P2.G135: Impact of teleneonatology on time to goal temperature in outborn neonates treated with therapeutic hypothermia for hypoxic-ischemic encephalopathy

Background: Neonates with hypoxic-ischemic encephalopathy (HIE) that require transfer to a neonatal intensive care unit (NICU) for therapeutic hypothermia (TH) have higher rates of morbidity and mortality compared to neonates born in a hospital with an NICU. It is unknown whether support of referring hospital care teams via real-time, audio-video telemedicine consults with a neonatologist (termed “teleneonatology”) impacts the timeliness of TH initiation or early neurologic outcomes compared to neonates managed with usual care.

Methods: This retrospective cohort study at a single center included neonates born from February 2013 to November 2022. Those born outside a hospital birthing unit or for whom neonatal transport was present at delivery were excluded. The intervention group included neonates that received teleneonatology consultation during initial resuscitation; the control group did not. The primary outcome was time from birth to achievement of goal temperature (33-34 degrees C). The secondary outcome was a composite of early neurologic morbidity or death, which included electrographic seizures, evidence of significant brain injury on MRI (grade 2A or greater), and in-hospital mortality. Linear and logistic regression were used for the primary and secondary outcomes, respectively. For causal inference analysis, a directed acyclic graph (DAG) was generated with the R package dagitty version 0.3-1 (Figure 1), and the backdoor criterion was used to identify appropriate adjustment variables.

Results: The neonates in teleneonatology group (n=42) and control group (n=35) were generally similar. Time from birth to goal temperature (median [IQR]) was lower in the teleneonatology group compared to the control group, which remained significant when adjusting for patient acuity with blood gas pH (3.4 [2.5, 5.0] vs 4.6 [3.3, 6.5] hours; adjusted mean ratio 0.76; 95% CI, 0.58-0.99; Table 1). As part of a causal inference analysis, total and direct effects among the exposure, time from birth to activation of the transport team, and the primary outcome were examined, demonstrating that the effect of teleneonatology on time to goal temperature was at least partially mediated by more rapid activation of the transport team. Teleneonatology was not associated with a difference in the composite outcome of early neurologic morbidity or death in unadjusted or adjusted analyses.

Conclusion: Teleneonatology consultation was associated with a reduced time from birth to achievement of goal temperature in neonates requiring transport to a NICU for TH, and this effect was mediated at least in part by more prompt initiation of the transport process. Further multi-site, prospective research with larger sample sizes and adequate controlling for confounding is needed to confirm these findings.