Effect of Transitional Care Model on Low Birth Weight Premature Infants:a meta-analysis

Ya-Nan Leng ,Ming Sang ,Ting-Ting Liu ,Yu-Qi Li ,Xiao-Li Pang

1Graduate School,Tianjin University of Traditional Chinese Medicine,Tianjin,300193,China;

2School of Nursing,Tianjin University of Traditional Chinese Medicine,Tianjin,301617,China.

Abstract Objective:To systematically review the effect of Transitional Care model (TCM) on the growth and development of premature infants.Methods:Randomized controlled trials (RCTs) or quasi-RTCs regarding the effect of TCM in low birth weight premature infants were retrieved in electronic databases such as the Cochrane Library,PubMed,EMbase,Web of Science,CBM (Chinese Biomedicine Database),CNKI (China National Knowledge Infrastructure),VIP (Chinese Scientific Journals Database) and Wanfang Database.Then,we adopted RevMan 5.3 software to perform a meta-analysis.Results:A total of 11 articles were included,including 1282 preterm infants.The result showed that compared with the routine care model,TCM can effectively increase the weight when premature infants discharged one week [MD=225.57,95%CI(171.78,279.37),P＜0.001],increase the weight after discharged one month [MD=0.89,95%CI (0.72,1.06),P＜0.001],increase the weight after discharged three months [MD=670.44,95%CI (527.65,813.23),P＜0.001],promote the height of newborns [MD=4.54,95%CI (2.42,6.65),P＜0.001],reduce readmission rate [RR=0.38,95%CI (0.25,0.58),P＜0.001],alleviate adverse skin reactions [RR=0.33,95%CI (0.22,0.50),P＜0.001],increase nursing satisfaction of the families [RR=1.21,95%CI (1.13,1.31),P＜0.001].Conclusion:TCM can effectively promote the growth and development of the low birth weight premature infants,reduce the hospital readmission rate,alleviate adverse skin reactions of premature infants and improve the nursing satisfaction of the families.However,due to the limitation of the region and quality of the included studies,which the accuracy of the result still be treated with more caution.Further high-quality studies are needed to verify the conclusion.

Keywords:Transitional care,Premature infants,Growth and development,Meta-analysis

Introduction

It is estimated that more than 15 million premature babies are born globally each year,accounting for 5% to 18% of newborns.In China,the incidence of preterm birth is about 7% [1,2].The organs of low birth weight premature infants are immature,which can easily lead to high-risk health problems such as death,nerve dysplasia and abnormal behavior [3].With the establishment of neonatal intensive care unit,the rapid development of intensive care and various technologies,the survival rate of premature infants has increased,and people pay more attention to the prognosis of their babies [4].Therefore,the transition from intensive care unit to general ward or family is critical to the rehabilitation of premature infants [5].However,the change of environment and nursing methods is apt to make the infants and parents maladaptive.

Transitional care model (TCM) refers to the transfer of patients between medical institutions due to the change of nursing needs during disease treatment and rehabilitation [6].The focus of this model is to implement basic nursing,strengthen health education,and carry out personalized management,which can ensure the continuity and coordination of nursing practice to a certain extent [7].At present,the role of TCM in reducing readmission rate and promoting physical and mental recovery has been confirmed in patients with heart failure,inflammatory bowel disease and the elderly [8-10],and there is no uniform conclusion on the effect of TCM on premature infants.Therefore,this study systematically evaluates the effect of TCM on low birth weight premature infants,in order to provide scientific evidence for clinical practice.

1 Materials and methods

1.1 Inclusion and exclusion criteria

1.1.1 Study Design:

Randomized controlled trials (RCTs) or Quasi-RTCs of the TCM were applied to preterm infants.

1.1.2 Subjects:

Preterm infants less than 37 weeks have stable vital signs and their parents with clear consciousness and communicative ability were willing to participate in this study.

1.1.3 Types of interventions

Interventions in the transitional care model group included the establishment of a TCM group consisting of specialist doctors,matron,and specialist nurses.Fully understand the needs and family situation of premature infants and their families to implement personalized care schemes.Before discharge,the family members were given health counseling and practical operation training,and their grasp of the nursing knowledge was evaluated.Guidelines for home care after discharge were given,which was about the information of infection prevention,feeding and skin care,and regular telephone follow-up was conducted.The control group was given routine nursing care,including health education for the families before and after discharge led by the duty nurse,and telling them to regular back the hospital for examination.

1.1.4 Outcome

The primary outcomes included the weight status of premature infants after discharge,the height of premature infants after discharge one month,the hospital readmission rate.

The secondary outcomes included incidence rate of adverse skin reactions of low birth weight premature infants and the nursing satisfaction from the parents of premature infants.

1.1.5 Exclusion criteria

The exclusion criteria included animal experiments,cell experiments,duplicate literature,literature with incomplete information,no data available for analysis and review..

1.2 Literature Search

We systematically searched the qualified RCTs or Quasi-RTCs from the Cochrane Library,PubMed,EMBASE,Web of Science,CBM (Chinese Biomedicine Database),CNKI (China National Knowledge Infrastructure),VIP (Chinese Scientific Journals Database) and Wanfang Database.The retrieval time was from the establishment of each database to Mar 29,2019.Search terms were determined by repeatedly consulting literature,the corresponding retrieval strategies were formulated according to the characteristics of different databases,the combination of medical subject headings and free words was adopted,and references of the included documents were traced.The search terms were listed as follows,(“transitional nursing model”O(jiān)R“transitional care model”O(jiān)R“Transitional Care Measure*”O(jiān)R“Care,Transitional”O(jiān)R“Cares,Transitional”O(jiān)R“Transitional Care*”O(jiān)R“Transition Care*”) AND(“premature infant*”O(jiān)R“preterm infant*”O(jiān)R“neonatal prematurity”O(jiān)R“Prematurity,Neonatal”O(jiān)R“l(fā)ow birth weight”O(jiān)R“preterm newborn*”O(jiān)R“premature newborn*”O(jiān)R“Premature”O(jiān)R“prematurity”O(jiān)R“preemie”O(jiān)R“Infants,Premature”O(jiān)R“Infant,Preterm”O(jiān)R“Infants,Preterm”).

1.3 Literature screening and data extraction

All the retrieved studies were imported into EndNote X7 literature management software for preliminary repeated screening.According to the inclusion and exclusion criteria,two researchers independently read the title and abstract to screen the literature,read the full text further,cross-check the literature screening results.The third-party researcher was invited to arbitrate the controversial part when there was disagreement.The data extracted included:the title of included studies,the first author,publication time,national,sample size,baseline level of relevant subjects,intervention,assessment time and outcomes.

1.4 Methodological Quality Assessment

Two researchers independently evaluated the quality of included literatures by using the methods proposed by the Cochrane Handbook for Systematic Reviews of Interventions,Version5.1.0 [11].Seven evaluation contents were included as follow:generation of the allocation,concealment of allocation,blinding participants and personnel,blinding outcome assessment,incomplete outcome data,selective outcome reporting and other sources of bias.If the above criteria are fully met,the probability of bias is small,and the quality is“A”.If partial satisfied,the probability of bias is moderate,and the quality is“B”.If the probability of bias is high,the quality is“C”.Finally,the two researchers gave evaluation of low risk,high risk or unclear risk.When there was disagreement,it could be discussed or invite the third-party to judge.

1.5 Statistical analysis

The RevMan 5.3 software was used for analysis according to the Cochrane collaboration.(1)Heterogeneity test:the heterogeneity between the included results was tested by chi-square test (X2test),the test level α=0.05.WhenP＞0.05 andI2＜50%,the homogeneity was considered.Fixed effect model was used for analysis.WhenP≤0.05 andI2≥50%,heterogeneity was considered,and random effect model was selected.Subgroup analysis was used according to the factors that may produce heterogeneity in each study.If the heterogeneity between included studies was too large and the source could not be determined,only descriptive analysis was conducted.(2) Effect size combination:the application effect estimates of all trials were calculated and expressed as the mean differences (MD) for continuous data and relative risk(RR) for dichotomous outcomes along with the 95%confidence interval (95% CI).

2 Results

2.1 Study Selection

One thousand and twenty-one articles have been collected during the initial literature search,finally included 11 [12-22]articles,the total sample size was 1282,including 641 in TCM group and 641 in control group.The detailed process of literature screening,such as reasons and number of selection or deletion,were shown in Figure 1.Eleven articles were from China and only one come from Iran.The basic characteristics of the included researches was shown in Table 1.

2.2 Literature Search

Initial electronic searching retrieved a total of 1,792 citations.Of these,1,544 were excluded because they were duplicates or irrelevant studies.Finally,248 eligible studies were remained.

2.2 Methodological Quality Assessment and Evidence Classification

The methodological quality evaluation and evidence classification results of the included literature in the study were shown in Table 2.The results of risk of bias assessment were shown in Figure 2.

2.3 Meta-Analysis Results

Figure 1.Study flow diagram

Table 1.The basic characteristics of included studies

Table 2.Methodological Quality Assessment

Figure 2.Risk of bias summary and graph

2.3.1 The weight status of premature infants after discharge

(1) After discharge one week,a total of 2 [15,17]studies were included 96 in the TCM group and 96 in the control group.The meta-analysis of the fixed model showed the weight gain of premature infants in TCM group was higher than the control group,and the difference was statistically significant [MD=225.57,95%CI (171.78,279.37),P＜0.001](Figure 3).

(2) After discharge one month,four [14,16,20-21]studies,including 540 low birth weight premature infants,compared the weight status between the two groups.The meta-analysis of the random model showed the weight gain of premature infants in TCM group was higher than the control group,and the difference was statistically significant [MD=0.89,95%CI (0.72,1.06),P＜0.001](Figure 4).

(3) After discharge three months,four trials [16,18-19,22]involving 430 low birth weight premature infants reported the weight status of premature Infants after discharge three months.There was statistically significant difference between the TCM and control

Figure 3.Forest plot shows the weight of premature infants after discharge one week

Figure 4.Forest plot shows the weight of premature infants after discharge one month

Figure 5.Forest plot shows the weight of premature infants after discharge three months

2.3.2 The height of premature infants after discharge

Three studies [14,16,20]reported the height of premature infants after discharge one month.The results showed that the height growth of premature infants in the TCM group was higher than that in the control group,and the difference was statistically significant [MD=4.54,95%CI (2.42,6.65),P＜0.001](Figure 6).

2.3.3 Hospital readmission rate

4 [12-13,16,21]of the 11 studies reported hospital readmission rate.The meta-analysis of the fixed model showed that the hospital readmission rate of premature infants in the TCM group was significantly lower than that in the control group when they had discharged one month,and the difference was statistically significant[RR=0.38,95%CI (0.25,0.58),P＜0.001](Figure 7).

2.3.4 Adverse skin reactions

A total of 4 [12,15-17]studies were included 196 in the TCM group and 196 in the control group.The infants randomly assigned to the TCM group had effectively reduced adverse skin reactions such as rash,red buttocks,diaper rash,breakage,etc.The difference was statistically significant [RR=0.33,95%CI (0.22,0.50),P＜0.001](Figure 8).

2.3.5 Nursing satisfaction

Nursing satisfaction were included in 4 studies[13,16,18,21],186 parents in TCM group and 186 parents in control group.The results of meta-analysis of fixed model showed that the level of parental nursing satisfaction of preterm infants in TCM group was higher than that in control group.The difference was statistically significant [RR=1.21,95%CI (1.13,1.31),P＜0.001](Figure 9).

Figure 6.Forest plot show s the height of premature infants after discharge one month

Figure 7.Forest plot shows the hospital readmission rate of premature infants

Figure 8.Forest plot shows the incidence of adverse skin reactions of premature infants

Figure 9.Forest plot shows the nursing satisfaction of parents of premature infants

3 Discussion

3.1 TCM can promote the growth and development of premature infants

Low birth weight infants are prone to complications due to insufficient nutritional reserve,and their growth and development are hindered obviously [4].A study shows that reasonable feeding is an important factor affecting the early growth rate of premature infants[23].However,although the infants were carefully cared for during hospitalization,due to their parents'role maladjustment and lack of nursing knowledge,some of infants suffered from inadequate nutritional intake after discharge,thus blocking their growth and development.This research showed that TCM had a significant effect in promoting the growth of weight and length of premature infants,and the growth change was the most obvious one month after discharge.The reason may be that the medical staff repeatedly emphasized feeding knowledge and introduced the manifestations and hazards of dysplasia,so that families could have a clearer understanding of children's physical condition and easier to comprehend the key points of nursing.According to the guideline of NICE in 2017 [24],parents should be given information support based on the specific conditions of premature infants,make them recognize the reasons that hinder the growth of premature infants can let infants obtain a good quality of life,which also supports the conclusions of this study.Therefore,the establishment of multidisciplinary cooperation group for premature infants to develop a thorough discharge plan and give families information and emotional support is crucial to promote growth of premature infants.

3.2 TCM can reduce the readmission r ate and adverse skin reactions of premature infants

Neonatal Intensive Care Unit (NICU) is mostly an unaccompanied ward.The families of premature infants only receive a short-term health guidance in the hospital.There is often an interruption of effective care in home care of premature infants,which makes the premature infant re-admission [7].Sneath also concluded that high-risk families who are not fully prepared for discharge will increase the risk of readmission of their babies [25].Besides,the occurrence of skin adverse reactions in premature infants mainly lies in parents lack of full observation and the health care ability.The results showed that the readmission rate of premature infants in the TCM group was 0.38 times higher than that in the control group,and the incidence of skin adverse reactions was 0.33 times higher than that in the control group.The TCM could reduce premature infants' readmission rate and skin adverse reactions.A systematic review shows that the TCM based on telephone follow-up after discharge could reduce the readmission rate of patients,which also supported this study [26].Therefore,it is recommended that nurses ensure clear handover and communication with the parents of premature infant before discharge,implement transitional nursing with rich contents and forms,and guide families to seek certain guidance through telephone consultation and network information support,so as to fully meet the needs of infants,avoid infection and reduce the occurrence of readmission and skin adverse reactions.

3.3 Nursing satisfaction of families increased due to the application of TCM

Studies have shown that parents of premature infants have obvious anxiety and uncertainty after discharge,eager to receive outside support and strive to adjust themselves to the role of caregivers [27,28].The results of this study show that TCM can improve the nursing satisfaction of families.The reason may be that TCM can reduce the number of emergencies and readmission rate of premature infants,relieve the financial burden and mental pressure of families,which is consistent with Liu's research [29].In addition,the TCM provides family members with the opportunity to participate in the care of premature infants continuously,which helps medical staff communicate with patients in time,enhance parents' confidence and readiness in nursing,improve breastfeeding rate,shorten hospitalization time,and to a certain extent improve parents' satisfaction [30].Therefore,nurses should give targeted discharge guidance in light of the education level of the family members and the specific situation of the family.To provide appropriate community resource information and play the role of community medical service institutions in linking hospitals and families,aiming to provide timely guidance for parents of premature infants and improve their nursing satisfaction.

3.4 Limitations of this research

Meta-analysis is a retrospective study whose quality is directly inf luenced by the original literature [31].All the studies included in this research are open literature,and the unpublished literature is not retrieved,and the implementation of blind method and allocation concealment is not clear,which may lead to bias.Although this study systematically searched the foreign language database,only one foreign literature was included,which may lead to language bias.In addition,each of the included studies has some differences in the implementation content,intervention time and intensity of TCM,which also increases the risk of bias.

4 Conclusion

The evaluation of the system has shown that application of transitional care model in low birth premature infants may has a promising effect.However,due to the limitation of methodological,insufficient sample size and geographical restriction,the clinical efficacy and prognosis of it cannot be confirmed fully.In addition,the accuracy of the result should be treated cautiously.

Authors' contributions

Ya-Nan Leng conceived and designed this experiment.Ming Sang and Ting-Ting Liu performed the search.Yu-Qi Li and Ming Sang analyzed the data.Xiao-Li Pang recheck the data and results.Ya-Nan Leng wrote the paper.All authors offer to help when submitting materials.