Ethan Rhodes
The transportation of infants in hospitals is a critical aspect of ensuring their well-being and timely access to specialized care. In cases where infants require intensive care or experience critical illnesses, they may need to be transferred to Neonatal Intensive Care Units (NICUs) or tertiary perinatal centres. These transfers can be facilitated by specialized transport teams and services, such as the Neonatal Transport Program in Boston, which utilizes ground ambulances or helicopters to rapidly relocate infants to the appropriate facilities. The history of neonatal transportation dates back to the initiatives of American physician Joseph Bolivar DeLee, who recognized the importance of a thermo-regulated environment for preterm infants during transfer. Adequate stabilization prior to transport and the availability of necessary equipment and skilled personnel for resuscitation are also crucial factors in ensuring the safe transportation of infants within and between hospitals.
| Characteristics | Values |
|---|---|
| Temperature | The World Health Organization (WHO) defines normothermia and hypothermia in infants weighing less than 1500 g. The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) recommend an axillary temperature of 36.5º C to avoid hyperthermia, which is associated with progressive cerebral injury. |
| Training | All delivery room personnel should be adequately trained in neonatal resuscitation. The Neonatal Resuscitation Program (NRP), developed by the AAP and AHA, is a highly respected source of training. |
| Equipment | Appropriately sized equipment for resuscitating infants of all gestational ages should be available in all delivering institutions. |
| Stabilization | Newborn transport teams typically stabilize a baby's condition before transport to avoid clinical deterioration en route. |
| Transport Service | Boston MedFlight is an example of a critical care medical transport service specifically trained to transport newborn infants via ground ambulance or helicopter. |
| NICU Transport | Many infants are referred to neonatal intensive care units (NICUs) for specialized care, and back transport to community hospitals closer to the parents' residence can be safe and cost-effective. |
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What You'll Learn
Neonatal transport programs
The safe and timely transport of infants between hospitals is a critical aspect of neonatal care. Neonatal transport programs have been in existence since the 1940s, and they play a crucial role in ensuring that newborns, especially those who are critically ill or premature, receive the necessary medical attention and intensive care. These programs facilitate collaboration between hospitals and specialised healthcare providers to provide optimal care for newborns.
One example of a successful neonatal transport program is the Maryland Regional Neonatal Transport Program (MRNTP), a joint partnership between the Johns Hopkins Children's Center and the University of Maryland Medical System. The MRNTP has been in operation for over 25 years, providing safe, effective, and efficient ground and air transportation services for infants and their families. The program utilises specially designed ambulances, helicopter support from the Maryland State Police, and a dedicated team of neonatal nurse practitioners, transport nurses, and specially trained medics.
Another notable program is the Yale New Haven Children's Hospital Neonatal Transport Program. This program offers 24/7 access to safe and timely transport to and from referring hospitals. Their neonatal transport team includes NICU nurses, respiratory therapists, advanced practice providers, and physicians trained in neonatal medicine. They utilise state-of-the-art equipment and a specially designed ambulance to provide comprehensive care and support during transport.
The Neonatal Transport Program in Boston, in collaboration with Boston MedFlight, also stands out for its rapid transfer of critically ill infants from community hospitals to Level III newborn intensive care units (NICU) at Brigham and Women's Hospital (BWH). Boston MedFlight's unique logistical capabilities, including real-time tracking of weather, traffic, and NICU bed availability, ensure efficient transportation. The program provides advanced modes of ventilation and medical consultation services, ensuring the highest level of neonatal intensive care.
These neonatal transport programs highlight the importance of collaboration, specialised training, and technological advancements in providing safe and timely transport for critically ill newborns. The goal is to improve patient outcomes, reduce stress on parents, and increase access to the necessary medical resources and intensive care that newborns require.
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Resuscitation procedures
It is important that all personnel involved in the delivery room care of newborns are adequately trained in all aspects of neonatal resuscitation. Additionally, equipment that is appropriately sized to resuscitate infants of all gestational ages should be available in all delivering institutions. The practitioner should also have a good comprehension of transitional physiology and adaptation, as well as an understanding of the infant's response to resuscitation.
The Neonatal Resuscitation Program (NRP), jointly developed by the American Academy of Pediatrics (AAP) and the American Heart Association (AHA), is a highly respected source of information on the training, skills, and procedures needed for delivery room resuscitation of newborns. The program covers topics such as ventilation, which is the most important intervention in neonatal resuscitation, and the unique physiology of the transition from fetal to neonatal life, which informs resuscitation recommendations.
Before performing resuscitation, it is important to check the scene for safety, form an initial impression, obtain consent from the parent or guardian, and use personal protective equipment (PPE). If the infant is unresponsive and not breathing normally, call for emergency services and start cardiopulmonary resuscitation (CPR) straight away. When calling for an ambulance, basic life-saving instructions can be provided over the phone, including advice about CPR.
To perform CPR on an infant, place them on their back and ensure the head is in a neutral position, with the head and neck in line. Give 5 initial rescue breaths by covering the baby's mouth and nose with your mouth, making sure it's sealed. If you cannot cover both the mouth and nose at the same time, just seal either one. Blow a breath steadily over 1 second, and repeat this sequence 4 more times. If there is a gag or cough response, this is a sign of life. After the initial rescue breaths, perform chest compressions on the breastbone with the tips of 2 fingers, pushing down approximately one-third of the chest diameter (about 5cm). The quality (depth) of chest compressions is very important.
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Stabilisation before transport
Stabilisation is a critical aspect of infant transport in hospitals, especially for critically ill newborns. Without adequate stabilisation, an infant's condition may deteriorate during transport, leading to adverse events.
The process of stabilisation aims to ensure the infant's vital signs are stable and any necessary medical interventions are provided before transport. This includes addressing issues like hypoventilation, hypoxaemia, and hypotension, which are commonly found in critically ill infants. Additionally, ensuring normothermia is crucial to prevent hypothermia, which has been associated with increased mortality. The World Health Organization (WHO) has defined normothermia and hypothermia in infants, with the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) recommending an axillary temperature of 36.5º C as the target.
Resuscitation may also be necessary for stabilisation, and all delivery room personnel should be adequately trained in neonatal resuscitation. The Neonatal Resuscitation Program (NRP), jointly developed by the AAP and the AHA, is a highly respected source for training and procedures. Post-resuscitation care is also important, with neonates requiring close monitoring even after brief resuscitation interventions.
The availability of appropriately sized equipment for resuscitation and stabilisation is vital, especially in institutions that do not routinely care for preterm or intensive care infants. Transport teams often spend time stabilising the infant's condition before transfer, and the median stabilisation time for neonates has been reported as 80 minutes.
Overall, stabilisation before transport is essential to ensure the safety and well-being of infants, particularly those who are critically ill or premature. Adequate stabilisation reduces the risk of clinical deterioration during transport and ensures uninterrupted care from the referring hospital to the destination.
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Hypothermia prevention
The World Health Organization (WHO) has defined normothermia and hypothermia in infants, and the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) have stated that the goal is to achieve an axillary temperature of 36.5º C. This is to avoid hyperthermia, which is associated with progressive cerebral injury.
To prevent hypothermia in infants during hospital transport, it is essential to prevent excessive heat loss. This is important in the delivery room, during stabilization, and throughout transport to the neonatal unit. Maintaining a suitable environmental temperature is crucial in controlling heat loss in newborns.
In some cases, therapeutic hypothermia may be used as a standard intervention for neonates with moderate to severe hypoxic-ischemic encephalopathy (HIE). HIE is caused by oxygen deprivation at birth, leading to brain injury and high mortality rates. Therapeutic hypothermia has been shown to reduce brain injury and improve survival rates with fewer neurological complications. However, it is important to closely monitor infants undergoing therapeutic hypothermia, including frequent neurologic assessments and, in some cases, the administration of morphine for cold stress.
To ensure the safe and effective transport of critically ill infants, hospitals may collaborate with specialized medical transport services, such as Boston MedFlight, which offers ground ambulance or helicopter transportation. These services are specifically trained and equipped to transport newborns, providing real-time tracking of weather, traffic, and neonatal intensive care unit (NICU) bed availability.
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Transport methods
In the United States, transport methods for critically ill infants include programs like Boston MedFlight, which provides rapid transfer of infants from community hospitals to Level III NICUs at hospitals like Brigham and Women's Hospital (BWH). Boston MedFlight is a critical care medical transport service with a team specifically trained to transport newborn infants. They offer ground ambulance or helicopter transportation and have unique logistical capabilities, including real-time tracking of weather, traffic, and NICU bed availability.
In the United Kingdom, the first dedicated neonatal ambulance was introduced by neonatologist Herbert Barrie in 1968. This ambulance collected babies requiring intensive care from maternity hospitals and transported them back to the neonatal intensive care unit at Charing Cross Hospital.
It is important to note that regular ambulance staff and their vehicles may not be equipped to transport sick newborns. Therefore, specialized newborn transport teams are often utilized, with compositions varying by country and including combinations of nurses, doctors, and respiratory therapists. These transport teams prioritize stabilizing the infant's condition before transport to prevent clinical deterioration en route.
Additionally, maintaining a thermo-regulated environment during transport is crucial to prevent excessive heat loss, especially in preterm infants. Hypothermia on admission to the neonatal unit has been associated with increased mortality, emphasizing the importance of normothermia during transportation.
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Frequently asked questions
The safest way to transport an infant between hospitals is to use a specialist neonatal transport service. These services are provided by either particular hospitals or across a wider region. Teams are typically made up of a nurse, doctor and respiratory therapist, and they will stabilise the infant before transport.
The first organised neonatal transportation program was the New York Premature Infant Transport Service, which began in 1948. The first dedicated neonatal ambulance was introduced in the United Kingdom in 1968 by neonatologist Herbert Barrie.
If an infant is not adequately stabilised before transport, their condition may deteriorate en route. Hypothermia is also a risk, and it has been linked to increased mortality rates.
