Neonatal transport

Taking Right New born at the Right Time , By Right Personnel, to the Right Place, By the
Right form of Transport, and receive the Right Care Throughout
-UNKNOWN

NICU Seminar
 History
 Neonatal transport was first started by
the American physician J B De Lee
(1920)

 Showed Necessity of a thermo-

regulated environment during their
transfer.

 First organized neonatal

transportation program began in New
York in 1948 (New York Premature Infant
Transport Service).

 1968-UK Herbert Barrie introduced the

country’s first dedicated neonatal
ambulance.
 Introduction
• Specialized neonatal intensive care units (NICU) has
been associated with decrease in mortality and
morbidity.

• 1960s, concept of neonatal transport; to make NICU

accessible to needy neonates.

• Regionalization of neonatal and pediatric intensive

care services - driven the development of specialized
transport programs.
 Introduction
• Inutero transfer- best & safe;
• But preterm delivery, perinatal
illness, GCMF difficult to anticipate,

need of hour is focus on neonatal

transportation.

• Most neonates are transported

without any pre-transport
stabilization or care during
transport.
 Practical problems
• Facilities are scarce and not easily available
• Families have poor resources
• Organized transport services are not available.
• No health provider is available to accompany the baby

• Mostly self-transport (Taxi/Rickshaw/public transport)

• Facilities are not fully geared up to receive sick
neonates
• Communication systems are non existent or inefficient
DISCUSSION:
1. Why transport of sick neonates is necessary?
2. What are different types/Modes of transports?
3. How to organize a Neonatal Transport System?
4. Communication and neonatal transport?
5. Medico-legal issues?
 Why ????
1. Majority of the deliveries still occur at home (~ 60% in rural areas as
per NFHS 3).

2. Transportation of the sick or preterm babies to a centre with expertise

has been shown to improve outcomes. $

3. Prematurity, asphyxia and sepsis are the most common cause of

neonatal mortality in our setting.

4. State governments –SNCU provided better care if they are timely

transported in a stable condition.

5. Utilization of health care facilities will be better if there is good

transport/communication between 2 centres.
$ Orr RA, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics 2009
Jul;124(1):381-383
 Difference between self transport and
organized transport?
 Organized transport service- equivalent to advanced care facility.

 Should have - Mechanical ventilation, multiple fluid infusion therapy and

cardio-respiratory monitoring.

 India, most sick neonates are transferred by their parents or paramedical

personnel either in private vehicles or poorly equipped ambulance.

 No dedicated neonatal transport service provided by the states in India.

 Evidence suggest that the transport by a skilled organized team

reduces neonatal mortality/mortality.
Chance G, Neonatal transport: A controlled study of skilled assistance. J Pediatr 1978;93(4):662-66
Hood J Effectiveness of the neonatal trasnport team. Crit Care Med 1983;11(6):419-23.
 Which babies ??INDICATION
• Babies -Advance medical and/or nursing care
need transfer to higher centre.
 Types of transports?

 From Home to Hospital

 Intra-hospital transport

 To facilitate specialist management of the neonate

 Peripheral hospital to higher centre.

 Reverse Transport
Develop a neonatal transport system?
 Committee on Perinatal Health
 Develop perinatal regionalization with SNCU at district level and referral
centers at state level.

 key components are:

 Human Resource
 Vehicles and equipments
 Communication and Family Support
 Documentation and consent form
 Feed back to Referring unit
 Human Resource
 Identification of danger signs and their immediate remedy.
 Leadership:
– Medical director: Physician with specialty training.
– Manager: Controls day to day management, budget and maintenance of
equipment. (nurse or paramedic personnel).

 Transport Team Model (Physician-Nurse and Nurse-Nurse

team)
Many transport teams require certifications to improve staff competence/ knowledge.
courses–someNo difference
of them: in outcomes- neonates are transported by trained paramedics
• Advanced/ RN or physicians.
Cardiac Life Support (ACLS)
–WeOutcomes
• BasicLife Support
need to (BLS)
for the 2a cadre
develop types of nurses
teams were equivalent.personnel for more
and paramedic
• Pediatric Advanced
– Non-physician
effective neonatalLife transport.
Support (PALS)
teams responded more quickly and spent less time at the
Addition
• Advanced Pediatric Life Support
to clinical
referring facility (APLS)
expertise, team members must possess excellent
• Neonatal Resuscitation
interpersonal skills Program
and solve(NRP)
problems.
• Trauma Nursing Core Course (TNCC)

King BR, King TM, Foster RL, McCans KM. Pediatric and neonatal transport teams with and without a physician: a comparison of
outcomes and interventions. Pediatr Emerg Care. 2007 Feb;23(2):77-82.
 Vehicle and Equipments
 Ambulance - minimum meet the requirements for a basic life
support .

 Design of Ambulance-no specific guidelines available; based on

ergonomics of activities inside the ambulance and road and weather
conditions.

 Options (ambulance, helicopter, fixed-wing aircraft or ferries) is

dependent on local factors.

 Ambulances are least costly, and fixed-wing aircrafts are less

expensive than helicopters.
Modes:
Road Ambulance: (10- 200 kms)
 Advantages:
– Relatively easily available, lower costs, least influenced by weather
– Can be stopped or diverted to the nearest hospital if necessary for any emergency interventions
 Disadvantages:
– speed limitations, traffic delays and road conditions

Rotary Wing (helicopter): (50- 300 kms)

 Advantages
Speedy retrieval, better utilizations of medical staffs (less travel time and out of hospital )
 Disadvantages:
– High costs, influenced by weather conditions/landing site close to the hospital.
– high noise and vibration levels
Fixed Wing Aircraft: Indication: (>200 km)
 Advantage:
– long distance retrievals, reasonable space/access to patient,
– family can travel with their baby.
 Disadvantages:
– Require near by airport, immigration clearance
Air Transport- comfort or not
• High altitude:
– Maximize oxygen delivery by maintaining systemic BP and Hb.
– Air expands at high altitude – caution for air leaks.
– Risk of air leaks(MAS)- transported with cabin altitude set at sea level.

• Take off and landing:

– Rapid acceleration /deceleration: secured head: theoretically risk of
reduced/increased cerebral perfusion.
– Premature more risk of IVH.
– Thermal issues: ↓ 2°C for every ↑ 300 m of altitude

• Noise and vibration:

– Can dislodge lines and tubes.
– Effect monitoring equipment.(Specifically designed equipments
required/Masimo or Oxismart)
– Visual rather than audio alarms should be used where possible.
Equipment
• Power backup:
– Equipment should charged fully. Inverter/Generator should be available.
• Ventilators:
– Transport ventilators with incubator system (Air-Shields Globetrotter TI500,
Draeger Medical) or standalone systems. With spare gas cylinders.

• Transport Incubators:
– Adequate temperature control.
– Phase-change gel mattresses (alternative).
– 5-point body harness(adults)- inappropriate for a premature neonate.
– Neonatal harnesses within the transport incubator- protective during
transport.

• Monitors:
– Multi-parameter monitor.
– ETCO2 monitor can be very useful in determining the placement and patency
of an endotracheal tube.
 Organize neonatal transport system?
• Principles: Assessment for need

Transport teams require a clear vision to achieve objectives and enable to

meet important organizational goals.

Stabilization before transport Care during transport

• Available models for pre-transport stabilization and care during transport

are:
– STABLE: Sugar, Temperature, Artificial breathing, Blood pressure,
Laboratory work, Emotional support.
– SAFER: Sugar, Arterial circulatory support, Family support,
Environment, Respiratory support.
– TOPS: Temperature, Oxygenation (Airway & Breathing), Perfusion,
Sugar.
Pre-transport stabilization : Evidences
• TOPS a simple assessment of neonatal acute physiology - good prediction
of mortality.

• Hypoglycemia, hypothermia, poor perfusion and oxygenation - high

mortality in transported neonates.

• Prior stabilization and adequate care during transport results in decreased

of hypoglycemia, acidosis and mortality.

• Low cost/effective - Thermocol boxes, Plastic wraps or bags, skin-to-skin

care and transwarmer mattresses.

Mathur NB, Role of TOPS (a simplified assessment of neonatal acute physiology) in predicting mortality in transported neonates. Acta Pædiatrica
2007:96;172–175.
Sehgal A. Factors contributing to outcome in newborn delivered out of hospital and referred to a teaching institution. Indian Pediatr 2001; 38:1289–
1294.
 Recommendations: stabilization of sick neonates before and
care during transport.
• Step 1: Temperature: Correct hypothermia if present before transport – KMC,
provide warm clothing or under radiant warmer.
• Step 2: Airway: Assess airway for presence of any secretions (suction if present)
and position of neck (place shoulder roll)
• Step 3: Breathing: Assess for respiratory distress; assess whether baby requires
ventilation (PPV device such as self inflating bag)
• Step 4: Circulation: Check Heart rate, CRT, Urine output, Blood pressure (if
feasible); Assess the need of fluid bolus. Adjust infusion of inotropes as per need
• Step 5: Sugar: Check sugar treat If Blood glucose < 40 mg/dl. Check the patency of
iv cannula.
• Step 6: Transport personnel: Mother/ Attendant/ ASHA from community or basic
health facility. Trained nurse, paramedic or physician at the referring hospital
• Step 7: Equipment: Well equipped Ambulance.

Communication: Inform SCNU / NICU to arrange and organize baby cot.

Feeds: It is best to not attempt feeding sick babies with abnormal sensorium or severe
respiratory distress before or during transfer.
 Transport in specific conditions

• Respiratory distress syndrome: Oxygenation, perfusion maintained

throughout the transport. (Ventilation/CPAP/Free flow O2 ).

• Air leak syndromes: Even mild pneumothoraces may worsen during

transport due to vibrations and bumps of the ride.(drain the
pneumothorax adequately, chest tube in place)

• Meningomyelocele: exposed swelling covered with guaze piece soaked in

normal saline; baby should lie on the side and not back during transport.
What is the role of CPAP during transport?
• Evidence:
– limited evidence is available for its safety and efficacy during transport.
– Bomont t al- Nasal CPAP appears to be a safe method of respiratory support
• Recommendation:
– Important- Transport Team experience and familiarity to CPAP equipment.
– Team trained in ET intubation and resuscitation
– Nasopharyngeal CPAP –alternative.

What is the role of intubation before transport?

• Intubation - depends on disease/pathophysiology, potential for
deterioration and travel distance.
• Indications where ET intubation is preferable before transport:
– Respiratory distress worsening with increasing oxygen requirement (FiO2 of more than 70%)
– Recurrent apnea / seizure
– CHD on prostaglandin E1 infusion >0.05 microgram /kg/min
– Limited space and skills to perform any resuscitation
What should be done in case the neonate
deteriorates during transport?

• Most appropriate action - depends on the level of skills of team, space and
equipments available.

• Two major strategies:

– Stop the vehicle and resuscitate: If skills and space is available.(Intubation or
chest tube insertion).
– Don’t perform procedure in a moving vehicle; -nearest hospital, stabilize,
before proceeding.
Communication
• Success effective communication between the referral and receiving
institute.
• Dedicated communication centre- operating 24 *7; for constant
communication during the triage process and transport.
• Communication for neonatal transport before, during and after reaching
referral centre.
• Decision for transport – communication with parents / family/ physician:
– Illness and the need for transport,
– Facilities available at Referral hospital (examples of previous successful transfers and
outcomes ),
– Availability of bed should be asked before starting transport.
– If referred hospital refuses to accept patient due to some reasons, bed facility should be
asked in other health care facilities and baby should be transported by same team to the
place where bed should be available.
Medico-legal issues
• No Law, Poorly defined
• Result of poor communication and inadequate information.

• Condition of baby, risks during transport, financial implications and

treatment at the referral centre --discussed with family with
documentation.
• Referring Physician -final responsibility for the appropriateness of the
transferring team. (Mode of transport; see Chapter 7 on legal
issues).- EMTALA; US AAP

• If baby dies during transport:

– The ambulance should be stopped and CPR should be performed as per NRP guidelines
– He/she should be first taken to the higher health facility
– Casualty admission should be done.
– Death certificate made by the medical personnel of higher health care facility.
– It’s the responsibility of transporting team to make death certificate of baby.
 Stress Management, Debriefing,
and Team Health
• Transport professionals actually thrive on stress, referred to
as eustress. (Eustress vs Distress)

• Eustress is the positive stress that challenges but also offers a

sense of accomplishment or fulfillment.

• The best way to manage distress is to recognize it and prevent

stress as much as possible.

• Behaviors that are known to decrease stress are healthy

habits, such as proper nutrition, adequate rest, exercise, and
other elements of self-care.
Identifying Contributing Factors
– sources of stress that are unique- related to geography,
patient population, team composition, customer service,
cultural diversity.

– Strategies shown to improve communication, conflict

resolution, and team work contribute to reducing stress
and increasing job satisfaction.

– “flattening of the hierarchy,” allowing any member of the

team to freely voice concerns.
Personal Responsibilities
• Exercising self-care, maintaining healthy habits and establishing
proper communications within the team, minimizing tensions
within the workplace.

• Includes --self-awareness, attendance, respect for other team

members, emotional intelligence, accountability, adherence to
program policies.

• The phrase “do not get too hungry, angry, lonely, and tired” or
HALT.

• Stressful situations, difficult conversations, and challenging

medical conditions are often recreated through simulation
education.
 Regionalization of neonatal care
• The practice of categorizing hospitals and units by their
staffing and other resources.

• Basis for regulatory or procedural rules regarding interfacility

transport.

• Regionalization of specialty services requires- transport

programsfamiliar with capabilities of sending and receiving
facilities.

• Transport program can facilitate appropriate triage and

streamline communication.
Transport Program Training, and Assessment
• No one team configuration is ideal for every situation.

• The type of providers used is best determined by the team’s mission(s) and
clinical needs.

• Teams that respond to out-of-hospital emergencies will need personnel with pre-
hospital experience.

• Staff members- training to enhance their knowledge, learn and interpret certain
assessments, techniques, studies such as laboratory and radiographic analyses;
and to train them for procedures not usually expected in their standard positions.

• Practice sessions and continuing education allow team members to rehearse the
management of unusual conditions in advance of need.
 Patient- and Family-Centered Care
• Philosophy of care that recognizes and respects the pivotal role of
both the patient and the family in the delivery of medical care.

• Concepts includes
– Respect and dignity to patient and family perspectives and choices.
– Information sharing
– Participation & Collaboration

• Benefits
– Stronger alliance with the family in promoting child’s health and development
– Improved clinical decision making .
– Greater understanding of the family’s strengths and care giving capacities
– More efficient and effective use of professional time and health care
resources
– Improved communication among members of the health care team
 Indigenous ways of transportation?
• Thermocol boxes- to maintain neonate’s body temperature; needs
appropriate size and enough ports for air circulation.

• Even though this low cost intervention was found to be effective,

one needs to be careful as the sick may neonate may suddenly
deteriorate.

• Today’s era of air-conditioned cars ambient temperatures inside

the vehicle can be maintained between 26 – 28oC.

• Caregiver provide KMC during transport for euthermia.

• The vehicle should be halted during feeding.
We are yet to start the journey……
THANKS