EUROPAINsurvey: EUROpean Pain Audit In Neonates

Sponsor

Hôpital Armand Trousseau (Other)

Overall Status

Completed

CT.gov ID

NCT01694745

Collaborator

(none)

6,489

Enrollment

242

Locations

Duration (Months)

26.8

Patients Per Site

3.4

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

EUROPAIN Survey is an epidemiological study aimed at assessing current clinical practices regarding the use of sedative and analgesic drugs in newborns admitted to NICUs or PICUs in different countries in Europe. This study is conducted as part of the NeoOpiod study.

The main objective of this study is to determine the current clinical practices regarding the use of sedative and analgesic drugs in newborns in intensive units in different countries in Europe. The principal criteria are: the frequency of ventilated neonates receiving sedation and analgesia, the medications used for sedation and analgesia in ventilated neonates, the length of use of medications administered for sedation and analgesia in ventilated neonates and similarities and differences in sedation and analgesia practices among European countries.

The secondary objectives are: a) to determine the proportion of neonatal units that have developed and implemented local written guidelines to provide continuous sedation and analgesia in ventilated newborn infants as well as to prevent and treat procedural pain, b) to document the published guidelines for neonatal analgesia and sedation in different European countries and develop consensus for common European standards that can be applied in all medical settings, c) to determine the frequency of use of pain assessment tools in ventilated newborn infants and evaluate their impact on pain management practices and d) to determine practices to assess and prevent withdrawal syndromes.

The EUROPAIN STUDY is observational and therefore it will not interfere with routine practices of participating units. No changes in diagnostic, therapeutic or any managing strategy of patients are imposed by the participation in this study. This epidemiological study will only collect data on clinical practices in each unit. It will include all neonates up to a corrected age of 44 weeks post conception.

The maximum duration of data collection for every included infant is 28 days. Data collection will stop before 28 days if the infant leaves the unit (discharge, death, transfer to another hospital). Data will be entered on a secure web-based questionnaire.

Condition or Disease	Intervention/Treatment	Phase
Pain Analgesia Sedation Intesive Care Intratracheal Ventilation

Detailed Description

1.1 Background and rationale The alleviation of pain is a basic and human right regardless of age. Neonates do feel pain and it has been shown that preterm infants are even more vulnerable to pain than older infants. The more vulnerable preterm neonates are precisely those that are more exposed to pain. Neonates admitted to intensive care units, both neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU), undergo dozens or even hundreds of painful procedures during their stay. These painful procedures include, for many of the ICU neonates, a tracheal intubation followed by mechanical ventilation. The pain and stress that are induced by mechanical ventilation as well as by repetitive procedures or painful diseases has led medical staff to use sedation and analgesia in neonates admitted to intensive care units. The subjectivity and difficulty inherent to pain measurement in neonates have probably contributed to a wide variety of neonatal sedation and analgesia practices. To date, these practices have been rarely studied.

Why would sedation and analgesia be necessary? Mechanical ventilation is a potentially painful intervention. Adults often describe mechanical ventilation as a painful and anxiety-provoking experience. The main objectives of sedation and analgesia are: reduction of pain, stress and irritability, promotion of blood pressure stability, promotion of ventilator synchrony and improvement of oxygenation. In the long term, reduced stress, as well as reduced fluctuations in oxygenation and blood pressure is believed to minimize the risks of neurological injury and death. However, the use of sedation and analgesia is only conceivable in the respect of the principle that must accompany all medical actions: first, do no harm.

Pain and stress undergone during the neonatal period can have deleterious short-term and long-term consequences. Some of these consequences have been reduced with adequate analgesic treatment. Current data show the necessity to give adequate sedation and analgesia to ventilated neonates.

Statements promoting the use of sedation and analgesia The increased awareness that neonates feel pain, the ethical obligation to treat this pain with analgesics, the growing body of evidence demonstrating that untreated neonatal pain can lead to altered reactivity to pain that persists throughout infancy and childhood as well as the need for a humane management of neonates have lead to the development of International and National Guidelines promoting the use of analgesics in the neonatal population. These Guidelines state that units that provide neonatal care should develop and implement guidelines concerning neonatal pain. However, the existing literature is still conflicting regarding the use of sedation and analgesia for ventilated neonates. Current data indicate that there is insufficient evidence to recommend the routine use of opioids in mechanically ventilated newborns and that opioids should be used selectively. Sedation and analgesia in non ventilated babies is extremely rare.

Practices across Europe and USA Data on sedation and analgesia practices in ventilated neonates are very rare. In 1995 the SOPAIN study carried out in the United States showed that factors predicting the use of on-going analgesia and sedation in neonates included: mechanical ventilation, higher gestational age, and male gender. In 2005, the French EPIPPAIN study showed that the rate of continuous sedation and analgesia was 69.6% in ventilated neonates with large variations among centers (16.7% to 90.9%). The most frequently used drugs were midazolam and morphine.

To date, there are no data permitting the comparison of neonatal pain management within the European countries. The availability of these data will enable comparison of practices with state-of-the-art knowledge.

Study Hypothesis

The EUROPAIN study is an epidemiological study that is based on the following hypothesis:

Most newborn ventilated infants receive continuous sedation and analgesia.
Non ventilated babies are not sedated.
Morphine, fentanyl and midazolam are the most frequently drugs used in this setting.
Infrequent use of validated pain assessment tools to monitor sedation and analgesia occurs in ventilated newborn infants.
Most units have developed written local guidelines for sedation and analgesia in ventilated neonates, but huge variability exists among practitioners in the same unit, across different units in the same country, and across different countries in Europe.
Development, dissemination, and regular updates of common European standards will improve the care and clinical outcomes of ventilated newborn infants.

1.2 Main objective • To determine the current clinical practices regarding the use of sedative and analgesic drugs for ventilated newborns in different countries in Europe.

1.3 Principal criteria

The frequency of ventilated neonates receiving sedation and analgesia in different European units
The medications used for sedation and analgesia in ventilated neonates across Europe.
The length of use of medications administered for sedation and analgesia in ventilated neonates
Similarities and differences in sedation and analgesia practices among European countries

1.4 Secondary objectives and criteria

To determine the proportion of neonatal units that have developed and implemented local written guidelines to provide continuous sedation and analgesia in ventilated newborn infants as well as to prevent and treat procedural pain.
To document the published guidelines for neonatal analgesia and sedation in different European countries and develop consensus for common European standards that can be applied in all medical settings.
To determine the frequency of use of pain assessment tools in ventilated newborn infants and evaluate their impact on pain management practices.
To determine practices to assess and prevent withdrawal syndromes. Secondary criteria
Variations across European countries of the proportions of units that have developed and implemented local written guidelines for sedation and analgesia in ventilated neonates
Identification and description of national guidelines for sedation and analgesia in neonates in all participating countries. Identification of recommended drugs.

1.5 Type of study

• Epidemiological observational study.

1.6 Study plan The EUROPAIN STUDY is observational and therefore it will not interfere with routine practices of participating units. No changes in diagnostic, therapeutic or any managing strategy of patients are imposed by the participation in this study. This epidemiological study will only collect data on clinical practices in each unit.

The inclusion criteria are:

• All neonates up to a corrected age of 44 weeks post conception. That means, for example, that a baby of 40 weeks gestational age can be included up to 28 days (4 weeks) of post natal age or that a baby of 32 weeks gestational age can be included up to 12 weeks of post natal age.

At the unit level

No modifications of current managing protocols or strategies are required by the participation in the EUROPAIN STUDY. The unit coordinators will only provide data on local protocols to manage procedural pain and sedation and analgesia in neonates as well as on general statistics of the unit. All treatments are authorized for included neonates since this study does not include any intervention
A nurse and physician coordinator as well as a data quality manager will be designated for each unit.

At the national level

• The country coordinator will provide data on national guidelines to treat or prevent procedural or continuous pain in neonates.

Data collection

The duration of data collection for every included infant is 28 days. However, data collection will stop before 28 days if the infant leaves the unit (discharge, death, transfer to another hospital).
Data will be collected on individual data collection forms. These forms include demographic data, modes of respiration, continuous or intermittent sedative, analgesic or neuro-blocking drugs, pain assessment and drug withdrawal practices.
Paper patient data collection forms are written in English with a subtitled translation in the country language. The web-based databases display questionnaires in the country language.
The data collection forms will be completed by the unit nurse or physician coordinator or the person that they will designate.
For each center, the duration of the inclusion period will be one month.
Data will be entered on a secure web-based questionnaire.

1.7 Justification of number of patients Regarding the number of neonates to include in order to show possible differences in sedation and analgesia practices among the participating European countries, we have considered a scenario where differences are small. Thus, we have chosen an effect size (W) of 0.1. We have also assumed that 15 countries will participate. Using NCSS-PASS 2008 software, we have found that a total sample size of 2303 neonates will achieve 90% power to detect an effect size (W) of 0.1 using a 14 degrees (15 centers) of freedom Chi-Square test with a significance level (alpha) of 0.05. Therefore, we aim at including an average of 154 neonates per participating country.

1.8 Main Actions carried out during the study

In each country, the National Principal Investigators (NPI) will send invitations to join the study to all level 3 neonatal units of the country. The NPI will then communicate the names, emails and telephone numbers of the units that accept to participate to the EUROPAIN STUDY principal investigators
The NPI is responsible for the coordination of all units in the country and ensures communication with the EUROPAIN STUDY principal investigators
The NPI will collect demographic data about the participating country.
A nurse and physician coordinator as well as a data quality manager will be designated for each unit. The nurse and physician coordinator are responsible for informing all the unit staff about the study.
The EUROPAIN STUDY principal investigators have prepared a specifically designed web-based database to enter data. Data can be entered directly from the patient's file. A paper copy of this database will be distributed to allow centers that prefer to perform a preliminary entry on paper forms before entering data on the web-based database. The medical coordinator or a person that he (she) will choose will enter the data into these specifically designed databases.
The physician coordinator will report general statistics of the unit such as number of beds, number of admission, year ventilator-days etc to the Europain study principal investigators.
Every unit will also report existing local guidelines on sedation and analgesia in ventilated infants, including routines for withdrawal and on the use of pain assessment tools.
MONITORING PANEL. A monitoring panel will be created to monitor the progress of the study. This panel will ensure communication with all the participating units. This monitoring panel will be constituted by two persons working full-time during the study period. They will be stationed in Paris and working under the responsibility of EUROPAIN STUDY principal investigators.

Study Design

Study Type:

Observational

Actual Enrollment :

6489 participants

Observational Model:

Cohort

Time Perspective:

Prospective

Official Title:

European Survey of Sedation and Analgesia Practices for Newborns Admitted to Intensive Care Units

Study Start Date :

Oct 1, 2012

Actual Primary Completion Date :

Jun 1, 2013

Actual Study Completion Date :

Jun 1, 2013

Outcome Measures

Primary Outcome Measures

The frequency of ventilated neonates receiving sedation and analgesia in different European units [one year]

Secondary Outcome Measures

The medications used for sedation and analgesia in ventilated neonates across Europe [one year]
The length of use of medications administered for sedation and analgesia in ventilated neonates [one year]
Similarities and differences in sedation and analgesia practices among European countries [one year]

Other Outcome Measures

Variations across European countries of the proportions of units that have developed and implemented local written guidelines for sedation and analgesia in ventilated neonates [one year]
Identification and description of national guidelines for sedation and analgesia in neonates in all participating countries. Identification of recommended drugs [one year]

Eligibility Criteria

Criteria

Ages Eligible for Study:

N/A to 45 Weeks

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

• All neonates up to a corrected age of 44 weeks post conceptional. That means, for example, that an infant born at 40 weeks gestational age can be included up to 28 days (4 weeks) of post natal age or that a baby of 32 weeks gestational age can be included up to 12 weeks of post natal age.

NOTE: Since this is an observational epidemiological study, all eligible infants of the unit during the study period should be included.

Exclusion Criteria:

• The only exclusion criteria of this observational study is the participation of the neonate in a research study including a randomization for the use of sedative or analgesic drugs in ventilated neonates.

Contacts and Locations

Locations

	Site	City	State	Country
1	Universitäts-klinik für Kinder- und Jugendheilkunde Innsbruck	Innsbruck		Austria
2	Landeskran- kenhaus Leoben	Leoben		Austria
3	Universitäts-klinik für Kinder und Jugendheilkunde Salzburg	Salzburg		Austria
4	Universitäts klinik für Kinder-und Jugenheilkunde Wien	Wien		Austria
5	Universitaire Ziekenhuis Antwerpen	Antwerpen		Belgium
6	Hôpital Erasme ULB,	Bruxelles		Belgium
7	Centre Hospitalier Universitaire Tivoli	La Louvière		Belgium
8	Centre Hospitalier Régional de la Citadelle	Liège		Belgium
9	Neonatal Intensiv Care Unit, Arch. Makarios Hospital	Nicosia		Cyprus
10	Department of Anesthesiology and Intensive Care, Tallinn Children's Hospital	Tallinn		Estonia
11	Paediatric Intensive Care Unit, Clinic of Anaesthesiology and Intensive Care, Tartu University Clinics	Tartu		Estonia
12	Helsinki University Hospital	Helsinki		Finland
13	Kuopio University Hospital	Kuopio		Finland
14	Oulu University Hospital	Oulu		Finland
15	Tampere University Hospital	Tampere		Finland
16	Turku University Hospital	Turku		Finland
17	CHR Félix Guyon	Saint Denis	La Réunion	France
18	CHU Amiens	Amiens		France
19	CHU Angers	Angers		France
20	CH Arras	Arras		France
21	CH Côte Basque	Bayonne		France
22	CHU Besançon	Besançon		France
23	CHU Bordeaux	Bordeaux		France
24	CHU de Brest	Brest		France
25	CHU Caen	Caen		France
26	CH Chambéry	Chambéry		France
27	CH Cherbourg	Cherbourg		France
28	CHU Clermont Ferrand	Clermont Ferrand		France
29	CHU Dijon	Dijon		France
30	CH Le Havre	Le Havre		France
31	CH Le Mans	Le Mans		France
32	CHU Lyon Croix Rousse	Lyon		France
33	Hôpital Femme,Mère, enfant	Lyon		France
34	Hôpital de la conception - APHM	Marseille		France
35	CHU de Montpellier	Montpellier		France
36	CHU Nancy	Nancy		France
37	CHU Nice	Nice		France
38	CHU de Nîmes	Nîmes		France
39	CHR Orléans	Orléans		France
40	CHU Pau	Pau		France
41	CHU Poitiers	Poitiers		France
42	CHU Reims	Reims		France
43	CHU Rennes	Rennes		France
44	CH Rouen	Rouen		France
45	Ch Saint Etienne	Saint-Etienne		France
46	CHRU de Strasbourg	Strasbourg		France
47	CHU Toulouse	Toulouse		France
48	CHU Tours	Tours		France
49	CH Troyes	Troyes		France
50	CH Bretagne Atlantique	Vannes		France
51	Klinik fUr Kinder und Jugendliche Sozialstiftung Bamberg	Bamberg		Germany
52	Klinikum Coburg	Coburg		Germany
53	Department of Paediatric and Adolescent Medicine University Hospital Erlangen	Erlangen		Germany
54	Cnopf'sche Kinderklinik	Nuremberg		Germany
55	"Gaia" Maternity Hospital	Athens		Greece
56	"Lito" Maternity Hospital	Athens		Greece
57	"Mitera" General Maternity and Pediatric Clinic	Athens		Greece
58	"Rea" Maternity Hospital	Athens		Greece
59	Alexandras Hospital general	Athens		Greece
60	Children's Hospital "Agia Sophia"	Athens		Greece
61	Helena Venilezoy Maternit y Hospital	Athens		Greece
62	University Hospital of Heraklion	Heraklion		Greece
63	University of Ioannina	Ioannina		Greece
64	University of Patras	Patras		Greece
65	1st Dept of Neonatalogy, Aristole University of Thessaloniki	Thessaloniki		Greece
66	2nd Dept of Neonatalogy, Aristole University of Thessaloniki	Thessaloniki		Greece
67	Menn Esy, Hippokratio General Hospital	Thessaloniki		Greece
68	TIN Ospedale San Giovanni di Dio	Agrigento		Italy
69	UO TIN Neonatologia AOU Sant'Orsola Malpighi	Bologna		Italy
70	TIN Bolzano	Bolzano		Italy
71	UO TIN e Patologia Neonatale	Camposampiero		Italy
72	TIN Como Valduce	Como		Italy
73	U.O. di Neonatologia e PatNeo con T.I. - Istituti Ospitalieri	Cremona		Italy
74	Ospedale Careggi	Firenze		Italy
75	Patologia Neonatale Lodi	Lodi		Italy
76	IN Ospedale Macedonio Melloni Milano-AO Fatebenefratellied Oftalmico	Milano		Italy
77	TIN Centro IRCSS Ca Granda-Policlinico Osp.Maggiore Mangiagalli LI	Milano		Italy
78	TIN Modena	Modena		Italy
79	TIN/Neonatologia- fondazione MBBM- H San Gerardo	Monza		Italy
80	TIN E Patologia Neonatale Dip. di Salute della donna e del bambino- Università di Padova	Padova		Italy
81	UTIN Perugia	Perugia		Italy
82	UO Neonatologia Santa Chiara	Pisa		Italy
83	TIN A.O.Bianchi-Melacrino-Morelli	Reggio Calabria		Italy
84	Azienda Ospedaliera ASMN, Reggio Emilia	Reggio Emilia		Italy
85	NICU Rimini	Rimini		Italy
86	TIN Ospedale Pediatrico Bambino Gesù	Roma		Italy
87	TIN Ospedale San Pietro FBF	Roma		Italy
88	Azienda Ospedaliera Universitaria di Sassari	Sassari		Italy
89	Ospedale Maria Vittoria, Torino	Torino		Italy
90	UO Neonatologia e TIN Ospedale Santa Chiara	Trento		Italy
91	UO TIN e Patologia Neonatale	Treviso		Italy
92	Patologia Neonatale Ospedale S.M.Misericordia	Udine		Italy
93	Terapia Intensiva Neonatale e Pediatrica	Verona		Italy
94	U.O.Patologia e Terapia Intensiva Neonatale AOUI Borgo Roma	Verona		Italy
95	TIN Ospedale San Bortolo	Vicenza		Italy
96	Department of Neonatology Lithuanian University of Health Sciences,	Kaunas		Lithuania
97	Mater Dei Hospital, Triq Dun Karm	Msida		Malta
98	Academic medical Center Amsterdam - Emma Children's Hospital	Amsterdam		Netherlands
99	ErasmusMC - Sophia Childrens Hospital	Rotterdam		Netherlands
100	University Hospital Utrecht - Wilhelmina Children's Hospital	Utrecht		Netherlands
101	Maxima Medical Center Veldhoven	Veldhoven		Netherlands
102	Isala Clinics Zwolle - Amalia Children's Hospital	Zwolle		Netherlands
103	Haukeland University Hospital	Bergen		Norway
104	Nordland Hospital	Bodø		Norway
105	Vestre Viken Hospital	Drammen		Norway
106	Ostfold Hospital	Fredrikstad		Norway
107	Haugesund Hospital	Haugesund		Norway
108	Sorlandet Hospital	Kristiansand		Norway
109	Sykehuset Innlandet Lillehammer	Lillehammer		Norway
110	Akershus University Hospital	Lørenskog		Norway
111	Oslo University Hospital - Rikshospitalet	Oslo		Norway
112	Oslo University Hospital - Ullevaal	Oslo		Norway
113	Telemark Hospital	Skien		Norway
114	Stavanger University Hospital	Stavanger		Norway
115	University Hospital of North Norway	Tromsø		Norway
116	St. Olavs hospital	Trondheim		Norway
117	Vestfold Hospital	Tønsberg		Norway
118	Aalesund Hospital	Ålesund		Norway
119	Oddzial Noworodkow	Bydgoszcz		Poland
120	Szpital Wojewódzki Koszalin	Koszalin		Poland
121	Children's Memorial Health Institute Warsaw	Warsaw		Poland
122	Clinical Hospital Ks.Anna Mazowiecka	Warsaw		Poland
123	Department of obstetric and gynecology, medical University of Warsaw	Warsaw		Poland
124	Hospital Orłowskiego Warsaw	Warsaw		Poland
125	Oddział Neonatologiczny	Warsaw		Poland
126	Departement of Neonato- logy Medical University in Wrocław	Wrocław		Poland
127	Hospitale Divino Espirito Santo	Açores		Portugal
128	Hospital San Marcos	Braga		Portugal
129	Maternidade Bissaya Barreto	Coimbra		Portugal
130	Maternidade Daniel Matos	Coimbra		Portugal
131	Hospitale Espirito Santa	Evora		Portugal
132	Hospitale Faro	Faro		Portugal
133	Hospitale Vila Nova Gaia	Gaia		Portugal
134	Hospital Dona Estefânia	Lisboa		Portugal
135	Hospital Santa Maria	Lisboa		Portugal
136	Hospitale Amadora Sintra	Lisboa		Portugal
137	Hospitale Sao Francisco Xavier	Lisboa		Portugal
138	Maternity Dr Alfredo da Costa	Lisboa		Portugal
139	Hospitale Funchal	Madeira		Portugal
140	Hospital San João	Porto		Portugal
141	Complexo Hospitalario Universitario de A Coruña	A Coruña		Spain
142	Hospital Universitario Principe de Asturias	Alcalá de Henares		Spain
143	Hospital General de Alicante	Alicante		Spain
144	Hospital Clinic de Barcelona	Barcelona		Spain
145	Hospital de la Santa Creu i Sant Pau	Barcelona		Spain
146	Hospital Sant Joan de Déu	Barcelona		Spain
147	Hospital Vall d´Hebron	Barcelona		Spain
148	Hospital General de Castellón	Castellón de la Plana		Spain
149	Hospital Universitario Puerta del Mar	Cádiz		Spain
150	Hospital Universitario de Donostia	Donostia		Spain
151	Hospital Universitari Josep Trueta	Gerona		Spain
152	Hospital Universitario Severo Ochoa	Leganés. Madrid		Spain
153	Hospital San Pedro de Logroño	Logroño		Spain
154	Hospital Clínico San Carlos (Madrid)	Madrid		Spain
155	Hospital General Universitario Gregorio Marañón	Madrid		Spain
156	Hospital Infantil Universitario La Paz	Madrid		Spain
157	Hospital Universitario 12 de Octubre	Madrid		Spain
158	Hospital Universitario Central de Asturias	Oviedo		Spain
159	Complejo Hospitalario de Navarra	Pamplona		Spain
160	Complexo Hospitalario de Pontevedra	Pontevedra		Spain
161	Hospital Universitario de Salamanca	Salamanca		Spain
162	Hospital Universitario Marqués de Valdecilla	Santander		Spain
163	Complexo Hospitalario Universitario de Santiago	Santiago de Compostela		Spain
164	Hospital Virgen Macarena	Sevilla		Spain
165	Hospital Virgen de la Salud (Toledo)	Toledo		Spain
166	Hospital Universitari i Politecnic La Fe	Valencia		Spain
167	Complexo Hospitalario Universitario de Vigo	Vigo		Spain
168	Hospital Clínico Lozano Blesa	Zaragoza		Spain
169	Hospital Universitario Miguel Servet	Zaragoza		Spain
170	Hospital Universitario de Álava	Álava		Spain
171	Hospital Lasarettet	Falun		Sweden
172	Universitetssjukhuset	Lund		Sweden
173	Karolinska University Hospital (Stockholm)	Stockholm		Sweden
174	Sachsska Barnsjukhuset (Stockholm)	Stockholm		Sweden
175	Akademiska Barnsjukhuset	Uppsala		Sweden
176	Universitetssjukhuset	Örebro		Sweden
177	Aberdeen Maternity Hospital	Aberdeen		United Kingdom
178	Royal United Hospital	Bath		United Kingdom
179	Royal Berkshire NHSFT	Berkshire		United Kingdom
180	Birmingham Children's Hospital	Birmingham		United Kingdom
181	Birmingham Heartlands Hospital	Birmingham		United Kingdom
182	Birmingham Womens Hospital	Birmingham		United Kingdom
183	Sandwell and West Birmingham	Birmingham		United Kingdom
184	Blackpool Teaching Hospital Foundation Trust	Blackpool		United Kingdom
185	Royal Bolton Hospital	Bolton		United Kingdom
186	Bradford Royal Infirmary	Bradford		United Kingdom
187	Royal Alexander Children's Hospital	Brighton		United Kingdom
188	Bristol Royal Infirmary	Bristol		United Kingdom
189	Southmead Hospital	Bristol		United Kingdom
190	St Michael's Hospital, Bristol NICU	Bristol		United Kingdom
191	Royal Brompton Hospital	Brompton		United Kingdom
192	Burnley General Hospital	Burnley		United Kingdom
193	Countess of Chester	Chester		United Kingdom
194	North Tees Hospital	Cleveland		United Kingdom
195	Colchester General Hospital	Colchester		United Kingdom
196	University Hospitals Coventry & Warwick	Coventry		United Kingdom
197	Royal Derby Hospital	Derby		United Kingdom
198	Royal Devon and Exeter NHS Foundation Trust	Devon		United Kingdom
199	Doncaster Royal Infirmary	Doncaster		United Kingdom
200	Edinburgh Royal Infirmary	Edinburgh		United Kingdom
201	Medway Maritime Hospital	Gillingham		United Kingdom
202	Gloucestershire Royal Hospital	Gloucestershire		United Kingdom
203	Royal Gwent Hospital	Gwent		United Kingdom
204	Airedale NHS Foundation Trust	Keighley		United Kingdom
205	Kettering General Hospital	Kettering		United Kingdom
206	Leeds General Infirmary	Leeds		United Kingdom
207	Leicester Royal infirmary NICU	Leicester		United Kingdom
208	Leicester Royal Infirmary PICU	Leicester		United Kingdom
209	Leighton or Mid Cheshire NHS Trust	Leighton		United Kingdom
210	Liverpool Women's Hospital NICU	Liverpool		United Kingdom
211	Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust PICU	London		United Kingdom
212	Great Ormond Street Hospital for Sick Children PICU	London		United Kingdom
213	Imperial College London NICU	London		United Kingdom
214	Royal London Hospital	London		United Kingdom
215	Pennine Acute Hospitals NHS Trust	Manchester		United Kingdom
216	St Mary's Hospital	Manchester		United Kingdom
217	King's Mill Hospital, Mansfield	Mansfield		United Kingdom
218	James Cook University Hospital, Middlesborough	Middlesborough		United Kingdom
219	West Middlesex University Hospital	Middlesex		United Kingdom
220	Newham University Hospital	Newham		United Kingdom
221	Northampton General Hospital Neonatal Unit	Northampton		United Kingdom
222	Queen's Medical Centre	Nottingham		United Kingdom
223	Southport & Ormskirk & District General Hospital Neonatal Unit	Ormskirk		United Kingdom
224	John Radcliffe Hospital	Oxford		United Kingdom
225	Derriford Hospital, Plymouth	Plymouth		United Kingdom
226	Royal Preston Hospital	Preston		United Kingdom
227	Queen's Hospital, Romford	Romford		United Kingdom
228	Rotherham District General Hospital	Rotherham		United Kingdom
229	Jessop Wing, Sheffield Teaching Hospitals NHS Trust	Sheffield		United Kingdom
230	Royal Shrewsbury Hospital	Shrewsbury		United Kingdom
231	Singleton Hospital	Singleton		United Kingdom
232	University Hospital Of North Staffordshire NHS Trust	Staffordshire		United Kingdom
233	Great Western Hospitals NHS Foundation Trust	Swindon		United Kingdom
234	Musgrove Park Hospital, Taunton	Taunton		United Kingdom
235	Royal Cornwall Hospital	Treliske		United Kingdom
236	Warrington Hospital	Warrington		United Kingdom
237	Calderdale Royal Hospital	West Yorkshire		United Kingdom
238	Pinderfields General Hospital	West Yorkshire		United Kingdom
239	New Cross Hospital, Wolverhampton	Wolverhampton		United Kingdom
240	Worcester Royal Hospital	Worcester		United Kingdom
241	University Hospital of South Manchester, Wythenshawe	Wythenshawe		United Kingdom
242	York Teaching Hospital NHS Foundation Trust	York		United Kingdom