Community Perspective Michael Sylvia, MD FAAP Care of the neonate Community Perspective Michael Sylvia, MD FAAP

Context: Maria Parham Health Located in Henderson, Vance County 44,000 people ; median income $32,000 ; 25% poverty ; 60% non-Caucasian* Additional 140,000 citizens in surrounding Warren, Franklin and Granville Counties* 102 bed hospital built in 1925 500-600 annual deliveries Level II NICU status 2-4 transfers per month Joint venture between Duke and LifePoint Health *Data sources: US Census Bureau and Data USA

Level of Care >34 weeks gestation without significant need of support Mild respiratory distress Neonatal withdrawal monitoring Neonatal sepsis evaluation and observation Hypoglycemia Poor feeding CPAP but no HFNC / HiVNI Echo available non-emergently Stabilize and transfer all additional neonates

Common Scenario 36 week GA infant, mother had prenatal care, delivered through meconium fluid developed persistent respiratory distress after delivery. Started on CPAP, but remains distressed. Likely TTN or mild meconium aspiration. 1, maybe 2, nurse(s) available to assist Respiratory therapy needs to be double checked Infant needs labs, IV access, Xray, etc Infant may require central line placement

Transfer Process Data Duke Neonatal Fellow Phone No collaborative agreement, generally fist call Parent has right to refuse but cannot specify location UNC then Wake Med typical order of succession Bed available  transfer usually accepted No bed availability requires subsequent calls to other neonatal ICU Arrange / discuss with transport service Ground ~1 – 1.5 hours, Air 0.5 – 1 hr Compile patient chart, copy notes / labs / etc.

Limitations Staff Time Resources Capability Mother typically unable to transfer Limited information to convey to parent(s) Follow-up lacking Currently no process for back transfer