CHAPTER 21 1. Discuss planning for an intrafacility transport of a critically ill neonate. 2. Identify important considerations in the selection of transport vehicles. 3. Discuss the important factors to be considered in selecting team composition. 4. Describe the process of neonatal transport from the referring call, to transport of the patient, to arrival at the receiving hospital. 5. List four methods to increase safety in the transport environment. 6. Discuss legal and ethical considerations relating to neonatal transport. In the late 1950s and early 1960s, intensive care for newborn infants first became available. As the scope of care for critically ill infants expanded, so did the number of hospitals offering this service. Unfortunately, because of the uneven distribution of these services, many areas remained without available resources. In the early 1970s, the need to regionalize perinatal care was recognized by health care providers. In 1976, the National Foundation-March of Dimes released the report “Toward Improving the Outcome of Pregnancy,” which described regionalized care and identified criteria for level I, II, and III hospitals (Committee on Perinatal Health, 1976). The report also recommended the establishment of formal relationships between hospitals delivering different levels of care within a region so that every infant could receive appropriate care. The concept of regionalization led naturally to the need for the development of neonatal transport. The U.S. Department of Health and Human Services reported almost 4 million live births in the United States in 2010, with 8.1% of low birth weight (less than 2500 grams) (Martin et al., 2010). Advances in neonatology and technology have led to increased survival rates of these low birth weight infants. These infants may be born outside a regional center and require transport to a neonatal intensive care unit. Infants with congenital anomalies or multisystem problems may also require transport to a regional neonatal intensive care center. The neonatal period is defined as the first 4 weeks of life and is the period of greatest mortality in childhood, with the highest risk occurring during the first 24 hours of life (March of Dimes, 2005). Intrafacility and interfacility transport of the critically ill neonate presents unique challenges. Transport of neonates occurs over 20,000 times annually in the United States (Shah et al., 2008). The transport environment does not provide optimal conditions. The goal is to transport these critically ill neonates in the most stable condition possible and to minimize adverse effects. The neonatal transport team must be knowledgeable about neonatal physiology and clinical requirements to provide optimal care and outcome. This chapter discusses various aspects of intrafacility and interfacility neonatal transport. A. 1899: When most infants were born at home, the first ambulance incubator was developed to transport premature infants from home to Chicago’s Lying-In Hospital (Butterfield, 1993; Cone, 1985). B. 1935: The Chicago Board of Health operated a special ambulance with incubator, oxygen, and humidity and was staffed with public health nurses (Chou and MacDonald, 1989). C. 1948: The New York City Department of Health, Maternity and Newborn Division established a well-organized transport service staffed with ambulance drivers, nurses, a pediatrician, and a transport clerk (Losty et al., 1950; Wallace et al., 1952). D. 1966: Dr. Sydney Segal published guidelines for neonatal transport (Segal, 1966) that were expanded in 1972 into a comprehensive transport manual (Segal, 1972). E. 1970s: The number of organized transport programs increased as a result of regionalization of perinatal care (Wood and Bose, 2005). A. The neonatal transport team is an extension of the neonatal intensive care unit (Ohning et al., 2012). 2. The level of care should remain the same or increase during neonatal interfacility transport. B. Crew and patient safety must be the highest priority of a transport program (American Academy of Pediatrics [AAP], 2007; Blumen, 2002; Levick, 2010). C. The neonate is a member of a family unit (Kenner and McGrath, 2010). D. Intrafacility and interfacility neonatal transport should be planned and organized with appropriate transport staff and adequate equipment. E. Intrafacility and interfacility preparation, stabilization, and transport should be performed as efficiently as possible using skilled staff and appropriate equipment. The continuum of care should not be interrupted during the transport process. 2. Level of care must be maintained or increased. B. Staffing. 2. The type and number of personnel required is determined by patient acuity level and equipment. 3. It is beneficial to have the bedside registered nurse as part of the transport staff because of patient knowledge. It may not be feasible with staffing shortages and patient care assignments. C. Effective communication between staff of the neonatal intensive care unit, intrafacility transport team, and procedure department is critical. Formal hand-off process should be performed. D. Equipment. 1. Type of equipment selected is based on patient acuity level. 2. Anticipate potential complications. 3. Maintenance of a neutral thermal environment during the procedure presents challenges. The neonate may be transported to the procedure in a transport incubator or radiant warmer, depending on the patient’s clinical condition and potential problems with hypothermia. Prevention of hypothermia during the procedure may require additional supplies. b. Warm blankets. c. Hat. d. Crushable heat packs or thermal pad (do not place against fragile skin). e. Polyurethane wrap or bag. 4. Monitoring devices should be compatible with the type of procedure performed. 5. Equipment should have battery back-up capabilities. Plug in equipment to an electrical outlet to maintain the battery charge. E. Safety. 1. Use the most expeditious route between the unit and the procedure department. 2. Anticipate and plan for potential problems (e.g., elevator not functioning). 3. Supplies and equipment should be packaged for safe transport. 4. Staff remaining with patient during the procedure should be provided with protective clothing and monitoring devices depending on type of procedure. 5. The neonate and monitoring equipment should be positioned for optimal visualization. 6. Staff may be required to stay with the neonate during the procedure given that other health care providers may not have the expertise to manage a neonate. 7. The neonate should be assessed frequently during the procedure. 2. Advantages of one-way transport. a. Time-saving in patient arrival to the receiving center. b. Knowledge of the patient by referring staff. 3. Disadvantages of one-way transport. b. May deplete the resources of local EMS or the referring hospital for the duration of the transport. c. Referring hospital and local EMS staff may not have appropriate equipment or training for transport of neonates. Studies have shown that there is an increased morbidity and mortality when neonates are transported by an untrained versus a trained neonatal team. B. Two-way transport. 2. Advantages. a. More cost-effective use of expensive equipment. b. More experienced transport staff trained specifically in neonatal transport. c. Improved neonatal stabilization techniques. d. Provide equipment specifically for neonatal transport. 3. Disadvantages. a. Time delay in moving patient from referring facility. b. Expense of maintaining transport program. C. Three-way transport. D. Back-/return transport (National Association of Neonatal Nurses [NANN], 2010a). a. Parents should visit the local or birth hospital prior to the transfer. 2. Advantages. a. More efficient use of beds at regional center. b. Improved relations between community hospitals and tertiary care center. c. Greater opportunity for parental involvement. d. Familiarity of primary physician with infant before discharge home. e. Decreased cost during convalescence. 3. Disadvantages. b. Potential need for transport back to higher-care facility if patient’s condition deteriorates at community hospital. c. Parental anxiety and loss of continuity of care. E. Transfers out. 2. Neonate may be transported by a team from the receiving hospital, the referring hospital, or a third facility or company. 3. Receiving facility should consider back-transport after completion of the treatment or procedure. A. General considerations (AAP, 2007; Ohning et al., 2012). 2. Vehicles must be appropriately equipped, including power supplies, inverter, oxygen and air supply, suction, lighting, altitude pressurization where appropriate, means for securing incubators and all equipment, and room for adequate personnel. 3. An integrated system using multiple modes of transportation allows maximum flexibility to meet patient needs in a cost-effective manner. 4. Decisions regarding the appropriate vehicle for individual transport should be made by the medical control physician at the tertiary hospital, the transport team, and the referring physician in consideration of the impact on patient care and outcome, advantages and disadvantages of each vehicle, and cost. 5. Vehicle design and equipment placement must allow for continuation of patient care throughout the transport. 6. The vehicle must be equipped with appropriate locking devices and storage to secure the incubator and equipment. B. Specific vehicle considerations. 1. Ambulance (AAP, 2007; Ohning et al., 2012). (2) Operates in weather conditions that restrict air transport. (3) Does not require a landing zone or runway. (4) Ability to carry equipment and personnel for two incubators in specially equipped ambulances. (5) Increased space and patient more accessible. (6) Ability to stop vehicle or divert to the closest hospital in an emergency. b. Disadvantages. (2) Delay of admission to tertiary care center because of long-distance ground transport. 2. Helicopters (AAP, 2007; Ohning et al., 2012). (2) Decreased response time to the referring facility. (3) Use of one-way helicopter transport to increase team’s response time to referring hospital. (4) Avoid traffic delays and ground obstacles. b. Disadvantages. (2) Increased noise and vibration levels. (3) Difficult to identify problems when they occur because of noise and vibration (e.g., pneumothorax, extubation). (4) High operational costs. (5) Space and weight limitations, including restricted patient access during flight. (6) Increased downtime because of weather. (7) May require ground transportation depending on landing zone location. (8) Securing the same incubator in a helicopter and an ambulance may not be possible because of different mounts and stretcher configurations. This must be evaluated prior to the transport. 3. Fixed-wing aircraft (AAP, 2007; Ohning et al., 2012). (1) Primarily beneficial for long-distance transports, usually greater than 150 miles. (2) Although fixed-wing transportation is expensive, favorable cost comparison possible over long distances when staff time is taken into consideration. b. Disadvantages. (2) Requires coordination of ground transportation on both ends of the flight. (3) Space limitations, and patient access may be limited. (4) Securing the same incubator in a fixed-wing aircraft and an ambulance may not be possible because of different mounts and stretcher configurations. This must be evaluated before the transport. (5) Requires an airport for landing and takeoff. (6) Multiple patient movements from aircraft and ambulances. A. Composition of a neonatal transport team varies with federal, state, and local regulations as well as budget, availability, professional standards, patient population, mission, referral area, expectations and available resources at referral hospital, skill and educational level of team, acuity, and volume of transports. The team must possess the combined expertise to assess, plan, implement, and evaluate actual and potential complications during transport of a critically ill neonate (Commission on Accreditation of Medical Transport Systems [CAMTS], 2012; NANN, 2010a; Woodward et al., 2002). The team may be staffed by using various combinations of personnel, with a minimum of two patient care providers trained in the management of critically ill neonates. These patient care providers are in addition to the ambulance drivers or pilots. At least one of the patient care providers should be a physician, registered nurse, or neonatal nurse practitioner. Team composition may remain constant or vary according to patient acuity (Woodward et al., 2002). When transporting two neonates in the same vehicle, specific patient care providers should be assigned to each infant. Cross-training staff within scope of practice and licensure increases efficiency of the team. Transport teams may be configured using a combination of the following personnel: 1. Physicians and neonatologists. 2. Fellows and residents. 3. Registered nurses. 4. Neonatal nurse practitioners. 5. Respiratory therapists. 6. Emergency medical technicians or paramedics. B. Roles for transport personnel, including functions, responsibilities, qualifications, and competencies, must be clearly outlined in job descriptions. 1. Transport personnel should function as a team. 2. Cross-training personnel within scope of practice and licensure. 3. The program should have a written policy specific to job performance for physical requirements and disqualifying mental conditions of team members. a. Weight and height requirements, especially in air transport. b. General physical condition. c. Notification to transport administration of use of prescription and over-the-counter medications (certain medications may delay mental function and reflexes). 4. Staff should participate in neonatal transport with sufficient frequency to maintain expertise. C. Team composition considerations (AAP, 2007; CAMTS, 2012). a. Neonatologists should be utilized when their additional expertise is required. b. May limit resources in a busy neonatal practice. c. Residents provide less consistency as a result of rotations and lack of educational experience in neonatal intensive care. d. Fellows provide more consistency and increasing levels of expertise as they advance through their fellowship. 2. Registered nurses. a. Requires advanced knowledge and experience in neonatal intensive care. b. May be the team leader. c. Educational requirements may include in-service programs and national certifications, including the Basic Life Support Course, the AAP/American Heart Association (AHA) Neonatal Resuscitation Program, the AAP/AHA Pediatric Advanced Life Support Course, the S.T.A.B.L.E. (Sugar and Safe Care, Temperature, Airway, Blood Pressure, Lab Work, Emotional Support) Program, the S.T.A.B.L.E. Program Cardiac Module, Certified Flight Registered Nurse (CFN), Certified Neonatal and Pediatric Transport (CNPT), and Certified Transport Registered Nurse (CTRN). 3. Neonatal nurse practitioners. a. Licensed in most states to perform diagnostic and therapeutic procedures. b. Highly skilled, in addition to their advanced knowledge of neonatal intensive care therapies. c. Increased cost in comparison to a registered nurse; however, this may obviate the need for resident/fellow/neonatologist presence. d. Educational requirements may include in-service programs and national certifications, including the Basic Life Support Course, the AAP/AHA Neonatal Resuscitation Program, the AAP/AHA Pediatric Advanced Life Support Course, the S.T.A.B.L.E. Program, the S.T.A.B.L.E. Program Cardiac Module, CFN, CNPT, and CTRN. 4. Respiratory therapists. a. Frequent team members because the majority of neonates transported have a respiratory problem. b. Require advanced knowledge in neonatal intensive care. c. May assist with nursing functions as licensed by the state. d. Responsible for respiratory equipment, airway maintenance, and maintaining adequate oxygenation and ventilation during transport. e. Educational requirements may include in-service programs and national certifications, including the Basic Life Support Course, the AAP/AHA Neonatal Resuscitation Program, the AAP/AHA Pediatric Advanced Life Support Course, the S.T.A.B.L.E. Program, the S.T.A.B.L.E. Program Cardiac Module, CNPT, and Neonatal Pediatric Specialty (NPS). 5. Emergency medical technicians and paramedics. a. Role varies, depending on experience and education in neonatal care. b. Functions may include nursing or respiratory therapy responsibilities. c. Educational requirements may include in-service programs and national certifications, the Basic Life Support Course, the AAP/AHA Neonatal Resuscitation Program, the AAP/AHA Pediatric Advanced Life Support Course, the S.T.A.B.L.E. Program, the S.T.A.B.L.E. Program Cardiac Module, Certified CNPT, and Critical Care Paramedic (CCP). 6. Expertise required within the transport team (Demmons and James, 2008; NANN, 2010a). (2) Physical examination and gestational age assessment. (3) Interpretation of laboratory and radiologic findings. b. Knowledge of neonatal physiology and pathophysiology. c. Excellent communication and public relations skills. d. Technical and clinical competence. e. Leadership skills. f. Ability to work on a team. g. Physical examination and fitness criteria (physical agility and stamina). h. Knowledge of aviation physiology. i. Transport safety. j. Knowledge of transport environment and vehicles. k. Independence and flexibility. l. Procedures. (2) Endotracheal intubation. (3) Laryngeal mask airway insertion. (4) Arterial access (umbilical artery catheters, percutaneous artery catheters, arterial sampling). (5) Needle thoracostomy. (6) Thoracostomy tube insertion. (7) Venous access (umbilical venous catheters, peripheral intravenous [IV] lines). (8) Intraosseous insertion. (9) Administration of nitric oxide and nitrogen, as applicable. (10) Mobile extracorporeal membrane oxygenation, as applicable. (11) Administration of surfactant. 7. Justification for a neonatal team. a. Staffing: dedicated, unit based, on call. b. Use of personnel when there are no transports. c. Volume of transports. d. Review of other systems that could transport neonates. These systems should demonstrate appropriate clinical expertise and possess equipment to transport a critically ill neonate. e. Cost and reimbursement. D. Medical director (AAP, 2007; Woodward et al., 2002). The role of the neonatal transport team medical director, including qualifications and responsibilities, must be clearly outlined in a job description. 1. A neonatologist or a physician with acute care expertise or subspecialty training in neonatology. 2. License to practice medicine in the transport program’s state. 3. Knowledgeable in transport medicine. 4. Oversees medical aspects of the transport program. 5. Involved in the quality management program. 6. Involved in administrative aspects: selection of team members, orientation, education, program operation, policies, public relations, and outreach education. B. Recommended equipment must be operable on battery power. 2. Cardiorespiratory monitor with pressure tracing and recorder. 3. Pulse oximeter. 4. Infant ventilator. 5. Air–oxygen blender. 6. End-tidal carbon dioxide monitor or adaptors. 7. Airway humidification system. 8. Invasive and noninvasive blood pressure monitors. 9. IV infusion safety pumps. 10. Transilluminator. 11. Point-of-care testing, including portable blood gas analyzer and glucometer (state regulations vary regarding use and quality control checks in mobile intensive care environments). 12. Defibrillator/pacer (minimum capacity, 2 watt-seconds). 13. Liquid oxygen, oxygen tank in vehicle, or portable oxygen cylinders. 14. Air tank in vehicle, portable air cylinders or air compressor. 15. Inverter in vehicle. Equipment should have battery backup. 16. Specialized equipment: nitric oxide, nitrogen, extracorporeal membrane oxygenation, and high-frequency ventilation during neonatal transport. C. Supplies for neonatal transport (Box 21-1).
Intrafacility and Interfacility Neonatal Transport
HISTORICAL ASPECTS
PHILOSOPHY OF NEONATAL TRANSPORT
INTRAFACILITY NEONATAL TRANSPORT (AAP, 2007; DEMMONS AND JAMES, 2008; NATIONAL ASSOCIATION OF NEONATAL NURSES, 2010a; SALYER, 2003)
INTERFACILITY NEONATAL TRANSPORT
Types of Transports (AAP, 2007)
Selection of Transport Vehicles
Transport Personnel
TRANSPORT EQUIPMENT (GERSHANIK, 2006; ORLANDO ET AL., 2007)
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