Centre-specific differences in short-term outcomes in neonates with hypoxic-ischaemic encephalopathy

Abstract

AIMS OF THE STUDY:To investigate and compare the centre-specific short-term outcome indicators seizures, arterial hypotension, infection and mortality during therapeutic hypothermia until discharge from the neonatal/paediatric intensive care unit in term and near-term neonates with hypoxic-ischaemic encephalopathy (HIE) registered in the Swiss National Asphyxia and Cooling Register between 2011 and 2018.METHODS: Retrospective analysis of prospectively collected national register data between 1 January 2011 and 31 December 2018. Pregnancy, maternal, delivery and neonatal characteristics were compared between the centres. Four short-term outcomes were defined: seizures, arterial hypotension, infection and mortality. The outcome indicators were defined as stated in the protocol of the Swiss National Asphyxia and Cooling Register. Descriptive analyses of the de-identified centre to centre analysis were performed, and standardised observed-to-expected values (risk adjusted for male sex, small for gestational age, Sarnat score on admission, pregnancy/delivery complications) of each centre were compared using with the entire network indirectly standardised mortality/morbidity ratio charts. RESULTS: 570 cooled neonates with HIE receiving therapeutic hypothermia in 10 different centres were included. Clinical or subclinical seizures were reported in a median of 32% (range 17-49%). Arterial hypotension occurred in a median of 62% (range 30-90%). Median infection rate was 10% (range 0-31%). Median mortality rate until discharge was 14% (range 0-25%).CONCLUSIONS: Short-term outcome indicators of seizures, arterial hypotension, infection and mortality showed significant differences in incidence between the centres. These data will help to establish benchmarks for the assessed outcome measures. Benchmarking is a con-tinuous need with the ultimate goal of improving modifiable short-term outcomes in neonates with HIE.

Process variations between Swiss units treating neonates with hypoxic-ischemic encephalopathy and their effect on short-term outcome

“…Passive cooling showed higher odds for infection and arterial hypotension in our cohort. As passive cooling was performed to a largest part by unit 5 and this unit also had the highest rate of infection (Table 2), we interpret these results as an effect of unit variation in short-term outcome as recently published [21] rather than as an association between passive cooling and the occurrence of infection or hypotension.…”

“…The short-term outcomes reported in our study are discussed in detail in a recent publication [21]. It summarizes the difficulty in comparing outcomes between units that have different approaches for diagnosing arterial hypotension or different degrees of expertise in detecting seizures.…”

“…Neonatal deaths did not occur in unit 6 (of the 11 included neonates, 7 were recorded with 2-year follow-up and 4 with discharge data confirming survival) and reached up to 27% in units 2 and 3. More details on unit-specific outcome have recently been published by Grass et al [21].…”