Effect of skill-based educational training for ambulance personnel on neonatal transport&nbsp;for newborn care in coastal South India – a single arm intervention study

Santosh Kalyan; Sowmini Padmanabh Kamath; Subhodh Shetty S; Ramesh Holla; Leslie Lewis; Harsha Lashkari P; Suchitra Shenoy M; Shantharam Baliga B

doi:10.12688/f1000research.150058.2

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Research Article

Revised

Effect of skill-based educational training for ambulance personnel on neonatal transport for newborn care in coastal South India – a single arm intervention study

[version 2; peer review: 2 approved, 1 approved with reservations]

Santosh Kalyan¹, Sowmini Padmanabh Kamath ¹, Subhodh Shetty S², [...] Ramesh Holla³, Leslie Lewis⁴, Harsha Lashkari P¹, Suchitra Shenoy M⁵, Shantharam Baliga B¹

Santosh Kalyan¹, Sowmini Padmanabh Kamath ¹, [...] Subhodh Shetty S², Ramesh Holla³, Leslie Lewis⁴, Harsha Lashkari P¹, Suchitra Shenoy M⁵, Shantharam Baliga B¹

PUBLISHED 02 Jan 2025

Author details Author details

¹ Department of Pediatrics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India
² Department of Neonatology, Kasturba Medical College, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India
³ Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India
⁴ Department of Pediatrics, Kasturba Medical College, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India
⁵ Department of Microbiology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India

Santosh Kalyan
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Sowmini Padmanabh Kamath
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Subhodh Shetty S
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Ramesh Holla
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Leslie Lewis
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Harsha Lashkari P
Roles: Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Suchitra Shenoy M
Roles: Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Shantharam Baliga B
Roles: Conceptualization, Data Curation, Investigation, Methodology, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Manipal Academy of Higher Education gateway.

Abstract

Background

Quality of neonatal transport services may impact outcomes. We assessed the effect of skill-based education of ambulance personnel (AP) on outcomes of transported neonates.

Methods

We conducted a single-arm intervention study (pre and post) over 18 months. We assessed the perceptions and practices of AP on neonatal transport along with ambulance equipment availability/usage. We compared neonatal clinical vital parameters at arrival and clinical outcomes from Neonatal Intensive Care Unit (NICU) pre versus post intervention. We analysed data using SPSS version 25.

Results

Of 77 AP receiving education, there was significant (p < 0.001) improvement in the perceptions/practices towards temperature regulation (44.55 ± 23.94 vs. 25.94 ± 21.36), glucose homeostasis (46.27 ± 18.83 vs. 18.60 ± 17.50), maintaining asepsis (67.05 ± 17.53 vs. 39.35 ± 16.85), supporting airway (47.73 ± 25.39), circulation (85.26 ± 23.27 vs. 48.45 ± 25.10), along with ambulance equipment availability/usage postintervention. Of 53 neonates studied post intervention, there was a significant reduction in hypothermia (17% vs. 48.4%, p < 0.001), hypoglycemia (16.9% vs. 38.7%, p=0.010), and prolonged capillary refill time (71.7% vs. 46.8%, p=0.042), improvement in the use of intravenous fluids (69.8% vs. 29%, p <0.001), a reduction in growth from umbilical swabs (15.1% vs. 42%, p=0.002) and duration of NICU stay (p = 0.001).

Conclusions

After educational intervention there was significant improvement in the perceptions and practices of ‘108’ ambulance personnel towards transporting neonates and a significant decrease in hypothermia, hypoglycemia, and duration of NICU stay with improvement in maintenance of circulation and asepsis in neonates.

Keywords

Ambulances, Checklist, Hypothermia, Hypoglycemia, Infant, Intensive care units, Neonatal, Newborn

Corresponding author: Sowmini Padmanabh Kamath

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2025 Kalyan S et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Kalyan S, Kamath SP, Shetty S S et al. Effect of skill-based educational training for ambulance personnel on neonatal transport for newborn care in coastal South India – a single arm intervention study [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2025, 13:767 (https://doi.org/10.12688/f1000research.150058.2) First published: 08 Jul 2024, 13:767 (https://doi.org/10.12688/f1000research.150058.1) Latest published: 02 Jan 2025, 13:767 (https://doi.org/10.12688/f1000research.150058.2)

Revised Amendments from Version 1

Based on the comments and suggestions from the reviewers, we revised and modified the abstract, introduction, methodology, results, and discussion sections. References were added and updated in the manuscript.

See the authors' detailed response to the review by Rakesh Kotha
See the authors' detailed response to the review by A Shashidhar Rao
See the authors' detailed response to the review by Sanoj Karayil Mohammad Ali

Introduction

The first month of life is the most critical time for a child’s survival and demands higher-quality intrapartum and neonatal care. An essential component of newborn care is neonatal transport. Worldwide, neonatal mortality has decreased from 5.0 million to 2.3 million deaths between 1990 and 2022. Approximately 6500 newborns die every day, accounting for 47% of the deaths of children under the age of five. Preterm birth, infections, birth asphyxia, and birth abnormalities cause most neonatal deaths but conditions during transfer to a higher center, may also contribute to mortality and morbidity. The neonatal mortality rate globally is 17/1000 live births, whereas in India, it is 23/1000 live births.^1,2

Neonatal transport is an evolving and challenging concept in the Indian context,³ due to the constrained and nonuniform distribution of health care facilities and inadequate systems. Although in-utero transport is best, we cannot predict preterm delivery/prospective perinatal problems. Thus the need arises for a dedicated transport facility to an apt well-equipped health care center.^4–6 Among the ambulances, the ‘108’ ambulance service of the Emergency Management and Research Institute (EMRI)⁷^,⁸ is a public–private partnership with ‘108’ being the toll-free emergency telephone number across various Indian states. They provide services for the public free of cost, are time-trusted, frequently used, and available across multiple districts of Karnataka but specialized neonatal ambulances from EMRI are available only in Tamilnadu and Goa. Our study focused on only neonates transported by ‘108’ ambulances.

The Indian government has demonstrated a strong political commitment to lowering newborn mortality. In India, newborn fatalities constitute 27% of all neonatal deaths worldwide. The Sustainable Development Goal target 3.2⁹^,¹⁰ and the Indian Newborn Action Plan (INAP) goal¹¹ of a neonatal mortality rate of 12 or fewer per 1000 live births by 2030 is yet to be achieved by most states in India and is challenging. One of the significant obstacles to achieving this goal is the lack of dedicated neonatal transport. Neonatal survival depends not only on the quality of care delivered to the neonate in the NICU but also on the neonate’s condition during NICU admission.¹²

The golden hour of management in neonatal care, stabilization before and during transport, has improved outcomes.^13–15 Transporting sick neonates via specialized transportswith well-assembled and skilled teams can reduce mortality.³^,^13,15 Navjat Shishu Suraksha Karyakram (NSSK), introduced by the Government of India (GOI), also highlights safe neonatal transport.¹⁶

Early identification of babies with altered acute physiology to determine the need for referral, care during transport, and timely therapy at the neonatal intensive care unit (NICU) is known to stop the progression of morbidity, aid recovery, and reduce mortality.¹⁷ Moreover, ineffectual transport can lead to complications such ashypothermia, hypoxia, and hypoglycemia, which can adversely affect neonatal outcomes. Previous studies related to transported neonates have recorded hypothermia between 27 to 55.3%,^17–24 poor circulation in 8.6 to 43.42%,^{17,18,21,23,24} and hypoglycemia in 7.4 to 35%^18,20–24 of neonates. However, facilitated referral in dedicated neonatal ambulances have far lower incidences of hypothermia and hypoglycemias.^3,13,15,25

Thus, understanding and rectifying the ambulance personnel’s perception/practices towards neonatal transport is essential for effective neonatal outcomes. We studied skills of the ‘108’ ambulance personnel towards recognition, monitoring, and preventive strategies for hypothermia, hypoglycemia, abnormal respiratory rates, heart rates, and perfusion, practices of aseptic measures during neonatal transport before and after a skill based educational intervention. In addition, we assessed the impact of the intervention on the arrival clinical parameters (e.g. vitals, temperature, blood glucose, etc.) and clinical outcomes (survival/mortality, NICU duration of stay, blood culture positivity rates).

Methods

Study design, setting and ethics

This research follows the “Consolidated Standards of Reporting Trials (CONSORT) statement guidelines.”²⁶ The Reporting guidelines contain a completed CONSORT 2010 checklist.²⁷ Figure 1 depicts the study flow according to CONSORT 2010 criteria.²⁷ This single-arm intervention trial (pre- versus postintervention) was designed to assess the impact of skill-based educational training on ‘108’ ambulance personnel for early newborn care over 18 months at a tertiary neonatal intensive care unit attached to a medical college hospital in southern India.

The participant recruitment and data collection process started on 1 June, 2016.

The study was conducted in accordance with the 1964 Declaration of Helsinki, its subsequent revisions, and other relevant ethical guidelines. The institutional ethics committee of Kasturba Medical College, Mangalore, Manipal Academy of Higher education, Karnataka, Manipal, India (IEC KMC MLR 05-16/102, dated May 18, 2016) authorized the study. We took necessary permissions from the hospital authorities and the authorities concerned with the ‘108’ ambulance personnel. We obtained written informed consent from the ‘108’ ambulance staff and the parents/guardians of the newborns to participate in the study and publish the results (as in Extended data).²⁷

We registered the study on 26 March 2018 in the Clinical trial registry of India: CTRI registration number CTRI/2018/03/012830 (https://ctri.nic.in/Clinicaltrials/login.php).

Although this study was a prospective trial, it allowed us to register the protocol trial even after we initiated the first enrollment of the patient/subject, and this was applicable as per CTRI rules until March 31st, 2018.

However, CTRI announced that from April 1st, 2018, registration will be allowed only prospectively for clinical trials/studies, that is, before the enrolment of the first patient.

Participant recruitment:

The inclusion criterion for the study population was as follows:

1. The neonates transported to the center by ‘108’ ambulance services:
All the consecutive neonates transported only by the ‘108’ ambulances to our center during the study period were included for the neonatal outcomes (primary and secondary) measures.
2. The neonates transported to the center by ‘108’ ambulance services:
All the consecutive neonates transported only by the ‘108’ ambulances to our center during the study period were included for the neonatal outcomes (primary and secondary) measures.

Exclusion criteria: The AP and the parents/guardians who expressed unwillingness to be a part of the research were excluded. The AP’s who could not attend the educational intervention program were excluded.

Data collection

We collected the data via the following tools:

Tools 1, 2 and 3 were filled by the resident duty doctor.

Tool 1: A structured questionnaire for ambulance personnel to assess their perceptions and practices towards neonatal transport (as in Extended data).²⁷ The questionnaire had two sections: section (A) included personal information of the AP; section (B) included the questions that assessed perceptions and practices related to temperature regulation, glucose control, vital parameters, and asepsis of the neonates transported.

Tool 2: Checklists to assess the availability and utilization of the equipment in the ‘108’ ambulances (as in Extended data).²⁷

Tool 3: A pre-structured proforma for residents at the arrival center to document the primary and secondary outcome measures of the neonates that are transported (as in Extended data).²⁷

We used tools 1,2 and 3 to capture the relevant data both before and after the educational intervention for comparison. Subject experts validated the content of tools 1,2 and 3.

The clinical tools used included digital thermometers, one-touch glucometer strips, and umbilical culture swabs. Instead of specific neonatal probes, adult probes were used for assessing continuous vitals during transport; thus, oxygen saturation levels were not included as a parameter in our study.

On the arrival of neonates at our center, the resident duty doctor-using tool 3 proforma, documented clinical parameters such as temperature, blood glucose, vitals, and the presence of connected intravenous (IV) fluids on the transported neonates. Upon reaching the hospital, a digital thermometer was used to record the axillary temperature. A glucometer was used to measure blood sugar levels. Heart rate and SpO₂ measurements were taken via a multipara monitor. The respiratory rate was estimated via manual counting.

Umbilical swabs were cultured on chocolate agar and MacConkey agar media, incubated at 37 degrees centigrade for 18-24 hours, and organisms grown were identified via biochemical reactions. These neonates were further followed for documentation of secondary outcome measures on tool 3 proforma by the first author. The clinical parameters and outcomes of transported neonates documented pre- and post-intervention were compared. The study flow of methodology is depicted in Figure 1.

Operational definitions

The clinical physiological vital parameters were defined as follows i). Hypothermia - axillary temperature of less than 36.5 degree centigrade ii). Hypoglycemia - blood sugar of less than 50 mg/dl, iii). Prolonged capillary filling time (CFT) - CFT of more than 3 seconds, iv). Tachycardia - heart rate ≥ 160 beats per minute, v). Bradycardia - heart rate ≤ 100 beats per minute vi). Tachypnea - respiratory rate > 60 cycles per minute. Neonatal sex was determined by external examination of body characteristics (external genitalia examination).^28,29

Intervention

We divided the ‘108’ ambulance personnel into five batches for the skill-based educational intervention program ( Table 1). Each set was given skill-based academic training as per NRP guidelines for seven hours each, on five separate days, by a team of pediatricians (first three authors) in their local language. We stressed the following concepts as per neonatal resuscitation program (NRP) guidelines³⁰ during skill-based education training in the form of theoretical knowledge, video-based teaching, and hands-on training for ambulance personnel:

Table 1. Skill-based educational intervention training program for ambulance personnel.

Sl no	Skill-based educational intervention training program for ambulance personnel
1.	Hand washing skills, use of sterile gloves
2.	Basic NRP training ▪ Drying, positioning, suctioning, stimulation, repositioning ▪ Selection of appropriate size mask for bag and mask ventilation ▪ Hands-on training in providing a correct method of positive pressure ventilation (PPV) ▪ Observing adequate chest rise. ▪ Ventilator corrective steps
3.	Keeping baby dry and warm
4.	Transport with clean, covered clothing
5.	Secure and check IV-line functioning
6.	Glucose/Temperature monitoring during transport
7.	Regular Sanitization of ambulance and transport trolley
8.	Equipment availability and usage

After five months of intervention, we assessed the retention capacity of skills among the ambulance personnel via the tool 1 questionnaire and the equipment availability/usage via tool 2 checklists.

Outcome measures

1. Outcomes in AP - Perceptions and practice
2. Outcomes in neonates

a). Primary outcome measures: included assessment of clinical parameters at arrival to our center related to

• Thermoregulation,
• Blood glucose levels,
• Vitals (heart rate, respiratory rate, and capillary filling time),
• Presence of connected IV fluids at arrival, and
• Umbilical swab colonization.

b). Secondary outcome measures: included assessment of the clinical outcomes of transported neonates admitted to NICU related to

• Survival/mortality,
• Neonates discharged against medical advice,
• Duration of NICU stay,
• Presence/absence of blood culture positive sepsis.

Statistical analysis

We analyzed the data collected by IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. We used the Chi-square and Fischer exact P test to compare the primary and secondary outcome measures. To assess the ambulance personnel's knowledge, we calculated a mean score and used paired t-tests to compare pre- and post-intervention scores.

Results

Figure 1. Depicts the study flow according to CONSORT 2010 criteria.²⁷

Baseline characteristics of AP and transported neonates

The numbers of neonates transported in the pre-intervention and the post-intervention phases were 62 (29 females and 33 males) and 53 (23 females and 30 males), respectively.²⁷ The distance travelled by the 108 ambulances for neonatal transport varied between 0.5 km and two hundred kms: duration of transport ranging between 10 minutes and 360 minutes. Mean birthweight of transported neonates was 2.01 kgs and 2.04 kgs in the pre- and postintervention phases. Most neonatal cases referred to were preterms (nearly 30%); neonatal sepsis in 25.8 % & 22.6%, and respiratory distress in 13% & 18.9% of neonates in the pre- and postintervention phases, respectively. Pediatric surgical cases accounted for 6.4% and 7.5% in the pre- and postintervention phases respectively. For the 80 APs recruited, data on 77 were available for both before and after the intervention. Educational qualifications of 77 APs included 52 matriculates, 23 preuniversity, and two graduates.

Primary and secondary outcome measures of transported neonates

After intervention ( Table 2), there was significant reduction in hypothermia (p < 0.001), hypoglycemia (p = 0.010), prolonged capillary refill time (p = 0.042), and a significant parallel improvement in the use of intravenous fluids (p < 0.001) in transported neonates. There was a trend towards improvement of vital parameters such as heart rate and respiratory rate postintervention which was not statistically significant. The growth of the organisms from the umbilical swabs significantly decreased (p = 0.002) from 42% to 15.1% and the predominant organism viz. Staphylococcus aureus decreased from 32.2% to 11.3% postintervention.

Table 2. Clinical Parameters of Neonates at Arrival to Centre (pre-intervention versus post-intervention).

Variables	Interpretation	Pre-Intervention Phase (n = 62)	Post Intervention Phase (n = 53)	P-Value
Heart rate	Normal	37 (59.7%)	42 (49.2%)	0.074
	Tachycardia	19 (30.6%)	9 (17%)
	Bradycardia	6 (9.7%)	2 (3.8%)
Respiratory rate	Normal	42 (67.7%)	44 (83%)	0.169
	Tachypnea	15 (24.2%)	7 (13.2%)
	Apnea	5 (8.1%)	2 (3.8%)
Capillary Filling Time	< 3 seconds	33 (46.8%)	38 (71.7%)	0.042 *
Capillary Filling Time	>3 seconds	29 (53.2%)	15 (28.3%)	0.042 *
Hypothermia	Yes	30 (48.4%)	9 (17%)	< 0.001 *
Hypothermia	No	32 (51.6%)	44 (83%)	< 0.001 *
Hypoglycaemia	Yes	24 (38.7%)	9 (16.9%)	0.010 *
Hypoglycaemia	No	38 (61.3%)	44 (83.1%)	0.010 *
Intravenous fluids at admission	Yes	18 (29%)	37 (69.8%)	< 0.001 *
Intravenous fluids at admission	No	44 (71%)	16 (30.2%)	< 0.001 *
Umbilical swab colonisation	Growth present	26(42%)	8(15.1%)	0.002 *
Umbilical swab colonisation	No growth	36 (58%)	45 (84.9%)	0.002 *

* Significant at < 0.05.

There was a significant reduction in the duration of NICU stay (p = 0.001) postintervention. There was a nonsignificant decrease in mortality from 14.5% to 9.43%, growth in blood culture from 24.2% to 15.1%, and yield of staphylococcus in blood cultures from 33% to 25 % post-educational intervention ( Table 3).

Table 3. Clinical Outcomes of the Neonates Transported Pre-intervention versus post-intervention phases.

Outcome Measures	Pre-Intervention phase (n=62)	Post Intervention phase (n=53)	P-Value
Duration of NICU stay (days)			0.001 *
< 5	15 (24.2%)	17 (32.1%)
5-10	20 (32.3%)	12 (22.6%)
11-20	25 (40.3%)	10 (18.9%)
>20	2 (3.2%)	14 (26.4%)
Final Outcome of neonates			0.372
Discharged	49 (79.03%)	41 (77.36%)
Mortality	9 (14.52%)	5 (9.43%)
Leave against medical advice	4 (6.45%)	7 (13.21%)
Blood Culture Growth			0.224
Growth present	15 (24.2%)	8 (15.1%)
No Growth	47 (75.8%)	45 (84.9%)

* Significant at < 0.05.

Perceptions and practices of ambulance personnel towards neonatal transport

There was a significant improvement (p < 0.001) in the mean scores of perceptions and practices of ambulance personnel (retention capacity) in the post-intervention versus preintervention phase which was related to different domains in the questionnaire ( Table 4).

Table 4. Assessment of ambulance personnel's perceptions and practices toward neonatal transport (pre-intervention versus post-intervention phases) (n=77).

Questions related to domains	Pre-Intervention score Mean ± SD	Post- Intervention score Mean ± SD	P-value
Temperature regulation	25.94 ± 21.36	44.55 ± 23.94	< 0.001 *
Glucose homeostasis	18.60 ± 17.50	46.27 ± 18.83	< 0.001 *
Respiration	20.45 ± 18.46	47.73 ± 25.39	< 0.001 *
Circulation	48.45 ± 25.10	85.26 ± 23.27	< 0.001 *
Sepsis prevention	39.35 ± 16.85	67.05 ± 17.53	< 0.001 *

* Significant at < 0.05.

Ambulance equipment availability and usage

Among the 24 ambulances that transported neonates, there was an improvement in the availability and usage of the following equipment: digital thermometer, glucometer, glucometer strips, neonatal masks, and pulse oximeters postintervention. The use of hand rubs had improved with a reduction in the blood culture growth and umbilical swab colonization.

Discussion

Neonates’ prospects for survival depend not only on the quality and extent of neonatal care offered, but also on the state of the newborn at admission. We studied variations pre versus posteducational intervention in terms of i) newborn arrival clinical parameters, ii) clinical outcomes, iii) ambulance crew perspectives and practices toward neonatal transport, and iv) the availability and use of ambulance equipment.

Most neonates transported in pre- and postintervention phases of the study were for preterm care and their issues. This observation is akin to other studies performed in developing countries.^4,17,25,31 After the intervention, the rates of hypothermia and hypoglycemia reduced from 48.4% to 17% and 38.7% to 16.9%, respectively. Neonatal hypoperfusion reduced to 28.3% and IV fluid administration significantly improved it from 29% to 69.8% postintervention. Different studies on neonatal transport have shown that 27% to 55.3%,^17–24 of neonates are hypothermic, and 7.4 to 35 %.^18,20-24 are hypoglycemic. Hypoperfusion was observed in 8.6 to 43.42%^{17,18,21,23,24} of newborns in other studies.

The significant reduction in the incidence of hypothermia and hypoglycemia postintervention is similar to that reported in the study by Kaushal et al., which was performed in two phases (before versus after training).³² Kaushal et al.,³² adopted crew training via the STABLE neonatal education program, which has six assessment care modules related to Sugar, Temperature, Airway, Blood pressure, Lab work, and Emotional support; however, in our study, training was performed in accordance with the NRP guidelines.³⁰

Research on neonatal transport has demonstrated a substantial correlation between abnormal physiological parameters and newborn mortality.^20,21,33 Conversely, favorable outcomes were observed when hemodynamic stability was preserved with improved vitals^33,34 throughout transport; these outcomes were noticeably greater when a committed, knowledgeable team provided neonatal care.^3,13,15,25 The efficiency of dedicated neonatal ambulance services was indicated by the significantly lower rates of hypothermia (2.3%²⁵ & 3.2%³), hypoglycemia (3.2%³ & 4.59%²⁵), and hypoperfusion (3.44% of cases²⁵).

Contrary to other studies,^19,24,25 our study had lower mortality rates of transported neonates and a significant reduction in NICU stay duration. This could be because of improved neonatal transport postintervention and because of different spectra of cases during both phases. In addition, the reduction in incidence rates of hypoglycemia, hypothermia, and abnormal CRT in our study was probably because of i) concurrent improvements in the availability and usage of thermometers and glucostrips, ii) clean clothing for wrapping baby, iii) neonatal masks for supplementing oxygen and iv) transporting newborns with IV access and fluids as indicated.

Despite the intervention, equipment such as neonatal saturation probes, neonatal warmers, and embrace was unavailable. Our study documented the facilities available for transporting neonates by ‘108’ ambulance needs optimization. Upgrading facilities of ‘108’ ambulances and training ambulance personnel would improve outcomes of transported newborns and is similar to findings by Manikyamba et al.²³

Postintervention, the transported neonates in the current study showed significant reductions in umbilical swab colonization growth and in blood culture positivity rates, with parallel increases in hand rub availability and use. The selection of antibiotics and the cleanliness of referral facilities are two further factors that could have impacted our study’s results.

The mean scores of the perceptions and practices of the ambulance personnel in our study had improved in the postintervention phase with skill-based educational intervention measures. It has been shown to have an impact on primary and secondary outcome measures and the availability and usage of equipment to a certain extent.

The retention knowledge (perception and practices) of ambulance personnel even after six months of intervention, along with improvement in the arrival clinical parameters and clinical outcomes at discharge indicates the sustainability of the intervention. In addition, capacity-building or reinforcing skills at the primary level in newborn care, recognizing danger signs, implementing early referrals, adopting safe neonatal transport measures, and conducting repeated refresher courses for ambulance personnel would aid in achieving the goal of single-digit NMR.^25,35 We could appropriately use evidence-based Kangaroo mother care interventions during transport. A Cochrane review³⁶ suggested that cluster trials (comparing groups of hospitals) with specialist teams for neonatal transport could provide better evidence about mortality and morbidity issues.

Limitations

The current study had confounding factors, which could have caused a bias in the results. Knowledge bias could be produced via the use of preintervention questionnaire surveys and background information to determine ambulance personnel awareness and practices. Factors such as choice of antibiotics administered and variations in prior treatment and referral hospital environments could have affected the blood culture growth, the details of which we did not collect in the study because of feasibility issues. Although preterm cases were the primary referrals, the spectrum of cases that arrived in both phases varied. Our findings may have been influenced by risk factors for early onset sepsis; thus we recommend that future research should undertake molecular typing of organisms from a variety of locations, such as ambulances and referral clinics, to help determine the main point of infection dissemination. The neonatal clinical parameters at arrival and neonatal outcomes during NICU stay can differ from case to case. We also suggest quality improvement approach will be more useful to address the gaps in similar studies in the future.

Conclusions

The education of ambulance personnel on basic newborn resuscitation, asepsis, temperature regulation, and glucose maintenance reduces the frequency of hypothermia, hypoglycemia, hypoperfusion, and infection in transported neonates and improves their perceptions/practices.

Ethics & consent

The study was conducted in accordance with the 1964 Declaration of Helsinki, its subsequent revisions, and other relevant ethical guidelines. The institutional ethics committee of Kasturba Medical College, Mangalore, Manipal Academy of Higher education, Karnataka, Manipal, India (IEC KMC MLR 05-16/102, dated May 18, 2016) authorized the study. We obtained necessary permissions from the hospital authorities and the authorities concerned with the ‘108’ ambulance personnel. We obtained written informed consent from the ‘108’ ambulance staff and the parents/guardians of the newborns to participate in the study and publish the results.

Data availability

Underlying data

Open Scientific Framework: Effect of skill-based educational training for ambulance personnel on neonatal transport for newborn care in coastal south India -A single arm intervention study. https://doi.org/10.17605/OSF.IO/J5GQ7.²⁷

This dataset contains the following underlying data:

• Pre intervention phase data excel sheet.
• Post intervention phase data excel sheet.

Extended data

This dataset contains the following underlying extended data:

• Participant information sheet (ambulance personnel)
• Parent/guardian information sheet
• Informed consent form for ambulance personnel
• Informed consent form for parents/guardians of neonates
• Perceptions and practices questionnaire (ambulance personnel)
• Checklist questionnaire for equipment availability and usage
• Questionnaire for Primary and Secondary Outcome measures of neonates

Reporting guidelines

Open Scientific Framework: CONSORT 2010 checklist for ‘Effect of skill-based educational training for ambulance personnel on neonatal transport for newborn care in coastal south India -A single arm intervention study’. https://doi.org/10.17605/OSF.IO/J5GQ7.²⁷

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgements

We thank the “108” ambulance personnel, neonates and the parents/guardians of neonates who participated in the study

References

1. World Health Organization: Newborn Mortality.Key facts.2024, Mar 14. Reference Source
2. UNICEF: Neonatal mortality. 2024, Mar 1. Reference Source
3. Kumar PP, Kumar CD, Venkatlakshmi A: Long distance neonatal transport--the need of the hour. Indian Pediatr. 2008; 45: 920–922. PubMed Abstract
4. Sehgal A, Roy MS, Dubey NK, et al.: Factors contributing to outcome in newborns delivered out of hospital and referred to a teaching institution. Indian Pediatr. 2001; 38: 1289–1294. PubMed Abstract
5. National Neonatology Forum: Evidence based clinical practice guidelines.2010. [Last accessed on 2023 Nov 23]. Reference Source
6. Rashid A, Bhuta T, Berry A: A regionalised transport service, the way ahead? Arch. Dis. Child. 1999; 80: 488–492. PubMed Abstract | Publisher Full Text | Free Full Text
7. Kumutha J, Rao GV, Sridhar BN, et al.: The GVK EMRI maternal and neonatal transport system in India: a mega plan for a mammoth problem. Semin. Fetal Neonatal Med. 2015 Oct; 20(5): 326–334. PubMed Abstract | Publisher Full Text
8. 108 Emergency Management and Research Institute: [Last accessed on 2023 Nov 25]. Reference Source
9. World Health Organization: Every newborn: an action plan to end preventable deaths.2014. (Last accessed on 2023 Dec 29). Reference Source
10. Kumar S, Kumar N, Vivekadhish S: Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs): Addressing Unfinished Agenda and Strengthening Sustainable Development and Partnership. Indian J. Community Med. 2016; 41(1): 1–4. PubMed Abstract | Publisher Full Text | Free Full Text
11. Ministry of Health and Family Welfare, Government of India: National Health Mission. INAP India Newborn Action Plan.2014. [Last accessed on 2024 Jan 15]. Reference Source
12. Aggarwal KC, Gupta R, Sharma S, et al.: Mortality in newborns referred to tertiary hospital: An introspection. J. Family Med. Prim. Care. 2015; 4: 435–438. PubMed Abstract | Publisher Full Text
13. Kempley ST, Sinha AK; Thames Regional Perinatal Group: Census of neonatal transfers in London and the Southeast of England. Arch. Dis. Child Fetal Neonatal Ed. 2004; 89: F521–F526. PubMed Abstract | Publisher Full Text | Free Full Text
14. Ramji S: Transport in community. J. Neonatol. 2005; 19: 328–331. Publisher Full Text
15. Kumar PP, Kumar CD, Shaik F, et al.: Transported neonates by a specialist team - how STABLE are they. Indian J. Pediatr. 2011; 78: 860–862. PubMed Abstract | Publisher Full Text
16. Ministry of Health and Family Welfare, Government of India: Navjaat Shishu Suraksha Karyakram: Resuscitation and essential Newborn Care Resource Manual.2020. [Last accessed on 2021 Feb 15]. Reference Source
17. Rao SK, Bajaj N, Rawat A: Pre-transport factors and transport quality affecting the neonatal outcome. J. Evol. Med. Dent. Sci. 2015; 04: 1991–1995. Publisher Full Text
18. Sampathkumar P, Gobinathan S: A study on status of neonatal transport to a level III neonatal intensive care unit. Int. J. Contemp. Pediatr. 2018; 5: 1040–1043. Publisher Full Text
19. Rathod D, Adhisivam B, Bhat BV: Transport of sick neonates to a tertiary care hospital, South India: condition at arrival and outcome. Trop. Dr. 2015; 45: 96–99.
20. Singh J, Dalal P, Gathwala G, et al.: Transport characteristics and predictors of mortality among neonates referred to a tertiary care centre in North India: a prospective observational study. BMJ Open. 2021 Jul 6; 11(7): e044625. PubMed Abstract | Publisher Full Text | Free Full Text
21. Kiputa M, Salim N, Kunambi PP, et al.: Referral challenges and outcomes of neonates received at Muhimbili National Hospital, Dar es Salaam, Tanzania. PLoS One. 2022 Jun 15; 17(6): e0269479. Publisher Full Text
22. Tongo O, Abdulraheem MA, Orimadegun AE, et al.: Immediate Outcomes of Neonatal Transport in a Tertiary Hospital in South-West of Nigeria. Glob. J. Ped. Neonatol. Car. 2020; 2(1): GJPNC.MS.ID.000529. Publisher Full Text
23. Manikyamba D, Madhavi N, Reddy SM, et al.: Status of Neonatal Transport and Impact of Facilitated Referral on the Outcome of Transported Sick Newborns: At Tertiary Care Hospital. Sch. J. App. Med. Sci. 2017; 5: 3929–3934.
24. Dalal E, Vishal G, Solanki D: Study on neonatal transport at tertiary care centre. Int. J. Sci. Res. 2013; 2: 289–292.
25. Punitha P, Kumaravel KS, Pugalendhiraja KV, et al.: A study on the current status of neonatal transport to a special newborn care unit. Stanley Med. J. 2016; 3: 55–58.
26. Schulz KF, Altman DG, Moher D, et al.: CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann. Intern. Med. 2010 Jun 1; 152(11): 726–732. PubMed Abstract | Publisher Full Text
27. Kalyan S, Kamath SP, Subodh Shetty S, et al.: Effect of skill-based educational training for ambulance personnel on neonatal transport for newborn care in coastal south India -A single arm intervention study. [Dataset]. OSF. 2024. Publisher Full Text
28. Eichenwald EC, Hansen AR, Martin CR, et al.: Cloherty and Starks Manual of Neonatal Care.8th ed.New Delhi: Wolters Kluwer Health (India) Pvt Ltd.; 2021.
29. Agarwal R, Deorari A, Paul VK, et al.: AIIMS protocols in Neonatolgy Core Protocols. 3rd e book edition.New Delhi: CBS Publishers & Distributors Pvt Ltd.; 2024.
30. National neonatology forum: Teaching aids for facility based newborn care based newborn care at district level in neonatal resuscitation. [Last accessed on 2023 Dec 25]. Reference Source
31. Okechukwu AA, Nwalozie C: Morbidity and mortality pattern of admissions into the Emergency Paediatric Unit of University of Abuja Teaching Hospital, Gwagwalada. Niger J. Med. 2011; 20: 109–113. PubMed Abstract
32. Kaushal S, Hoy DA: Reducing the Incidence of Hypothermia and Hypoglycemia during Neonatal Transport. Paper presented at: AAP experience: National Conference and Exhibition; 2015 Oct 24-27; Washington, DC.
33. Rasania M, Patel P, Bothra A, et al.: Neonatal Transport Facilities and Its Effect on Outcome: An Experience from Tertiary Care Hospital of Central Gujarat. J. Neonatol. 2022; 36(4): 302–310. Publisher Full Text
34. Gray MM, Riley T, Greene ND, et al.: Neonatal Transport Safety Metrics and Adverse Event Reporting: A Systematic Review. Air Med. J. 2023 Jul-Aug; 42(4): 283–295. PubMed Abstract | Publisher Full Text
35. PHFI, AIIMS, and SC- State of India’s Newborns (SOIN) 2014- a report: Zodpey S, Paul VK, editors. Public Health Foundation of India. New Delhi, India: All India Institute of Medical Sciences and Save the Children; [Last accessed on 2023 Dec 15]. Reference Source
36. Chang AS, Berry A, Jones LJ, et al.: Specialist teams for neonatal transport to neonatal intensive care units for prevention of morbidity and mortality. Cochrane Database Syst. Rev. 2015 Oct 28; 2015: CD007485. PubMed Abstract | Publisher Full Text | Free Full Text

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Version 2

VERSION 2 PUBLISHED 08 Jul 2024

Author details Author details

Santosh Kalyan
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Ramesh Holla
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Leslie Lewis
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Harsha Lashkari P
Roles: Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Suchitra Shenoy M
Roles: Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

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Published: 02 Jan 2025, 13:767

https://doi.org/10.12688/f1000research.150058.2

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Published: 08 Jul 2024, 13:767

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Kalyan S, Kamath SP, Shetty S S et al. Effect of skill-based educational training for ambulance personnel on neonatal transport for newborn care in coastal South India – a single arm intervention study [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2025, 13:767 (https://doi.org/10.12688/f1000research.150058.2)

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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Version 2

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PUBLISHED 02 Jan 2025

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Reviewer Report 09 Jan 2025

A Shashidhar Rao, Dept of Neonatology, St Johns Medical College Hospital, Bangalore, Karnataka, India

Approved

https://doi.org/10.5256/f1000research.176171.r355414

The authors have satisfactorily addressed the concerns ... Continue reading

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Reviewer Report 22 Aug 2024

Sanoj Karayil Mohammad Ali, Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar

Approved

https://doi.org/10.5256/f1000research.164592.r301765

This is a clinically relevant interventional study with well-defined methodology and positive findings, which is similar to other studies.

-Clear working title, which states the study design, setting and population.

-Objective outcome data along with subjective survey from personnel is appropriate for the study

-Unsure about the significance of umbilical swab colonization as a surrogate marker for compliance with asepsis measures. There was no significant reduction in blood culture positive rates, which can also be affected by factors other than transport.

-Limitations of the study and risk of bias has been clearly outlined.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Neonatology, Respiratory physiology, Neonatal transport, hemodynamics

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Author Response 02 Jan 2025

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India

02 Jan 2025

Author Response

1. This is a clinically relevant interventional study with a well-defined methodology and positive findings, which is similar to other studies.
2. Clear working title, which states the study design, setting, ... Continue reading 1. This is a clinically relevant interventional study with a well-defined methodology and positive findings, which is similar to other studies.
2. Clear working title, which states the study design, setting, and population.
3. Objective outcome data along with subjective survey from personnel is appropriate for the study

Author response: Thank you

4. Unsure about the significance of umbilical swab colonization as a surrogate marker for compliance with asepsis measures. There was no significant reduction in blood culture positive rates, which can also be affected by factors other than transport.
Author response: Umbilical care is a part of essential newborn care & umbilical artery is an important site for entry of bloodstream infections in newborns. This study was to look for the colonization of the umbilical area but as not a surrogate marker for neonatal sepsis. The correlation between umbilical swabs & blood culture was not a part of the study. As highlighted in the study's limitations section, we agree that factors other than transport could have affected blood culture growth.

5. Limitations of the study and risk of bias have been clearly outlined.
Author response: Thank you
1. This is a clinically relevant interventional study with a well-defined methodology and positive findings, which is similar to other studies.
2. Clear working title, which states the study design, setting, and population.
3. Objective outcome data along with subjective survey from personnel is appropriate for the study

Author response: Thank you

4. Unsure about the significance of umbilical swab colonization as a surrogate marker for compliance with asepsis measures. There was no significant reduction in blood culture positive rates, which can also be affected by factors other than transport.
Author response: Umbilical care is a part of essential newborn care & umbilical artery is an important site for entry of bloodstream infections in newborns. This study was to look for the colonization of the umbilical area but as not a surrogate marker for neonatal sepsis. The correlation between umbilical swabs & blood culture was not a part of the study. As highlighted in the study's limitations section, we agree that factors other than transport could have affected blood culture growth.

5. Limitations of the study and risk of bias have been clearly outlined.
Author response: Thank you
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 02 Jan 2025

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India

02 Jan 2025

Author Response

1. This is a clinically relevant interventional study with a well-defined methodology and positive findings, which is similar to other studies.
2. Clear working title, which states the study design, setting, ... Continue reading 1. This is a clinically relevant interventional study with a well-defined methodology and positive findings, which is similar to other studies.
2. Clear working title, which states the study design, setting, and population.
3. Objective outcome data along with subjective survey from personnel is appropriate for the study

Author response: Thank you

4. Unsure about the significance of umbilical swab colonization as a surrogate marker for compliance with asepsis measures. There was no significant reduction in blood culture positive rates, which can also be affected by factors other than transport.
Author response: Umbilical care is a part of essential newborn care & umbilical artery is an important site for entry of bloodstream infections in newborns. This study was to look for the colonization of the umbilical area but as not a surrogate marker for neonatal sepsis. The correlation between umbilical swabs & blood culture was not a part of the study. As highlighted in the study's limitations section, we agree that factors other than transport could have affected blood culture growth.

5. Limitations of the study and risk of bias have been clearly outlined.
Author response: Thank you
1. This is a clinically relevant interventional study with a well-defined methodology and positive findings, which is similar to other studies.
2. Clear working title, which states the study design, setting, and population.
3. Objective outcome data along with subjective survey from personnel is appropriate for the study

Author response: Thank you

4. Unsure about the significance of umbilical swab colonization as a surrogate marker for compliance with asepsis measures. There was no significant reduction in blood culture positive rates, which can also be affected by factors other than transport.
Author response: Umbilical care is a part of essential newborn care & umbilical artery is an important site for entry of bloodstream infections in newborns. This study was to look for the colonization of the umbilical area but as not a surrogate marker for neonatal sepsis. The correlation between umbilical swabs & blood culture was not a part of the study. As highlighted in the study's limitations section, we agree that factors other than transport could have affected blood culture growth.

5. Limitations of the study and risk of bias have been clearly outlined.
Author response: Thank you
Competing Interests: No competing interests were disclosed. Close
Report a concern

Views

Reviewer Report 22 Jul 2024

Rakesh Kotha, Osmania Medical College, Hyderabad, Telengana, India; neonatology, Niloufer Hospital, Hyderabad, Telangana, India

Approved with Reservations

https://doi.org/10.5256/f1000research.164592.r301769

Yes, great study. Mention who took the data; it is better to be the third person who is not involved in the study. Questionnaire validation to be done and mention who prepared. Sample size justification is needed; a low sample size is a limitation. Reference for sample size is better to add. SPSS country version is better to mention. The cause of attrition is better to mention. Is it a quasi-experimental study? Definitions need citations.What is the significance of statistical errors as pre- and post-test people are different? Ambulance drivers qualifications may affect the internal study result; knowing the data better for comparing other studies. Any novelty? Better to add.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: neonatology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 02 Jan 2025

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India

02 Jan 2025

Author Response

1. Mention who took the data; it is better to be the third person who is not involved in the study.
Author response: The duty resident at NICU collected the data.
... Continue reading 1. Mention who took the data; it is better to be the third person who is not involved in the study.
Author response: The duty resident at NICU collected the data.
We agree that it is better if a third person who is not involved in the study collects the data

2. Questionnaire validation to be done and mention who prepared
Author response: The questionnaire was prepared by the first four authors after a thorough review of the literature pertaining to the topic. The content was validated by three senior pediatricians working in NICU set-ups. The wordings of the questions with ambiguity were changed as per their suggestions

3. Sample size justification is needed
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited; thus, we did not have a separate sample size calculation

4. A low sample size is a limitation
Author response: We agree that the low sample size is a limitation.

5. Reference for sample size is better to add-
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited; thus, we did not have a separate sample size calculation

6. SPSS country version better to mention-
Author response: New York is written as NY

7. Cause of attrition is better to mention
Author response: Postintervention, the three APs were excluded since they had been assigned emergency ambulance duties. Thus, for the final analysis, we included 77 APs to assess perceptions and practices

8. Is it a quasi-experimental study
Author response: It is a single arm intervention (pre-and post) study.

9. Definitions need citations
Author response: citations included as suggested

10. Significance of statistical errors as pre and post-test people are different
Author response: The subject population for AP was the same pre- and post-intervention, except that three APs could not give the post-test questionnaire because of their ambulance duties.
However, the subject population for outcomes of neonatal transport ought to be different pre- versus postintervention, which could give a possibility of random error/bias.

11. Ambulance driver’s qualifications may affect the internal study result; Knowing the data better for comparing other studies
Author response: We agree that the qualifications of ambulance personnel would affect the results of the internal study. We have included the educational status of AP in the baseline characteristics part of the results section. However, we did not assess the educational status with their mean perception and practice scores since it was not our study objective; we can include this as a limitation of our study.

12. Any novelty, better to add
Author response: It is an intervention study that aims to improve the quality of transport of neonates. There is limited literature on pre-versus-post intervention studies on ambulance personnel, specifically ‘108’ ambulances.
1. Mention who took the data; it is better to be the third person who is not involved in the study.
Author response: The duty resident at NICU collected the data.
We agree that it is better if a third person who is not involved in the study collects the data

2. Questionnaire validation to be done and mention who prepared
Author response: The questionnaire was prepared by the first four authors after a thorough review of the literature pertaining to the topic. The content was validated by three senior pediatricians working in NICU set-ups. The wordings of the questions with ambiguity were changed as per their suggestions

3. Sample size justification is needed
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited; thus, we did not have a separate sample size calculation

4. A low sample size is a limitation
Author response: We agree that the low sample size is a limitation.

5. Reference for sample size is better to add-
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited; thus, we did not have a separate sample size calculation

6. SPSS country version better to mention-
Author response: New York is written as NY

7. Cause of attrition is better to mention
Author response: Postintervention, the three APs were excluded since they had been assigned emergency ambulance duties. Thus, for the final analysis, we included 77 APs to assess perceptions and practices

8. Is it a quasi-experimental study
Author response: It is a single arm intervention (pre-and post) study.

9. Definitions need citations
Author response: citations included as suggested

10. Significance of statistical errors as pre and post-test people are different
Author response: The subject population for AP was the same pre- and post-intervention, except that three APs could not give the post-test questionnaire because of their ambulance duties.
However, the subject population for outcomes of neonatal transport ought to be different pre- versus postintervention, which could give a possibility of random error/bias.

11. Ambulance driver’s qualifications may affect the internal study result; Knowing the data better for comparing other studies
Author response: We agree that the qualifications of ambulance personnel would affect the results of the internal study. We have included the educational status of AP in the baseline characteristics part of the results section. However, we did not assess the educational status with their mean perception and practice scores since it was not our study objective; we can include this as a limitation of our study.

12. Any novelty, better to add
Author response: It is an intervention study that aims to improve the quality of transport of neonates. There is limited literature on pre-versus-post intervention studies on ambulance personnel, specifically ‘108’ ambulances.
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 02 Jan 2025

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India

02 Jan 2025

Author Response

1. Mention who took the data; it is better to be the third person who is not involved in the study.
Author response: The duty resident at NICU collected the data.
... Continue reading 1. Mention who took the data; it is better to be the third person who is not involved in the study.
Author response: The duty resident at NICU collected the data.
We agree that it is better if a third person who is not involved in the study collects the data

2. Questionnaire validation to be done and mention who prepared
Author response: The questionnaire was prepared by the first four authors after a thorough review of the literature pertaining to the topic. The content was validated by three senior pediatricians working in NICU set-ups. The wordings of the questions with ambiguity were changed as per their suggestions

3. Sample size justification is needed
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited; thus, we did not have a separate sample size calculation

4. A low sample size is a limitation
Author response: We agree that the low sample size is a limitation.

5. Reference for sample size is better to add-
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited; thus, we did not have a separate sample size calculation

6. SPSS country version better to mention-
Author response: New York is written as NY

7. Cause of attrition is better to mention
Author response: Postintervention, the three APs were excluded since they had been assigned emergency ambulance duties. Thus, for the final analysis, we included 77 APs to assess perceptions and practices

8. Is it a quasi-experimental study
Author response: It is a single arm intervention (pre-and post) study.

9. Definitions need citations
Author response: citations included as suggested

10. Significance of statistical errors as pre and post-test people are different
Author response: The subject population for AP was the same pre- and post-intervention, except that three APs could not give the post-test questionnaire because of their ambulance duties.
However, the subject population for outcomes of neonatal transport ought to be different pre- versus postintervention, which could give a possibility of random error/bias.

11. Ambulance driver’s qualifications may affect the internal study result; Knowing the data better for comparing other studies
Author response: We agree that the qualifications of ambulance personnel would affect the results of the internal study. We have included the educational status of AP in the baseline characteristics part of the results section. However, we did not assess the educational status with their mean perception and practice scores since it was not our study objective; we can include this as a limitation of our study.

12. Any novelty, better to add
Author response: It is an intervention study that aims to improve the quality of transport of neonates. There is limited literature on pre-versus-post intervention studies on ambulance personnel, specifically ‘108’ ambulances.
1. Mention who took the data; it is better to be the third person who is not involved in the study.
Author response: The duty resident at NICU collected the data.
We agree that it is better if a third person who is not involved in the study collects the data

2. Questionnaire validation to be done and mention who prepared
Author response: The questionnaire was prepared by the first four authors after a thorough review of the literature pertaining to the topic. The content was validated by three senior pediatricians working in NICU set-ups. The wordings of the questions with ambiguity were changed as per their suggestions

3. Sample size justification is needed
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited; thus, we did not have a separate sample size calculation

4. A low sample size is a limitation
Author response: We agree that the low sample size is a limitation.

5. Reference for sample size is better to add-
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited; thus, we did not have a separate sample size calculation

6. SPSS country version better to mention-
Author response: New York is written as NY

7. Cause of attrition is better to mention
Author response: Postintervention, the three APs were excluded since they had been assigned emergency ambulance duties. Thus, for the final analysis, we included 77 APs to assess perceptions and practices

8. Is it a quasi-experimental study
Author response: It is a single arm intervention (pre-and post) study.

9. Definitions need citations
Author response: citations included as suggested

10. Significance of statistical errors as pre and post-test people are different
Author response: The subject population for AP was the same pre- and post-intervention, except that three APs could not give the post-test questionnaire because of their ambulance duties.
However, the subject population for outcomes of neonatal transport ought to be different pre- versus postintervention, which could give a possibility of random error/bias.

11. Ambulance driver’s qualifications may affect the internal study result; Knowing the data better for comparing other studies
Author response: We agree that the qualifications of ambulance personnel would affect the results of the internal study. We have included the educational status of AP in the baseline characteristics part of the results section. However, we did not assess the educational status with their mean perception and practice scores since it was not our study objective; we can include this as a limitation of our study.

12. Any novelty, better to add
Author response: It is an intervention study that aims to improve the quality of transport of neonates. There is limited literature on pre-versus-post intervention studies on ambulance personnel, specifically ‘108’ ambulances.
Competing Interests: No competing interests were disclosed. Close
Report a concern

Views

Reviewer Report 22 Jul 2024

A Shashidhar Rao, Dept of Neonatology, St Johns Medical College Hospital, Bangalore, Karnataka, India

Approved with Reservations

https://doi.org/10.5256/f1000research.164592.r301768

Authors need to be complimented for a social project. Few suggestions
1. The abstract should be rewritten for better clarity. Include the hypothesis in the background and only the primary objective. Results should include data and not only p values. the data perception component is not presented. (Authors to decide if it is worth presenting).
2. The introduction can be better organized from general newborn survival/care to the Indian scenario and can be shorter.
3. The flow of participants is part of the results.
4. The objectives are a part of introduction and not methods and are better written as a paragraph.
5. The authors are referred to any other published trial to better organize the methodology section
7. Results need better clarity and be divided as outcomes of newborns, outcomes of AP etc. baseline characteristics of AP are missing(training, qualification).
8. There is a significant chance of assessor bias as the assessors are the same as authors
9. Sample size is not calculated. Could be included even now.
10. It is unclear if any system changes were made or only training as the changes are expected to last longer.
11. Embrace needs to be made clear, KMC or mother accompanying is missing,
12. QI approach would have been more useful to address this gap.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Neonatology

CITE

Report a concern

Author Response 02 Jan 2025

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India

02 Jan 2025

Author Response
1. The abstract should be written for better clarity. Include the hypothesis in the background and only the primary objective.
Author response: The abstract is modified for better clarity. The ... Continue reading
1. The abstract should be written for better clarity. Include the hypothesis in the background and only the primary objective.
Author response: The abstract is modified for better clarity. The hypothesis and the primary objective have been included in the background

2. Results should include data and not only p values. The data perception component is not presented (authors to decide if it is worth presenting).
Author response: The data, along with the p values, have been included. We have now presented the data on the perception component.

3. The introduction can be better organized from general newborn survival/care to the Indian scenario and can be shorter.
Author response: The introduction is organized and modified as suggested.

4. The flow of participants is part of the results.
Author response: The flow of participants in the consort figure 1 has been included at the beginning of the results section.

5. The objectives are part of the introduction and not methods and are better written as a paragraph.
Author response: The objectives of the study have been incorporated in the last paragraph of the introduction section.

6. The authors are referred to any other published trial to better organize the methodology section
Author response: We have reorganized the methodology section as suggested.

7. Results need better clarity and can be divided as outcomes of newborns, outcomes of AP etc. Baseline characteristics of AP are missing (training, qualification):
Author response: We have reorganized the results into

The baseline characteristics of AP and transported neonates –

The minimum qualification to join an ambulance crew was completing a Secondary School Leaving Certificate(S SLC); few of them had completed the 12th class, and very few had completed their bachelor’s degree. Once they joined, they received 7-day training by the GVK Emergency organization to deal with medical emergency conditions.

Outcomes of AP -perceptions and practices.

Outcomes of transported neonates -described under subheadings primary and secondary outcome measures.

Ambulance equipment availability and usage

8. There is a significant chance of assessor bias as the assessors are the same as authors
Author response: As per us, all assessors in the study had adhered to research principles and guidelines. They were unbiased in assessing the perception and practices of AP.

9. Sample size is not calculated. Could be included even now
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited thus we did not have a separate sample size calculation

10. It is unclear if any system changes were made or only training as the changes are expected to last longer
Author response: There was an improvement in the availability and usage of the following equipment: digital thermometer, glucometer, glucometer strips, neonatal masks, and pulse oximeter post-intervention. The use of hand rubs had improved. System changes have been explained in the results section.

11. Embrace needs to be made clear, KMC or mother accompanying is missing.
Author response: Embrace infant warmers are portable sleeping bag-like devices that keep low birthweight babies warm in hospital setups and in ambulances that are involved in neonatal transport. It is intended to be utilized in situations when skin-to-skin care is not feasible or when high-tech incubators are not available.
Adopting Kangaroo mother care will allow skin-to-skin contact between the mother and baby, thereby providing warmth; however, we did not document data on the same since most of the time, the mothers did not accompany the babies that are transported immediately after delivery to our center.

12. QI approach would have been more useful to address this gap.
Author response: We agree the QI approach would have been more useful to address this gap and have included this as a limitation in the study
1. The abstract should be written for better clarity. Include the hypothesis in the background and only the primary objective.
Author response: The abstract is modified for better clarity. The hypothesis and the primary objective have been included in the background

2. Results should include data and not only p values. The data perception component is not presented (authors to decide if it is worth presenting).
Author response: The data, along with the p values, have been included. We have now presented the data on the perception component.

3. The introduction can be better organized from general newborn survival/care to the Indian scenario and can be shorter.
Author response: The introduction is organized and modified as suggested.

4. The flow of participants is part of the results.
Author response: The flow of participants in the consort figure 1 has been included at the beginning of the results section.

5. The objectives are part of the introduction and not methods and are better written as a paragraph.
Author response: The objectives of the study have been incorporated in the last paragraph of the introduction section.

6. The authors are referred to any other published trial to better organize the methodology section
Author response: We have reorganized the methodology section as suggested.

7. Results need better clarity and can be divided as outcomes of newborns, outcomes of AP etc. Baseline characteristics of AP are missing (training, qualification):
Author response: We have reorganized the results into

The baseline characteristics of AP and transported neonates –

The minimum qualification to join an ambulance crew was completing a Secondary School Leaving Certificate(S SLC); few of them had completed the 12th class, and very few had completed their bachelor’s degree. Once they joined, they received 7-day training by the GVK Emergency organization to deal with medical emergency conditions.

Outcomes of AP -perceptions and practices.

Outcomes of transported neonates -described under subheadings primary and secondary outcome measures.

Ambulance equipment availability and usage

8. There is a significant chance of assessor bias as the assessors are the same as authors
Author response: As per us, all assessors in the study had adhered to research principles and guidelines. They were unbiased in assessing the perception and practices of AP.

9. Sample size is not calculated. Could be included even now
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited thus we did not have a separate sample size calculation

10. It is unclear if any system changes were made or only training as the changes are expected to last longer
Author response: There was an improvement in the availability and usage of the following equipment: digital thermometer, glucometer, glucometer strips, neonatal masks, and pulse oximeter post-intervention. The use of hand rubs had improved. System changes have been explained in the results section.

11. Embrace needs to be made clear, KMC or mother accompanying is missing.
Author response: Embrace infant warmers are portable sleeping bag-like devices that keep low birthweight babies warm in hospital setups and in ambulances that are involved in neonatal transport. It is intended to be utilized in situations when skin-to-skin care is not feasible or when high-tech incubators are not available.
Adopting Kangaroo mother care will allow skin-to-skin contact between the mother and baby, thereby providing warmth; however, we did not document data on the same since most of the time, the mothers did not accompany the babies that are transported immediately after delivery to our center.

12. QI approach would have been more useful to address this gap.
Author response: We agree the QI approach would have been more useful to address this gap and have included this as a limitation in the study
Competing Interests: Nil Close
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Author Response 02 Jan 2025

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India

02 Jan 2025

Author Response
1. The abstract should be written for better clarity. Include the hypothesis in the background and only the primary objective.
Author response: The abstract is modified for better clarity. The ... Continue reading
1. The abstract should be written for better clarity. Include the hypothesis in the background and only the primary objective.
Author response: The abstract is modified for better clarity. The hypothesis and the primary objective have been included in the background

2. Results should include data and not only p values. The data perception component is not presented (authors to decide if it is worth presenting).
Author response: The data, along with the p values, have been included. We have now presented the data on the perception component.

3. The introduction can be better organized from general newborn survival/care to the Indian scenario and can be shorter.
Author response: The introduction is organized and modified as suggested.

4. The flow of participants is part of the results.
Author response: The flow of participants in the consort figure 1 has been included at the beginning of the results section.

5. The objectives are part of the introduction and not methods and are better written as a paragraph.
Author response: The objectives of the study have been incorporated in the last paragraph of the introduction section.

6. The authors are referred to any other published trial to better organize the methodology section
Author response: We have reorganized the methodology section as suggested.

7. Results need better clarity and can be divided as outcomes of newborns, outcomes of AP etc. Baseline characteristics of AP are missing (training, qualification):
Author response: We have reorganized the results into

The baseline characteristics of AP and transported neonates –

The minimum qualification to join an ambulance crew was completing a Secondary School Leaving Certificate(S SLC); few of them had completed the 12th class, and very few had completed their bachelor’s degree. Once they joined, they received 7-day training by the GVK Emergency organization to deal with medical emergency conditions.

Outcomes of AP -perceptions and practices.

Outcomes of transported neonates -described under subheadings primary and secondary outcome measures.

Ambulance equipment availability and usage

8. There is a significant chance of assessor bias as the assessors are the same as authors
Author response: As per us, all assessors in the study had adhered to research principles and guidelines. They were unbiased in assessing the perception and practices of AP.

9. Sample size is not calculated. Could be included even now
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited thus we did not have a separate sample size calculation

10. It is unclear if any system changes were made or only training as the changes are expected to last longer
Author response: There was an improvement in the availability and usage of the following equipment: digital thermometer, glucometer, glucometer strips, neonatal masks, and pulse oximeter post-intervention. The use of hand rubs had improved. System changes have been explained in the results section.

11. Embrace needs to be made clear, KMC or mother accompanying is missing.
Author response: Embrace infant warmers are portable sleeping bag-like devices that keep low birthweight babies warm in hospital setups and in ambulances that are involved in neonatal transport. It is intended to be utilized in situations when skin-to-skin care is not feasible or when high-tech incubators are not available.
Adopting Kangaroo mother care will allow skin-to-skin contact between the mother and baby, thereby providing warmth; however, we did not document data on the same since most of the time, the mothers did not accompany the babies that are transported immediately after delivery to our center.

12. QI approach would have been more useful to address this gap.
Author response: We agree the QI approach would have been more useful to address this gap and have included this as a limitation in the study
1. The abstract should be written for better clarity. Include the hypothesis in the background and only the primary objective.
Author response: The abstract is modified for better clarity. The hypothesis and the primary objective have been included in the background

2. Results should include data and not only p values. The data perception component is not presented (authors to decide if it is worth presenting).
Author response: The data, along with the p values, have been included. We have now presented the data on the perception component.

3. The introduction can be better organized from general newborn survival/care to the Indian scenario and can be shorter.
Author response: The introduction is organized and modified as suggested.

4. The flow of participants is part of the results.
Author response: The flow of participants in the consort figure 1 has been included at the beginning of the results section.

5. The objectives are part of the introduction and not methods and are better written as a paragraph.
Author response: The objectives of the study have been incorporated in the last paragraph of the introduction section.

6. The authors are referred to any other published trial to better organize the methodology section
Author response: We have reorganized the methodology section as suggested.

7. Results need better clarity and can be divided as outcomes of newborns, outcomes of AP etc. Baseline characteristics of AP are missing (training, qualification):
Author response: We have reorganized the results into

The baseline characteristics of AP and transported neonates –

The minimum qualification to join an ambulance crew was completing a Secondary School Leaving Certificate(S SLC); few of them had completed the 12th class, and very few had completed their bachelor’s degree. Once they joined, they received 7-day training by the GVK Emergency organization to deal with medical emergency conditions.

Outcomes of AP -perceptions and practices.

Outcomes of transported neonates -described under subheadings primary and secondary outcome measures.

Ambulance equipment availability and usage

8. There is a significant chance of assessor bias as the assessors are the same as authors
Author response: As per us, all assessors in the study had adhered to research principles and guidelines. They were unbiased in assessing the perception and practices of AP.

9. Sample size is not calculated. Could be included even now
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited thus we did not have a separate sample size calculation

10. It is unclear if any system changes were made or only training as the changes are expected to last longer
Author response: There was an improvement in the availability and usage of the following equipment: digital thermometer, glucometer, glucometer strips, neonatal masks, and pulse oximeter post-intervention. The use of hand rubs had improved. System changes have been explained in the results section.

11. Embrace needs to be made clear, KMC or mother accompanying is missing.
Author response: Embrace infant warmers are portable sleeping bag-like devices that keep low birthweight babies warm in hospital setups and in ambulances that are involved in neonatal transport. It is intended to be utilized in situations when skin-to-skin care is not feasible or when high-tech incubators are not available.
Adopting Kangaroo mother care will allow skin-to-skin contact between the mother and baby, thereby providing warmth; however, we did not document data on the same since most of the time, the mothers did not accompany the babies that are transported immediately after delivery to our center.

12. QI approach would have been more useful to address this gap.
Author response: We agree the QI approach would have been more useful to address this gap and have included this as a limitation in the study
Competing Interests: Nil Close
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Version 2

VERSION 2 PUBLISHED 08 Jul 2024

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Version 1 08 Jul 24	read	read	read

A Shashidhar Rao, St Johns Medical College Hospital, Bangalore, India
Rakesh Kotha, Osmania Medical College, Hyderabad, India; Niloufer Hospital, Hyderabad, India
Sanoj Karayil Mohammad Ali, Sidra Medicine, Doha, Qatar

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Reviewer Report

3 Views

09 Jan 2025 | for Version 2

A Shashidhar Rao, Dept of Neonatology, St Johns Medical College Hospital, Bangalore, Karnataka, India

3 Views Cite this report Responses(0)

Approved

The authors have satisfactorily addressed the concerns raised and have modified the manuscript accordingly.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Neonatology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

9 Views

22 Aug 2024 | for Version 1

Sanoj Karayil Mohammad Ali, Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar

9 Views Cite this report Responses(1)

Approved

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Neonatology, Respiratory physiology, Neonatal transport, hemodynamics

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Responses (1)

Author Response

02 Jan 2025

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India

1. This is a clinically relevant interventional study with a well-defined methodology and positive findings, which is similar to other studies.
2. Clear working title, which states the study design, setting, and population.
3. Objective outcome data along with subjective survey from personnel is appropriate for the study

Author response: Thank you

4. Unsure about the significance of umbilical swab colonization as a surrogate marker for compliance with asepsis measures. There was no significant reduction in blood culture positive rates, which can also be affected by factors other than transport.
Author response: Umbilical care is a part of essential newborn care & umbilical artery is an important site for entry of bloodstream infections in newborns. This study was to look for the colonization of the umbilical area but as not a surrogate marker for neonatal sepsis. The correlation between umbilical swabs & blood culture was not a part of the study. As highlighted in the study's limitations section, we agree that factors other than transport could have affected blood culture growth.

5. Limitations of the study and risk of bias have been clearly outlined.
Author response: Thank you

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

11 Views

22 Jul 2024 | for Version 1

Rakesh Kotha, Osmania Medical College, Hyderabad, Telengana, India; neonatology, Niloufer Hospital, Hyderabad, Telangana, India

11 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

neonatology

Respond to this report

Responses (1)

Author Response

02 Jan 2025

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India

1. Mention who took the data; it is better to be the third person who is not involved in the study.
Author response: The duty resident at NICU collected the data.
We agree that it is better if a third person who is not involved in the study collects the data

2. Questionnaire validation to be done and mention who prepared
Author response: The questionnaire was prepared by the first four authors after a thorough review of the literature pertaining to the topic. The content was validated by three senior pediatricians working in NICU set-ups. The wordings of the questions with ambiguity were changed as per their suggestions

3. Sample size justification is needed
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited; thus, we did not have a separate sample size calculation

4. A low sample size is a limitation
Author response: We agree that the low sample size is a limitation.

5. Reference for sample size is better to add-
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited; thus, we did not have a separate sample size calculation

6. SPSS country version better to mention-
Author response: New York is written as NY

7. Cause of attrition is better to mention
Author response: Postintervention, the three APs were excluded since they had been assigned emergency ambulance duties. Thus, for the final analysis, we included 77 APs to assess perceptions and practices

8. Is it a quasi-experimental study
Author response: It is a single arm intervention (pre-and post) study.

9. Definitions need citations
Author response: citations included as suggested

10. Significance of statistical errors as pre and post-test people are different
Author response: The subject population for AP was the same pre- and post-intervention, except that three APs could not give the post-test questionnaire because of their ambulance duties.
However, the subject population for outcomes of neonatal transport ought to be different pre- versus postintervention, which could give a possibility of random error/bias.

11. Ambulance driver’s qualifications may affect the internal study result; Knowing the data better for comparing other studies
Author response: We agree that the qualifications of ambulance personnel would affect the results of the internal study. We have included the educational status of AP in the baseline characteristics part of the results section. However, we did not assess the educational status with their mean perception and practice scores since it was not our study objective; we can include this as a limitation of our study.

12. Any novelty, better to add
Author response: It is an intervention study that aims to improve the quality of transport of neonates. There is limited literature on pre-versus-post intervention studies on ambulance personnel, specifically ‘108’ ambulances.

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

15 Views

22 Jul 2024 | for Version 1

A Shashidhar Rao, Dept of Neonatology, St Johns Medical College Hospital, Bangalore, Karnataka, India

15 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Neonatology

Respond to this report

Responses (1)

Author Response

02 Jan 2025

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India

1. The abstract should be written for better clarity. Include the hypothesis in the background and only the primary objective.
Author response: The abstract is modified for better clarity. The hypothesis and the primary objective have been included in the background

2. Results should include data and not only p values. The data perception component is not presented (authors to decide if it is worth presenting).
Author response: The data, along with the p values, have been included. We have now presented the data on the perception component.

3. The introduction can be better organized from general newborn survival/care to the Indian scenario and can be shorter.
Author response: The introduction is organized and modified as suggested.

4. The flow of participants is part of the results.
Author response: The flow of participants in the consort figure 1 has been included at the beginning of the results section.

5. The objectives are part of the introduction and not methods and are better written as a paragraph.
Author response: The objectives of the study have been incorporated in the last paragraph of the introduction section.

6. The authors are referred to any other published trial to better organize the methodology section
Author response: We have reorganized the methodology section as suggested.

7. Results need better clarity and can be divided as outcomes of newborns, outcomes of AP etc. Baseline characteristics of AP are missing (training, qualification):
Author response: We have reorganized the results into

The baseline characteristics of AP and transported neonates –

The minimum qualification to join an ambulance crew was completing a Secondary School Leaving Certificate(S SLC); few of them had completed the 12th class, and very few had completed their bachelor’s degree. Once they joined, they received 7-day training by the GVK Emergency organization to deal with medical emergency conditions.

Outcomes of AP -perceptions and practices.
Outcomes of transported neonates -described under subheadings primary and secondary outcome measures.
Ambulance equipment availability and usage

8. There is a significant chance of assessor bias as the assessors are the same as authors
Author response: As per us, all assessors in the study had adhered to research principles and guidelines. They were unbiased in assessing the perception and practices of AP.

9. Sample size is not calculated. Could be included even now
Author response: All ambulance personnel of ‘108’ ambulances during the study time were recruited thus we did not have a separate sample size calculation

10. It is unclear if any system changes were made or only training as the changes are expected to last longer
Author response: There was an improvement in the availability and usage of the following equipment: digital thermometer, glucometer, glucometer strips, neonatal masks, and pulse oximeter post-intervention. The use of hand rubs had improved. System changes have been explained in the results section.

11. Embrace needs to be made clear, KMC or mother accompanying is missing.
Author response: Embrace infant warmers are portable sleeping bag-like devices that keep low birthweight babies warm in hospital setups and in ambulances that are involved in neonatal transport. It is intended to be utilized in situations when skin-to-skin care is not feasible or when high-tech incubators are not available.
Adopting Kangaroo mother care will allow skin-to-skin contact between the mother and baby, thereby providing warmth; however, we did not document data on the same since most of the time, the mothers did not accompany the babies that are transported immediately after delivery to our center.

12. QI approach would have been more useful to address this gap.
Author response: We agree the QI approach would have been more useful to address this gap and have included this as a limitation in the study

View more View less

Competing Interests

Nil

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. World Health Organization: Newborn Mortality.Key facts.2024, Mar 14. Reference Source

[2] 2. UNICEF: Neonatal mortality. 2024, Mar 1. Reference Source

[3] 3. Kumar PP, Kumar CD, Venkatlakshmi A: Long distance neonatal transport--the need of the hour. Indian Pediatr. 2008; 45: 920–922. PubMed Abstract

[4] 4. Sehgal A, Roy MS, Dubey NK, et al.: Factors contributing to outcome in newborns delivered out of hospital and referred to a teaching institution. Indian Pediatr. 2001; 38: 1289–1294. PubMed Abstract

[5] 5. National Neonatology Forum: Evidence based clinical practice guidelines.2010. [Last accessed on 2023 Nov 23]. Reference Source

[6] 6. Rashid A, Bhuta T, Berry A: A regionalised transport service, the way ahead? Arch. Dis. Child. 1999; 80: 488–492. PubMed Abstract | Publisher Full Text | Free Full Text

[7] 7. Kumutha J, Rao GV, Sridhar BN, et al.: The GVK EMRI maternal and neonatal transport system in India: a mega plan for a mammoth problem. Semin. Fetal Neonatal Med. 2015 Oct; 20(5): 326–334. PubMed Abstract | Publisher Full Text

[8] 8. 108 Emergency Management and Research Institute: [Last accessed on 2023 Nov 25]. Reference Source

[9] 9. World Health Organization: Every newborn: an action plan to end preventable deaths.2014. (Last accessed on 2023 Dec 29). Reference Source

[10] 10. Kumar S, Kumar N, Vivekadhish S: Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs): Addressing Unfinished Agenda and Strengthening Sustainable Development and Partnership. Indian J. Community Med. 2016; 41(1): 1–4. PubMed Abstract | Publisher Full Text | Free Full Text

[11] 11. Ministry of Health and Family Welfare, Government of India: National Health Mission. INAP India Newborn Action Plan.2014. [Last accessed on 2024 Jan 15]. Reference Source

[12] 12. Aggarwal KC, Gupta R, Sharma S, et al.: Mortality in newborns referred to tertiary hospital: An introspection. J. Family Med. Prim. Care. 2015; 4: 435–438. PubMed Abstract | Publisher Full Text

[13] 13. Kempley ST, Sinha AK; Thames Regional Perinatal Group: Census of neonatal transfers in London and the Southeast of England. Arch. Dis. Child Fetal Neonatal Ed. 2004; 89: F521–F526. PubMed Abstract | Publisher Full Text | Free Full Text

[14] 14. Ramji S: Transport in community. J. Neonatol. 2005; 19: 328–331. Publisher Full Text

[15] 15. Kumar PP, Kumar CD, Shaik F, et al.: Transported neonates by a specialist team - how STABLE are they. Indian J. Pediatr. 2011; 78: 860–862. PubMed Abstract | Publisher Full Text

[16] 16. Ministry of Health and Family Welfare, Government of India: Navjaat Shishu Suraksha Karyakram: Resuscitation and essential Newborn Care Resource Manual.2020. [Last accessed on 2021 Feb 15]. Reference Source

[17] 17. Rao SK, Bajaj N, Rawat A: Pre-transport factors and transport quality affecting the neonatal outcome. J. Evol. Med. Dent. Sci. 2015; 04: 1991–1995. Publisher Full Text

[18] 18. Sampathkumar P, Gobinathan S: A study on status of neonatal transport to a level III neonatal intensive care unit. Int. J. Contemp. Pediatr. 2018; 5: 1040–1043. Publisher Full Text

[19] 19. Rathod D, Adhisivam B, Bhat BV: Transport of sick neonates to a tertiary care hospital, South India: condition at arrival and outcome. Trop. Dr. 2015; 45: 96–99.

[20] 20. Singh J, Dalal P, Gathwala G, et al.: Transport characteristics and predictors of mortality among neonates referred to a tertiary care centre in North India: a prospective observational study. BMJ Open. 2021 Jul 6; 11(7): e044625. PubMed Abstract | Publisher Full Text | Free Full Text

[21] 21. Kiputa M, Salim N, Kunambi PP, et al.: Referral challenges and outcomes of neonates received at Muhimbili National Hospital, Dar es Salaam, Tanzania. PLoS One. 2022 Jun 15; 17(6): e0269479. Publisher Full Text

[22] 22. Tongo O, Abdulraheem MA, Orimadegun AE, et al.: Immediate Outcomes of Neonatal Transport in a Tertiary Hospital in South-West of Nigeria. Glob. J. Ped. Neonatol. Car. 2020; 2(1): GJPNC.MS.ID.000529. Publisher Full Text

[23] 23. Manikyamba D, Madhavi N, Reddy SM, et al.: Status of Neonatal Transport and Impact of Facilitated Referral on the Outcome of Transported Sick Newborns: At Tertiary Care Hospital. Sch. J. App. Med. Sci. 2017; 5: 3929–3934.

[24] 24. Dalal E, Vishal G, Solanki D: Study on neonatal transport at tertiary care centre. Int. J. Sci. Res. 2013; 2: 289–292.

[25] 25. Punitha P, Kumaravel KS, Pugalendhiraja KV, et al.: A study on the current status of neonatal transport to a special newborn care unit. Stanley Med. J. 2016; 3: 55–58.

[26] 26. Schulz KF, Altman DG, Moher D, et al.: CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann. Intern. Med. 2010 Jun 1; 152(11): 726–732. PubMed Abstract | Publisher Full Text

[27] 27. Kalyan S, Kamath SP, Subodh Shetty S, et al.: Effect of skill-based educational training for ambulance personnel on neonatal transport for newborn care in coastal south India -A single arm intervention study. [Dataset]. OSF. 2024. Publisher Full Text

[28] 28. Eichenwald EC, Hansen AR, Martin CR, et al.: Cloherty and Starks Manual of Neonatal Care.8th ed.New Delhi: Wolters Kluwer Health (India) Pvt Ltd.; 2021.

[29] 29. Agarwal R, Deorari A, Paul VK, et al.: AIIMS protocols in Neonatolgy Core Protocols. 3rd e book edition.New Delhi: CBS Publishers & Distributors Pvt Ltd.; 2024.

[30] 30. National neonatology forum: Teaching aids for facility based newborn care based newborn care at district level in neonatal resuscitation. [Last accessed on 2023 Dec 25]. Reference Source

[31] 31. Okechukwu AA, Nwalozie C: Morbidity and mortality pattern of admissions into the Emergency Paediatric Unit of University of Abuja Teaching Hospital, Gwagwalada. Niger J. Med. 2011; 20: 109–113. PubMed Abstract

[32] 32. Kaushal S, Hoy DA: Reducing the Incidence of Hypothermia and Hypoglycemia during Neonatal Transport. Paper presented at: AAP experience: National Conference and Exhibition; 2015 Oct 24-27; Washington, DC.

[33] 33. Rasania M, Patel P, Bothra A, et al.: Neonatal Transport Facilities and Its Effect on Outcome: An Experience from Tertiary Care Hospital of Central Gujarat. J. Neonatol. 2022; 36(4): 302–310. Publisher Full Text

[34] 34. Gray MM, Riley T, Greene ND, et al.: Neonatal Transport Safety Metrics and Adverse Event Reporting: A Systematic Review. Air Med. J. 2023 Jul-Aug; 42(4): 283–295. PubMed Abstract | Publisher Full Text

[35] 35. PHFI, AIIMS, and SC- State of India’s Newborns (SOIN) 2014- a report: Zodpey S, Paul VK, editors. Public Health Foundation of India. New Delhi, India: All India Institute of Medical Sciences and Save the Children; [Last accessed on 2023 Dec 15]. Reference Source

[36] 36. Chang AS, Berry A, Jones LJ, et al.: Specialist teams for neonatal transport to neonatal intensive care units for prevention of morbidity and mortality. Cochrane Database Syst. Rev. 2015 Oct 28; 2015: CD007485. PubMed Abstract | Publisher Full Text | Free Full Text

Effect of skill-based educational training for ambulance personnel on neonatal transport for newborn care in coastal South India – a single arm intervention study

Abstract

Background

Methods

Results

Conclusions

Keywords

Revised Amendments from Version 1

Introduction

Methods

Study design, setting and ethics

Data collection

Operational definitions

Intervention

Table 1. Skill-based educational intervention training program for ambulance personnel.

Statistical analysis

Results

Figure 1. Depicts the study flow according to CONSORT 2010 criteria.27

Baseline characteristics of AP and transported neonates

Primary and secondary outcome measures of transported neonates

Table 2. Clinical Parameters of Neonates at Arrival to Centre (pre-intervention versus post-intervention).

Table 3. Clinical Outcomes of the Neonates Transported Pre-intervention versus post-intervention phases.

Perceptions and practices of ambulance personnel towards neonatal transport

Table 4. Assessment of ambulance personnel's perceptions and practices toward neonatal transport (pre-intervention versus post-intervention phases) (n=77).

Ambulance equipment availability and usage

Discussion

Limitations

Conclusions

Ethics & consent

Data availability

Underlying data

Extended data

Reporting guidelines

Acknowledgements

References

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Figure 1. Depicts the study flow according to CONSORT 2010 criteria.²⁷