The development of a retrospective neonatal clinical audit tool for transfers: a modified delphi study

Venter, Maryna

The development of a retrospective neonatal clinical audit tool for transfers: a modified delphi study

Thesis / Dissertation

2024

Publisher

University of Cape Town

Department

Division of Family Medicine

Faculty

Faculty of Health Sciences

Abstract

Background: Due to limited availability of neonatal and paediatric specialist centres in South Africa, interfacility transfer of high-risk neonates is frequently required in order to access appropriate care, often across vast distances. Due to limited Emergency Medical Services (EMS) capacity, the majority of inter-facility transfers are undertaken by general EMS, as opposed to dedicated neonatal transfer teams. Many high-risk neonates are therefore transported by EMS personnel with very limited neonatal care experience and knowledge, as well as limited equipment capabilities. Interfacility transport of at-risk neonates is directly associated with increased mortality and morbidity, and numerous studies have described higher rates of adverse events and mortality particularly when neonates are transported by non-specialist transfer teams. There is currently no standardised clinical audit tool to assess the risks and clinical quality of care provided during neonatal retrieval. An established clinical audit tool that could be used in further research to establish the safety of neonatal transfers in the South African context would provide clinical value. Aim: The aim of this study is to develop a retrospective neonatal clinical quality audit tool according to which the safety of neonatal transfers in South Africa can be assessed. Methods: This study was conducted in two phases using multiple methods. First, a scoping review was conducted to identify normal clinical parameters, aspects of neonatal patient safety, adverse events, and quality of care during transport. Multiple databases were searched using an a priori developed search strategy. Titles and abstracts were screened for relevance, before selecting full text articles for review and data extraction. Data from articles were collated into an extraction matrix, summarise and reported narratively. The results of the scoping review informed the first round survey tool of a modified Delphi study – the second phase of this study. A modified Delphi study was undertaken to obtain a list of consensus-based items that could be collated into a clinical quality audit tool for neonatal transfers in South Africa. Experts in neonatal retrieval, neonatology, paediatrics and intensive care were approached and asked to indicate whether they agreed with each item. They were also requested to provide free-text feedback on items. Consensus was set at 75%. Two rounds of the modified Delphi study were undertaken. Results: For the scoping review, a total of 866 articles were identified initially. Following application of eligibility criteria, ten articles were finally included in the scoping review. Most articles originated from high-income countries and were observational in nature. However, six categories of adverse events were identified (clinical events, equipment events, medical errors, patient safety risks, quality of care, and other). Specific adverse events and clinical parameters were also extracted and combined to form the first-round survey tool of a modified Delphi study. In round one 28 respondents consented to form part of the expert panel, and completed the Delphi questionnaire, yielding a response rate of 70%. In round one the expert panel consisted of neonatologists (n=4), paediatric intensivists (n=2), paediatricians (n=2), other medical doctor working in the field of retrieval (n=1) registered nurses (n=3), and advanced life support (ALS) paramedics or emergency care practitioners (ECPs) (n=16). In round two, 19 experts consented and completed the Delphi questionnaire, yielding an attrition rate of 33%. In round two the expert panel consisted of neonatologists (n=1), paediatric intensivists (n=2), other medical doctor working in the field of retrieval (n=1), registered nurses (n=3), and advanced life support (ALS) paramedic or emergency care practitioners (ECPs) (n=12). Following two rounds of consensus, a 41-item 6 retrospective audit tool was developed and organised into five sections: Airway, respiratory and ventilation, haemodynamic events, medication events, or general and logistic events. Additionally, each item was allocated a severity rating or range requiring additional information gathering to ascertain the severity of the event. Conclusion: This study enabled the development of a consensus-based retrospective clinical audit tool that can be utilised to assess the quality of care of neonatal transfers performed in South Africa. The clinical audit tool was developed through literature-based evidence, and validated for content through the contributions of a national multidisciplinary panel of experts in the field of neonatal retrieval. The utilisation of the audit tool in the framework of a robust clinical governance system, would enable reporting of adverse events according to standardised parameters. This would contribute to the identification of risk factors and knowledge gaps in neonatal transfer teams, which could assist in the development of improvement projects. In addition, it can be used in before-and after interventional studies, to assess for the effectiveness of the intervention in the setting of improved patient safety. Through utilisation in future research projects it can assist in the development of standardised guidelines for clinical care standards during neonatal transfer.

Keywords

Medicine

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