Neonatal Hotline Telephone Network

(1)

Neonatal

Hotline

Telephone

Network

Paul H. Perlstein, MD, Neil K. Edwards, MS PE, and

James M. Sutherland, MD

From the University of Cincinnati Medical Center, Crosley Memorial Nursery, Cincinnati General Hospital, Cincinnati Children ‘s Hospital Medical Center and the Children’s Hospital Research Foundation, Cincinnati

ABSTRACT. By simplifying the process by which

tele-phone contacts are made, improved communications were

established between a university-affiliated newborn in-tensive care center and some of the community hospital nurseries that it serves as a regional resource. Initiation

of the improved system of communications was

associ-ated with a significant improvement in the survival of

infants transferred from the community hospitals to the

regional care facility. Pediatrics 64:419-424, 1979; corn-munications, regionalization, rnortality.

Since 1968, the Cincinnati Children’s Hospital

Newborn Special Care Unit (NBSCU) has been a

southwest Ohio regional facility to which more than

7,000 sick newborn infants have been transported

for intensive observation and care. Since their

in-auguration, the newborn intensive care facilities in

Cincinnati have always been very well used by the

community; but soon after the NBSCU was

estab-lished it became clear that, except for the

conver-sations needed to physically implement an infant

transfer, dialogues between personnel in the

refer-ring and referral centers were almost nonexistent.

Beginning in 1972, with assistance from the Ohio

Department of Health, an attempt was made to

bridge a possible gap in communication by initiating

a program to install direct, unswitched hotline

tel-ephones connecting some of the community hospi-.

tat nurseries to the Children’s Hospital NBSCU. It

was hoped that these phones would enhance the

sense of community within the regional network of

hospitals and make the consultation services in the

NBSCU more available to those responsible for

Received for publication Dec 27, 1978; accepted Feb 20, 1979. Reprint requests to (P.H.P.) University of Cincinnati, College of Medicine, 231 Bethesda Ave. Room 6103, Cincinnati, OH 45267.

PEDIATRICS (ISSN 0031 4005). Copyright © 1979 by the American Academy of Pediatrics.

evaluating and delivering care to high risk infants not yet transferred to the special care regional nursery.

In the following report, this hotline telephone

system is described along with the measures used

to evaluate its effect as a device for bringing regional

medical resources closer together.

METHODS

Between 1972 and 1975, telephones were installed

in six different hospital nurseries and connected by

direct lines to a special phone located in the

NBSCU at the Cincinnati Children’s Hospital.

Each of the six hospitals was located in a

five-county southwest Ohio region within a 50-mile

ra-dius of Cincinnati. Since the direct wires precluded

the use of switching equipment, no dialing was needed and the personnel in these community

nur-series had only to lift the phone off its cradle to

establish an immediate contact with the Cincinnati

special care nursery. At the Cincinnati Children’s Hospital, the phone was answered by clerks, nurses, pediatric housestaff, neonatology fellows, or staff

neonatologists. If the person answering the phone

did not feel qualified to deal with the particular call

received, the call was referred to an appropriate

resource person.

The NBSCU nursery personnel were encouraged to use the telephones to exchange information

about procedures and principles important to

pro-viding optimal care to newborn infants born in the

participating hospitals. The phones also were used

to help facilitate the transfer of sick infants from

their hospitals of birth to the Children’s Hospital

Regional Intensive Care Unit, and to keep

person-nel and parents remaining at the hospital of birth

informed of the clinical condition and progress of their babies after transfer. To maintain records of

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information exchanged, an approved recording

ma-chine with an audible tone generator was attached

to the phone system and all telephone calls were electronically monitored.

Changes in neonatal mortality were used as the

major measure in evaluating the system’s impact

on newborn care. Three of the six hospitals served

by the hotlines were selected as the sources of study

data. These three phone-connected study hospitals

were selected from among the six simply because

they were not university-affiliated. In addition,

dur-ing the years of study, these hospitals were

gener-ally immune from major changes in policy,

person-nel or other influences, such as expansion in the use

of fetal monitoring, which would have made it

dif-ficult to separate an effect of the telephone from

those resulting from coincident forces. Conversely,

the three phone-connected hospitals not included

in this analysis were eliminated because of their

university affiliations and identifiable multiple

changes in infant care practices associated with and

including the fact that each had a neonatologist in

charge of their nursery during the study period.

Four other non-university-affiliated hospitals

which did not have access to the hotline phone

service during the study years are located within 50

miles of Cincinnati. Of the four

non-phone-con-nected hospitals, three were used for tabulating

control data with which the study data could be

compared. These three hospitals had obstetric and

newborn services of the same size as the three study

phone-connected hospitals and similarly use the

Children’s Hospital as a regional referral center for their high risk infants. The eligible hospital not

used as a source of control data was eliminated

because of its small obstetric service which delivers

less than 300 infants each year.

In summary, the hospitals eliminated from this

analysis were eliminated strictly because of

over-whehning influences that interfered with making a

clear separation between the effect of the telephone

installation and the effects of other variables.

The raw data upon which the analyses were

performed were obtained from the Ohio

Depart-ment of Health, the Cincinnati Bureau of Vital

Statistics, the American Hospital Association, and

from each of the studied hospitals.

SUBJECTS

There was a total of 45,000 babies born in the

three study and three control hospitals in the years

1970 through 1974. The individual hospital births

ranged between 1,100 and 2,500 births in 1970 with

a gradual decline in births recorded in each of these

hospitals between 1970 and 1974. This decline was

consistent with and representative of the changing

birth rates in all of Ohio during these same years.

The percentage of infants born weighing less than

2,500 gm in these six hospitals ranged from 6% to

8% and in none of the hospitals did the percentage

of low birth weight infants change with any

statis-tical significance in the years 1970 through 1974.

Additionally, there was no statistically significant

yearly variation in the 6% to 8% of nonwhite infants

delivered in any of the study or control hospitals

during this period of time.

In expressing the results, no correction has been

made to account for interhospital variations in the

hospital specific baseline percentages of low birth

weight or non-white infants delivered. When made,

these corrections do not alter the significance of the

results. Because of difficulty in obtaining the

nec-essary information, the mortality figures are not

limited to infants who died within the first 28 days

oflife but include all liveborn infants who died prior

to discharge from the hospital care occasioned by

their births. In all of the hospital specific tabula-tions, the deaths of infants after their transfer to

the NBSCU were reassigned to their hospitals of

birth. Absolute mortality rates are expressed as

deaths per 1,000 live births.

RESULTS

The yearly neonatal mortality rate for infants

born in the first study hospital varied insignificantly

between 12.0 in 1970 to 13.1 deaths per 1,000 live

births in 1972. At the end of 1972, a hotline

tele-phone was installed in the hospital’s nursery.

In 1973 (the year following the installation of the

telephone), the mortality rate ofinfants born in the

first study hospital, as tested by analysis, dropped

a significant 21% from 13.3 to 10.4 (P

<

.01). As

ifiustrated in Figure 1, this 21% fall in mortality rate

also was significantly different (P

<

.01) from the

15.4 to 14.4 fall in mortality rate that was registered

by infants born in the first non-phone-connected

control hospital, the 127 to 12.1 change recorded

for infants born in the second control hospital, and

the stable mortality rate of 9.8 tabulated for infants

born in the third control hospital during 1972 and

1973.

Between 1970 and 1974, the mortality rate

changes that occurred in the second and third study

hospitals were relatively stable and similar to those

recorded in the three control hospitals and shared

with the control hospitals the same significant

dis-similarity when compared to the first study hospital

change that occurred in 1973.

In 1974, the mortality rate for infants born in the

first study hospital declined another 12% to 9.1 per

1,000 live births. This continuing decline in

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cz\

\ 6

5

4

3

2

II

0

9

8 7

6

- study hospitals -- control hospitals

MEAN DEAThS

PER 1000 LIVE

BIRTHS

YEAR

BEFORE YrAR YEAR YEAR

PHONE AFTER BEFORE AFTER I Lived 4982 4906

F

Lived 3474 3451J

r

Died 55 40 pied 42 4Lj

[

Toto No 5037 4946 Total No 3516 3492

p(.0O5

I

N.S. ] Fig 2. Mean mortality rates of babies born in study and

control hospitals before and after phones installed in

study hospitals.

.25

-I SE

.20

-

____

MEAN CHANGE IN % OF

LIVEBORN INFANTS I 5

-TRANSFERRED BEFORE & AFTER

PHONES AVAILABLE .1

.05

-PHONE NO PHONE STUDY CONTROL

HOSPITALSHOSPITALS

DIFFERENcE NOT SIGNIFICANT Fig 3. Change in infant transfer rates.

An attempt was made to elucidate the

mecha-nisms by which the presence of direct line

tele-phones enhanced survival. Prior to the installation of phones, a mean of 2.7 ± 0.6% SE of babies born

in the three study hospitals were transferred for

DEATHS care to the NBSCU. Following the phone

installa-PER 000 tions, this proportion remained stable at a mean of

LIVE BIRTHS

2.4

± OM%

SE. A

similar constancy was found in

the percentage of babies transferred out ofthe three

control hospitals during the same time periods. The

phone installations, therefore, did not coincide with

any significant change in the number of patients

transferred out of either the study or control

hos-pitals (Fig 3). In addition, after the phones were

I I I I I

970 1971 972 973 974

s=phone installed

Fig I . Yearly mortality rates of infants born in each

study and control hospital.

mortality rate tabulated for infants born in the

three non-phone-connected control hospitals. In

1974 (the year after hotline phones were installed

in both the second and third study hospitals’

nur-series), the mortality rate of infants born in the

second study hospital was 7.5 which was a

signifi-cant (P

<

.01) decrease of 28% from the 10.4 deaths

per 1,000 live births tabulated for infants born in

that same hospital in 1973. Likewise, the 6.1

mor-tality rate for infants born in the third study

hos-pital in 1974 was a significant 36% less than the 9.5

___________________________

per 1,000 livebirth rate tabulated for infants born in

1973.

__________

Combining the mortality data for the three study

hospitals, an annual mean rate of 10.9

±

1.1 SE per

1,000 live births was tabulated with data generated

by infants born before telephones were installed in

each of the hospitals. This pre-phone installation

death rate was not significantly different from the

12.3

±

1.9 SE death rate tabulated for infants born

in the same years in the three control hospitals.

This contrasted significantly, using a paired t test

(P

<

.005), when compared to the annual mean

death rate of 7.6 ± 0.9 SE per 1,000 live births computed with data on infants born in each of the

three study hospitals after the phones were

in-stalled. In contrast, a comparison of the combined

annual mortality data on infants born during the

same years in the three non-phone-connected

con-trol hospitals demonstrated no significant differ-ence between the mean of 123

±

1.9 SE and the

12.5 ± 1.1 SE per 1,000 live births, respectively,

generated before and after phones were installed in

the study hospitals. These combined data are

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10

F Iter

PHONE NO PHONE

STUDY CONTROL HOSPITALS HOSPITALS

made available, there was no decrease in the rate of

neonatal deaths that occurred in the hospitals of

birth before infants were transported to the

NBSCU.

Whether the transfer of infants occurred before

or after the phones were installed, however, did

make a difference in the ultimate survival of those

infants who were admitted to the NBSCU. Of

ba-bies transferred from the study hospitals in the year

prior to the phone installation, 17.3

±

3.6% SE died

before discharge from the NBSCU. With paired t

test, this was a significantly higher death rate than

the 12.9

±

3.1% SE rate tabulated for infants

trans-ferred from those same three hospitals in the year

following the initial access to the phone service.

This contrasted with the statistically insignificant

difference in the mortality rates of infants cared for

in the NBSCU after transfer from the three

non-phone-connected control hospitals during the same

time periods (Fig 4).

The enhancement in the survival of infants from

the study hospitals was coincident with an

associ-ated increase in the percentage of infants who were

transferred because of clinical decisions arrived at

more quickly following the installation of the

hot-lines.

In the following analysis, a two-hour maximum

was used as a dividing time in tabulating the ages

of infants at the time the decision was made to

transfer each to the NBSCU from each of the study

and control hospitals in the years 1972, 1973, and

1974. This two-hour dividing time was selected after

it first was determined that in 1974 all infants with

respiratory distress syndrome born in local

Cincin-% OF

TRANSFERRED INFANTS

THAT DIED

Lp<02J

Fig 4. Mortality rates of infants after transfer from

hospitals of birth to Newborn Special Care Unit

(NBSCU). Comparison of rates before and after phones

available in study hospitals.

nati hospitals and cared for in the NBSCU who

survived were transferred to the NBSCU at a mean

age of 2.7 hours. This contrasted significantly when

compared to the 9.7-hour mean transfer age of

Cincinnati-born infants with respiratory distress

syndrome who died after arrival at the NBSCU.

Since approximately 45 minutes is the minimum

time needed to transfer a baby from a local

Cincin-nati hospital to the NBSCU, it was presumed that

the decision to transfer the surviving infants was

made by 2 hours of age.

In 1972 (the year prior to the installation of a

direct line telephone), 23 infants were transferred

from the first study hospital. Only in one, or 4.3%,

of the 23 transfers completed, was the decision to

send the infant to the NBSCU made by the time

the baby was 2 hours of age. In 1973 (the year after

the phone was installed), the two-hour decision

time was met in the cases of six, or 33%, of the 18

infants transferred from the first study hospital.

This increase in the number of infants transferred

because of more rapid decisions was significant at

P < .05. In 1974 (the second year after the phone

was installed), the percentage of infants transferred

because of early decisions remained stable at the

significantly higher level of 35% of all transfers

made.

Of the 76 decisions to transfer infants from the

second study hospital to the NBSCU in 1972, 18, or

24%, were made by the time the infants were 2

hours old. In 1973, a similar 12, or 22%, of the 55

infants had their transfers initiated by 2 hours of

age. Both 1972 and 1973 were years prior to the

installation of a hotline telephone in the second

study hospital. In 1974 (the year after a phone was

installed in the second study hospital), a

signifi-cantly greater (P < .05) 40% of the 58 infants

transferred from the second study hospital were

transferred in response to decisions made by 2 hours

of age.

There were 46 infants born in the third study

hospital and transferred to the NBSCU in 1972. A

decision was made by two hours to transfer seven,

or 15%, of these 46 babies. In 1973, the proportion

of babies transported because of rapid decisions

remained stable at 14%, or eight out of 59 infants

transferred. At the end of 1973, a direct phone was

installed in the third study hospital and,

subse-quently, in 1974 when 44 babies were transferred to

the NBSCU, a significantly greater (P < .05) 32%,

or 14 infants, were transferred because of decisions

made by the time the patients were 2 hours old.

Therefore, paralleling the improvement in survival

that followed phone installations in each of the

study hospitals, a significant increase was tabulated

(5)

37.0

.) 36.

35.0

% OF

TRANSFER DECISIONS.

MADE BY 2 Hrs

AFTER BIRTH

P972 913974 1972 973 t974 972913974

r-i_] r1 Efl rIL

NS IIIIik_] C.05 (05 CONTROL FSTDJ ISTUDY L_!p!m Fig 5. Change in transfer decision time before and after phones available in study hospitals.

the phone service became available than was

tab-ulated for transfers made in prior years.

In contrast, annual transfers of infants from the

three control hospitals during this same period of

time remained essentially constant in the

propor-tion of transfers initiated by the 2-hours-of-age

breakpoint time. In 1972 this proportion was 22%;

in 1973, 22%; and in 1974, 19%. These data are

summarized in Figure 5.

Finally, coincident with the significant increase

in the speed with which decisions were made to

transfer infants after the phones were installed

when compared to the pre-phone years, there was

a significant increase (P < .02) in the mean admis-sion rectal temperatures ofstudy infants transferred

after the direct phone service became available (Fig

6).

DISCUSSION

That good communication plays a role in any

effective system of regionalized medical care is

probably so evident that acceptance of its role does

not depend necessarily on proof of its importance.

There are so many examples, however, of errors

being promulgated by solely trusting in the inherent

and obvious virtue of a technique, that it is

reassur-ing to find statistical support for a practice that

might have had no effect beyond simply being

time-consuming and expensive.

At least one other hotline system has been

de-scribed as a resource for improving care in a regional

perinatal system.’ The system described in this

paper, therefore, is not unique. This present study,

however, provides some insight into how telephone

communications can be enhanced to the point of

demonstrably improving the survival of high risk

infants whose management requires transfer to a

specialized center for newborn intensive care.

Since regular dial phone service was available

before the direct hotline phones were installed in

Before After

PHONE

Fig 6. Mean rectal temperatures ofinfants born in study

nurseries on admission to Newborn Special Care Unit

(NBSCU).

the study hospitals, the fact that the hotline

tele-phones were connected by direct wires and required

no dialing to call the NBSCU leads easily to a

conclusion that telephone communications can be

improved by simplifying the process by which

tel-ephone calls are initiated. In addition, the very

presence and clear single purpose of the hotline

telephones in the community hospital nurseries

must be presumed to have helped overcome at least

some of the inertia in the processes by which

trans-fer decisions are reached. That this decision process

is important in reducing neonatal mortality is

sug-gested by the observation that the enhanced

sur-vival associated with the activation of the hotline

telephone service coincided with an acceleration in

the transfer decision and subsequent transport of

infants from the phone-connected community

hos-pitals to the regional NBSCU.

It is also realistic to presume that the complete

cause and effect mechanisms are far more complex

than suggested by the simple statistical

relation-ships demonstrated. For example, review of the

tape-recorded telephone conversations that were

monitored during the study period produced

nu-merous examples of the telephone being used

infor-mally and effectively to teach community hospital

personnel how to quantify their assessments of

ba-bies’ conditions. Undoubtedly these informal

les-sons were aids in enhancing the speed with which

infant transfers were initiated.

During the years of this study, an average of 21

calls a day were handled by the hotline telephone

system. This approximates 13 telephone calls per

year per patient served. The average call was about

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served, approximately 32 minutes of total personnel

time was expended during these conversations.

Both personnel time and hardware expenses were

used in making a cost analysis of this study which

leads to a final observation. if bified directly to

patient care, this telephone service would have

in-creased the cost of each patient’s hospitalization by

less than 0.13%. This seems a small price to pay for

the demonstrated coincident 30% improvement in

infant survival and the unquantifiable but immense

improvement in the quality of relationships that

now exist between the regional Cincinnati special

Infant care center and the greater community that

it serves.

ACKNOWLEDGMENTS

This work was supported in part by Department of

Health, Education and Welfare Grant MCR 390290 and

Ohio Department of Health Grant 731.

The authors acknowledge the cooperation, support,

and advice of all physicians, nurses, and parents who

have participated in making the system described for

communication work to the benefit of the babies born in

the region served.

REFERENCE

1. Baum RS: Consultation by newborn hotline. J md State Med Assoc 66:317, 1973.

THE PRODUCTIVE IDLENESS

Why do intelligent and competent Americans who have spent many years in

a series of reputable educational insitutions often appear to English people to

be fundamentally uneducated?

I think it’s because they work too hard.

From an early age they have spent so much time writing term papers, studying

for tests and pursuing independent research projects, that they have never had

a moment to themselves.

As a result (I must say this even if it sounds insufferable), they lack that sense

of measure, that instinct for what is of value in the life of the mind, that only

comes with years of productive idleness. I mean by “productive idleness” time

spent in undirected reading, uninterrupted thinking, and aimless talk. It is in

these idle hours that an intelligent person becomes an educated person.

Submitted by Student

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1979;64;419

Pediatrics

Paul H. Perlstein, Neil K. Edwards and James M. Sutherland