eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Transport of the Critically Ill Newborn

Author: Bryan L Ohning, MD, PhD, Medical Director of NICU, Medical Director of Neonatal Transport Team, Department of Neonatology, Greenville Children's Hospital; Clinical Associate Professor of Pediatrics, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Oct 17, 2008

Introduction and Historical Perspective

Critically ill neonates are often born in specialized centers either because of prenatal detection of a problem or because the referral center routinely delivers care to at-risk perinatal populations. These babies are termed "inborn." However, a significant number of "outborn" neonates (ie, those born elsewhere) require emergent transfer to a tertiary care center, often because of medical, surgical, or rapidly emerging postpartum problems. Studies show that shortened interfacility transport time leads to improved outcomes for the smallest and most critically ill neonates.

Medical transport of this high-risk and critically ill population requires skilled personnel and specialized equipment. Ideally, a neonatal transport team forms a single component associated with a larger system of perinatal care composed of a tertiary care neonatal ICU (NICU), the perinatal care unit, the cadres of medical and surgical pediatric subspecialists, and the neonatal outreach program. This article reviews the issues related to transport of the critically ill newborn population, including personnel, medical control, equipment, policy development, and transport administration. The medical and surgical problems of the newborn are discussed in other articles.

Because the outcome of an outborn neonate with major medical or surgical problems (including extreme prematurity) remains worse than for an inborn infant, primary emphasis should always remain on prenatal diagnosis and subsequent in-utero (ie, maternal) transfer whenever possible. Despite advanced training and technology, mothers usually make the best transport incubators.

Development of neonatal transport, perinatal regionalization, and neonatal intensive care unit referral centers

The emergence of skills to care for ill or premature newborns can be linked to exhibits of premature infant care at public expositions, such as the 1933 World's Fair in Chicago. These exhibits preceded the emergence of NICUs and the transport of ill infants.

After establishment of centers to care for ill neonates, attention shifted to caring for infants who were either born at home or in inadequately equipped centers. Transport of outborn neonates to specialty centers initially used clever adaptations of incubators otherwise carried in an automobile. Butterfield has written an excellent and personal review of these beginnings.¹

The next evolution in transport developed from the lessons in aeromedical transport of the wounded in World War II, Korea, and Vietnam. The need for rapid evacuation of trauma patients from the scene of accidents led to the development of a system of trauma centers and aeromedical transport services.

In 1976, the Committee on Perinatal Health, sponsored by the March of Dimes, proposed a system for regionalized perinatal care and defined three levels of hospital care, which served throughout the 1970s and 1980s as a national model for the rapid development of neonatal referral centers.² This model required the development of a neonatal transport system, which was associated with a significant reduction in the US neonatal mortality rate.

Because neonatal transport was required for NICU referral centers, and because pediatric transports to pediatric ICUs (PICUs) were increasing, the American Academy of Pediatrics (AAP) formed a Task Force on Interhospital Transport and subsequently developed guidelines.³

Appearance of various commercial products for care of the neonatal patient in the transport environment paralleled the proliferation of neonatal transport programs.

Administrative Aspects of Neonatal Transport Services

Program director

As health care financing becomes increasingly problematic, pressure increases to achieve efficiency. However, transport scheduling is an intrinsically unpredictable and inefficient process, especially for a low-volume/high-acuity specialty team such as that required for the neonatal population.

A committed hospital administration should provide an experienced manager or program director for a transport service and encourage communication between the hospital administration, the transport team personnel, and the medical director.

Medical control physician

The on-call medical control physician is immediately available to provide advice before and during transport. The medical control physician has the appropriate knowledge to manage critically ill neonatal patients and must be familiar with the capabilities and procedures of the neonatal transport team.

Medical director

The neonatal transport team medical director, who should be a licensed physician and familiar with air and ground emergency medical services, supervises and evaluates the quality of medical care. Ideally, this physician is a board-certified subspecialist in neonatal/perinatal medicine, pediatric intensive care, or both. However, as an alternative, an adult-oriented medical director of a transport team may use subspecialty physicians as consultants.

The medical director should be actively involved in (1) selection of appropriate personnel, (2) continuing team education and training, (3) development and review of policies, (4) the quality management program, and (5) selection, orientation, and supervision of medical control physicians.

Communications

To initiate the transport process, a mechanism is needed for immediately contacting the appropriate medical control physician upon receiving a transport request. The medical control physician decides whether transfer is appropriate, discusses stabilization issues with the referring physician, and, if indicated, authorizes or recommends a mode of transport. Additional communication occurs between referring physicians, accepting physicians, medical control physicians, transport team members, and pilots or drivers.

Ideally, a dedicated communications center operates 24 hours a day, 7 days a week to allow for constant communication during the triage process and transport. A dedicated communications center is especially valuable for rotor-wing aircraft transport or for teams with multiple ground units. Several viable models are available for communications; to increase efficiency, the trend is to share resources via consolidated communications centers. An alternative method of initial contact is for the referring physicians to call the NICU directly and have the unit personnel place them in contact with the appropriate transport team medical control physician. This mechanism of routing communications is more commonly used by smaller centers and transport teams.

Medical transport systems appropriately focus on rapid arrival of the transport team and medical direction of the team upon arrival at bedside. However, prior to the arrival of the transport team, medical direction and advice to the stabilizing personnel at the referring hospital may be invaluable.

Upon being informed of a transfer request, the medical control physician is put in contact with the referring physician to discuss the case. Such discussion is essential to allow for adequate preparation of the accepting hospital and transport team and to provide direction on pretransport stabilization prior to the arrival of the transport team. Communication of vital signs, laboratory values, and previous therapies allows for effective comanagement of the patient.

Procedures and protocols

The Commission on Accreditation of Medical Transport Systems (CAMTS) develops standards that address patient care and safety in the transport environment and is an excellent resource for the transport industry.⁴ CAMTS strives to maintain accreditation standards in accordance with current medical research and transport industry developments and publishes these standards in order to define quality issues.

The medical director is responsible for the development and supervision of transport protocols. The process involves the input of the medical control physicians, transport team personnel, and any applicable subspecialty services (eg, surgery, cardiology) who are encouraged to create a wide spectrum of protocols that cover the most common clinical scenarios encountered in this neonatal population, especially those requiring immediate recognition and action.

Protocols usually include care guidelines for transport team configurations that require a physician (see Neonatal Team Configuration). However, with the more common team configurations, the protocols may serve as standing orders to allow the transport team personnel to expedite the care of a critically ill neonate in the absence of direct physician input. The medical director should review protocols at least annually and distribute them to all medical personnel involved in the transport process.

Neonatal Team Configuration

Skills required for neonatal transport

• Airway
  • Most critically ill neonates who require transfer to a neonatal ICU (NICU) have existing or impending respiratory failure, either as a primary diagnosis or secondary to their primary disease process. For this reason, transport teams commonly include respiratory therapists. Competence in airway management for resident physicians widely vary, depending on the level of experience of the resident and the skill level attained. Because competence in airway management must be dependable and consistent, this issue dictates the extent of resident participation in neonatal transport.
  • Team competence in neonatal airway management is imperative. The team should be capable of (1) recognizing impending respiratory failure, (2) performing effective bag-valve-mask ventilation, (3) performing atraumatic intubation with appropriate endotracheal tubes, (4) instillation of artificial surfactant, and (4) management of ventilator settings.
• Intravenous access: Nearly all ill neonates require peripheral or central intravascular access during transport. The team must have the necessary equipment and skills for routinely and reliably securing intravenous (IV) access in these tiny and challenging patients.
• Advanced procedures: Staff competency also ideally includes training in other unusual invasive procedures, such as percutaneous needle aspiration of the chest, chest tube insertion, umbilical catheter insertion, and intraosseous vascular access.
• Other important skills
  • Independent thought and action
  • Extensive experience in the rapid performance of advanced clinical skills under less-than-ideal conditions
  • Experience in other areas of patient care

Neonatal team

Paramedics, nurses, respiratory therapists, nurse practitioners, and physicians have the role of rapidly stabilizing critically ill newborn patients for immediate transfer. The services of a specialized neonatal transport team has been shown to be associated with reductions in hypothermia and acidosis, as well as reduced mortality in low birth weight infants.

A number of transport team configurations are used for neonatal transport. Traditionally, adult advanced life support (ALS) ground transport units are staffed by an emergency medical technician (EMT) and a paramedic (EMT-P), using the military transport configuration. Critical care transport teams are commonly configured with an experienced registered nurse (RN) working with another nurse, a paramedic, a respiratory therapist, or a physician. The most common crew configuration is an RN and EMT-P. The 2-RN configuration is the second most common. However, in many pediatric/neonatal transport programs, a respiratory therapist (RT) is the second crew member because of airway management expertise. Each kind of specialist, however, has advantages and disadvantages.

These attributes, in reference to neonatal transport, are listed in Table 1. Versatility in this context refers to neonatal infant care only. Obviously, paramedics would have a high degree of versatility and experience when generalizing to adult care scenarios.

Within a perinatal system, the transport team should be regarded as serving several other functions, including on-site teaching, communicating strengths and weaknesses of the referral hospital to the outreach personnel at the tertiary center, and public relations.

The data in the table below are used to determine crew configuration for a neonatal transport team. These relative scales are only generalizations.

Table 1. Advantages and Disadvantages of Potential Transport Team Staff Relative to Neonatal Transport Skills and Abilities

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Team recruitment, training, and orientation

Team configuration is determined largely by local availability of personnel, patient characteristics, and tradition. Little published data is available on these issues to assist in the decision process.

Applicants should be informed of any mandatory outreach educational roles and expectations as well as any public relations aspects of the job. Potential team members must be informed of the precise job requirements, especially if additional training, such as EMT or paramedic certification, is required. Additionally, due to requirements of aeromedical transport, personnel may have rigorous physical fitness and/or strength requirements and body weight limits. Continuing education, which includes practice labs, should be undergone at least annually. Because some skills are rarely used in the field, maintaining competence is essential.

Cross-training issues

Schedule a structured series of skill sessions to ensure competency. Sessions may occur in the clinical realm (ie, neonatal intensive care units, delivery room suites, or operating room suites) or in practice labs with models, animals, or cadaveric material.

Often, the critically ill neonatal patient cannot be adequately stabilized and managed in an outlying referring hospital, leading to time pressures in arranging for transport team arrival. One possible alternative to long delays and increasing costs is to use seasoned cross-trained personnel, including cross-trained NICU personnel, to perform transports. The feasibility of this alternative is dependent on adequate planning and training and a carefully defined triage mechanism. Because personnel cross-training necessitates more training, demands should be carefully evaluated.

Mode of Transport

Ground ambulance

This mode is used for relatively short-distance transport (up to 25 miles) when surface transportation is more efficient and often more rapid than air transport. It must also be used when climactic conditions preclude air transport.

• Advantages
  • Lowest transport costs
  • Relative immunity to weather: Table 2 summarizes weather and other considerations for each mode of transport.
  • Roomy interior space allowing for improved patient access (See Media file 1.)
• Disadvantages
  • Slowest mode of transport while en route
  • Necessity of physically securing neonatal incubator inside the transport vehicle and ensuring that neonatal-specific equipment is available if the ambulance is not dedicated to neonatal transport

Rotor-wing aircraft (helicopter) transport

This mode may be used for medium-distance transfers (up to 150 miles).

• Advantages
  • Speed and versatility
  • Rapid departure and arrival of the team to the patient, decreased out-of-hospital time space
• Disadvantages
  • Need for a landing zone in close proximity to the hospital
  • Likelihood of grounding due to adverse weather conditions
  • Higher costs
  • Restricted patient access during flight
  • Compromised patient assessment and/or interventions during flight due to high environmental noise and vibration levels (See Media file 2.)

Fixed-wing aircraft (airplane) transport

This mode's defined use is for long-distance transportation (typically farther than 150 miles).

• Advantages
  • Efficient fuel costs over long distances
  • Interior space allowed for patient transport is adequate
  • Reasonable access to patient during flight
• Disadvantages
  • Requires an airport for landing and takeoff operations
    (see Media file 3)
  • Increased time with subsequent team ground transfer  

Table 2. A Comparison of the Advantages and Disadvantages of Various Modes of Transport Used in the Transport of the Critically Ill Neonate

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Predeparture Stabilization

Method 1

The transport team assumes patient care and rapidly loads the neonatal patient for transport, thereby reducing out-of-hospital time and maximizing access to neonatal ICU (NICU) management. For neonates with rapidly progressing disease processes, this reduces the potential for progression of the disease prior to arrival. Method 1 is more often used with less experienced team personnel, with rotor-wing transfer, or both. This approach leads to shorter out-of-hospital intervals. The addition of several low-level interventions, such as peripheral intravenous insertion, nasogastric tube insertion, oxygen administration, or Foley catheter insertion, does not generally add significant delay to the time of stabilization. This transport model is similar to the model typically used in trauma calls, affectionately known as "swoop and scoop."

Method 2

The neonate is maximally stabilized prior to departure from the referring hospital. This minimizes the need for interventions en route to the NICU in the relatively uncontrolled transport environment but results in longer stabilization times and may lead to more time for disease progression. The performance of high-level interventions, such as intubation, arterial cannulation, central venous cannulation, or chest tube insertion, will lead to markedly prolonged stabilization times. Method 2 is used more often with transport teams that incorporate physicians or highly skilled physician extenders and/or with longer ground or fixed-wing transports.

Combination method

Each neonatal patient undergoes a careful assessment (eg, vital signs), a rapid blood glucose determination, and establishment of intravenous access. Because respiratory distress is such a frequent problem with a large proportion of critically ill neonates, special effort should be paid to assessing the airway and the competence of oxygenation and ventilation.

Following this initial rapid assessment, most neonates who are not stable or are deteriorating rapidly are stabilized quickly and then expediently transferred. Alternatively, some clinical situations require more extensive and immediate interventions in the field, including artificial surfactant administration for extreme respiratory failure, and evacuation of a pneumothorax, among others.

Care of the Neonate in the Transport Environment

Thermal control

The critically ill neonate often may be an extremely premature infant who may have a birthweight of less than 1 kg and markedly immature skin that is prone to massive insensible fluid losses. The low fat stores render this patient vulnerable to hypothermia.

In the neonatal ICU (NICU), infants are managed with specially designed neonatal radiant warmers or incubators, which decrease and/or compensate for these fluid and heat losses. During transport, thermal control becomes very difficult due to environmental conditions which may include cold weather, high winds, high elevations, travel over a long period of time, and less efficient equipment. Polyethylene bags or sheets placed over the infant may help maintain body temperature during resuscitation and/or transport of very low-birthweight infants.

A hypothermic neonate should be rewarmed in a highly controlled fashion (approximately 1°C/h), which is extremely difficult to accomplish during transport. Rapid rewarming of hypothermic neonates is associated with increased mortality and increased severe morbidities.

Ventilation and airway management

In those patients who require positive pressure ventilatory assistance, the first level of intervention is bag-valve-mask ventilation, although it is unacceptable for prolonged airway management during transport.

Intubation in the neonate requires an uncuffed endotracheal tube of appropriate size, varying from 2.5-4 French external diameter. The neonatal transport team must know how to perform rapid, atraumatic intubation, with subsequent tube positioning and security.

Positive pressure ventilation can be accomplished by hand-bag ventilation for transports of short duration, but transport ventilators are generally used for most transports. Transport ventilators are often different from those models used in the receiving NICU; therefore, the transport personnel must be experienced in the setup and use of these ventilators. Due to limitations in current technology, transport ventilators are not currently capable of patient synchronization, patient-triggered ventilation modes, heated ventilation circuits, or high-frequency ventilation modes.

Monitoring issues

Routine NICU care involves patient monitoring with cardiorespiratory monitors that use adhesive chest leads and pulse oximetry monitors that use pulse-detecting extremity probes. Continuous monitoring of blood pressure requires the use of transducers that are in line with indwelling central lines (eg, umbilical catheters). The increased vibration and electromechanical interference associated with transport environment frequently interferes with or precludes such monitoring.

The premature neonate's small size and small signals complicate electronic interference issues. These interference problems are greatest during aircraft takeoff and landing. During this time, the crew may be distracted by required flight protocols, are restrained for safety reasons, and may be unable to accurately assess the patient. The highest probability of monitoring failure, therefore, occurs during the periods when the patient is most likely to become destabilized and require intervention.

Flight physiology

Increasing altitude affects physiology in a number of ways, including decreased partial pressure of gasses, expansion of trapped gas compartments (eg, pneumothorax), lowered environmental temperatures, and altered drug metabolism. Flight crew members and medical control physicians must be familiar with these concepts.

Flight team personnel are also affected by the transport environment and need to be familiar with how their own performances are altered. For example, if a flight team member with a head cold and upper airway congestion experiences a sinus squeeze upon takeoff, they need to recognize and deal with this phenomenon quickly so that patient care and team safety is not compromised.

Neonatal pharmacology issues

Neonatal patients are not simply scaled-down adults with respect to pharmacologic issues. One historical example of this is the use of the drug chloramphenicol, which, if given to an infant in a dose that is simply proportional to the infant's smaller size, causes shock and possibly death from "gray baby syndrome."  This discrepancy in drug metabolism in this example is due to decreased and altered hepatic elimination.

For hepatically eliminated drugs, the neonate may have either a reduced or absent capacity for certain enzymatic degradation pathways. Thus, a drug that is metabolized by one enzymatic pathway in adults (eg, glucuronidation) may, instead, be metabolized in infants via a completely different pathway (eg, sulfation); this can result in unpredictable drug metabolism. The enzymatic processes progressively develop in the fetal liver, with more complex enzymatic processes requiring more gestational development (ontogeny of development).

One should use caution when administering drugs excreted by the kidney because the neonate, especially the premature and/or critically ill infant, initially has a decreased glomerular filtration rate and generally has decreased renal function. Prolonged dosing intervals are often used for medications with renal excretion, and serum drug levels are often required.

Quality Assurance

Quality management program

In addition to patient care issues, a quality management program assesses all aspects of the transport program. This includes continuous monitoring and assessment of communications, initial and continuing education, maintenance of required licensure and certifications, ambulance and aircraft maintenance, and operational issues, especially safety.

Quality management should be deeply imbedded into the program by beginning with a program scope of care and mission statement. Hospital administration should guide the process with the involvement of transport staff and the medical director.

Transport programs should have established patient care guidelines that are reviewed on an annual basis by the staff, management, and medical director. There should be prospective agreement on the applicable quality indicators. Industry guidelines for standards of operation and standards of care, such as those issued by the Association of Air Medical Services (AAMS)⁵ and the Commission on Accreditation of Medical Transport Systems (CAMTS),⁴ are available and should be used. However, for many other issues, the team should decide on the indicators (objective measures that are prospectively delineated and collected for analysis) and the thresholds (statistical measure of compliance on the specific indicator) for acceptable outcome or compliance. Thresholds must be attainable, realistic goals for assessing compliance and quantifying improvement.

Annual review needs to be made of the quality assurance process itself. Involving the staff in a peer review process increases the success of a quality assurance program.

Data collection

Data collection provides important information that is used in quality assurance functions, as described above. The transport team often takes on the task of data collection so that it functions as a component of a larger system of perinatal care.

Transport data are monitored to provide hospital or physician-specific topics for review by perinatal outreach programs. Referring practitioners are interested in hearing discussions on issues they perceive to be timely. Discussing recent cases and situations in their institutions is effective in outreach and continuing education efforts.

Data collection increases the efficiency of a transport service. Monitoring the hour of transport requests, length of transport time, length of time at bedside, incidence of delayed calls, and incidence of overtime is useful in altering schedules or timing of elective reverse transports.

Finally, data collection should be increasingly used for clinical or outcomes research. Published data on neonatal transport issues and outcomes is surprisingly limited.

Reverse Transport of the Convalescent Neonate

Patient Issues

• Does the convalescing newborn's medical condition require care that can be provided at the proposed accepting hospital? In other words, is the accepting hospital capable of providing the care required by the recovering neonate?
• Can the predictable future needs of the infant be met by the institution (eg, subspecialty medical or surgical consultations)?
• Have the parent(s) granted permission for the infant to be transported?
• Does the remaining estimated length-of-stay balance the costs and risks of reverse transport?
• Have any social factors that may affect the choice of convalescing hospital been identified?
• Does the third-party payer (eg, insurance company) "approve" the transfer? Will the costs of the transport and subsequent hospitalization be approved by or be acceptable to the parents?
• Do the physicians and hospitals at both facilities agree the transfer is in the baby's and family's best interests?
• Will the ultimate follow-up physician provide care at the receiving hospital, thereby facilitating continuity of care?

Administration issues

• Are adequate Level I and II nursery personnel available who are sufficiently experienced in caring for the infant population?
• Are enough Level II beds available at the tertiary center?
• Is a well-functioning working relationship noted between the tertiary and Level I and II hospitals, relative to physicians, staff, and administration?
• What motivates the Level I and II hospitals to participate in the perinatal system as full partners, rather than be resigned to a role such as "patient donors" or competitors to the tertiary hospital?

Team configuration issues

• The triage of personnel for a reverse transport is generally easier because the infant is more stable and the medical condition is known. This allows matching the transport team configuration to the infant's medical needs. For example, if the infant has stable respiratory status (ie, no oxygen requirement), then the presence of a physician or respiratory therapist is less important.
• These considerations reduce costs and maintain the availability of the primary team for incoming calls.

Multimedia

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Media file 1: Interior of an ambulance configured for neonatal ground transport. Two incubators are loaded; the transport incubator is in the foreground, and a second incubator is in the background. Two crew members are on board. The vehicle is a Freightliner FL60 chassis (Mt Holly, NC), configured for medical transport by Innovative Coachworks (Birmingham, Ala). Note the excellent patient access and equipment availability.

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Media file 2: Interior of a rotor-wing aircraft (helicopter) configured for neonatal transport. A flight incubator and 2 crew members are on board. The aircraft is an MBB (Messerschmidt-Bolkow Blohn) Model BK-117A4 manufactured by American Eurocopter (Grand Prairie, Tex), reconfigured and operated by Omniflight (Dallas, Tex). Note the limited access to the incubator and equipment that highly restricts crew movements.

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Media file 3: Interior of a fixed-wing aircraft configured for neonatal transport. A flight incubator and 2 crew members are on board. The aircraft is a King Air Model 200 (Raytheon-Beech Aircraft, Witchita, Kan). Note that interior space is adequate.

Keywords

transport of the critically ill newborn, emergent transfer, interfacility transport, medical transport, neonatal intensive care unit, NICU, respiratory failure, bag-valve-mask ventilation, percutaneous needle aspiration of the chest, chest tube insertion, umbilical catheter insertion, intraosseous vascular access, respiratory distress, pneumothorax, hypothermia

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