Clinical Review ABC of preterm birth

Moving the preterm infant

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7471.904 (Published 14 October 2004) Cite this as: BMJ 2004;329:904
  1. Peter W Fowlie,
  2. Philip Booth,
  3. Charles H Skeoch

    Introduction

    Many different health service models for providing neonatal intensive care have been established over the past 30 years, and much of the developed world is moving towards a centralised model of care. At least initially, preterm infants often require specialised care in an intensive care setting. As a result, newborn infants and pregnant mothers may have to move between hospitals for appropriate care because of prematurity or the threat of preterm delivery. Sometimes this move means that the infant and family have to travel hundreds of miles.

    This article focuses on the postnatal transfer of preterm infants between hospitals. Antenatal transfer of pregnant women is not considered here, although in utero transfer has better clinical outcomes for mother and infant than transfer after birth. Many of the issues discussed are applicable to transfers within hospitals.


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    Neonatal transport system—mobile intensive care unit for safe and comfortable transport of infants

    Interhospital transport services

    In utero transfer is not always possible—for example, if labour is too advanced. Of the several models for transporting newborn infants, the most sophisticated are regional transport services that carry out all neonatal moves in a defined area using dedicated staff and equipment. These teams are responsible for neonatal transport only and are often “independent,” not being affiliated to a particular maternity or neonatal unit. A medical director usually runs such regional services, and the staff carrying out the transports may be medical or nursing staff with other professionals sometimes contributing. Referring hospitals and receiving hospitals do not have to provide staff or equipment, and each transport is undertaken by dedicated staff who have training and experience in transporting sick neonates.

    Reasons for transferring preterm infants between hospitals

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    When no regional transport service is available, medical and nursing staff from either referring or receiving units undertake the transport on an ad hoc basis. The staff will have variable experience in neonatal transport and the equipment used, and the vehicle may not be dedicated for neonatal use. Running these ad hoc teams often puts resources under strain because there will be fewer staff on site in the unit that carries out the transport. With less experienced staff, the risk of adverse events on such transports can be greater than with dedicated teams. In some parts of the world even ad hoc transport services are not available and transports with no clinical escort or untrained escorts use unsuitable equipment and vehicles.

    Safe transport of the preterm infant

    Anticipating the need for transfer early, appropriate preparation for transfer, and ongoing high quality care during transfer, are the cornerstones of good neonatal transport. To achieve this staff need to be trained appropriately, all equipment and vehicles must be fit for the purpose, and lines of communication must be well established.


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    An ambulance dedicated to, and equipped for, neonatal transport

    Anticipation

    When in utero transfer is not possible, there may still be an opportunity to seek advice, gather staff with the right skills, and prepare appropriate equipment. Direct communication between senior staff in the two centres involved is important.

    The ethos of neonatal transport medicine is to keep the infant stable and, preferably, improve the clinical status of the infant

    Stabilisation

    Preparing for transport begins as soon as the decision to move an infant is made. Specific treatments such as antibiotic treatment, surfactant replacement, volume support or inotrope support, analgesia, sedation, paralysis, anticonvulsant treatment, and nitric oxide should be considered. Any remedial action should be taken before moving the baby and not during the transport. Although the infant should be in as good a clinical condition as possible before setting off, the decision to stabilise the infant further or institute specific treatments must be weighed against a delay in transfer. These difficult decisions should be made in collaboration with experienced staff. The choices made will depend on many factors, including the clinical condition and progress of the infant, experience of staff on site, and equipment and treatments available.

    Clinical stabilisation before transfer

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    Infant care during the journey

    With good preparation and stabilisation before setting off, minimal active intervention should be needed during the transfer. However, infants can deteriorate spontaneously (for example, pneumothorax), or equipment (for example, endotracheal tubes and intravenous lines) can be dislodged. Equipment to deal with such eventualities must be carried.

    The infant's temperature should be maintained during any journey. When possible, the environmental temperature of the vehicle should be raised.

    Minimising heat loss from the infant during transport

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    Communication and documentation

    Good verbal and written communication between health professionals throughout transport episodes is vital. Using clinical guidelines, operational policies, and checklists is helpful. Parents also need to know plans for their baby's care, and the transport team should meet the parents when possible. In some settings informed consent is needed for transport and care. If parents are not travelling in the ambulance with their infant, they may need to know how to get to the destination hospital and what facilities will be available for them when they arrive. Helpful written information (for example, leaflets about the destination neonatal unit and maps) can be stored electronically and downloaded as needed.

    Choice of vehicle

    Different types of vehicles can be used to transport neonates. The mode of transport that is most appropriate will depend on resource availability, geography, clinical pathology, urgency of the situation, and the experience of the staff. More organisation is needed for an air transfer than for road transfers. Air transfer also requires specialist training and skills from staff, and the important physiological effects of flying must be taken into account. These effects include hypoxia, barometric pressure drop, thermal change, dehydration, gravitational forces, noise, vibration, and fatigue.


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    Scottish ambulance service helicopter—air transfer may be used to move infants depending on factors such as the geography of the journey, urgency of the situation, and the experience of the available staff

    Equipment

    Systems are based around an incubator fixed to a transport trolley with integrated ventilator, monitor, intravenous pump, and medical gas supply. Unfortunately, an infant cannot be secured in the transport incubator itself, and so is susceptible to substantial movement and potential trauma if there is sudden movement. Comfort factors (such as warmth, noise reduction, padding, and chemical sedation) can be adjusted.

    Transport equipment*

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    The equipment should be designed to function while in motion. Although adequate portable power sources should be available, all equipment should be run from the transport vehicle's power supply if possible. Medical gases sourced from the transport vehicle should be used whenever possible.

    Estimates for the quantity of all medical gases needed should allow for delays. Gas consumption can be estimated as flow delivered (l/min) x fraction of inspired oxygen x journey time (minutes) x 2.

    Many types of equipment bag exist and their contents vary, depending on the type of move. Bearing in mind that too much can cause confusion in an emergency, equipment should be kept to the minimum required for essential procedures.

    Staff safety

    Transport systems should comply with regulations on the safe loading and fixation of transport incubators in vehicles. Staff may sustain serious injury if loose equipment is dislodged during a journey, or while loading the transport systems. Historically, transport systems have been extremely heavy, sometimes over 200 kg, although lighter systems have now been developed. In the United Kingdom the health and safety regulation limit is 140 kg. The transport system must be fixed securely in the vehicle using a mechanism that has been appropriately “crash tested.” All employers should have adequate insurance that covers staff and equipment.


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    Equipment bags and their contents vary according to the type of neonatal transport that they are used for

    Personnel and training

    Transporting sick preterm infants requires specific skills and a high level of clinical competence. All staff involved—medical, nursing, paramedical, and others such as medical physicists—should have appropriate training in neonatal transport medicine, be familiar with local organisational procedures, and know how to use the equipment. No agreed standards on training in neonatal transport medicine exist in the United Kingdom. However, formal training programmes are becoming available.


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    Loading mechanism for loading transport incubators into ambulances. All transport systems must meet regulation standards

    Risk management

    Clinical risk management aims to identify shortfalls in standards and suggest appropriate remedial action. Unfortunately, only broad national clinical standards are available. However, some specific standards against which transport services can be audited have been used locally. Non-clinical aspects of neonatal transport medicine can be audited against directives from the Health and Safety Executive and medical electrical equipment standards. Audit and review with regard to avoidable adverse events is vital to the ongoing improvement and development of transport services for preterm infants.


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    Neonatal transport unit must be secured safely in the ambulance

    Conclusion

    Some newborn infants will always need to be moved between hospitals. Neonatal transport services must be well organised and should aim to provide clinical care to a high standard. The service should be staffed by professionals trained in neonatal transport medicine and in using appropriate equipment.

    Further reading

    Footnotes

    • Philip Booth is consultant paediatrician at Aberdeen Maternity Hospital and Charles H Skeoch is a consultant paediatrician at the Princess Royal Maternity Hospital, Glasgow

      This is the fifth in a series of 12 articles

      The ABC of preterm birth is edited by William McGuire, senior lecturer in neonatal medicine, Tayside Institute of Child Health, Ninewells Hospital and Medical School, University of Dundee; and Peter W Fowlie, consultant paediatrician, Perth Royal Infirmary and Ninewells Hospital and Medical School, Dundee. The series will be published as a book in spring 2005.

    • Competing interests For WMcG's competing interests see first article in the series.

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