Bridging the Gap: Passive Hypothermia Prior to Transport in the Neonate At Risk for Hypoxic-Ischemic Encephalopathy

Perinatal depression occurs after hypoxic insult to the fetus or neonate either during the intrapartum period, or immediately after birth. Obstetrical emergencies can cause hypoxic insult and have potential to precipitate perinatal depression. Hypoxic-ischemic encephalopathy (HIE) results from lack of cerebral blood flow causing cellular oxygen deprivation and energy failure. HIE is attributed to perinatal depression which leads to neurodevelopmental sequelae. Active hypothermia has emerged as a promising therapy for HIE. However, due to the subtle signs of progressive brain injury in the neonate, clinicians in rural facilities continue to struggle in identifying neonates at risk for HIE, facilitating timely transfer to a tertiary center for active hypothermia, and managing the neonate until the transport service arrives. Optimally, hypothermia should be induced six hours post-insult. In light of this gap in care, a clinical guideline in the form of a triage algorithm and order set were needed to provide clinicians a simple tool to use in identifying and managing neonates at risk for HIE while awaiting transport. The overall aim of this project was to reduce the time between hypoxic-ischemic incidents to attainment of target hypothermic temperature. Evidence suggests that this aim is best accomplished by initiating passive hypothermia prior to transport. Secondarily, this project aimed to improve ability to identify candidates for hypothermia, appropriate medical management, and prevention of potential complications resulting from passive hypothermia. The following project objectives were met: First, medical management of HIE and barriers to initiation of passive hypothermia while awaiting transport were identified by a review of the literature. Second, recommended practice was condensed into a triage algorithm with ccompanying order set targeted to rural clinicians for use while awaiting neonatal transport. Next, the algorithm and order set were presented to the nursing staff and pediatric medical staff in a rural 21 bed, level IIB nursery in Logan, Utah. The medical staff voted unanimously to accept the triage algorithm and order set into their practice. The nursing staff utilized the algorithm and order set as part of a simulation-based training to establish competence. Finally, the algorithm and order set, along with a description of the project, were submitted as an abstract for presentation at a national neonatal nursing conference. The author's review of literature, the developed guideline, order set, and dissemination abstract were reviewed by the project chair and two neonatal content experts for evaluation of appropriate content and utility. By utilizing the algorithm and order set, neonatal clinicians are prepared to identify risk for HIE, communicate efficiently with clinicians at tertiary centers, and effectively manage affected neonates until the transport service arrives. As a result, the neonate at risk for HIE is provided with the most current and promising therapy available regardless of birth location or circumstance.