4: Infant Transport

A seamless transport of infants from a referring hospital to a higher level neonatal intensive care unit (NICU) enables each patient to benefit from the regionalization and specialization of critical care personnel and services. Clear guidelines and a transport algorithm must be established regarding transport procedures, personnel, and necessary equipment. The goals of an infant transport are:

1. Provide early stabilization and initiation of advanced care at a referring institution.

2. Continue critical care therapies and monitoring during transport to ensure safety and a positive neonatal outcome.

1. Procedures. Policies and procedures reflect the unique characteristics of each region (size, geography, and level of medical services). Lines of communication must always be open between the referring hospital and the NICU at all levels (ie, administrators, physicians, nurses) and with ambulance or air services. On receiving a request for a transport, an intake record should be completed, documenting the referring physician and hospital contact information and patient information. A predeparture assessment of the patient may determine transport team composition and guide the referring hospital with management.

2. Personnel. The team may include physicians, nurses, neonatal nurse practitioners or advanced practice nurses, respiratory therapists, and perhaps emergency medical technicians. Limited research supports similar outcomes from transport teams with and without the direct presence of a transport physician. Team members should have received special training regarding issues and equipment specific to transport and have the ability to contact the medical command at any time during transport.

3. Equipment. Each transport team should be self-sufficient (ie, be a mobile NICU). Special emphasis is placed on having the necessary equipment to enable maximal stabilization of the infant at the referring hospital to facilitate an uneventful transport. Medications and equipment can be chosen according to published lists. Well-calibrated monitoring equipment is necessary given the added noise and vibration during transport, which often compromise auditory and visual monitoring. An instant camera is an important consideration to provide pictures of the infant to the family.

4. Transport mode. Clear guidelines should be established regarding the indications for air versus ground transport based on distance, time of day, geography, weather, location of landing sites, and severity and stability of the patient's condition. The most critical factor in determining mode of transport is the safety of the team and patient. Decisions regarding flight safety should be made according to weather and other flight conditions and not be influenced by patient status. Follow instructions from the flight crew regarding loading and unloading of the aircraft. Transport personnel should be restrained in safety harnesses throughout every transport.

1. General procedures. Unless active resuscitation is underway, the team's first task at the referring hospital is to listen to the history and assessment of the infant's status. Team members should conduct themselves as professional representatives of the NICU, avoiding situations of conflict or criticism with the staff. A complete physical assessment should be performed, as well as review of all laboratory values and radiographic studies. Obtain copies of the medical record and radiographic studies if possible. The accepting NICU should be given an expected arrival time and update on the infant's status.

2. General stabilization. Attention to the details of stabilization is important! In most cases, an infant is not ready for transport until basic neonatal needs are met: acceptable cardiac and respiratory function, establishment of vascular access, acceptable blood gas and glucose levels, and thermal stabilization. Catheters and tubes should be appropriately placed and positions confirmed. Infants at risk for sepsis should have antibiotic therapy initiated after blood cultures are obtained.

3. Respiratory stabilization

   1. Surfactant administration. Surfactant administration to premature infants before transport is associated with a low incidence of complications and is generally considered safe and beneficial in the initial respiratory management. There is no consensus on timing of transport after surfactant administration, but most agree on ~30 minutes or after respiratory parameters are stabilized.

   2. Inhaled nitric oxide. Inhaled nitric oxide (iNO) used for the treatment of hypoxic respiratory failure in term and near-term infants with pulmonary hypertension may be continued or initiated during transport. An infant who is already receiving iNO therapy must be transported by a team capable of continuing iNO because abrupt discontinuation may result in deleterious effects.

   3. Elective intubation. Elective intubation of otherwise stable infants receiving a prostaglandin infusion who are at risk for apnea may not be necessary. However, consultation with cardiology is recommended to weigh the risks of transport complications after intubation with possible benefits of prophylactic intubation before the transport of such infants.

4. Gastric intubation. If the infant has a gastrointestinal disorder (eg, an ileus or a diaphragmatic hernia) or if positive airway pressure is administered, venting of the stomach with a nasogastric or orogastric tube is indicated before departure, especially if air transport is used. See Chapter 32.

5. Temperature control and fluid balance. Special attention to temperature and fluid balance is required for infants with open lesions (eg, myelomeningocele or omphalocele) or premature infants at risk of excessive insensible water loss. A dry or moist protective dressing over an open defect can be covered by thin plastic wrap to reduce evaporative heat loss. An occlusive plastic wrap may be used in very low birthweight infants after birth to minimize evaporative losses. Infants at risk of hypoxic ischemic encephalopathy who may be candidates for head cooling should not be warmed and may be passively cooled by turning off active heating devices. Attention to continuous central temperature monitoring is important to avoid excessive cooling.

6. Family support. Keep parents updated by outlining the initial medical concerns and potential hospital course. The parents should be offered to see and touch the infant before transport and if possible be provided with pictures. Contact information and directions to the accepting hospital should be supplied. Obtain consents for transport and admission. After transfer is completed, the team should update the parents and referring physician.

1. Monitoring. During transport, monitoring of respiratory rate, heart rate, blood pressure, and pulse oximetry should continue to assess changes in the infant's status. The infant's status, vital signs, assessment, and interventions performed should be documented until arrival at the accepting hospital.

2. Special considerations during air transport. In helicopters and unpressurized aircraft, dysbarism (imbalance between air pressure in the atmosphere and the pressure of gases within the body) causes predictable problems. Partial pressures of inspired gases decrease as altitude increases (Dalton's law), so infants require an increased concentration of inspired oxygen. Trapped free air in the thorax or intestines expands in volume (as pressure decreases; Boyle's law) and may cause significant pulmonary compromise or intraabdominal changes. A cuffed tube or catheter should be evacuated before takeoff. Gastric venting should be performed before transport because the air trapped in the gastrointestinal tract will expand in volume as atmospheric pressure decreases. Because blood pressure varies with changing gravitational force, fluctuations noted during climbing or descent should not be cause for alarm. Hearing protection should be worn by the transport team and patient because of excessive noise.

1. Outreach education. Transport team members should regularly meet with professionals from each referring hospital. Such a forum for discussion of transport issues and specific transported patients provides mutual feedback and stimulates interhospital protocol decision making as well as quality improvement processes.

2. Evaluation of transports. Each transport should have a scoring system that reflects the “before” and “after” status of the infant. This system provides quality control of transports and is useful in outreach education to convey constructive criticism to referring hospitals. It is also important to regularly review team response time, referring hospital satisfaction, difficult transports, safety updates, team credentialing, medical protocols, and so forth as part of quality assurance and safety evaluation.