Neonatal Transport
Monica E. Kleinman
KEY POINTS
Whenever possible, transport of the mother and fetus prior to delivery is preferable to a postnatal transport.
Newborns transported by air are subject to specific physiologic stresses associated with altitude.
The risk of interfacility transport can be reduced by the use of specially trained and equipped neonatal transport teams.
I. INTRODUCTION. Regionalization of perinatal services necessitates that newborns requiring intensive care or specialty treatment be transported between facilities. Most experts agree that whenever possible, it is preferable to safely and expeditiously transfer the mother to a center with the necessary resources prior to delivery of a high-risk newborn. Unfortunately, some infants requiring expert neonatal care are not identified prior to birth, and others deliver too quickly to permit maternal transfer. It is important that a system exists for timely referral, clear communication of information and recommendations, and access to specially trained personnel who can provide neonatal resuscitation and stabilization before and during transport.
II. INDICATIONS
A. Interhospital transport should be considered if the medical resources or personnel needed for specialized neonatal care are not available at the birth hospital. Because the birth of a high-risk infant cannot always be predicted, all facilities providing maternity services should ensure that personnel caring for infants at birth or in the immediate newborn period are proficient in basic neonatal resuscitation and stabilization.
B. 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 the patient’s condition before the transport team’s arrival.
C. Criteria for neonatal transfer depend on the capability of the referring hospital as defined by the American Academy of Pediatrics (AAP) policy statement on levels of neonatal care and as dictated by local and state public health regulations. The AAP defines neonatal levels of care as shown in Table 17.1.
Table 17.1. Levels of Neonatal Care | ||||||||||||||||||||||||
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All hospitals with level 1 or 2 neonatal care services should have agreements with regional perinatal centers outlining criteria for perinatal consultations and neonatal transfer. Conditions that typically require transfer to a center that provides neonatal intensive care include the following:
1. Prematurity (<32 weeks’ gestation) and/or birth weight <1,500 g
2. Respiratory distress requiring continuous positive airway pressure (CPAP) or high concentrations of oxygen (FiO2 >0.6).
3. Hypoxic respiratory failure requiring invasive mechanical ventilation
4. Persistent pulmonary hypertension
5. Congenital heart disease or cardiac arrhythmias
6. Congenital anomalies and/or inborn errors of metabolism
7. Hypoxic-ischemic encephalopathy
8. Seizures
9. Other conditions that may be indications for neonatology consultation and/or transfer
a. Severe hyperbilirubinemia that may require exchange transfusion
b. Infant of diabetic mother with hypoglycemia or other complications
c. Severe intrauterine growth restriction
d. Birth weight between 1,500 and 2,000 g and gestational age between 32 and 36 weeks
e. Procedures or therapies unavailable at referring hospital (ECHO, surgery, extracorporeal membrane oxygenation [ECMO], etc.)
III. ORGANIZATION OF TRANSPORT SERVICES
A. 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. A medical control physician, who may be the attending neonatologist or fellow, should supervise each individual patient transport. The medical control physician should be readily available by telephone for consultation to assist in the management of the infant during transport.
B. 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: neonatal nurse practitioners, critical care nurses, respiratory therapists, paramedics, and physicians. Senior pediatric residents and subspecialty fellows can participate in transports for those services that include physician team members. The transport team’s skills should be assessed periodically, and procedural and situational training should be part of routine ongoing education.
C. Types of transport teams
1. 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 cost-effective; however, each team member has little opportunity to gain experience or maintain skills specific to transport.
2. 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 specialized skills for transport and facilitates rapid mobilization to transport requests.
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 specialized skills for transport and facilitates rapid mobilization to transport requests.
D. Modes of transport include ambulance, rotor-wing (helicopter), and fixedwing (airplane) aircraft. The type of vehicle(s) operated will depend on each program’s individual needs, specifically the distance of transports anticipated, acuity of patients, and geographic terrain to be covered by the vehicle. Some hospitals own, maintain, and insure their own vehicles, whereas others contract with commercial vendors for vehicles that can accommodate a transport incubator and appropriate equipment. Although 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, and transport team personnel should use appropriate passenger safety restraints.
Each mode of transport—ground, rotor-wing, and fixed-wing—has advantages and disadvantages. Ground transport is used most commonly among neonatal transport programs. Advantages include a larger workspace than air ambulances, ability to accommodate multiple team members and passengers, and the option to stop the vehicle to assess the patient or perform procedures. Rotor-wing transport has the advantage of a rapid response with hospital-to-hospital 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, has limitations with regard to weather and weight, and has inherently more safety considerations. 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 airport and the hospital. Fixed-wing aircraft have fewer restrictions for weather than do helicopters.
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