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A regional approach to the early management of infants with hypoxic-ischaemic encephalopathy

Presented at the Neonatal Society 2011 Autumn Meeting.

Walston FE1, Baron M1, Farrer KF2, Austin T3

1 East of England Perinatal Network, UK
2 Acute Neonatal Transfer Service for the East of England, UK
3 Neonatal Unit, The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, UK

Background: Therapeutic hypothermia is now recommended as the standard of care for the management of infants with moderate or severe hypoxic-ischaemic encephalopathy (HIE) (1,2). The TOBY register, set up in December 2006, has been notified of over 2100 infants cooled from over 65 neonatal units in the UK (3). While BAPM recommends that cooling is undertaken in regional NICUs, the majority of infants with HIE will be born outside these centres; there is evidence that therapeutic hypothermia is time-critical and so delay in initiating cooling should be avoided.
The East of England Neonatal Neuroprotection project was set up in April 2010. This is a two year quality improvement project to develop a regional, coordinated, family centred service for neonatal neuroprotection, with follow up, for term infants born with HIE.
One of the key aims of the project was to ensure that all eligible infants born outside of the three regional NICUs were identified early and cooled in a safe and expedient manner.

Methods: Five key quality variables were identified, indicative of performance. These were 1) age at referral, 2) age cooling commenced, 3) age to target temperature. 4) continuous core (rectal) temperature monitoring and 5) incidence of overcooling. Baseline data was collected at the start of the project. A series of education and training initiatives for key stakeholders was then launched. This included regional study days, individual hospital training visits and multidisciplinary case reviews, offered to units after each new cooling case.
Monthly performance data was collected and improvement defined as a reduction in the time-dependent variable, an increase in the uptake of continuous core temperature monitoring and reduction in the incidence of overcooling.

Results: A total of 82 infants were referred for cooling between October 2009 and September 2011. All infants were cooled passively at the local hospital. The results are summarised in the table above. An improvement in all of the variables has been seen over this time; the most important improvement is the reduction in time to target temperature (linear regression slope coefficient -12.8 95%CI -19.2 to -6.5, p=0.002).

A regional approach to the early management of infants with hypoxic-ischaemic encephalopathy

Conclusion: For therapeutic hypothermia to be effective it must be initiated as soon as possible after delivery. We have shown that with a regional programme of education and training it is possible to reduce the time to referral, the time to start cooling and, most importantly, the time to target temperature. Adoption of continuous rectal temperature monitoring by local hospitals has reduced the incidence of overcooling. Training local staff on the early management of infants with HIE is crucial for ensuring these improvements are sustained.

Corresponding author: florence.walston@nhs.net

1. Edwards AD, Brocklehurst P, Gunn AJ, et al. Neurological outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: synthesis and meta-analysis of trial data. BMJ. 2010;340:c363.
2. NICE IPG374: Therapeutic hypothermia with intracorporeal temperature monitoring for hypoxic perinatal brain injury: guidance. Issued May2010 http://www.nice.org.uk/nicemedia/live/11315/48809/48809.pdf
3. NPEU TOBY register: www. http://www.npeu.ox.ac.uk/tobyregister

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