Neonatal transport began in 1900 with the development of the first mobile incubator for premature infants by Dr. Joseph DeLee of the Chicago Lying-In Hospital (1). This “hand ambulance” provided warmth while transporting premature infants to the hospital following home birth. The development acknowledged the need to create a controlled environment for the transport of infants that simulated the inpatient setting. In 1934, the first dedicated neonatal transport vehicle in the United States was donated to the Chicago Department of Health by Dr. Martin Couney (2), following the closure of the Chicago World’s Fair where the vehicle was used to transport premature babies to the exhibit. The first organized transport program in the United States began in 1948 with the development of the New York Premature Infant Transport Service by the New York Department of Health in conjunction with area hospitals (3,4). This remarkable system, created more than a decade before the evolution of neonatal intensive care units (NICUs), incorporated many of the features of modern neonatal transport programs, including around-the-clock staffing by specially trained nurses, dedicated vehicles, a clerk to receive referral calls, and equipment designed specifically for neonatal transport. During a 2-year period, this program transported 1,209 patients, of whom 194 weighed less than 1,000 g (4).

Neonatal transport took to the air in 1958 with the first fixed-wing transport of a newborn infant by the Colorado Air National Guard (2). The 1967 flight of a premature baby to St. Francis Hospital in Peoria, Illinois, using the Peoria Journal Star helicopter, marked the first rotor-wing neonatal transport (2). Routine use of air transportation for neonatal patients began in 1972 with Flight for Life of Denver’s St. Anthony Hospital (5).

Proliferation of organized transport programs occurred in the late 1970s, in conjunction with regionalization of perinatal care. Regionalization initially minimized the number of infants requiring transport by promoting maternal-fetal transport. Regionalization also shifted the responsibility for transporting infants born in community hospitals to referral centers. Subsequently, the next decade saw improvements in perinatal mortality (6) and neonatal morbidity (7) as the percentage of very-low-birth-weight (VLBW) infants delivered in referral centers increased.

Since the late 1980s patterns of referral dictated by schemes of regionalization have deteriorated in many areas (8), coincident with an increase in community hospitals capable of providing some degree of neonatal intensive care. As a result, increasing numbers of infants deliver at centers without subspecialists or the necessary support services demanded by some VLBW infants. Community-based neonatal intensive care creates a need to transport infants at a critical time in their illness, occasionally while receiving therapies such as high-frequency ventilation or inhaled nitric oxide, which are not easily portable. Even in areas where regionalized perinatal care persists and prenatal risk assessment is routine, unpredictable, emergent events may precipitate the delivery of an infant in an unsuitable hospital. Collectively, these situations mandate increasingly sophisticated neonatal transport systems.

Neonatal transport can be performed by either the community hospital referring the patient (one-way transport) or the referral center receiving the patient (two-way transport). Two-way transport offers an economic advantage, offers generally more skilled and experienced transport personnel (9), and may result in improved survival (10,11). The American Academy of Pediatrics supports two-way transport (12), and in most perinatal regions, referral centers have assumed this responsibility. The major disadvantage of two-way transport is the time delay to get the transport team to the community hospital. In the remainder of this chapter, two-way transport is discussed exclusively.

A variety of personnel participate in the inpatient care of infants, and all should be considered candidates for caretakers during neonatal transport. These personnel include the following:

The selection of the type of personnel used by each program is based on the unique aspects of that program; however, some general principles apply that determine the relative desirability of various professionals. As the number of transports increases, it becomes less practical to send physicians on transport. Neonatologists rarely have the time to devote to frequent transports, and reimbursement is not sufficient to justify their presence. Although participation in transport can be educational, in high-volume programs, time spent on transport by pediatric residents and neonatal fellows competes with other aspects of training. In addition, the interest in participation and expertise may vary considerably among trainees. This is a particular problem if participation is mandated. Pediatric residents who participate in transport should be senior-level trainees under close supervision.

Most high-volume programs choose to use nonphysician personnel as attendants during transport. The use of neonatal nurse practitioners offers an attractive alternative to physician attendance (14,15). Nurse practitioners are highly skilled in neonatal stabilization and care and provide a consistency of expertise not usually encountered in other professional groups. They are licensed in most states to perform all of the diagnostic and therapeutic procedures required during transport. The greatest disadvantages to the use of neonatal nurse practitioners are scarcity of workforce in certain locations and cost. In addition, neonatal nurse practitioners are rarely trained, or willing, to transport patients other than neonates.

As a cost-effective alternative to nurse practitioners, many centers train NICU staff nurses to participate in transport. In addition, most states permit nurses to perform invasive procedures as an extension of their inpatient nursing role under guidelines and protocols approved by the Boards of Nursing. Therefore, NICU staff nurses can be trained to provide all the care required by a critically ill neonate during transport. This training often is extensive, however, because the cognitive knowledge necessary to diagnose disorders and the experience to perform invasive procedures must be mastered. This extensive training must be considered when estimating the cost of using staff nurses as compared to nurse practitioners. The requirement of training is particularly burdensome when there is a high personnel turnover rate.

Most patients transported to the NICU either have respiratory failure requiring mechanical ventilation or are receiving supplemental oxygen. Respiratory therapists should be considered when selecting transport personnel because of their expertise in the use and maintenance of respiratory care equipment. The therapists’ ability to adapt this equipment to the unique environment of transport can be lifesaving, particularly in circumstances when unexpected events occur. The disadvantage of using therapists is the narrow focus of their usual training. Further education and crosstraining allows their scope of practice to be expanded.

Eliminating physicians from attendance during transport can create problems that must be anticipated. For example, leadership of the team is not defined by the usual medical model in which a physician assumes this role. Designating one member of the transport team as the leader, accountable for communication, decision making, and documentation can solve this problem.

Advisory personnel at the referral center, particularly physicians, often are unwilling to endorse a patient care program that does not mandate initial evaluation by a physician. This resistance usually stems from a concern for the well-being of the patient and can be overcome by the selection and training of competent non-physician personnel. The support and endorsement of an involved medical director may also be critical. A similar attitude may prevail in community hospitals. Community physicians may find it unacceptable to relinquish care of a critical patient to nonphysician personnel. In an environment in which referral centers compete for patients, this may be a motivation for maintaining physician attendance during transport. Most community physicians, however, are concerned only with transferring their patients in a safe and timely fashion. Anecdotal experience, as well as retrospective and prospective studies, suggests that properly selected and trained nurses provide a level of care during transport that approximates the level provided by physicians (5,16,17,18). Once a nonphysician team demonstrates competence and efficiency, the concerns of most community physicians vanish. Because the use of specially trained nonphysician personnel represents both a safe and economic alternative to physician participation in neonatal transport, most programs now rely on nonphysician personnel for patient care.

Transport personnel must be proficient in cognitive knowledge of neonatal diseases, management principles of acute problems, and technical skills. The method and extent of training necessary to reach proficiency will depend on the type of personnel; however, the pattern of preparation will be similar for all professionals (19). Cognitive knowledge is best provided in didactic sessions in conjunction with self-study exercises. Management principles may also be taught in a didactic setting, but refinement of these skills requires repeated experiences in the inpatient setting. Laboratory simulation of technical skills and patient care scenarios is essential. These skills can then be refined in the inpatient setting under supervision. Demonstration of proficiency in these areas should be ensured by examination or observation by a qualified supervisor. After initial preparation, a period of training should be provided, during which the trainee accompanies a more experienced team member on transport. Final certification of competence should be awarded by both the medical director and the coordinator for the trainee’s professional group.

The quality of the communication system that supports a transport program may be the key determinant of its success. The communication system serves two basic functions: to provide a point of access for community physicians, and to coordinate the activities of the transport team (20). A single call by the community physician should provide access to all of the neonatal services of the referral center. The use of a transfer center or a toll-free hot line, often associated with a memorable acronym, is favored by some institutions (21). Alternatively, community physicians can call the NICU directly. If consultation is requested, the community physician should be connected in a timely fashion with a consultant of appropriate training. If transfer is requested and deemed appropriate, an available bed in the NICU of the referral center or an alternative should be identified. Bed procurement and all subsequent details of the transport should then occur without additional calls by the community physician.

Once the decision is made to transport the patient and an NICU referral center bed is located, the role of the communication system shifts to dispatching the team and disseminating information regarding the transport. In this role, the system is best served by a communication center that is staffed and equipped for emergency medical service functions. The community hospital should be informed of the estimated time of arrival and of any necessary preparations for the arrival of the vehicle. The receiving NICU should be notified and be provided with medical information necessary for admission of the patient.

During the conduct of the transport, periodic communication between the dispatch center and the vehicle operator is advisable. Unexpected delays or mishaps are identified promptly, and appropriate action is taken. Most high-volume transport programs use satellite-tracking systems to monitor the movement of their transport vehicles, which can be useful if diversion is necessary. When the transport team does not include a physician, the team should have the capability of communicating directly with the consulting physician at all times. The nurse practice acts in some states mandate this level of communication.

Communication capabilities are usually a trivial problem while the team is in the community hospital; however, they can present a challenge during transit. The gravity of this problem declines each year with the evolution of telecommunications equipment. Cellular phones are typically used during ground transport. VHF, UHF, and SHF radios are utilized for communication in rotor-wing aircraft with air traffic control, medical control, and general communications using separate frequencies. Fixed-wing aircraft generally use satellite communication systems.

Many communication centers are equipped with automated devices that record all communications. Although not essential, the recorded transmissions may be valuable educational tools and aids in identifying system errors; in addition, they are often critical for medicolegal questions.

Communication should not end with the conclusion of the transport. The transport team should contact both the patient’s family and the community facility to relate the events of the transport. The receiving physician should update the community physician following admission and give further follow-up information at regular intervals, including at the patient’s discharge. This update should be expedited if an acute event occurs and should occur immediately in the event of death. Failure to effectively communicate subsequent patient information remains one of the most common criticisms of referral centers.

Subjecting a transport program to periodic cost-benefit analyses is a critical aspect of the program’s operation. The following elements should be included in the cost of operation:

Identifying the costs associated with the program may be difficult if its operation is financially integrated into the operation of the NICU. For example, personnel costs often are difficult to quantify because, except in high-volume programs, transport personnel usually contribute to inpatient services during transport duty time. Therefore, the cost allocated to the transport program should be discounted based on this contribution. The proportion of time devoted by the medical director is even more difficult to quantify and often ignored in the financial analysis. The cost of equipment is usually separable from the cost of inpatient equipment as transport equipment rarely is used for other purposes. Included in estimates of equipment costs should be allowances for depreciation and maintenance.

The nonmedical components of a program are often more costly than the medical components because of expenses related to transportation. This is particularly true when air transportation is used.
Sharing resources with other hospitals or agencies can minimize these expenses. Ground ambulances can be shared with local emergency medical service agencies or be used for convalescent transport. Aircraft can be used by a consortium of hospitals. The major disadvantage of the shared approach is the possible vehicle unavailability at the time of transport request; however, the potential for this occasional conflict may be far outweighed by the cost reduction.

The revenue of a transport program comes from three general sources: reimbursement, support from governmental agencies, and support from other extramural organizations (22). Support from government and charitable organizations are unusual in the United States, and hospitals are increasingly dependent on reimbursement to support transport programs. Most third-party payers will reimburse the majority of the initial transport as long as the care rendered at the referral center was unavailable at the community hospital. Reimbursement for back transport is less consistent. In general, the cost of a transport program exceeds its revenue. Subsistence of the program, therefore, depends on financial assistance from the sponsor hospital.

The decision to fund a transport program usually is based on a favorable cost-benefit analysis. Benefit can be quantified by reductions in mortality, morbidity, and length of hospital stay. Among low-birth-weight (LBW) infants with respiratory disease, it has been demonstrated that the services of a hospital-based neonatal transport team reduce hypothermia and acidosis, the greatest prognostic indicators of mortality (10). However, little other evidence supports the advantage of specialized neonatal transport teams. In an attempt to quantify the utility of a neonatal transport program, the most prudent approach may be to scrutinize the type of patients requiring transport to ensure potential benefit. These medical benefits should be combined with nonmedical benefits to the institution, such as improved public relations and the recruitment of new patients. Ultimately, many institutions in the United States elect to support a neonatal transport program, despite its financial disincentives, in order to increase occupancy of NICU beds.

A potential economy for transport programs may be to combine services, either within a program or between programs. An example of the former would be to cross-train members of specialty transport teams (e.g., pediatric, neonatal, and adult) such that the total number of personnel can be reduced. This strategy invariably results in some loss of expertise but may be necessary to ensure financial viability. Collaboration between programs may include sharing vehicles or teams. Smaller institutions may benefit from outsourcing entirely by contracting with larger medical centers for the provision of all transport services.