Transport protocol for transfer of a neonate
Importance of standard transport protocol for transfer of a neonate from a primary care center to a referral center.
Treatment of the sick neonate in specialized neonatal intensive care units has been associated with decrease in mortality and morbidity. Organized emergency neonatal transport systems developed and became an important component in the regionalization of perinatal care [1-4]. In utero transfer is the safest transfer but unfortunately, preterm delivery, perinatal illness and congenital malformations cannot always be anticipated, resulting in a continued need for transfer of babies after delivery [5]. These babies are often critically ill, and the outcome is partly dependent on the effectiveness of the transport system [6]. Facilities for neonatal transport in India are dismal. Most neonates are transported without any pre-transport stabilization or care during transport. Any available vehicle is used which often takes long hours to reach. With less experienced staff, the risk of adverse events on such transports can be greater than with well equipped and trained staff [7-9]. Many of the babies thus transported are cold, blue and hypoglycemic and 75% of the babies transferred this way have serious clinical implications
Why Transport of Sick Neonates is Necessary?
Transportation of the sick or
preterm babies to a centre with expertise and facilities for the provision of
multi-organ intensive care has been shown to improve outcomes [13].
Prematurity, asphyxia and sepsis are the most common cause of neonatal
mortality [14]. Many of these are easy to correct and a significant decrease in
neonatal mortality can occur if specialized care can be made available to these
neonates. Patients may be transferred from the emergency department, critical
care units, operating theatres, wards or other areas of the hospital. Transfers
often occur outside of normal working hours and take place at short notice.
What Is The Difference Between Self Transport
and Organized Transport?
Organized transport service
provides almost the same level of monitoring and the quality of care during the
transport that is available in the advanced care facility. Ideally it should
have the ability to provide mechanical ventilation, multiple fluid infusion
therapy and cardio-respiratory monitoring. In India, most sick neonates are
transferred by their parents or paramedical personnel either in private
vehicles or poorly equipped ambulance. There is currently no dedicated neonatal
transport service provided by the states in India.
Evidence:
There is enough data to suggest
that the transport by a skilled organized team reduces neonatal mortality and
morbidity [16]. Neonates transported by the hospital team had significantly
higher survival as compared to those who came on their own [17]
Principals of Transport:
Pre-transport stabilization and care during transport are the two pillars of
care during transfer of critical ill patient. Hypoglycaemia, hypothermia, poor
perfusion and hypoxia have been shown to be associated with high mortality in
transported neonates. TOPS (Temperature, Oxygenation, Perfusion, Sugar) a
simplified assessment of neonatal acute physiology gives a good prediction of
mortality in these neonates. Prior stabilization and adequate care during
transport results in decrease of hypoglycaemia, acidosis and mortality
How Should One Communicate for Neonatal
Transport?
When a child that requires
transport is decided, the team for the sending centre contacts by phone the
centre where the child will be transported. The conversation will be held by
the highest level persons from the two centres. The transferring hospital has
the responsibility to equilibrate the child till the transfer team comes.
The transport documentation:
The hospital from which the
transfer is made has the obligation to provide the transport team the following
medical documents: The medical record of the patient in original .The transfer
paper as detailed as possible, containing data about parents, maternal history,
current pregnancy, birth process, the child status at birth, intensive care
measures and all the investigations done. If the transport team requests,
x-rays, ultrasounds and other investigations results should be released in
original. If some laboratory test’s results are not yet finished at the moment
of transfer, the results will be send to the receiving hospital as soon as they
became available.
The discussion with the family:
Transport is permitted only with the family
consent [18- 19]. The family should be explained about the child status, the
transport risk and benefits. The family has the right to refuse the transport.
Stabilization before Transfer:
Although transfers are
potentially associated with additional risk to patients, they can be safely
accomplished even in extremely ill patients [20]. Generally, a transfer should
not be undertaken until the patient has been resuscitated and stabilized. There
is a consensus that in order to have a good quality transport a good
equilibration before transport is required. The stabilization before the
transport is done by the team of the hospital where the child was born, with
the following objectives:
(1) To assure and maintain the
temperature. It is accepted as normal newborn temperature a value of the
central temperature (rectal or axillary) of 36.5-37.5 °C . This is the value of
the temperature equilibrium for which the energy consumption needed for keeping
it is minimum [21-22].
(2) To assure the respiratory
equilibrium. Most critically ill neonates who require transfer to a neonatal
intensive care unit have existing different degree of hypoxia, respiratory
distress or impending respiratory failure, either as a primary diagnosis or
secondary to their primary disease process. The patient is evaluated from the
point of view of the respiratory distress. The team should be capable of (a)
Recognizing impending respiratory failure, (b) Performing effective
bag-valve-mask ventilation, (c) Performing atraumatic intubation with appropriate
endotracheal tubes, (d) Instillation of artificial surfactant, and (e)
Management of ventilator settings. In case of respiratory distress oxygen under
tent will be given to the neonates. In 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.
(3) To assure the cardio-vascular
equilibrium The baby should have at least one vein punctured and a perfusion is
installed. Assess perfusion for warm peripheries, capillary refill time of ≤3
seconds, tone and activity, and blood pressure. Stabilize perfusion before
moving the baby to the ambulance. Syringe pumps are required to use inotropes
with accuracy. Continuous Pulse oximeter monitoring is preferable.
(4) To assure the metabolic
equilibrium and the glycemia. The normal glucose in blood is 40 mg/dl. The
following categories of children present a risk of hypoglycemia: newborns from
diabetic mothers big for their gestational age, newborn that are small for
their gestational age small premature, sepsis or in shock newborns. For all
these newborns the glucose will be checked through rapid tests every 2 hours.
The glycemia is monitored continuously [23,24].
Special Considerations Regarding Pre-Transport
Stabilization For Some Pathology:
Abdominal wall defects
(Omphalocele, Gastroschisis): An oro[1]gastric drainage
should be installed. The abdominal defect to be covered with soft, sterile
sheets. Optional, the sheets may be wet with warm physiologic saline. Also, a
special plastic cover may limit the heat losses.
Defects of the neural tube
(bifida spine): The defect to be covered with soft, sterile sheets. Optional,
the sheets may be wet with warm physiologic solution. Also, a special plastic
cover may limit the heat losses.
Diaphragmatic Hernia: it is
compulsory to put the child on oro[1]tracheal intubation
and naso gastric drainage.
Other malformations of the
digestive tube: Nasogastric aspiration should be installed.
Esophageal
Atresia/Tracheoesophageal fistula: aspiration should be started and maintained
[25,26].
Accompanying the Patient:
A critically ill patient should
be accompanied by a minimum of two attendants. The precise requirement for
accompanying personnel will depend upon the clinical circumstances in each
case.
Levels of Patients’ Critical Care
The decision should be made by a
senior doctor [26]
Level 0: Patients whose needs can
be met through normal care should not usually need to be accompanied by a
doctor, nurse or paramedic.
Level 1: At risk of their
condition deteriorating, support from the critical care team will require a
paramedic ambulance crew and may require a nurse, paramedic and/or medical
escort.
Level 2: Requiring more detailed
observation or intervention including support for a single failing organ system
or post[1]operative care must
be escorted by competent, trained and experienced personnel, usually a doctor
and a nurse or paramedic.
Level 3: Patients requiring
advanced respiratory support alone or basic respiratory support together with
support of at least two organ systems. These patients must be escorted by
competent, trained and experienced personnel, usually a doctor and a nurse or
paramedic.
All individuals involved in the
transport of critically ill patients should be suitably competent, trained and
experienced.
Monitoring, Drugs and Equipment:
Patients with level 1, 2 or 3
critical care needs will require monitoring during the transfer. Monitoring
needs to be established and secure before the transfer is started. The
personnel involved in the transfer should check that they have adequate
supplies of the necessary drugs. These may include sedatives, analgesics,
muscle relaxants, and inotropes. Many of these drugs are best prepared before
hand in pre-filled syringes. All equipment should be robust, durable and
lightweight. Electrical equipment must be designed to function on battery when
not plugged into the mains. Additional batteries should be carried in case of
power failure. Portable monitors should have a clear illuminated display
Portable mechanical ventilators should have minimum connection, disconnection
and high pressure alarms. It should be able to supply positive end expiratory
pressure and variable inspired oxygen concentration, respiratory rate,
inspiratory: expiratory ratio and tidal volume.
The Ambulance:
The European Committee for
Standardisation has published specifications for ambulances. Private transport
services may use Type C mobile ICU vehicles. These will have 240V AC power, a
secure critical care trolley, a ventilator, monitors and syringe pumps. It is
more usual to request an ambulance from the local ambulance service to perform
the transfer. This is a likely to be a Type B or equivalent vehicle that has
12V electric sockets, oxygen supply and limited monitoring and other equipment.
The oxygen supply and battery operated equipment must be more than sufficient
for the anticipated duration of the transfer. A major issue relating to safety
during transport is the speed of travel. For the majority of cases high-speed
travel is not necessary and the safety of all passengers and other road users
is paramount, the goal is to facilitate a smooth and rapid transfer with the
minimum acceleration and deceleration. While safety is of paramount importance
during transfer, there is always a remote possibility of an ambulance being
involved in an accident resulting in death or serious injury to staff.
What Care Should Be Given During Transport?
Temperature maintenance: Use a
transport incubator if available. Kangaroo mother care (KMC) by mother or
attendant is a useful way to maintain temperature. Kangaroo mother care is a
good method of temperature maintenance during transport especially in resource
limited conditions when transport incubators are not available. Other methods
like adequately covering the baby, and using improvised containers (Thermocol
box, basket, polythene covering) may help in maintaining temperature.
Airway and breathing: Keep neck
of the baby in slight extension position. If airway is unstable, it is better
to intubate and transport, if intubation is not considered necessary /possible,
short PPV or CPAP can be provided using a T-piece resuscitator.
Circulation: Assess perfusion for
warm peripheries, capillary refill time of ≤3 seconds, tone and activity, and
blood pressure. Syringe pumps are required to use inotropes with accuracy. IV
fluids should be continued, perfusion solution and volume should be according
to the need of the baby. Continuous Pulse oximeter monitoring is preferable.
Communication: Inform SCNU / NICU
to arrange and organize baby cot and keep the overhead radiant warmer on.
Feeds: It is best not to attempt
feed sick babies with abnormal sensorium or severe respiratory distress before
or during transfer. A well baby at risk of hypoglycemia may be fed in addition
to intra venous fluid. If baby can accept provide breast feeds, if not give
expressed breast milk (EBM) with spoon. If EBM not available give any available
milk. During feeding ambulance should be stopped.
What Are the Different Modes of Transport?
The choice of vehicle will depend
upon clinical urgency, travelling distance, weather conditions and its
availability.
Road Ambulance: Better suited for
distance of 10- 200 kms .It has advantages of relatively easily available,
lower costs, least influenced by weather, more space and better patient access.
Can be stopped or diverted to the nearest hospital if necessary for any
emergency interventions. Disadvantages being transport time is influenced by
speed limitations, traffic delays and road conditions.
Rotary Wing (helicopter): For
distance from 50- 300 kms .Advantages are speedy retrieval and better
utilizations of medical staffs. Disadvantages are high costs, limited space,
may be influenced by weather conditions, require a landing site close to the
hospital, limited patients access, high noise and vibration levels.
Fixed Wing Aircraft: Being good
for long distance retrievals, advantages being reasonable space and access to
patient, family can travel with their baby. Disadvantages are require nearby
airport, immigration clearance, longer retrieval time and assistance with road
transport. Air transport exposes patients and crew to particular risks
including: Reduced oxygen partial pressure, the need for pressurisation to sea
level when clinically indicated, risk of rapid depressurisation ,expansion of
air filled cavities both within the patient and the equipment, such as
endotracheal tube cuff, middle ear, air-filled spaces under airtight dressings
etc, limb swelling beneath plaster casts, worsening of air embolism or
decompression sickness, limited space, lighting and facilities for
interventions, noise, extremes of temperature, extremes of humidity,
acceleration, deceleration and turbulence, vibration, electromagnetic
interference between avionics and monitoring devices, danger from loose and
mobile equipment [27-29].
How Should The Family Be Supported During
Transport Process?
Families of the sick newborn are
under considerable stress, and the transport team can provide sensitive
support. Parents need accurate information about the neonatal clinical
condition and prognosis, and an opportunity to ask and have questions answered
by the team.
Documentation and Handover
Clear records should be
maintained at all stages. This is a legal requirement and should include details
of the patient’s condition, reason for transfer, names of referring and
accepting consultants, clinical status prior to transfer and details of vital
signs, clinical events and therapy given during transport. On arrival at the
receiving hospital, there should be a formal handover between the transport
team and the receiving medical and nursing staff who will assume responsibility
for the patient’s care. Handover should include a verbal and written account of
the patient’s history, vital signs, therapy and significant clinical events
during transport. X-rays, scans and other.
What Should Be Done In Case The Neonate
Deteriorates During Transport?
The most appropriate action
depends on the level of skills of transport team in resuscitation, space and equipments
available in the ambulance, and the distance from the receiving hospital. The
two major strategies can be used in case of acute deterioration are:
• Stop the vehicle and
resuscitate if skills and space is available.
• Don’t perform any procedure in
a moving vehicle; get to the nearest hospital, stabilize, before proceeding
further
What Are The Medico-Legal Issues Associated with
Transport?
Most medico-legal problems are a
result of poor communication and provision of inadequate information. The condition
of baby, risks involved during transport, financial implications of transport
and treatment at the referral centre should be discussed with family and
documented and recorded.
If baby dies during transport:
The ambulance should be stopped
and CPR should be performed as per NRP guideline, then should be first taken to
the higher health facility and casualty admission should be done. Parents
should b explained and death certificate to be issued by the medical personnel
of higher health centre .It is the responsibility of transporting team to make
death certificate of baby.
Summary of Recommendations:
I. The development of efficient
transport systems is crucial to the implementation of regionalization of
perinatal care.
II. Transportation of the sick or
preterm babies to a centre with expertise and facilities for the provision of
multi-organ intensive care improve outcomes.
III. Neonates needing special or
intensive care should preferably be transported by a skilled transport team
through an organized teamwork.
IV. Appropriate equipments and
vehicle customized for neonates should be available for safe transport.
V. Pre-transport stabilization is
the most vital step in the whole process of transport.
VI. Adequate and timely
communication with the family, referring hospital and the support group is
essential [30-56].
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