rate. Equipment-related mishaps are also not uncommon.2 Preterm infants frequently experience respiratory compromise and require additional respiratory support.12 Such patients with mechanical ventilators or required high ventilator settings are at an increased risk of transportation-related adverse events.13 Furthermore, the duration of transport was associated with equipmentrelated events.2 Complications during transport may aggravate the clinical status of ill neonates; however, many events are potentially preventable.14,15 There are guidelines for the transfer of critically ill patients that emphasize a comprehensive and effective interfacility transfer plan.16 The transfer plan should comprise the coordination and communication of a multidisciplinary team, the assessment of the facility including the transport personnel and equipment, and the continuous quality improvement process to refine the plan. Although the guideline is not designed for neonates, the principle can also be applied to the intrahospital transfer of NICU patients. In our unit, no matter where the surgeries are to be carried out, the
Please cite this article in press as: Wang Y-L, et al., Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan, Pediatrics and Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2014.10.003
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Operating room within the neonatal intensive care unit surgeon and the anesthesiologist visit the patient before the surgical procedure is performed. The neonatologist may discuss the specific condition of the patient with the surgeon and the anesthesiologist. After the surgical time is booked, the neonatologist and the NICU nurses make preparations for the proper vascular accesses, elective intubation, and equipment for transfer. Prior to and after the surgery, the NICU nurses and the surgical nurses will communicate to each other detailed information about the patient. If the surgery is performed in the NICU OR, the neonatologist will attend throughout the surgery. In addition, some studies provided suggestions to improve safety for transportation in pediatric or neonatal population. For example, good pretransport planning, transport team training, and use of checklists may reduce transportation-related mishaps.17e19 Transport conducted by specialized pediatric staff is also suggested to reduce the related risk.20,21 However, it often takes three or more staff for transportation to and from the main OR. Time taken and personnel costs would be increased by the long duration of transportations.22 Thus, for the critically ill neonates, avoiding transportation of long duration is a cornerstone of safety. There are numerous studies about the bedside operation in the NICU.23 However, no study has focused on an operating room within the NICU. In our study, we compared the transportation and surgically related events between the main OR and NICU OR. The NICU OR group infants in this study were much smaller and more immature than the infants in the main OR group. Furthermore, these two groups were from different cohorts. However, the data still demonstrate some essential differences. The significantly shorter waiting time prior to surgery in the NICU OR group reflects the shorter journey of transportation. This also suggests that the number of staff and time spent for transportation can be reduced. The incidence of hypothermia after transportation was significantly lower in the NICU OR group than in the main OR group. This indicates that the heat loss during transportation could be reduced. In the NICU OR, we kept the room temperature in the range of 24e26oC during the operation, whereas the room temperature was approximately 23e25oC in the main OR. There is a slight difference of the setting of room temperature at these two sites. This might be a factor for the lower hypothermia rate in the NICU OR group. The literature has demonstrated many complications that are encountered during transportation. In our study, we compared the rate of instrument dislocations during transportation. There was no case of intravenous line or arterial line dislocation in the two groups. However, two episodes of endotracheal dislocation occurred when the patient was being transported to the main OR, whereas no case showed endotracheal tube dislocation in the NICU OR group. We consider the endotracheal tube dislocation as a major adverse event that could cause harm to the patient. Thus, even though the difference does not reach statistical significance, it should be emphasized. Other than the shorter transportation distance and the lower risk of associate complication, surgery in the NICU provided additional benefits. One example is the continuity of care.24 The neonatologist attended during the surgery
5 with the cooperation of the anesthetist to adjust the ventilation setting. According to our data, the preoperation ventilation settings were not significantly different; however, the postoperation FiO2 was significantly higher in the main OR group. This finding was not discussed in previous literature. According to our experience, the attention of the neonatologist in the operation can avoid the inappropriate goal of high saturation during and after the operation. The average intravenous fluid given during the operation was also slightly more in the main OR group, and the incidence of hyperglycemia was also higher in this group. Nosocomial infection could further deteriorate the critically ill neonate.25,26 The infection rates are particularly high for neonates with mechanical ventilation or central venous catheter, such as in our study population. Some literature claimed that the rate of surgical infection is slightly higher when patients underwent bedside surgery in the NICU.11 In our study, surgery in the NICU OR, which had similar settings as the main OR, did not increase the rate of surgical infection. The surgical duration after adjustment to the procedure was the same in the NICU OR and the main OR. The mortality rate in the NICU OR group was higher than the main OR group. However, the NICU OR group infants were much smaller and more immature than those of the main OR group. There were three mortality cases in the NICU OR group. However, these deaths were not related to the surgery itself but to the severity of the underlying diseases: one patient died due to severe CDH with ECMO complication long after surgery and the others due to longterm complications of extreme prematurity. There are limitations of this study, such as small sample size, retrospective design, and the different baseline characteristics including gestational age and birth weight in the two groups. However, since the construction of our NICU OR, nearly all suitable operating procedures have been undertaken at the NICU OR. A prospective, randomized design may entail ethical issues and may not collect the comparable procedures between the main OR and the NICU OR groups. In the future, more surgical procedures may be performed in the NICU OR. The complexity of the diverse surgical procedures is a challenge to NICU and the surgical teams. The formal and comprehensive perioperative plan including a checklist will be amended. Simulation practice for transportation may also be introduced. For better infection control, the aims are to decrease unnecessary traffic into the OR during surgery, to separate the cleaning schedule for the OR, and to avoid unnecessary equipment in the OR.27,28 Many previous studies demonstrated that it was safe for some surgical procedures to take place at the bedside in the NICU. However, bedside surgery may disturb nearby patients and also increase the risk of infection.11,29 In our observation, the surgery in the NICU OR brought fewer disturbances to other NICU patients in comparison with bedside surgery. We further designed an independent space that was similar to the main OR. This may prevent some possible surgical infection and also provide sufficient space for the surgical team. Our study showed that this setting is safe and convenient for critically ill neonates. The NICU OR
Please cite this article in press as: Wang Y-L, et al., Operating Room Within the Neonatal Intensive Care UnitdExperience of a Medical Center in Taiwan, Pediatrics and Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2014.10.003
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6 is currently only for selected procedures such as PDA ligation and CDH repair or bowel perforation. We will attempt other procedures in cooperation with the surgical and anesthesia teams in future.
Conflicts of interest The authors declare that they have no financial or nonfinancial conflicts of interest related to the subject matter or materials discussed in the manuscript.
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Y.-L. Wang et al 13. Vieira AL, Santos AM, Okuyama MK, Miyoshi MH, Almeida MF, Guinsburg R. Predictive score for clinical complications during intra-hospital transports of infants treated in a neonatal unit. Clinics (Sao Paulo) 2011;66:573e7. 14. Moss SJ, Embleton ND, Fenton AC. Towards safer neonatal transfer: the importance of critical incident review. Arch Dis Child 2005;90:729e32. 15. Bowen SL. Transport of the mechanically ventilated neonate. Respir Care Clin N Am 2002;8:67e82. 16. Warren J, Fromm Jr RE, Orr RA, Rotello LC, Horst HM, American College of Critical Care Medicine. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004;32:256e62. 17. Chance GW, Matthew JD, Gash J, Williams G, Cunningham K. Neonatal transport: a controlled study of skilled assistance. Mortality and morbidity of neonates less than 1.5 kg birth weight. J Pediatr 1978;93:662e6. 18. Leppa ¨la ¨ K. Whether near or far...Transporting the neonate. J Perinat Neonatal Nurs 2010;24:167e71. 19. Fanara B, Manzon C, Barbot O, Desmettre T, Capellier G. Recommendations for the intra-hospital transport of critically ill patients. Crit Care 2010;14:R87. 20. Edge WE, Kanter RK, Weigle CG, Walsh RF. Reduction of morbidity in interhospital transport by specialized pediatric staff. Crit Care Med 1994;22:1186e91. 21. Orr RA, Felmet KA, Han Y, McCloskey KA, Dragotta MA, Bills DM, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics 2009;124:40e8. 22. Hatherill M, Waggie Z, Reynolds L, Argent A. Transport of critically ill children in a resource-limited setting. Intensive Care Med 2003;29:1547e54. 23. Finer NN, Woo BC, Hayashi A, Hayes B. Neonatal surgery: intensive care unit versus operating room. J Pediatr Surg 1993; 28:645e9. 24. Gavilanes AW, Heineman E, Herpers MJ, Blanco CE. Use of neonatal intensive care unit as a safe place for neonatal surgery. Arch Dis Child Fetal Neonatal Ed 1997;76:F51e3. 25. Kawagoe JY, Segre CA, Pereira CR, Cardoso MF, Silva CV, Fukushima JT. Risk factors for nosocomial infections in critically ill newborns: a 5-year prospective cohort study. Am J Infect Control 2001;29:109e14. 26. Won SP, Chou HC, Hsieh WS, Chen CY, Huang SM, Tsou KI, et al. Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2004;25:742e6. 27. Ayliffe GA. Role of the environment of the operating suite in surgical wound infection. Rev Infect Dis 1991;13:S800e4. 28. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97e132. 29. John T, Colvin R, Ferrall B. Improving the management and delivery of bedside patent ductus arteriosus ligation. AORN J 2007;86:231e8.
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