Neonatal Transport

Caraciolo J. Fernandes

I. INTRODUCTION.

Neonatal transport may be defined as the act of moving a neonate from one setting or facility to another to allow the provision of a level of care and/or type of service that is not available at the former. Although neonatal transport typically refers to interfacility transfers of high-risk neonates to tertiary care facilities to allow a higher level of care, the principles pertaining to neonatal transport are equally important for transfer of neonates from the birthing area to special care nurseries within the facility and for transport of infants from tertiary care facilities back to their referral hospitals or sometimes home. Ideally, babies should be delivered and cared for in hospitals adequately equipped and staffed to care for them; thus, high-risk infants should ideally only be born in tertiary care facilities. Careful attention to the history can identify maternal and fetal conditions that suggest a need for infants to be delivered at a hospital capable of providing the appropriate level of care (see Chap. 7). In such instances, maternal transport prior to birth is preferable to having a high-risk neonate be born in a setting that is not equipped to care for it. Unfortunately, not all high-risk infants are identified prior to birth, and infants are delivered in facilities that are not matched to their needs. In this case, prompt contact with the tertiary care facility is essential to allow early and timely involvement of specialists in the care of the infant.

II. INDICATIONS

Interhospital transport should be considered if the medical resources or personnel needed for a high-risk infant are not available at the hospital currently providing care. As the birth of high-risk infants cannot always be predicted, all facilities that care for pregnant women and newly born infants should ensure that personnel caring for infants at birth or in the immediate newborn period are proficient in basic neonatal resuscitation and stabilization.
Transfer to the regional tertiary neonatal center should be expedited following initial stabilization. Medical personnel from the referring center should contact their affiliated neonatal intensive care unit (NICU) transport service to arrange transfer and to discuss a management plan to optimize patient care before the transport team’s arrival at the referring center.
Criteria for neonatal transfer depend on the capability of the referring hospital as defined by the American Academy of Pediatrics policy statement on levels of neonatal care and as dictated by local and state public health guidelines. Conditions that require transfer to a center that provides neonatal intensive care include the following:
- Prematurity and/or birth weight <1,500 g
- Gestational age <32 weeks
- Respiratory distress requiring ventilatory support (continuous positive airway pressure [CPAP], mechanical ventilation)
- Hypoxic respiratory failure or persistent pulmonary hypertension
- Congenital heart disease or cardiac arrhythmias requiring cardiac services
- Congenital anomalies and/or inborn errors of metabolism
- Severe hypoxic-ischemic injury
- Seizures
- Other conditions requiring neonatology consultation and possible transfer
  - Severe hyperbilirubinemia that may require exchange transfusion
  - Infant of diabetic mother
  - Severe intrauterine growth restriction
  - Birth weight between 1,500 and 2,000 g and gestational age between 32 and 36 weeks
  - Procedures unavailable at referring hospital (surgery, extracorporeal membrane oxygenation [ECMO], etc.)

III. ORGANIZATION OF TRANSPORT SERVICES

All hospitals with established maternity services and Level I or II neonatal care services should have agreements with regional perinatal centers outlining criteria for perinatal consultations and neonatal transfer.
The regional NICU transport team should have an appointed medical director. The transport team should follow practice guidelines detailed in easily accessible written protocols and procedures, which should be reviewed on a periodic basis.
Transport teams. Qualified transport teams should be composed of individuals with pediatric/neonatal critical care experience and training in the needs of infants and children during transport, and who participate in the transport of such patients with sufficient frequency to maintain their expertise. Such teams typically consist of a combination of at least two or three trained personnel and can include one or more of the following: advanced practice nurses, neonatal nurse practitioners, respiratory therapists, and physicians. Senior pediatric residents and subspecialty fellows can provide the physician component for some teams. Skills of the transport team should be assessed periodically, and skills and situational training should be part of routine ongoing education. Each transport team should be supervised by a medical control officer, who may be the attending neonatologist. The medical control officer should be readily available by telephone for consultation to assist in the management of the infant during transport.

Types of transport teams:
- Unit-based transport teams consist of personnel (nurses, respiratory therapists, neonatal nurse practitioners, etc.) who are involved in routine patient care in the NICU and are deployed when a request for transport is received. If few infants are transported to the NICU, this type of staffing may be most costeffective; however, this arrangement would lack the experience and expertise of a dedicated transport team.
- Dedicated transport teams are staffed separately from NICU personnel specifically for the purpose of transport of patients to and from the hospital. These personnel do not have patient assignments, although they may assist NICU staff when they are not on transport. A large volume of transports is necessary to justify a dedicated transport team, which must consist of sufficient personnel for around-the-clock coverage. This arrangement allows dedicated personnel to maintain their skills for safe and efficient transport of patients.
Modes of transport include ambulance and fixed- (airplane) and rotor-wing (helicopter) aircraft. The type of vehicle chosen will depend on each program’s individual needs, specifically the distance of transport anticipated, acuity of patients, and geographic terrain to be covered by the vehicle. Some hospitals own, maintain, and insure their own vehicles, while others contract with commercial vendors for vehicles that can accommodate a transport incubator and appropriate equipment. While the type(s) of vehicle chosen for transport will vary depending on the individual program’s needs, the vehicles chosen must be outfitted to conform to standards that ensure safety and efficiency of transport. Vehicles should comply with all local, state, and federal guidelines for air transport and/or ground ambulances. The vehicles should be large enough to allow the transport team to adequately assess and treat patients as needed en route to the referral hospital, and should be equipped with appropriate electrical power supply, medical gases (with reserve capacity, in case of a breakdown), and communication systems. All equipment and stretchers should be properly secured. Each mode of transport— ground, fixed wing, and rotor wing—have advantages and disadvantages. Ground or rotor-wing transport has the advantage of a rapid response with hospital-tohospital service for patients up to a distance of 100 to 150 miles or less each way, although a rotor-wing service is more expensive to operate. Fixed-wing transport is advisable for transport of patients over greater distances (over 150 miles each way), is moderately expensive to operate, and requires an airport to land and an ambulance at either end of the flight to transport the patient between the airplane and the hospital.
Equipment. The team should carry with them all equipment, medications, and other supplies that might be needed to stabilize infants at a referring hospital. Teams should use checklists prior to departure to ensure that vital supplies and equipment are not forgotten. Packs especially designed for neonatal transport are commercially available. These packs or other containers should be stocked by members of the transport team, which ensures that they will know where to find required items promptly. The weight of the stocked packs should be documented for air transport (see Tables 17.1, 17.2, 17.3).
Legal issues. The process of neonatal transport may raise legal issues, which vary among states. Transport teams should periodically review all routine procedures and documentation forms with their hospital legal counsel to ensure compliance with changing laws that govern the transport of infants and accompanying family members (if present). The team should have the ability to contact via telephone appropriate hospital legal counsel as needed.

Malpractice insurance coverage is required for all team members. The tertiary hospital should decide whether transport is considered as an off-site or extended on-site activity as this can affect the necessary coverage.

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