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Year : 2016  |  Volume : 5  |  Issue : 4  |  Page : 238-242

Factors affecting the complications of interhospital transfer of neonates referred to the Neonatal Intensive Care Unit of Besat Hospital in 2012–2013

Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran

Date of Web Publication16-Nov-2016

Correspondence Address:
Dr. Behnaz Basiri
Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4847.194169

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Background and Objective: Correct interhospital transfer of neonates is an important factor in reducing their mortality. This study aimed at determining the prevalence and factors affecting the clinical complications of infants transferred to the Neonatal Intensive Care Unit of Besat Hospital within a year. Methodology: This cross-sectional study included all newborns transferred from the province cities to our center from October 2012 to September 2013 for 1 year. The clinical conditions were recorded during the transfer until arrival to the ward and the collected data were analyzed to determine the factors associated with clinical complications. Results: A total of 100 infants were enrolled in the study. The mean gestational age and the mean birth weight were 37.5 ± 1.8 weeks and 2800 ± 605 g, respectively. The reasons for neonate transfer were respiratory diseases (58%), need for surgery (21%), central nervous system diseases (9%), acute kidney injury (4%), fulminant sepsis (6%), and pathologic jaundice (2%). The mean time of transfer was 84 ± 42 min, being more than 120 min in 17% of the infants. Clinical complications occurred in 32% of the newborns with hypotension (18%) and hypothermia (9%) as the most common clinical complications and acidosis and hypercapnia as the most common laboratory abnormalities caused by transfer. Univariate analysis to evaluate the risk factors associated with complications revealed that gestational age of <37 weeks (preterm), mean birth weight, and intubation before transfer had a significant association with transfer complications. Conclusion: Interhospital transfer of neonates can increase the risk of complications, and since identification of infants requiring transfer is not possible before birth in all cases, it is necessary to develop an appropriate caring strategy and the transfer should be performed by an experienced team with adequate equipment.

Keywords: Complications, Neonatal Intensive Care Unit, neonatal transport, risk factors

How to cite this article:
Sabzehei MK, Basiri B, Shoukohi M, Torabian S, Razavi Z. Factors affecting the complications of interhospital transfer of neonates referred to the Neonatal Intensive Care Unit of Besat Hospital in 2012–2013. J Clin Neonatol 2016;5:238-42

How to cite this URL:
Sabzehei MK, Basiri B, Shoukohi M, Torabian S, Razavi Z. Factors affecting the complications of interhospital transfer of neonates referred to the Neonatal Intensive Care Unit of Besat Hospital in 2012–2013. J Clin Neonatol [serial online] 2016 [cited 2022 Jan 18];5:238-42. Available from: https://www.jcnonweb.com/text.asp?2016/5/4/238/194169

  Introduction Top

Advances in medical science and improved diagnostic and therapeutic services provided to sick infants is the reason for the transfer of this group of infants from lower care levels to higher care levels (level III). Although being born of high-risk infants in level III care centers is ideal, identification of infants requiring transfer (such as prematurity and perinatal illness) is not possible before birth in about 4% of the cases.[1],[2] Therefore, it is necessary to transfer infants to better-equipped centers. Since specialized neonatal transport service does not exist in many developing countries,[3] the transfer is done by staff with little experience and insufficient equipment which per se increases the complications of transfer,[4],[5] and many neonates develop hypothermia, cyanosis, and hypoglycemia, with serious clinical consequences occurring in 75% of infants.[6],[7],[8] These complications affect the infant's final prognosis; therefore, identification of complications during transfer will help their prevention and treatment through training the infant's transfer team and adequately equipping the transfer services to reduce infant mortality. The present study was designed and conducted in this regard.

  Methodology Top

This study was conducted for 1 year on all newborns transferred from the cities of the province to the Neonatal Intensive Care Unit (NICU) of Besat Hospital from October 2012 to September 2013. The data were collected through a predesigned questionnaire which was completed by residents of pediatrics.

Before transfer information, length of stay in the original hospital, infants' characteristics including gender, gestational age, birth weight, age and weight before transfer, vital signs before and during transfer and at arrival to the hospital, underlying diseases, respiratory support before and during transfer and at arrival to the hospital, and characteristics of the transfer including time, duration, and clinical complication during transfer were recorded. Diagnosis of the transferred infants was confirmed by the attending physician.

Hypothermia (TA <36°C), hyperthermia (TA >37.5°C), bradycardia (heart rate [HR] <80 bpm), tachycardia (HR <180 bpm), hypoxia (SaO2 <85%), hyperoxia (SaO2 >95%), hypertension (mean blood pressure >75 mmHg), hypotension (mean blood pressure less than gestational age +5 mmHg in newborns and <55 mmHg in older infants), apnea (cessation of breathing for 20 s with or without bradycardia or hypoxia), hypercapnia (pCO2 >45 mmHg), hypocapnia (pCO2 <35 mmHg), hypoglycemia (glucose <40 mg/dL), hyperglycemia (glucose >150 mg/dL), and acidemia (pH <7.25) were defined.

Then, the transferred neonates were divided into two groups of complicated transfer (group with at least one or more clinical complications) and uncomplicated transfer (without at least one of the clinical complications). The obtained data were analyzed through the Chi-squared test for categorical variables and t-test for continuous variables, and P < 0.05 was considered significantly different. Before implementation, the study was approved by the Ethics Committee of the Hamadan University of Medical Sciences.

  Results Top

A total of 100 infants with a mean gestational age of 37.5 ± 1.8 weeks and a mean birth weight of 2800 ± 605 g were enrolled in the study. The mean age of neonates at the time of transfer was 4.1 ± 5.9 days. Fifty percent were male and 25% were preterm. The reasons for neonate transfer were respiratory diseases (58%), need for surgery (21%), central nervous system diseases (9%), acute kidney injury (4%), fulminant sepsis (6%), and pathologic jaundice (2%).

All transfers were done by ambulance through land and the mean time of transfer was 84 ± 42 min, being more than 120 min in 17% of the infants. Most cases of transfer were performed by emergency medical staff (71%) and about 70% of infants received oxygen before birth [Table 1].
Table 1: Characteristics of the 100 transported patients included in the study

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Evaluation of neonates in terms of clinical complications of transfer on arrival showed an occurrence of 32%, with hypotension (18%) and tachycardia (2%) as the most and less common complications, respectively. Infants' mean HR, mean respiratory rate, mean systolic blood pressure, mean arterial oxygen saturation, and mean blood sugar were 138 ± 34, 56 ± 18, 66 ± 17, 75 ± 23, and 115 ± 91, respectively [Table 2].
Table 2: Clinical complication and laboratory abnormalities during interhospital transport

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Clinical and demographic characteristics between the two groups of complicated transfer and uncomplicated transfer were compared. Univariate analysis to evaluate the risk factors associated with complications revealed that gestational age of <37 weeks (preterm), mean birth weight, and intubation before transfer had a significant association with complications [Table 3].
Table 3: Comparison of patients with and without complication

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  Discussion Top

It was concluded in this study that the majority of newborns who required interhospital transfer to our unit have experienced complications which related to the quality of neonatal care and the severity of underlying disease.

Our study showed that technical complications occur in 26% of infants perhaps due to the transfer of infants from incubators or warmers to portable incubators, manual respiratory ventilation due to lack of portable ventilator, and roughness of the road during transfer, leading to failure or withdrawal of venous lines and displacement or extubation of endotracheal tube. Displacement or extubation of the tube occurred in 6% of infants; therefore, it is recommended that in addition to ambulance adequate equipment, lines and endotracheal tubes should be fixed appropriately, and head and limbs with a vessel should have sufficient support to prevent extubation or withdrawal of venous lines.[9],[10],[11]

The prevalence of clinical deterioration has been reported up to 57%.[10] In our study, 32% of infants developed one or more clinical complications. Hypotension (18%) was the most common complication in newborns transferred to our center which was less than the study of Porwal et al.[12] (28.8%) and Dalal et al.[13] (23.4%) but greater than other similar studies.[14],[15],[16] The reason of this high prevalence in our study was venous line failure, lack of fluid intake during transfer, unstable cardiovascular status of the transferred patients, and impossibility of blood pressure control during transfer.

Hypothermia was the second most common complication in the newborns and occurred in 9% of infants; this corresponds with the results of other studies, in which hypothermia has been reported as the most common clinical complication of transfer.[12], 13, [17],[18],[19] Therefore, it is recommended to use double-walled incubators to prevent heat loss, especially the more unstable infants' situation, such as the need for mechanical ventilation or low birth weight, the higher the risk of this complication.

In terms of metabolic disorders such as hypoglycemia, the results of this study are similar to those of Yeager et al. (17% of cases) but lower than those of Foc (26.3% of cases), Porwal et al. (28%), and Dalal et al. (20.6%).[12],[13],[15],[20] Regarding laboratory abnormalities at the time of arrival such as acidemia, hypoxemia, and hypercapnia, our results were similar to those of other studies.[14],[15],[16] Most transferred infants have experienced impaired blood gases due to respiratory distress or HIE. Since infants are transferred with an incubator, manual ventilation may result in large fluctuations in minute ventilation and severe disturbance in blood gases. On the other hand, open or semi-open door of incubators for air conditioning can lead to hypoxia, displacement of the endotracheal tube, and hypothermia. Therefore, to prevent metabolic disturbance, infants' temperature, circulation, and blood gases should be leveled before transferring; otherwise, the transfer will worsen their clinical conditions.

Univariate analysis in our study showed that prematurity, low birth weight, intubation, and manual ventilation were factors related to clinical complications. Goldsmit et al.[10] found no significant correlation between variables and clinical complications. In a study by Buch Pankaj et al.,[21] low birth weight and prematurity in transferred infants were significantly associated with mortality. As our study and other study show, mechanical ventilation due to bad clinical conditions and severity of the underlying disease increase the occurrence of complications during transfer.[17] Wallen et al. showed that corrective procedures during transfer are performed in 34.4% of infants needing ventilator compared to 9.5% of infants without the need for mechanical ventilation. They also showed that infants undergoing manual ventilation are more prone to complications such as dislocation of the endotracheal tube. In our study, endotracheal tube dislocation was occurred in 50% of the intubated infants.[17]

Although the transfer of high-risk mothers before labor is the best way to avoid complications during transfer (perinatal regionalization), the postpartum transfer is inevitable, because about 1% of newborns should be transferred to the third level of care. One-third of these cases occur in the first 24 h and the remaining during the 1st week.[22],[23] Therefore, as studies have shown, trained neonatal transport teams (including pediatricians, NICU nurses, and medical technicians), adequate equipment including portable ventilator in neonates requiring mechanical ventilation, and more importantly, stabilization before transfer are of strategies that can reduce complications of transfer.[15]

Study limitations

It was not possible to measure blood gases and blood pressure in some centers before transfer. Therefore, measurement of blood gases and laboratory findings on admission are used for analysis.

  Conclusion Top

Clinical complications during transfer are common and mostly occur in infants who have instable clinical conditions before transfer, and trained personnel, adequate equipment, especially portable ventilators and double-wall incubators can decrease the incidence of complications.


The author would like to give his gratitude to Dr. Massomeh Jamshidi, whose thesis was used to derive this article as well as the NICU nursing staff of Besat Hospital for their valuable collaboration in this project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Porwal G, Mahale R, Mahale K, Chetan G, Aggarwal R. Clinical profile and outcome underlying neonatal transport from periphery to a tertiary care center in South India. Karnataka Paediatr J 2013;28:10-5.  Back to cited text no. 12
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Buch Pankaj M, Makwana Aarti M, Chudasama Rajesh K, Doshi Smita K. Status of newborn transport in periphery and risk factors of neonatal mortality among referred newborns. J Pharm Biomed Sci 2012;16:1-6.  Back to cited text no. 21
O'Reilly M, Schmölzer GM. Monitoring during neonatal transport. Emerg Med 2012;S:1.  Back to cited text no. 22
Meberg A, Ruud Hansen TW. Neonatal transports – Risks and opportunities. Open J Pediatr 2011;1:45-50.  Back to cited text no. 23


  [Table 1], [Table 2], [Table 3]

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