KEY POINTS
- 1.
Transport is not a benign event for the neonate, the family, and the transport team.
- 2.
Transport is a significant transition in care and has risk and safety concerns beyond the physical movement of the neonate.
- 3.
Decompensation is not uncommon due to the movement, vibration, noise, and change in environment during transport and must be anticipated and addressed as needed.
- 4.
Neonatal transport is complex and labor and equipment intensive.
- 5.
Management may vary based on environment.
Introduction
Advances in neonatology and technology have led to increased survival rates of neonates, especially low birth weight infants. The neonatal period is defined as the first 4 weeks of life and is the period of greatest mortality in childhood. The mortality rate in infancy is 5.96 per 1000 infants, with a mortality rate during the neonatal period of 4.04 per 1000 neonates. Infants may be born outside a regional center and require transport to a neonatal intensive care unit due to low birth weight, congenital anomalies, or multisystem problems. Neonatal transport is a frequent, daily occurrence in which the process, workforce, resources, and quality of care may vary widely ( Box 5.1 ).
The primary reasons for neonatal transport often mirror the common causes of death in the neonatal period, followed by the need for subspecialty consultation, evaluation, and management.
- 1.
Prematurity and low birth weight
- 2.
Congenital and chromosomal anomalies
- 3.
Maternal complications (preeclampsia, maternal abruption, placenta previa, cord prolapse, or accidents)
- 4.
Sepsis
- 5.
Respiratory distress secondary to respiratory distress syndrome, transient tachypnea of the newborn (TTN), and metabolic derangements
- 6.
Necrotizing enterocolitis with or without bowel perforation
- 7.
Intrauterine hypoxia and birth asphyxia
Evaluation
Clinical Evaluation
When a referral is made for a neonatal transport, it is important and useful to make an initial brief assessment or brief clinical assessment and evaluation of the infant, his or her most likely diagnosis, and the urgency for the transport team to arrive at the referring facility. A transport referral or intake sheet is a tool commonly used by transport teams to obtain certain clinical data in order to better assess the acuity and potential urgency for transport. The personnel, equipment, and resources available at the referring facility may vary widely depending on the level of perinatal care designation and the services provided there. Assessment of this variability allows for triage and appropriate use of the transport team.
Initial Management Assessment
During the initial call, the accepting neonatologist or physician should make an initial management assessment and suggest any additional treatments to initiate while the team in en route. It is important to professionally suggest alternative therapies if an assessment is made for which initial management or therapies are not optimal.
Laboratory
If not already done, request that vital signs are assessed, including temperature, blood pressure of all four extremities, and respiratory rate. The initial laboratory evaluation will vary depending on the diagnosis but always should include a blood glucose level. If the glucose level is assessed by an automated bedside analyzer and is less than 50 to 110 mg/dL, recommend that a serum glucose sample be sent. Recommend immediate intravenous treatment if the blood glucose level is less than 50 to 110 mg/dL, depending on the clinical scenarios. A recommendation to obtain other laboratory analyses will depend on the suspected or confirmed diagnosis(es).
For respiratory symptoms, appropriate initial laboratory testing includes glucose, ABG/CBG, and serum electrolytes. For suspected infection, laboratory testing should include NEC, glucose, complete blood cell count (CBC), CRP if available, and a blood culture. An inquiry about history of maternal herpes simplex virus infection (HSV) should be made.
Imaging
Access to timely radiology testing can be a challenge at some facilities, but when available, a chest x-ray and/or an abdominal x-ray is recommended, depending on the presentation of the neonate. If the infant has been intubated, recommend a chest x-ray (with an orogastric tube in place before obtaining the film). Imaging for other less common diagnoses may be beyond the scope of this chapter but include a suspected subgaleal hematoma and thus an urgent need for further studies. Confirm endotracheal tube placement by at least two methods including chest x-ray, direct laryngoscopy, capnography, and auscultation.
Management
Temperature Regulation
One of the principles of a successful transition to extrauterine life is maintained thermoregulation. , Cold stress can mimic and indeed worsen other possible comorbidities such as hypoglycemia and respiratory distress syndrome and has been implicated in an increased risk factor for intraventricular hemorrhage and other long-term outcomes in the very low birth weight infant. The infant should be managed with appropriate support to ensure normothermia. The infant should be transported in a temperature-controlled isolette with additional thermal support when indicated, including but not limited to the use of a disposable, gel-filled warmer mattress, polyethylene bags, and blankets whenever cold stress is a concern during transport. ,
Respiratory Considerations
Pulse oximetry is an essential and useful tool in monitoring a transitioning or sick infant. An infant with respiratory symptoms (e.g., tachypnea, apnea, periodic breathing, grunting, flaring, or retractions) should have a chest x-ray and blood gas analysis to assess for hypoxia, hypercarbia, and acidosis. Recommendations should be made to the referring provider pending results of testing in order to support the infant until the transport team arrives to assist in care, stabilization, and transfer.
Infectious Disease
Sepsis should always be considered in an infant who is not transitioning well. A good history should be obtained and initial screening should be done. A blood culture and CBC with manual differential with or without CRP should be obtained, and antibiotics should be started. Ampicillin and an aminoglycoside should be initiated, with additional gram-negative and anaerobic coverage in the incidence of suspected intestinal pathology (NEC, bowel perforation, or obstruction). ,
CVS
Cardiovascular pulse oximetry should be initiated and preductal and postductal saturation recorded if the infant is in respiratory distress with or without cyanosis to screen for congenital ductal-dependent cyanotic heart disease. A blood gas measurement can be helpful in diagnosis, and an exhocardiogram (ECHO) is indicated but may not be available at the referring facility. The transport team should anticipate and have available all life-saving medications: for example, prostaglandin E1 and other vasoactive agents. The transport team must be prepared for any untoward side effects from any medications administered. Frequently seen during transport are complications such as apnea necessitating intubation, vasodilation resulting in hypotension, or vasoconstriction resulting in hypertension.
Hematology
Assessment for anemia in incidences of maternal hemorrhage at the time of delivery can be quickly assessed with hematocrit or a CBC. Emergent PRBCs may be indicated in incidences of severe maternal abruption or neonatal anemia. The transport team needs a mechanism for obtaining for the release of O-negative, leukocyte-washed, and irradiated PRBCs.
Metabolism
There are multiple diagnoses that lead to metabolic derangements. An initial assessment of acid–base status is key to ruling out an inborn error of metabolism that results in severe acidosis. Blood gas and serum electrolyte values should be obtained. Recommend that a state metabolic screen is obtained prior to transfer of the infant.
Neurology
Seizures can be an initial presenting symptom for infants with several diagnoses: infection, intracranial hemorrhage, or systemic or metabolic derangements such as hypoglycemia, hypocalcemia, hyponatremia, or hypoxia or opioid withdrawal. Initial treatment should be phenobarbital, with adjunctive treatment with lorazepam or midazolam. Secondary treatment depends on the underlying diagnosis. Hypoglycemia should always be ruled out and promptly treated if present.
Hypoxic-Ischemic Encephalopathy
With a history of a suspected perinatal hypoxic event, hypoxic-ischemic encephalopathy (HIE) should be considered. Cord blood analysis should be performed and an infant blood gas measurement obtained within the first hour of life (ideally) to be used in assessing an indication for neonatal cooling.
Recommend contacting the referral center for specific recommendations regarding eligibility for cooling and stabilization and ongoing management while awaiting the transport’s arrival. Instructions may be given regarding passive cooling, including turning off the radiant warmer bed heat source. A servo-controlled device should be used during the transport. There are ongoing clinical trials that may alter inclusion and exclusion criteria.
Cranial Hemorrhages
There are presently no universally accepted treatments for cranial hemorrhages, and the main strain of therapy in the transport arena is supportive care. Nonaccidental trauma is unusual in the immediate neonatal period but must be considered if the situation warrants.
Social/Emotional Considerations
The neonate is the newest member of the family, and the need for separation and transfer to another facility is often traumatic. The transport team should greet the family and give an update on the infant’s status and plan of care. The team should share information about the neonatal intensive care unit to which the infant will be transferred, including contact numbers. If feasible, the mother and family should be able to see the infant before he or she is transferred out of the facility. Whenever possible, the mother should be transferred to that facility so that she may be with her infant.
Communication
Transitions in care increase the possibility for miscommunication and errors to occur. The Joint Commission National Patient Safety Goals mandate implementing the use of handoffs within each institution. Safety programs such as Team Strategies and Tools to Enhance Performance and Patient Safety between staff and teams suggest standardized tools and strategies to avoid errors. In transport situations, there are more opportunities for errors and miscommunications because there is a transition of not only healthcare providers but also institutions.
Communication for transport consists of three major components: (1) the healthcare team, (2) the transport team, and (3) the family. Communication between the healthcare team and the transport team is ideally completed on a recorded telephone line for quality and safety purposes. Communication with the family may be in person at the bedside, on a recorded telephone line, or via other digital communications.
All communication must be clear, concise, comprehensive, and timely and documented appropriately. Communication that reflects these attributes is vital to the safety and well-being of the patient and the transport team.
Documentation
The purpose of documentation is to ensure ongoing optimal patient care and communication regarding the continuity of care during transport. Documentation must be complete, legible, dated, timed, and signed. Documentation must be completed to provide the most complete, clear assessment of the patient and the care that is provided. In the medical–legal arena, when subsequent providers, reviewers, and juries are unable to get a clear view of the patient and the care that was provided, there is often a negative impression or assessment of the care overall. Documentation must be factual and void of judgment, criticism, or editorial comments. If there is a concern about the adequacy or quality of care, there should be an internal process for review and feedback. Standardized documentation is also highly encouraged and may be mandated by the institution.
Consent
Written consent for transport must be obtained from the parents or legal guardian or designee. In a situation in which the mother is unable to consent and the referral and accepting physician deem the transport life-saving, a medical emergency consent can be obtained and signed by both providers (referring and accepting). This situation is known as the emergency exception rule or the doctrine of implied consent. Often the names of the physicians are documented on the consent form and signed by a witness on a recorded call. As soon as the mother, parent, or legal guardian is available, the signature is added to the written consent form signed by the physicians. Each facility that participates in transport must have a policy, procedure, or guideline to outline this situation or practice.
Consultation/Medical Director’s Role
The transport team, the medical control physician, and/or the consultant may not be privileged to practice medicine, nursing, or respiratory therapy in the referral facility. The transport team functions as a consultation service under the direction of the physician present. Recommendations should be made when appropriate. The transferring physician must remain involved in the care of the infant, has legal responsibility for care of the infant, and is responsible for signing the transfer certificate at the time of transfer.
If there is a disagreement regarding care that cannot be resolved at the time, the transport team may be instructed to depart as soon as possible and change care or management when the infant is loaded into the transport vehicle. Most often the patient becomes a patient of the accepting hospital at the time of transfer and/or when the patient departs the premises of the referral hospital. All decisions or disagreements should be documented by all caregivers.
Safety
The safety of the team, patient, and others must be paramount in all transport decisions. The transport team is exposed to additional risks including but not limited to weather, time of day, geography, traffic, natural and unnatural disasters, and physical conditions. For this reason, the transport team must have policies, procedures, and guidelines to address all of the above risks. Education and competencies must be included to address the specific conditions that may include but are not limited to altitude, extreme weather, natural and unnatural disasters, water egress, and cold weather survival. Transport is physically demanding, and some teams have specific fitness requirements. Chronic health issues that include but are not limited to diabetes, allergies, and hypertension must be considered. Self-limiting conditions such as pregnancy and injuries must also be addressed in transport policies, procedures, and guidelines and may differ from institutional requirements. There are often guidelines provided by professional associations or regulatory agencies.
Types of Transport and Other Considerations
Transport may become necessary to a higher level of care including but not limited to subspecialty care, diagnostic testing, and evaluation. Transport to a lower level of care is also considered to facilitate recovery and reunification with family to build ongoing support. There are several types of transport, each with advantages and disadvantages. The primary concern is the safe, efficient transport of the neonate with the most appropriate personnel and equipment ( Fig. 5.1 ).
