PC1098: U.s.-brazil Newborn Brain Care Initiative: Reducing Variability in Practice of Therapeutic Hypothermia for Hypoxic-ischemic Encephalopathy Through a Collaborative Telemedicine Initiative

Background: Brazil is a middle-income country with an estimated 20,000 newborns with hypoxic-ischemic encephalopathy (HIE) per year. Therapeutic hypothermia (TH) is considered standard of care, however, only 5% of Brazilian hospitals provide TH in a structured way, and 19% had trained healthcare providers. We aimed to evaluate the impact of longitudinal training and implementation of protocols and methodologies through a telemedicine system with the goal of improving the quality and homogeneity of care to newborns with HIE in Brazil.

Methods: We selected 12 Brazilian hospitals with varying levels of experience with TH and collected standardized data over a one-year period. A collaborative neonatal neurocritical care educational program was initiated after 3 months of baseline data collection. Twelve biweekly webinars were organized by content experts from the United States and Brazil with online interaction of all participating centers. Real-time automated translation English-Portuguese was provided using Microsoft PowerPoint tool. All sessions were recorded. At the end of the study period, an online survey was performed to assess the medical providers’ perspectives and knowledge retention. Descriptive statistical analysis was performed. The Stanford Office of International Affairs Exploration Fund was the funding source.

Results: 167 newborns were recruited, 107 (64.1%) were male and 88 (52.7%) were born by C-section. A modified Sarnat neurological exam prior to 6 hours of life was conducted in 154 (92.2%); 107 (69.5%) scored as moderate and 37 (24.0%) severe. Blood gases were available in 150 (89.8%). Deviation from the TH protocol occurred in 66 (39.5%) cooled infants and decreased over the study period (Figure 1). 82 (49%) newborns were monitored with aEEG or vEEG and 29 (17%) with NIRS. Clinical and/or electrographic seizures were diagnosed in 70 (42%) and were more frequent in centers without aEEG/EEG monitoring. Neurological assessment at discharge was performed in 89 (53%). Mortality prior to hospital discharge occurred in 15 (9%). The median number (IQR) of medical providers participating in each training session was 110 (96-202). The number of medical providers participating in the training sessions decreased over time (Table 1). 32 medical providers from the 12 centers answered the online survey, and 31 (96.9%) considered the educational training program good or excellent, reporting that they had made or would consider making changes in clinical practice. The main suggestions for improving the educational program included shorter and more practical sessions, provision of written materials, in-person training activities, additional case discussions, and longitudinal training to continuously educate the multidisciplinary team.

Conclusion: Implementing a neonatal neurocritical care tele-educational program in multiple, remote hospitals was feasible. Changes in clinical practices were noted over the study period. However, despite the importance of longitudinal training to improve clinical care, maintaining high webinar attendance was challenging, and new educational strategies and formats may be necessary.