Neonatal transport

is Associate Professor of Pediatrics, Section of Newborn Services, University of Michigan Medical Center, Ann Arbor. He received a B.A. degree from the University of Michigan and an M.D. degree from Tulane University. After completing a pediatric residency at the Medical Center Hospital of Vermont-University of Vermont, he held a fellowship in neonatology at the University of Michigan, Dr. Dorm’s research interests include the neurologic problems of the newborn, and neonatal hyperammonemia.

is Assistant Professor of Pediatrics, Section of Newborn Services, University of Michigan Medical Center, Ann Arbor. He received an A.B. degree from Dartmouth College and an M.D. degree from Cornell University. Following a pediatric residency at the University of Michigan Medical Center, he held a fellowship in neonatal-perinatal medicine at the Duke University Medical Center. Dr. Faix’s research interests include perinatal infectious diseases and immunology.

is the Perinatal Outreach Coordinator at the University of Michigan ter, Ann Arbor. She received in Communication from Hope College in Holland, Michigan and an MA, degree in Communication from Ohio University, Athens. Ms. Gates received her MSN. degree and certificate of Family Nurse Practitioner preparation at Pace University and New York Medical College in Briarcliff Manor, New York. Her nursing specialty is neonatal intensive care. She is certified by N.A.A.C.O.G. and has been a Primary Transport Nurse for an all-nurse transport team.

of perinatal services in the United States has been prompted by two factors: (1) neonatal and obstetric intensive care can dramatically improve maternal and neonatal mortality and morbidity in high-risk situations, and (2) limited resources and patient volume make it undesirable for all hospitals to provide services for all possible maternal-neonatal complications. Hospitals with nursery services have been classified as levels I, II, or III, based on their ability to provide increasing degrees of medical, surgical, nursing, and technical service for newborns. It is proposed that the regional level III (tertiary) hospital serve as the referral and consultation center for mothers or infants who require complex or chronic care that cannot be adequately provided at the level I or II hospitals. Level II hospitals provide an intermediate level of care for mothers or infants who require special services unavailable at level I (community) hospitals, but do not necessarily provide the broad range of services required for chronic or complex neonatal care. Both level I and level II hospitals should have facilities for resuscitation and stabilization of infants requiring transfer to higher level hospitals. Back-transfer patterns are incorporated into the theoretical system to promote optimal use of resources and to allow family involvement with the convalescent neonate.’ Safe transport of neonates and mothers is critical for this regionalization model to be effective. Intuitively, it seems that perinatal outcome should be better if the high-risk infant is transported in utero to the appropriate level hospital with a full range of support services for delivery, resuscitation, and stabilization rather than if the infant is delivered locally and transferred after birth. For a variety of insurmountable ethical and logistic reasons, prospective, randomized trials of this hypothesis do not exist. A number of studies conducted in a nonrandomized but otherwise controlled manner do strongly suggest that in utero transport results in significant decreases in neonatal mortahty and morbidity, even when stratified for maternal and fetal risk factors, and when corrected for bias inherent in comparing a group of exclusively sick neonates (neonatal transport) with a group of potentially sick infants (in utero transport).2-5 Maternal transport prior to labor can usually be conducted by means of traditional ambulance facilities with little additional equipment but with the need for an attendant skilled in obstetrics. If the patient is in early labor and travel distance is not great, traditional ambulance facilities may still be used, but equipment and personnel for fetal surveillance, unanticipated emergency delivery, and neonatal resuscitation are required. If cervical dilation exceeds 4 cm, or if other factors suggest that delivery may occur during transport, it is best to deliver, resuscitate, and stabilize the infant at the initial hospital and then transport the neonate (and mother, if desired). Antenatal circumstances do not, however, always predict the com-

REGIONALIZATION

8

promised state of the newborn. ‘Jp to 40% of admissions to some intensive care nurseries result from low-risk pregnancies.6 In utero transport is desirable, but even the most liberal referral pattern will not completely obviate the need for neonatal transport. Improvement in neonatal. mortaIi~y and morbidity among igh-risk infants has been s own to occur when re tal intensive care units are ed.7-g The ise of skill and nurses for neonatal transport has also been demonstrated to signifieantly reduce mortality, morbidity, and the duration of hospitalization among high-risk infants, even when unmodified TABLE

I.-&&ZDELINES

FOR NEONATAL TUNSFER

Prematurity Birth weight 5 2.0 kg Gestational age 5 34 weeks Respii$ory distress FI,, > 0.4 Need for positive pressure Airway obstruction Apnea Nypercarbia Pneumothorax Shock Acute hypotension Oliguria Poor perfusion Asphyxia Abnormal findings on neurologic examination Hypotonia Seizures Obtundation Intractable acidosis Biochemical derangements Kypoglycemia Hypocaleemia Prolonged cardiopulmonary resuscitation Surgical lesions Birth trauma Genetic/metabolic disease Congenital heart disease Gastrointestinal disease Need for parenteral nutrition Feeding difficulties Congenital malformations Diagnosis Therapy Miscellaneous Infant of diabetic mother (Class B-R) Rh-sensitized Intrauterine growt,h retardation Coagulopathy Maternal drug abuse Symptomatic sepsis Need for specialized procedures/facilities

9

ambulances with special portable equipment were used.i’, l1 A variety of clinical circumstances should prompt consideration of infant transfer from the community hospital (Table 1). Most regions have adopted a model wherein the level III center is responsible for operating and maintaining the regional transport system such that nearly all neonatal transports originate from and return to the regional center, although at least one region has successfully encouraged the development of well-trained and equipped supplemental community-based transport teams, with no adverse effects on neonatal survival.12 Wherever it is based, the transport team requires special personnel, equipment, and facilities for optimal speed, safety, and patient care. FACILITIES,

EQUIPMENT,

AND

SERVICES

COMMUNICATIONS Communications are essential for the initiation and conduct of neonatal transport. Well-publicized telephone lines for the exclusive use of incoming consultation and transport requests should be available for obstetrics and neonatology; many centers employ a central line for both perinatal services. If separate lines are employed, good interdisciplinary communications are essential so that the necessary services can be coordinated. Requests for neonatal consultation or transport should be handled by a neonatologist or other individual with appropriate neonatal training and experience. A standard worksheet (Fig 1) for recording pertinent information, noting suggestions for stabilization or management, and ascertaining that appropriate specimens and the accompanying paperwork are ready for transport is helpful in assuring that necessary communications are not inadvertently omitted. A projected departure and/or arrival time greatly facilitates the referring physician’s management of the case. A response time of 30 minutes from receipt of the call to departure from the center is a reasonable goal. If helicopter or fixed-wing aircraft transport is contemplated, landing site and mechanisms of infant transfer to aircraft (i.e., transfer at landing site or in nursery with subsequent transport to landing site) need to be arranged. A consistently designated individual should then contact the ambulance and other necessary members of the transport team (use of a consistently delegated person avoids the possibility of the “I thought someone else did it” syndrome). Anticipated consultants (surgeons, cardiologists, radiologists) should be notified so that necessary diagnostic and therapeutic procedures can take place as soon as possible after the infant’s arrival at the referral center. Once the team has arrived at the referring hospital and stabilized the infant, the receiving hospital must be notified of the infant’s condition, the expected time 10

Fig 1 .-Sample of a transportkonstiitation form for recording relevant pertaining to infant in community hospital. Form is completed in duplicate; is part of patient record, the other is part of transport fiie.

information one copy

of return, and the need for additional equipment or services on return to the receiving hospital, In the transport vehicle, equipment should be available for communicating within the vehicle (especially for ambulances and helicopters with a wall separating the drivers from the attendants) and with the referring and receiving hospitals. Stopping the vehicle to perform an emergency procedure may be very difficult if the vehicle operator cannot hear tke request. Unex-

petted delays or need for advice en route can be transmitted appropriate people in a timely fashion by mobile telephone radio.

to or

PERSONNEL

The composition of the transport team varies from institution to institution. The critical factor is that necessary skills (diagnostic, technical, and interpersonal) be provided, rather than particular professions or titles be represented. At our own institution, the transport team consists of a neonatology physician (usually a fellow or attending physician, but occasionally a senior pediatric resident), a neonatal intensive care unit nurse, and a pediatric respiratory therapist. Many centers have had excellent results using “physician extenders” (specially trained nurses, physicians’ assistants or emergency medical technicians) in close communication with physicians based at the receiving hospital or strictly following center-established protocols for management.13; ‘* A respiratory therapist may not be necessary if no respiratory difficulties are anticipated or if another individual on the team has the necessary skills to set up, operate, and evaluate the respiratory equipment. The advisability of having personnel devoted exclusively to neonatal transport is dependent on funding, the frequency of transport, and the availability of individuals with proper training or capable of such training, Centers with very busy neonatal transport services (more than 500 transports per year) have found that teams composed almost exclusively of specially trained nurses are efficient and cost-effective if the service is maximally busy.14 Less busy services have found it more advantageous not to devote personnel exclusively to transport but to assemble teams from appropriately trained individuals on call or already in the hospital. Transport personnel must have been oriented to transport and must have accompanied several transports as observers or assistants before serving as core transport team members. Since care delivered to the infant during transport must be at least as good and preferably better than that at the referring hospital, individuals without special training are not appropriate for neonatal transport. There is no perfect combination of transport personnel for every institution and every situation. Neonatologists can provide expertise but may not be available for fulltime coverage, and their salary costs are high. At hospitals with pediatric house staff, neonatology and pediatric trainees are available on an around-the-clock basis, with modest salary costs already incorporated into their training programs, but they have variable expertise and interest, and medicolegal or public relations difficulties may ensue. Nurse practitioners certainly have necessary expertise but they are not widely available, their salary costs 12

are relatively high, and use of them may not preclude medicolegal problems. Transport and staff nurses with appropriate training may provide necessary skills at reasonable cost, but may encounter difficulties with acceptance by referring physicians and occasional medicolegal problems. The composition of the team must be determined by each center, taking into account its own budget, available personnel, in atient demands, referral patterns, and me icolegal climate.14- 3:’ The occasional need for backup transport teams and vehicles for simultaneous transports must be incorporated into the system. Often overlooked, but essential to the safe and effective conduct of neonatal transport, are the vehicle operators. Although operators are rarely employed exclusively for neonatal transport, an appreciation of the special features of neonatal transport is very helpful. Timely transport of the sick infant requires more safety than speed; in most clinical situations, proper stabilization of the infant prior to loading the transport vehicle will avoid the necessity for high speed and potentially dangerous driving or flying maneuve f procedures such as intubation or placement of a thoracosto tube become unexpectedly necessary en route, they can be y and effectively performed in an ambulance or helicopt vehicle is stopped. The opessential should problems erator’s knowledge of the ve arise with the power source, gas supply, communications equipment, or the vehicle itself. Appropriate maps and sets of directions will facilitate navigation to and from referring hospitals. The vehicle operator supervises the safe loading and unloading of the infant, incubator, and attached essential equipment. The physician, nurse and other health professionals at the referring hospital are not usually perceived as members of the t based at the regional center, transport team since they are but their recognition of the ne for transport and their efforts at stabilization of the infant prior to the arrival of the team from the center are critical to the outcome of the infant and the transport. One drawback of ~eg~o~~~~~at~o~ is that some individuals at referring hospitals believe their patient responsibility ends once the transport request has been called to the regional center. The vital role of the personnel at the referring hospital in effective transport needs to be ern~~~s~~ed and encomaged whenever possible. TRANSPORT

VEHICLES

Selection of a transport vehicle is the distance traveled, geography, weather conditi re of the infant’s problem, and the need for speed. A conveyances are in popular use, including ground ambulances, helicopters, and fixed-wing aircraft. any centers find it best to have all. three available. Ground ambulance transport is generally the 13

least expensive per loaded mile and usually offers the advantage of shortest elapsed time to departure from the regional center; if the distance to the referring hospital exceeds 100 miles or requires considerable travel through heavily congested areas, the travel time may lead to exhaustion of oxygen reserves and cause fatigue in team members, with compromise of the infant’s care. Helicopter transport is very expensive per loaded mile unless it is heavily used. Noise and vibration make in-flight monitoring of the infant difficult, and meticulous stabilization of the infant is mandatory prior to loading. IHelicopters offer the advantage of speed and the ability to bypass heavy ground traffic. Fixed-wing aircraft make much less noise and vibration than helicopters and allow significantly easier intervention if problems arise in the air. One of the major disadvantages is that separate ground transport still must be arranged at both ends to move the baby between the airport and the nursery. For one-way distances exceeding 150 miles, however, it is often the vehicle of choice. The use pattern and economic situation of each center dictates whether it is advisable to have an appropriately outfitted ambulance or helicopter for the exclusive use of the transport team or to share the facilities with other emergency services. Clinical circumstances often arise that make it most appropriate to combine the use of both the helicopter and ground ambulance. If the infant at the referring hospital is acutely ill and requires emergency stabilization that the referring hospital is unable to provide, it is logical to rapidly transport the team with all appropriate equipment to the referring hospital by helicopter; if it appears that stabilization will take some time or if an intercurrent emergency need for the helicopter arises, the helicopter can return to its home base while the ground ambulance is dispatched to pick up the properly stabilized infant and team for the return trip to the center. To save time, it may occasionally be preferable to have the helicopter deliver the team and appropriate equipment to the referring hospital, and after stabilization of the infant, to have an ambulance from the referring hospital transport the infant and team to the center. Since helicopter services are most cost-efficient when use is heavy and ground time is minimal, these “fly-drive” options are often the logical choice, especially if the aircraft is shared with other emergency services. Although ground ambulance, helicopter, and fixed-wing aircraft transport obviously differ, some features for effective and safe neonatal transport are common to all. All should have a safe, easy means of lifting the incubator and patient into and out of the vehicle. Numerous anecdotes describe significant injury to infants as a result of trauma incurred when the incubator tips; the use of ramps, gurneys, or hydraulic lifts should obviate this possibility. There must be some means of safely anchoring the incubator, monitor, and ancillary equipment so 14

that sudden stops, starts, or swerves do not dislodge vital equipment or cause heavy objects to fall. Safety belts should be provided for all transport personnel, preferably arranged so that the infant can be continually observed through the clear plastic incubator wall at a short distance. Generator capacity and power outlets that are compatible with the transport equipment should be built into the vehicle so that battery-powered equipment will not have drained the batteries once the equipment is needed outside the vehicle. Firmly anchored large cylinders of oxygen and compressed air should be stored outside the patient care space but should have connecting piping or outlets available for use in that space. Means of controlling the infant’s environmental temperature should be available to minimize undue thermal stress. Since one system may fail, we recommend that several be available, including thermostat-controlled patient spaces in the ambulance, transport ine tor, radiant warmer, and exothermic chemical mattress. i9 intercom or some other means of facilitating communication between the infant caretakers and the vehicle operators should be present, as well as a mobile phone or a two-way radio for communication with both the receiving and referring spitals. Insulation or independent suspension systems to m s to the infant and the staff from vibration and noise are able but not always effective. Patient care workspace shoul e adequate to permit cardiopulmonary resuscitation, if necessary; space to stand up may seem desirable, but unless the vehicle is quite large, this may result in a center of gravity too high for reasonable safety during fast maneuvering. Standard safety equipment such as a fire extinguisher, flares, and vehicle repair equipment should be available. Other modifications that are specifically applicable to ambulance or aircraft a noted in the sections devoted to ground and air transport. A itional possible modifications are legion and range from conventional adult ambulances with little or no built-in neonatal equipment to large mobile homes with the capacity for transporting up to four infants at once, with extensive laboratory as well as life support equipment.i7 Modifications to increase vehicle speed are usually not warranted for neonatal transport because proper infant stabilization should decrease the need for breakneck speed and because such speed may well interfere with the safety of the transport. Backup vehicles and transport teams should be available for the not uncommon occurrence of multiple simultaneous transport requests, multiple births, and unexpected vehicle or major equipment failure. Ideally, backup vehicles should also have appropriate modifications for neonatal transport. It is often practical to have the backup vehicles shared by other emergency services or other hospitals. Preventive maintenance of the vehicles by experienced mecbanics, vehicle operators, and/or emergency medical techni15

cians (E&ITS) on a regularly scheduled basis is mandatory. The operators or EMTs should review the vehicle, power supply, fuel reserve, medical gas supplies, built-in medical equipment, and safety devices after every trip. Depleted supplies or equipment should be restocked or replaced. Leakage of exhaust fumes into the patient space should be sought and, if detected, corrected. Any mechanical or electrical difficulties with the vehicle should be reported and remedied before any subsequent transports. Even in the absence of any problems, a skilled mechanic experienced with ambulances shou d check the vehicle thoroughly at least once a week. Some vehicle failures are unavoidable, but others are clearly predictable and potentially preventable by proper maintenance. MEDICAL AND NURSING EQUIPMENT Much necessary equipment for neonatal transport cannot or should not be built into the ambulance, including many devices that are meant to be used during stabilization in the referring nursery. Equipment for virtually all neonatal emergencies should be brought for optimal delivery of care, since the referring hospital may not have necessary equipment. Even if the equipment is available, it may not be in proper operational condition because of infrequent use. Transport of such equipment also allows staff at the referring hospital to familiarize themselves with this equipment and consider its use in stabilization of future infants in their hospital. One essential piece of special equipment is the transport incubator (Fig 2). This should have clear plastic walls for continual observation of the infant, and adequate portholes for respiratory and intravenous (IV) tubing, monitor leads, and other electronic material. Double-walled incubators offer some advantage over single-walled incubators for reducing heat loss. The simple addition of a clear plastic heat shield or a Saran Wrap blanket may allow the less expensive single-walled incubator to function much more efficiently.” Built-in monitor, IV infusion pump, and infant ventilators are available from several manufacturers. Even if one chooses not to use commercially prepared combination incubators, it is still desirable to have such devices securely mounted to the transport incubator for ease of use and mobility. Servocontrolled and manual heating elements are available. The incubator and attached electronic equipment should be able to run on a self-contained battery, but usually battery use can be minimized by plugging the incubator into the ambulance power source while en route to and from the referring hospital and plugging it into a wall outlet at the referring hospital nursery while the infant is being stabilized. Stabilizing an infant typically takes enough time that even if the incubator 16

Fig 2.---Total portable life-support system for transport of the critically Included are incubator, ventilator with heated and humidified circuit, oxygen and air (with spare tanks), oxygen blender, electronic cardiorespiratory transcutaneous oxygen monitor, oxygen analyzer, infusion pump, warmed mattress, resuscitative equipment, and gurney.

ill newborn. compressed monitor, chemically

is initially eold, it is a equatefy warmed by the time the infant is ready to be loaded into the incubator. Heart and respiratory monitors should be anchored to the transport incubator and should be able to run on batteries. Both visual and auditory display of the heart rate should be incorporated into the device. The auditory portion will be helpful while the infant is in transit betwe e nursery and the ambulance, a time when the attendants pay attention to other items in addition to the infant; the visual display is essential once the infant is in the moving ambulance, since noise and vibration may preclude hearing auditory signals. A continuous display of the infant’s ECG is helpful for differentiating artifact from true heart rate abnormalities. Alarms for high and low heart rate should be incorporated and should be adjustable. The sensor electrodes should attach easily and firmly to the infant without interfering with access to the infant or the function of other vital! equipment. The monitor does not replace the need for careful observation and serial assessment by the transport personnel. With appropriate monitors and properly trained personnel, there is no excuse for repetition of the experience of some Dutch in17

vestigators, who noted that when untrained personnel were used for neonatal transport, several infants arrived at the regional center dead without the attendants being aware of it.‘r At least one IV infusion pump should be anchored to the incubator and should have the capacity to infuse as little as 1.0 ml/ hour. The use of syringe pumps minimizes difficulties with tubing and adaptor compatibility while permitting continuous assessment of infusion rate. Models that can be adjusted for multiple syringe sizes offer maximum flexibility for the multitude of clinical needs that may arise. RESPIRATORY AND OTHER EQUIPMENT A variety of respiratory therapy equipment is essential. Full E-tanks of oxygen and compressed air should be safely mounted with appropriate regulators on the incubators and an E-tank wrench securely attached to one of the cylinders for rapid availability. These tanks are necessary for providing medical gases to the patient once the infant has left the referring nursery. Both types of gas are essential so that oxygen concentration can be adjusted to the patient’s needs. A portable battery-powered oxygen analyzer is helpful. A low-flow blender is required for accurate mixture of the gases. Sterile, fresh ventilator tubing is requisite. Other essential respiratory equipment includes an oxygen hood, aerosol tubing, a self-inflating resuscitation bag (with adaptors to facilitate delivery of 100% oxygen) and attached manometer with variable positive end-expiratory pressure (PEEP) attachment, appropriate face masks for the smallest preterm through the largest full-term infant, nebulizer with nonimmersion heater, oxygen tubing and connectors, laryngoscope handle and blades, Magi11 forceps, uncuffed neonatal endotracheal tubes ranging in size from 2 to 4 mm internal diameter, extra battery and bulbs for the laryngoscope, nasal prongs for continuous positive airway pressure (CPAP), suction catheters, extension cords and tubing, and supplies to allow fixation of the endotracheal tube or nasal prongs (Table 2). A lightweight solid-state oxygen generator may be included, should oxygen supplies unexpectedly be exhausted.22 A functioning stethoscope is mandatory for assessing the adequacy of respiratory support, and at least one should be available for every member of the team. Since so many transported infants require respiratory support, careful attention should be paid to the selection and maintenance of respiratory therapy equipment. Though some centers prefer to hand ventilate all infants throughout transport, most find it more convenient and easier to make carefully controlled changes with the use of an infant mechanical ventilator. A number of commercial transport incubators are available with builtin ventilators, but some centers have chosen to model their own 18

TABLE

2.-RESPIRATORY

THEUPY

EQUIPMENT

FOR NEONATAL

TRANSPORT

Mechanical ventilator (anchored to transport incubator) Sterile ventilator tubing and water traps Full C&000-psi) E-tanks of oxygen and air with flow regulators E-tank wrenches Low-flow blender Air/oxygen high-pressure hoses to blender Air/oxygen quick-connect adaptors to high-pressure hoses Oxygen tubing and tubing connector3 Oxygen hood with aerosol tubing Resuscitation bag with variable PEEP attachment and 100% oxygen adaptor Manometer and bifurcation tubing to resuscitation bag Resuscitation masks: premie, newborn, infant size3 Stethoscope All-purpose nebulizer with plugs Nonimmersion heater Tape Miscellaneous set: hemostat, flowmeter nipple, wrenches, infant and small child airways Intubation set: laryngoscope handle; biades Nos. 0 and 1 with bulbs; Magill forceps; sterile stylet; spare bulbs and C batteries; adhesive tape; Tint-o-ben adhesive, Detach01 adhesive remover; cotton swabs; uncuffed endotracheal tubes 2.0 to 4.0 mm lumen internal diameter; DeLee suction catheter Continuous positive airway pressure set: nasal prongs, extra small to large; headbands; nasal lubricant; Ace bandage; tape

infant ventilator into their transport incubator. Whichever option is selected, the ventilator should operate on the continuous gas flow, intermittent man atory ventilation principle and should be capable of providing humidified and warmed gases to prevent excess water and heat losses. Application of CPAP or PEEP should be possible, and flow should be easily regulated by the operator. As with all infant ventilators, it is important to be able to limit the pressure applied to the airways, to alter the waveform of the respiratory cycle from sine to square wave, and to reliably alter the inspiratory and/or expiratory times. The inclusion of mean airway pressure monitors may be very helpful in the management of persistent pulmonary hypertension and prevention of air leak syndrome during transport. It is important to assess the adequacy of respiratory support as accurately as possible. The attendant’s eyes and ears allow him to assess chest excursions and breath sounds but do not allow accurate assessment of oxygenation or ventilation. Since blood gas analyzers are not available in most transport vehicles, portable transcutaneous monitors for oxygen and carbon dioxide may serve as useful indicators of respiratory adequaey.a3 If the infant is on a mechanical ventilator, use of an end-tidal carbon dioxide monitor may supplant the need for a transcutaneous carbon dioxide monitor. Battery-powered models of each are available. Appropriate electrodes, adhesives, contact gels, and connecting wires should be included with the neonatal transport equipment if such monitors are used. Preferably these monitors

Fig 3.--RMI Model 292 dual light source fiberoptic The system is completely portable and is ideally suited

transilluminator for neonatal

and transport.

battery.

arterial or capilshould be placed on the infant an correlating lary blood gas values obtained prior to departure from the referring hospital. Even if precise correlation cannot be obtained, the monitors may still serve as useful trend indicators. Another device that has proved useful for transport is a bat-

Fig 4.-Medications, equipment, and other supplies may be systematically in durable utility boxes for ground transports. Each !evel and compartment bered for ease of locating and restocking contents. 20

stored is num-

Fig S-For air transport, ~~~bt~ei~~t Mut durable soft packs should be used. These hold a considerable amount of supplies and medications but take up minimal space in the vehicle and are somewhat deformable for ease of storage. Note method of securing medication vials.

tery-powered fiberoptic ~ra~s~~~~~nator which can be used for rapid diagnosis of pneumothorax, pneumopericardium, pneumoperitoneum, and intracranial abnormalities, as well as the identification of peripheral arteries and veins for cannulation (Fig LO.24 Portable neonatal Doppler devices facilitate determination of arterial blood pressure even during transit. All the respiratory, medical, and nursing e uipment can either be stored in drawers built into the transport incubator or carried in separate utility boxes or knapsacks (Figs 4 and 5). Equipment necessary for the operation and maintenance of respiratory support should be stored separately from the medication and resuscitation equipment boxes to avoid confusion in emergencies. A Polaroid camera is be~pf~~ for recording pertinent physical findings and providing pictures of the infant for the mother and other family. The family usually greatly appreciates this and notes that it helps them feel that the baby is still theirs despite the distance that may be involved.

A well-identified box or other container should be supplied for the storage and rapid transpo of necessary m cations and equipment for resuscitation an stabilization of t infant. It is imperative that this box be ~b~rongb~y organized and that all 21

transport team members be well-oriented to its contents. Fumbling around to locate essential materials during resuscitation at a referring hospital can obviously contribute to deterioration in the infant’s condition and undermine the relationship between the regional center and the referring hospital. Although it is probably impossible for any readily transportable equipment box to contain all possible materials for every clinical circumstance, one should attempt to provide all materials necessary for keeping the critically ill infant alive and stable until arrival at the regional center. Since the quantity of equipment for resuscitation and stabilization may be very different for intrahospital transport than for interhospital transport, it may be advisable to provide different equipment boxes for intrahospital transport (Fig 6). Over 13 years of neonatal transport, we have found our medication needs to be met by the list given in Table 3. Some of these agents are used more frequently than others. Infrequent use should not prompt removal of an item from the stock, since when the need does arise, it will usually be on an emergency basis and the referring hospital may not have the required medication readily available. Other essential support equipment in the transport box is listed in Table 4. Pertinent history or physical findings elicited from the referring physician during the initial transport request may indicate the need for additional items. Hasty assemblage and dispatch of the transport team without thoughtful consideration of the needs of each infant prior to departure may cause grave regret later.

Fig 6.-A smaller equip1 ment and drugs, 22

utility box, containing is used for intrahospital

only the transport.

most

essential

resusc 5i iative

TABLE

3.-ESSENTWLIV~UGATIONS

FOR NEONATALTRANSPORT

Lidocaine 1% (for local anesthesia) Lidocaine 2% without epinephrine AlbuminPlasmanate Dextrose 50% in water Dextrose 10% in water, 500 ml Dextrose 5% in water Pancuronium Ampicillin Gentamicin Normal saline, for injection Vitamin K Phenobarbital Epinephrine 1: lO,OQ@ Atropine Heparin Sodium bicarbonate Calcium gluconate 10% Sterile water, for injection Naloxone Isoproterenol Dopamine Tolazoline Glucagon Prostaglandin El Furosemide Dexamethasone TABLE

4.-ESSENTIALMEDICALAND

Iodophor swabs, ointment, and solution Alcohol wipes Sutures, 4.0 silk with cutting needle Umbilical tape and clamp Labels Safety pins Rubber bands Infant restraints Tourniquet Tape Blood culture tubes Rubber bulb syringe Cotton balls Lancets Needles sizes, 18 G, 22 G, 25 G Lubricant gel Blood tubes-plain, EDTA, citrate Scalp vein needles sizes 23 6, 25 G Syringes, l-60 cc Sterile instruments: Forceps Iris forceps Hemostat, straight and curved Scissors Probe Tape measure

(for arrhythmia)

PJURSINGEQUIPMENTFORNEONATALTRANSPORT Sump tube Sterile gauze; 2 x 2 in. and 4 x 4 in. T-connectors Plastic IV catheters, 22 G, 24 G Armboard, small Iocking stopcocks, and extension sets Stethoscope Polaroid camera, film, flash cube Umbilical artery catheterization set Blunt-end needles Buretrol with microdrip chamber for IV fluid administration Tubing for IV fluid administration Sterile gloves, sizes 6%, 7, 71/2, 8 Thoracostomy tubes Umbilical artery catheters, sizes 3.5, 5, 8 French Tuomey syringes Thoracostomy tube water seal drainage Latex suction catheters Rextrostix or Chemstrips DeLee suction apparatus Stopcocks and plugs &Swain darts or IIeimlich valves Thermometers Tubing for infusion pump Feeding tubes, sizes 5 and 8 French 23

PAPERWORK A variety of paperwork necessarily accompanies each transport trip. Experience dictates that it is best for all this paperwork to be kept in one place and affixed to a clipboard to minimize the risk of forgetting or misplacing any documents. Among the necessary forms are the consent form for care by the transport team and transport of the infant to the regional center, a copy of the worksheet detailing all the information transmitted at the time of the transport request, nursing notes, respiratory therapy flow sheets, and sheets for the physician’s notes. In addition, booklets describing the regional center with maps and telephone numbers, pamphlets encouraging breastfeeding and techniques for induction and maintenance of milk flow for mothers who wish to provide breast milk, and brochures describing social services, parent support groups, and other family support structures should be provided for the family at the referring hospital. One additional item that may be helpful for centers that frequently employ pediatric residents for neonatal transport is a checklist describing the conduct of the transport, including reminders of the following: (1) to have the consent forms signed; (2) to give the appropriate literature to the parents; (3) to ascertain that copies of the mother’s and infant’s chart, the cord blood, and copies of all pertinent radiographs are obtained; (4) to assure that the parents receive a picture of the infant prior to the transfer; and (5) to reinforce the need for a call back to the receiving unit to alert personnel of the infant’s status and the need for additional equipment or support at the time of return. Many other items may be included in this checklist. The importance of preventive maintenance for all equipment and materials used in neonatal transport cannot be overemphasized. The equipment box, respiratory therapy equipment, incubator, infusion pump, monitors, camera, and documents must be reviewed before and after every transport to ensure that necessary items are not missing and to replenish stock depleted during transport. The selection of transport equipment should be periodically reviewed several times a year to determine the need for deleting or adding items as well as updating or replacing transport items. A monthly transport review conference at the perinatal center (as discussed in a subsequent section) will greatly facilitate the critical review of the performance and function of the transport team and serve as a useful index for constantly improving this vital service. STABILIZATION

OF THE C

THE COMMUNITY HOSPITAL ROLE Initial stabilization the basic principles 24

of a critically ill newborn of neonatal resuscitation

entails applying and monitoring.

tory support includes establishing and maintaining an by thorough suctioning of the nasopharynx, mouth, and, if necessary, the trachea. If airway obstruction is suspected, such as in patients with meconium aspiration or tracheomalacia, endotracheal intubation is indicated. In most other instances, however, ventilatory assistance can be adequately provided by positive-pressure breathing using a bag and mask technique. The use of an in-line manometer to measure delivered airway pressure may facilitate resuscitation and avoid overventilation sf the infant. Cardiac output in the newborn is most affected by changes in heart rate; maintaining a normal pulse rate is therefore essential. Bradycardia should be treated by oxygenating the infant and/or by pharmacologic means (epinephrine, sodium bicarbonate, or atropine; Table 5). External cardiac massage should be instituted if the infant heart rate falls below 80 beats per minute. Monitoring of the infant heart and respiratory rates by standard electronic devices is strongly recommended. The ability to measure neonatal blood pressure has greatly improved in recent years. Automated devices using Doppler ultrasound techniques are available and can determine heart rate, systolic, diastolic, and mean arterial blood pressures in even the tiniest babies. It is important to appreciate the ranges of normal blood pressures, which vary according to birth we;Fht and gestational age, to avoid overtreati~g smaller infants. Other measures of the adequacy of perfusion should also be observed, especially urine output and c lary refill. The initial treatment of hypotension is volume ansion using a colloid solution (plasma, 20% albumin, or Plasmanate) in a dose of 10-20 ml/kg IV. Pressor agents may be employed if volume expansion fails to correct hypotension (see Table 5). Of hallmark importance in the stabilization of the newborn is the maintenance of th@rmo~e~traIity. In a neutral thermal environment the infant’s oxygen consumption, basal metabolic TABLE

k---DRUGS

Coxcomb

II'XXCATION

DRUG

Atropine Calcium gluconate (10%) Dextrose (25%) Dopamine Epinephrine (1: 10,000) Naloxone Sodium

(Narcan bicarbonate

*IV, intravenous; cutaneous.

USED FORRESUSCITATINGNEONATES

Neonatal) IM,

Bradycardia Excessive secretions Hypocalcemia Hypoglycemia Hypotension Cardiac arrest Hypotension Narcotic depression Metabolic acidosis

intramuscular;

IC, intracardiac;

DOSE

0.01

mgikg

ROUTE"

IViIM

1-2 ml/kg 2-4 ml/kg 5-20 pgikglmin 0.5-1.0 ml

IV IV IV TCIIVIET

0.01 mg/kg 1-3 mEq/kg

IVlIMlSC IV

ET,

endotracheal;

SC, sub-

25

rate, and energy expenditure are minimal. Cold stress induces changes in these parameters which may lead to significant pathophysiology, including metabolic acidosis, pulmonary vasoconstriction, right-to-left shunting of blood, surfactant deficiency, and hypoxemia. It is essential that the newborn infant be dried immediately (in order to prevent evaporative heat loss) and placed in an environment that has been preheated to maintain thermoneutrality. This can be accomplished by using either an open-care bed with overhead radiant warmer or an enclosed incubator. An infant servocontrol device may be helpful in both maintaining an ambient temperature and monitoring the infant skin temperature. Additional warming devices may be necessary for the very low birth weight infant, whose larger surface-tovolume ratio and diminished subcutaneous fat result in increased heat loss. These devices have included radiant warmers, water gloves, chemically heated mattresses, and plastic heat shields. Establishing IV access is also of paramount importance in an unstable baby. Though the peripheral route is preferred, an umbilical venous catheter may be inserted as a temporary device until the transport team arrives Its position should be determined radiographically before administration of fluids, to avoid inadvertent hepatic injury. In almost all instances, infusion of 10% dextrose and water at a rate to provide 60-80 ml/kg/day will be appropriate. This IV line can also be used to provide volume expansion, resuscitative drugs, antibiotics, and other indicated pharmacologic agents. The initial laboratory assessment of the critically ill newborn should include determination of hematocrit, complete blood cell count, blood glucose, and blood gases and pH (if the infant is in respiratory distress). Almost all of these procedures can be done on capillary heel stick blood and do not require specialized methodology. Accuracy of these methods can be increased if the foot is prewarmed prior to drawing blood. Blood glucose may be screened by the use of test strip methods such as Dextrostix or Chemstrip. If the screening values are low (~45 mgidl), a serum or plasma glucose value should be obtained and treatment initiated. All of these studies require little time and the results should be available quickly enough to be included in the historical information which is communicated to the tertiary center. Additional laboratory studies should be obtained as indicated by the patient’s clinical condition. Infants in respiratory distress should bave a chest radiograph done and blood obtained for culture if sepsis is considered in the differential diagnosis. Antibiotics may be administered after blood is obtained for culture. If the infant is unstable, lumbar puncture may be deferred, although the infant should be treated for presumed meningitis. Placement of an orogastric tube in any infant with respiratory 26

distress or tachypnea (res~~r~tio~s > GO/minute) allows venting of the stomach, may decrease the risk of aspiration, and may facilitate diaphragm&c motion. Because the newborn infant is a predominantly nose-breather, we avoid the use of nasogastric tubes. At the time that communication with the tertiary center is made, all information pertaining to the infant’s condition and care already rendered should be made known to the tertiary facility. Historical data should include a brief history of the pregnancy, labor, and delivery. estinent information on the infant includes factors such as presentation and route of delivery, birth weight, estimated gestational age, Apgar scores at 1 and 5 minutes, resuscitative measures carried out, available laboratory data, therapeutic interventions, and condition of the infant. Once the decision has been made to transfer the infant, preparations should be undertaken to assemble a complete duplicate of hospital records pertaining to both the mother and the infant. This usually includes photocopies of hospital charts, duplicates of any radiographs of the infant, and accessory paperwork such as a signed consent form for transfer of the infant. Samples of maternal blood and infant cord blood should be clearly labeled and available in case they are requested. It is customary for the tertiary care facility to make recommendations for infant management based on the information communicated by the referring center. Accordingly, appropriate documentation should be made in the medical record. It is important for the tertiary facility to anticipate changes in the infant’s condition that might occur before arrival. Contact with the tertiary center while the transport team is en route may be beneficial in the event that the infant’s condition deteriorates before arrival. MLJR~ING

CARE

AT

THE

COMMUNITY

HOSPITAL

Nursing staff at the community hospital must be able to identify risk factors throughout the pregnancy and newborn period that would lead to the need to transfer. Because the nurse spends more time with the atient than other health care providers, the ongoing assessment and monitoring for difficulties in adaptation to extrauterine life are primarily a nursing responsibility. Findings must be t~oroughIy documented and eommunicated to physicians to ensure accurate and timely decisionmaking and intervention. The nurse also must be able to act promptly on behalf of tbe patient to promote rapid stabi zation. Often it is helpful to have standing orders or protocols eveloped jointly by nursing and pediatric staff which address the principles of stabilization previously described. This saves time and fosters consistency of response. Both are especially important for occasions when the 27

physician is not in the hospital at the time a problem is identified. When risk factors are present, the neonatal patient should be attended constantly. It may be necessary to call in additional staff or rearrange assignments quickly to provide adequate patient care coverage. Continuous observation is necessary to ensure prompt identification of subtle changes in the infant’s status which warrant interventionz6 Thorough, ongoing assessment and timely intervention often prevent or minimize life-threatening complications For example, careful screening for hypoglycemia provides the opportunity for early intervention. Detection of unequal breath sounds might identify a pneumothorax before respiratory status becomes severely compromised. Nurses may also be trained to utilize transillumination for this purpose. In this example, the additional lead time provided may allow obtaining an x-ray and controlled preparation of treatment, if it should become necessary. This contrasts with the frantic activity inherent in a crisis response. Generally, it is the nurse wbo initiates the procedures ordered for assessment and treatment: i.e., electronic monitoring, placement of an orogastric tube, institution of techniques for thermal regulation, etc. These procedures must be documented, and descriptive data on the infant response to interventions should be included. In the critically ill infant being stabilized and prepared for transport, vital signs must be assessed every 15-30 minutes. These can be intermittently noted from monitors so that the baby is not being bandled continuously. Axillary temperature measurement is recommended.27 A skin temperature reading will reflect thermal compromise before it significantly affects core temperature, thus enabling correction prior to the onset of hypothermic crisis. If a servocontrol device is used, probe placement and thermostat settings must be carefully monitored. Optimal probe placement is over the liver. Procedures with the infant can easily result in inadvertent movement of either the sensor probe or the controls for setting the parameters of the feedback loop mechanism, causing false readings and inappropriate mechanical response. Since hypothermia can cause as well as exacerbate respiratory distress, apnea, and hypoglycemia, establishment of a thermoneutral environment for the neonate is a critical nursing responsibility. Drawing on the principles of physiology and physics, plus a little common sense and creativity, the nurse should continually evaluate the environment’s effect on the patient’s metabolism and intervene to minimize caloric expenditure for thermal regulation.28 For example, the baby must be thoroughly dried after delivery to prevent cold stress by evaporation. The traditional bath should be deferred until after transport. The stress inflicted by bathing increases the rate of glucose and oxygen consumption, which an already distressed infant cannot afford. The facial area around 28

the newborn’s nose is ~~rt~c~~~~~lysensitive to cold stress, so oxygen should be heated and All surfaces (e.g., scales) armed prior to contact with the infant. The ~l~c~rne~t of warmers and incubators in the room should take into account air flow from doorways, window surfaces, and ventilation me. Personnel must be careful not to interpose their own b between the heat source and the patient. When using an i tor, staff should work through the portholes. If the door must be opened, a portable heat source should be positioned to increase the ambient air temperature at the opening.28 Stockinette caps and Saran Wrap blankets can be used to aid the neonate’s retention of body heat, This is especially helpful for the very low ht baby and the infant with compromised skin integri roschisis, myelomeningocele, omp lesions). Both types of parapid loss of body heat. Airway tients are at increa patency must be est er hyperextension or hyperflexion o eonatal trachea is easily occluded. Bulb s eLee mucus trap suction devices n intubated baby may need . Care should be taken to suctioning of the limit wall suction . Increasing the fraction of or suctioning will often help the inspired oxygen baby better tolerate the procedure. Endotracheal suctioning is an aseptic procedure. ~~~al~t~ d character of breath sounds should be assessed both before after suctioning. This should also be done whenever the ba s repositioned, since optimal tube placement can be easily altered by movement.30 For this reason, it is essential that t e nurse securely tape the tube at the time of placement. (The location of the tube markings should be noted on the chart as descriptively as possible, e.g., ‘“Size 3.0 ET taped so ‘T’ of ‘ET’ at gums”) The neonate’s ventilatory status, as assessed by res iratory rate, character and equality of breath sounds, and skin color, should be descriptively documented, along with the vit Placement of a No. 5 or orogastric tube enables removal of excess gastric con s will decompress the stomach, reducing pressure on the diaphragm and lessening risk of subsequent aspiration of gastric secretions The quantity and appearance of the secretions discarded are charted. This tube is taped in place and attached to a syringe barrel with the plunger removed. Such placement “to chimney” enables venting of swallowed air. The tube should be aspirated every hour during stabilization and as necessary (indications include gagging or regurgitation, as well as during bag and mask ventilation). Circulatory status is asse by pulses, blood pressure, illary refill, and skin color. apical pulse should be au y. Femoral and radial pulses tated for both rate and 29

should also be palpated for quality, strength, and bilateral equality. Absent or bounding pulses may be indicative of circulatory compromise. To ensure accurate blood pressure measurement, the cuff size must be appropriate. Wrapping of the cuff on the extremity should be snug but not constrictive. Identification of the extremity used for the measurement should be noted on the chart with the value obtained. Patients requiring stabilization and transfer should not be fed. IV fluids will be needed to provide fluid and calories for prevention of hypoglycemia and as an access route for medications. For peripheral IV lines, it is particularly useful to establish the line when status deterioration is predicted or suspected. Waiting for progressive deterioration to occur will make access more difficult because of vascular collapse. The nurse is involved with three aspects of IV therapy: initiation, monitoring, and maintenance.31 For transport, we prefer IV catheters, such as the QuikCath or Angio-Cath devices, because of their tolerance for movement within the vessel; however, the scalp vein needle remains an acceptable choice. Practically speaking, the selection of needle should be based on the preference of the practitioner available to start the line. Preferred sites are veins in the dorsum of the hand or in the scalp, excluding those over the fontanels. The delivery system requires a microdrip setup and a volumetric infusion pump. Monitoring includes careful recording of the infusion solution, rate, patency, location, and condition of the site. All should be checked at least hourly. At the first sign of infiltration, the infusion should be discontinued and restarted. For both the umbilical venous catheter and peripheral line, secure taping is necessary; however, the insertion site should not be obscured from view. Extremities may need to be gently restrained to avoid accidental loss of indwelling catheters. The general neurologic status, behavior, and appearance of the baby are included in the nurse’s observations. Subtle changes may be significant. For example, seizure activity in a neonate is not as readily discernible as in an adult and may be very brief in duration. In addition to clinical assessment, the nurse will be assisting with other diagnostic procedures, such as obtaining specimens for laboratory testing and helping to position the baby for radiologic studies. Screening for hypoglycemia can easily be done by the nurse using Dextrostix or a similar product. All newborns should undergo an initial screening within the first few hours of adaptation to extrauterine life, but the baby needing stabilization for transfer should be checked hourly. If concentrations are less than 45 mg/dl, additional intervention and more frequent monitoring are needed.32 Routine medications such as eye prophylaxis and vitamin K injections should be given. Additionally, the nurse needs familiarity with the drugs frequently used in resuscitation (see Table 30

5). It is important to be especially alert to the differences in strengths of certain medications when used for neonates instead of adults. This is particularly true of epinephrine (1: lO,OOO), sodium bicarbonate (0.5 mEq/ml), and dextrose (25%). The “old standard” medication rules for nursing remain valid as a safety check: right patient, rigbt drug, right route, right dose, and right time. Although the care of the neonate in distress may be all-consuming, the staff at the community hospital also must help prepare the family for the infant’s transport. The nurse should be familiar with the procedures in order to answer the parents’ questions and realistically them anticipate the sequence of events for the next few ho f possible, it is helpful for a hospital nurse to accompany the transport team to the mother’s room and remain with her. This nurse becomes a support liaison and can better reinforce the information shared by the team, after they have left. When the transport nurse arrives, introductions are exchanged and the hospital staff guides the team in the procedure for nursery access at that particular hospital. The team brings their portable equipment into the nursery. The hospital staff then gives a report of what has transpired for this patient. Using this information, the transport team conducts a supplementary evaluation of the baby before moving the baby. The transport staff assumes the respo ility for documentation of patient care. The team and the h ital staff work together to continue stabilization efforts and pare for transport, e.g., convert to portable equipment and ove the baby to the transport incubator. Care must be taken to position the baby for optimal observation and safety. The transport nurse must check that all IV lines and monitoring and respiratory support equipment remain properly attached and functional despite the movement. This check will be repeated on boarding the vehicle. A photograph is taken of the baby, which will be given to the parents. The nurses may then move the baby to the mother’s room so the parents have an opportunity to see and touch t baby before the team departs‘ In summary, the community hospital provides ongoing assessment, initiates primary stabilization, and prepares the family for the arrival of the transport team. The transport nurse conducts supplementary assessment, continues stabilization efforts, offers educational support to the community hospital staff and family, introduces the family to the perinatal center, and provides clinical observation and care of the neonate during transit to the perinatal center.33 The goal is establishing and maintaining of physiologic homeostasis for the neonate and emotional homeostasis for the family. The working relation&i developed by the team and the community hospital staff will contribute to the continuity of care 37

for both patient and family. This time of working together is an ideal opportunity to review the clinical procedures involved, and to offer explanations and answers to questions. The unique role of the transport team in providing continuing education and fostering interhospital relationships will benefit continuity of patient care. TRANSPORTTEAM Under most circumstances the care of the infant is assumed by the transport team as soon as it arrives. The referring physician may, however, choose to remain involved with care of the patient and offer assistance wherever possible. Members of the transport team should immediately communicate with their counterparts in the community hospital so that the former may be fully apprised of the patient’s condition and any changes that have transpired since the departure of the team from the center. Additional information should be verbally exchanged and a complete assessment of the infant should be made as soon as possible. After completion of a physical examination, any additional laboratory tests or therapeutic maneuvers should be performed before members of the transport team leave the nursery to communicate with the parents. It has been our custom, when meeting with parents for the first time, to do so without bringing the infant into the mother’s room. We do this to minimize distractions and maximize parent attention on the issues at hand. Members of the team are introduced to the parents and a brief explanation of the infant’s problems and the need for transfer to an intensive care unit are discussed. Informed consent for transfer and admission of the infant to the neonatal intensive care unit is obtained at this time. Parents are given information booklets which describe neonatal intensive care in general and our particular neonatal intensive care unit specifically. Parents’ questions are answered, and the patient data base is completed. Additional historical information, especially in regard to family history, may also be obtained. The parents are also told that they will have a chance to see and touch their baby as the team prepares for departure from the community hospital. The team makes the final preparations for leaving the community hospital, including transfer of the infant from the incubator or open-care bed to the transport incubator. Additional equipment is put into place, including transcutaneous oxygen monitors, infant servocontrol temperature probe, and mechanical ventilator, if necessary. A final assessment of the infant’s condition is made, including decisions about further laboratory work, such as arterial blood gases or repeat chest radiograph, and just prior to departure all equipment and paraphernalia are rechecked for stabilization. Particular attention is paid to the 32

endotracheal tube (if in ace), umbilical arterial catheter or peripheral IV line, orogas c tube, and proper restraint of the extremities. If requested, a member of the transport team may enter a transport note into the infant’s community hospital record. Careful record keeping of all diagnostic and therapeutic procedures performed following a~s~rn~t~on of the patient’s care is mandatory. After leaving the nursery, the infant is taken to the mother’s room, where both parents have a chance to see and touch their infant. Further questions m addressed at this time and the photograph of the infant ca given to the parents. Explanation of the specialized equi and life-support systems may be necessary. Immediately prior to departure a member of the transport team should contact. the tertiary care facility to give a current report on the infant’s condition, and advise what will be needed for the baby on arrival at the tertiary center. This might include requests for ventilator settings, F~os, IV solutions and rates, medications, and diagnostic or therapeutic procedures not yet done but indicated. Additional contact with the center can be maint.ained during transport through the use of a radio telephone. Any sudden chang in the infant’s condition should be reported to the center im

There are a number of clmical situations that may require special steps in preparation for transport. A diaphragmatic hernia may be suspected by asymmetric breath sounds, scaphoid abdomen, and failure to respond to conventional respiratory support. A standard chest x-ray film is often diagnostic. Placement of an orogastric tube shoul ordinarily be part of the management of an infant to be trans rted. In diaphragmatic hernia this tube may be life-saving, ince gaseous distention of the stomach and bowel could cause further compromise of the already hypoplastic lungs an lace the mediastinum, with resultant cardiac dysfunction, otracheal intubation is essential if such an infant requires positive pressure ventilation, since bag and mask ventilation will inevitably result in intestinal tention even with a wellioning orogastric tube in pl in positioning the endotracheal Great care should be exer tube since cannulation of main bronchus will further predispose to rupture of already bypoplastic lungs and convert a significantly compromised i to a moribund infant. Great care to insert the tip of the no more than 1-2 cm beyond the vocal cords or where the tube tip can be palpated in the suprasternal notch will facilitate proper placement of the tube.a4 Auscultation for asymmetric breath sounds will be of limited 33

utility in this circumstance because of the inherent breath sound asymmetry in this condition, Chest radiography is mandatory to confirm the proper positioning of the endotracheal tube, but the time required for the study necessitates that all possible care be taken to ensure proper placement before obtaining the film. Even with a properly placed endotracheal tube, the risk of pneumothorax or other manifestations of air leak syndrome is greatly increased because of the unavoidably hypoplastic lungs. Although prophylactic placement of chest tubes is not warranted, steps should be taken to facilitate immediate diagnosis and decompression if air leak should occur. Continuous transcutaneous oxygen monitoring, serial transillumination, and serial assessment of breath sounds will facilitate diagnosis. Equipment for needle evacuation of pneumothorax and subsequent placement of thoracostomy tubes should be available. Thoracostomy tubes should be connected either to a water seal with continuous suction (- 15 cm Hz01 or to a one-way valve, such as the McSwain dart (Fig 71, which will allow egress but not entry of air. Chest tubes should be firmly anchored to prevent dislodgment from vibration, acceleration, and deceleration en route. The infant with an open abdominal wall defect, e.g., gastroschisis, ruptured omphalocele, or cloaca1 extrophy, requires special steps to minimize excessive heat and fluid loss as well as to mevent further vascular or infectious compromise of the alreadv matted, swollen, and occasionally twisted bowel. The protuber-

Fig 7.-The McSwain dart can be attached to the distal end of a thoracostomy tube. Et allows venting 01 pleural air but prevents ingress of air into pleural space.

34

ant bowel should be carefully inspected; if areas require untwisting or careful manipulation for closer inspection, sterile technique should be employed. A o. 8 French orogastric tube should be inserted and frequently aspirated or connected to intermittent suction. The defect and protuberant bowel should be carefully and completely covered by sterile gauze that has been soaked in saline warmed to body temperature, with care taken that circulation to protruding organs is not impaired. The gauze should then be covered with Saran Wrap (Fig 8). Others prefer to manage the defect in transport by placing the baby in a plastic bag up to the axillae.35 Peripheral IV infusion should be initiated to provide at least maintenance fluids and glucose. Many prefer that the infusion be run at greater than maintenance levels to compensate for third space losses that may already be present, Colloid infusion is recommended by some centers to compensate for exudative protein losses from the exposed bowel. Broad spectrum antibiotic coverage is indicated because of potential intra-abdominal contamination. If positive pressure ventilation is required, placement of an endstracheal tube is preferable to the bag and mask technique. A supine position is obviously required for patient management. The infant with myelod lasia requires special attention for protection of the lesion prevention of contamination. Tbe infant should be maintain in the prone position with plastic collection bags placed over the anus and urinary area or in such a way as to prevent possible contact of excretions with the exposed area. The lesion itself is loosely covered with sterile gauze that has been soaked in saline previously warmed to body temperature, and this is in turn loosely covered by Saran Wrap (Fig 9). Intrauterine fixed ntractures may require placement of appropriate bolsters an padding to prevent injury to the skin

Fig B.-Suggested

method

for covering

an abdominal

wall defect. 35

Fig 9.-Suggested covering a neural

tube

method defect.

for

while maintaining the prone position. Placement of an orogastric tube will prevent abdominal distention, which might render maintenance of the prone position difficult. Broad-spectrum antibiotics with good CNS penetration are indicated if the lesion is open or if leakage of cerebrospinal fluid is suspected. Careful documentation of neurologic and circulatory status is essential before, during, and after transport. Inability to handle secretions may signify the presence of esophageal atresia with or without a tracheoesophageal fistula. A plain chest x-ray film may reveal the presence of a blind airfilled pouch. On several occasions we have made the diagnosis on arrival at the referring hospital when attempting to pass an orogastric tube to facilitate management of another problem. A chest x-ray film obtained with an attempted “orogastric” tube in place will confirm the diagnosis; since some fistulas may allow the tube to follow a circuitous route that resembles normal orogastric placement on the routine anteroposterior projection of a chest x-ray film, we recommen that a lateral projection also be obtained whenever considering this diagnosis. Once the diagnosis is suspected, the infant should be maintained in as upright a position as possible and a tube placed in the esophageal pouch 36

for continuous or frequent i~t~~rnitt~~t suction. Vascular access should be established and an IV infusion of maintenance fluids and glucose initiated. ere is disagreement as to whether it is better to maintain th by in a prone or supine upright position, but it is agreed that tke osition should be as upright as possible. If an esophageal atres witb. tracheoesophageal fistula is suspected, evaluation for other associated anomalies should be undertaken. Spinal cord injury may be suspected following traumatic delivery, presence of a lou pop at the time of delivery, or observation of suggestive rologic deficits. The head and trunk must be firmly stabili to prevent extension, torsion, or other movement that may exacerbate the injury. This may be done manually during emergency resuscitation, but prior to transport should be accomplished by carefully securing the head, trunk, and extremities to a firm surface (such as the clipboard for transport information) with bandages and blanket rolls as necessary (Fig 10). This should be done with as much care and patience as possible. Airway establishment and maintenance should be performed without extending the head by use of the

ig IO.---Suggested method for stabiiization and transport of an infant with a suspected spinal injury. (From Faix R.G., Donn SM.: Immediate management of the traumatized infant. Clin. Perinatasl. f&487, 1983; copyright 1983, W.B. Saunders Co. Reproduced by permission.)

I i

37

jaw thrust maneuver or placement of a tracheostomy. An orogastric tube and a peripheral IV line are again essential. The return trip to the regional center should be made with as little vibration and acceleration/deceleration as possible. Rehabilitation of such patients may be exceedingly difficult but is greatly facilitated by proper management before transport.36 Occasional infants with upper airway tumors or malformations of the proximal airway and who are refractory to positional therapy may not permit endotracheal intubation by the oropharyngeal or nasopharyngeal routes. Some of these infants may be managed adequately by vigorous bag and mask ventilation with orogastric decompression if obstruction is not complete. In others, an emergency tracheotomy may have to be performed. In the absence of an experienced operator or necessary surgical equipment, an emergency airway may be established by identifying the thyrocricoid space just below the larynx, rapidly preparing the skin over the site with an iodophor preparation, making a small skin incision, and advancing the largest bore plastic IV catheter possible into the distal tracheal lumen. Obviously this is not a satisfactory long-term airway, but it often suffices to allow stabilization and transport until a more definitive procedure can be performed. Creating an appropriate adaptor between the end of the catheter and the bag or mechanical ventilator can usually be accomplished with the use of a stopcock and some combination of tape or plastic wrap. While one is creating an appropriate adaptor, ventilation can be carried out mouth-tocatheter, with enriched oxygen supplied if necessary by placement of a tube from a 100% oxygen source into the corner of the mouth of the resuscitator. Newborn infants with congenital heart disease require conventional neonatal and pulmonary care for transport, but may occasionally require additional therapy for stabilization. Infants with severe obstruction to right or left ventricular outflow may be dependent on persistent patency of the ductus arteriosus for survival. Continuous infusion of PGEl (0.1 pglkgiminute) through peripheral vein or juxtaductal umbilical artery catheter will permit prolonged ductal patency until further evaluation and surgical intervention are undertaken.37 Since most community hospitals lack facilities for making anatomically specific cardiac diagnosis and since PGEi may have adverse effects on other cardiac and pulmonary conditions, use of this potent drug during neonatal transport should be restricted to significantly compromised infants with (1) suggestive differential cyanosis or blood pressures, or (2) generalized cyanosis without respiratory distress. Even with these restrictions, it is best to use the agent only after telephone consultation with a pediatric cardiologist and to discontinue the agent if its use is associated with worsening hypoxemia, acidosis, or hypoperfusion. 38

GROU Most neonatal transports in this country are performed with conventional groun that have been modified for this special mission (Fig 11). irable features of the vehicle were discussed in a previous ion. In brief, the vehicle and personnel should be intaining and preferably improving the infant’s e in motion. This is best facilitated by stabilizing much as possible prior to departure. Proper stab Id greatly decrease the need for breakneck speed. y, despite the goals of regionalization, not all hospitals are capable of adequate resuscitation and stabilization of the infant rior to arrival of the transport team; under such circumstance there may be need for considerable speed in transporting the team from the center to the referring hospital. In our experience the need for flashing ligbts and siren is often greater during the unloaded trip to the referring hospital than on the return trip. If infants from ifetal gestation are to be transported, extra equipment, tars, and personnel may be required.

Fig 11 .-Typical transport ambulance which has been modified and equipped for neonatal use. Note the ramps which facilitate loading and unloading of the incubator without requiring lifting. 35

Occasionally, the need for such a multiple transport may not have been anticipated, or a second unrelated infant may have become ill at the same institution after the transport team was en route to the referring hospital. In this circumstance one may choose either to transfer both infants in the same transport incubator using reserve equipment from the transport team or borrowed equipment from the referring hospital, or to stabilize the infants at the referring hospital and await the arrival of a backup transport team. The urgency of each infant’s problems, the availability of necessary equipment, and the distance to be traveled will strongly influence the choice. Selection of an appropriate portable battery-powered monitor for heart rate is important since heart rate changes may be one of the first signs to indicate an acute problem, though abnormalities of heart rate may also be one of the last physiologic changes to accompany clinical problems. The noise, vibration, and lack of other continuously determined data such as transcutaneous oxygen tension make heart rate one of the few readily available, continuously determined markers of the patient’s well-being. The monitor should display the EGG output continuously and have both auditory and visual markers for each QRS complex. The ECG display facilitates detection of electrical interference or arrhythmias. Some monitors also have continuous waveform readouts of respiration and blood pressure that allow continual assessment of these important variables and may detect clinical compromise earlier than abnormalities of heart rate. Not all centers use such monitors for transport because of frequent difficulties with accurate calibration, electrical interference, and artifact induced by vibration and motion in the vehicle. Electronic monitors do not obviate the need for an experienced observer to continuously evaluate the infant during the transport. If the electronic monitor fails, continual assessment of the respirations, pulse frequency and quality, perfusion, and neurologic status by an experienced observer will allow detection of difficulties. Adequate lighting in the patient work area is essential for such observation, whether or not an electronic monitor is also in operation. Support equipment as well as the infant must be monitored. Other members of the transport team should be designated by a standard protocol to assume this responsibility. Proper functioning of the respiratory equipment requires constant surveillance. The incubator heating element, infusion pumps, and suction for indwelling gastric and thoracostomy tubes require frequent assessment on the trip to the regional center. Patience, attention to detail, interpersonal skills, and an ability to work well under stress are important attributes for staff on the loaded return trip. 40

Noise and vibration during ulance transport are not as great as those experienced du helicopter transport but are nonetheless considerable. Several groups of investigators have studied noise levels during neonatal transport.38-40 A representative study is that by Campbell and colleagues, who noted that overall sound level (repre the total sound energy over the frequency range of 40-8 f ranged from 91-101 decibels, compared to an overall soun 1 of 77 decibels in an infant incubator in the nursery. They a itionally noted that the overall sound level was not uniform throughout the transport but varied with the type of road surface, vehicle speed, and whether the ambulance siren was in use.?‘* This noise level obviously interferes with the ability to auscultate breath sounds and heart rate as well as with commnni~ation between transport personnel. Of greater concern is potential physiologic disruption to the infant. Such excessive noise levels increase irritability, heart and pulse rates, and p ipheral vasoconstriction. In rats, noise energy in excess of 68 produced an increase in serum ACTH levels with a correspo ing increase in adrenal cortical activity. Levels exceeding 70 decibels may cause constriction of the spiral blood vessels supplying the organ of Corti, increasing the risk of permanent sensorineural hearing deficits as well as potentially increasing the susce tibility of the infant to hearing loss induced by other ototoxic ents. Efforts to minimize this auditory overload in the transported infant are probably indicated but not general1 plied Use of a double-walled transport incubator, a heat shi side a conventional single-walled incubator, or the use of c on plugs or some other device to protect the external auditory canals should decrease the noise level reaching the infant; efforts to better insulate transport incubators from external noise are in order. Mechanical vibration been assessed by at least two groups of investigators who n again that vibration in a ground ambulance was not as ba in a helicopter but still was considerable.*” *i Vibration was most prevalent in the hazardous low-frequency range of 3-N Hz. Intermittent jolts produced acceleration ranging from 5 to 13 m/sets, while averaged vibration ranged from 2 to 6 misec2. The impact of this vibration on infant monitoring is obvious, but again there may be physiologic consequences. Extensive studies of the effects of vibration on the human neonate are lacking, but animal studies have demonstrated adverse effects on peripheral nerve conduction time, thermsregulation, mean arterial blood pressure, and pulmonary mechanics. Better suspension systems in ground ambulances and complementary suspension systems in transport incubators mig t decrease these undesirable stresses. In addition to affecting the physiologic status of the infar&, noise and vibration may cause transport personnel to experience 41

motion sickness, headache, sensory fatigue, tinnitus, and general uneasiness which may interfere with their ability to function effectively during the transport. If the infant sustains any significant deterioration while en route, it is almost always better to instruct the driver to pull to the side of the road and stop, rather than accelerating and trying to reach the regional center as soon as possible. Diagnostic assessment and technical performance of procedures such as reintubation, placement of chest tubes, and replacement of peripheral venous or umbilical catheters are all more easily performed when the vehicle is stopped. AIR TRANSPORT

OF THE NEWBORN

The introduction of transport of the newborn by either fixedwing aircraft or helicopter has resulted in a means of rapidly moving a critically ill infant over a large geographical area and improving the accessibility of state-of-the-art medical care to remote areas. This has been particularly true for fixed-wing air transport in the Rocky Mountain area and the Southwest, and for helicopter transport in the Appalachian Mountain area and northern New England. These advantages, however, are not without complications. Air transport is hampered by a lack of in-flight space, which severely limits patient care activities in the event of deterioration in the patient’s condition. The problems of respiratory insufficiency may be further aggravated by the decline in the partial pressure of oxygen with increasing altitude and by the expansion of contained gases. Air transport is an expensive means of providing medical care and its cost-effectiveness has not been clearly established. Many of the problems encountered during ground transportation also exist for air transportation, including difficulties in maintaining thermoregulation and problems with noise and vibration. Finally, air transportation requires significant expertise in the coordination, dispatch, transfer, and return of the patient in order to maximize efficiency and minimize “‘down” time. Additionally, this form of neonatal transport is more dependent on weather conditions. FIXED-WING

AIRCRAFT

VERSUS

HELICOPTER

The major advantages of each type of air transport vehicle are summarized in Table 6. Fixed-wing aircraft appear to be of significant advantage for transports over longer distances, especially those in excess of 150-200 miles. Pressurized aircraft cabins allow the use of fixed-wing aircraft at altitudes greater than 8,000 feet. Use of fixed-wing aircraft, however, may be limited by a lack of appropriate landing facilities. On the other hand, there is virtually no restriction to where a helicopter may 42

TABLE

6.-FIXED-WINGVERSUSHELICOPTERAIRTRANSPORT FIXED-WING

HELICOPTER Advantages Minimal landing needs Immediate landing possible Urban use

Speed Range Pressurization Disadvantages

Landing requirement Ground transfers Limited patient access without landing (smaller vehicles)

Susceptibility to turbulence Marked noise/vibration Power conversion problems Limited range

land. This may include a hospital parking lot, designated helipad, or even the roof of a building. This obviates the need for the use of ground transportation at either the referring hospital or the tertiary center. Avoidance of traffic in large urban areas can also be achieved by helicopter use. Helicopters are, however, limited by lack of interior space, marked vibration, susceptibility to air turbulence, noise levels, nonpressurization, and occasional difficulties in the conversion of power to run incubators and other life-support or monitoring equipment.42X 43 One other major advantage over fixed-wing aircraft is the ability of the helicopter to make an imme iate landing in the event that extensive resuscitation or other medical procedures are needed. INFANT MONITORING Owing to problems from norse, mechanical vibration, electrical interference, and poor ambient lighting (especially at night), there is generally more difficulty in monitoring infant wellbeing during air transport. We have found this to be particularly true in the case of helicopter transport, where standard newborn cardiorespiratory monitors have been unable to produce a quality ECG readout or respiratory tracing. Since noise levels preelude effective auscultation of heartbeat and breath sounds, additional steps must be undertaken to provide adequate monitoring. We have utilized oppler ultrasound to detect the neonatal pulse rate and have adapted equipment so that this can be followed by the use of headphones throughout the duration of the flight. Equipment can also be ed to allow correspondence of a flashing light complex so that monitoring can be visual inste It has been estimated that ambient lighting should be a minimum of 75 foot-candles to allow effective assessment of changes in the infant’s skin color.42 The clinical diagnosis of cyanosis may be extremely difficult to make in inadequate lighting, as is often the case when transport is conducted at night. This impediment to clinical care can be obviated by the use of devices for 43

the continuous monitoring of transcutaneous oxygen during the transport. State-of-the-art equipment now includes reliable, lightweight, battery-powered monitors which are relatively inexpensive and ideal for transport. Similarly, transcutaneous carbon dioxide monitors are also available and should be considered if budget, weight, and space allow. SPECIAL EQUIPMENT Most of the equipment necessary for air transport has been described previously, but it should be emphasized that the problems encountered with decreased partial pressures of oxygen at higher altitudes and the expansion of contained gases require the capabilities of carefully monitoring arterial oxygenation and diagnosing and treating intrathoracic air leaks. The latter may be facilitated by inclusion of a device for transillumination of the chest.44 High-intensity fiberoptic light sources powered by batteries, which are both lightweight and durable (Model 292 Transilluminator, Radiation Measurements Inc., Middletown, Wis.), are available for this purpose. The presence of a pneumothorax is suggested by an increase in lucency when the fiberoptic probe is applied to the chest wall and illuminated. Normally the rim of lucency seen around the tip of the transilluminator probe is only 2-3 cm in diameter, but in the case of pneumothorax almost the entire hemithorax of the involved side may glow.24 Treatment of tension pneumothorax requires placement of a thoracostomy tube. This is generally connected to a device to apply continuous suction or to an underwater seal. However, space limitations may prevent the use of the standard pleural evacuation device and necessitate the use of alternative methods. One-way valve devices such as the Heimlich valve or the McSwain dart may be employed to vent air in the pleural space as it exceeds the pressure limit of the valves. If these devices are not available, the thoracostomy tube may be inserted into a small bottle containing sterile water and kept under water seal for the duration of the transport. A simple device may be fashioned from a feeding bottle with the nipple cross-cut and the tube inserted through the nipple into the water. This will help stabilize the tube and prevent it from slipping from the water bottle during flight. Periodic transillumination during the transport will help assure that reaccumulation of pleural air has not occurred. One additional piece of equipment that is indispensible in the performance of air transport is a radio with which to maintain communications between the air transport vehicle, the referring center, and the tertiary center. It is imperative that all parties be informed of changes in the patient’s condition, deviations from the anticipated flight plan, or any problems encountered in 44

flight. Transport persormel must be trained in the use of the radio and must be able to operate it in flight in the event tbat the pilot cannot do so. $HYSIOLOGIC

PROBLEMS

~k%3OCIATED

I~ff AIR TRANSPORT

Altitude The majority of neonatal transports involve the transfer of infants with respiratory diseases. It is therefore of utmost importance that transport personnel understand the physiologic aberrations that occur at higber altitudes. The ascent from sea level to hiTher altitudes is accompaanied by a fall in barometric pressure. 5 The reduction in barometric pressure reduces tbe partial pressure of oxygen and, if uncorrected, may contribute to the hypoxemia resulting from r ‘ratory disease. No matter what the F1oz is, there is a linear u&ion in the partial pressure of ately one-half that of sea level oxygen, which falls to appr at altitudes near 14,000 feet4” It has been suggested that if an infant in an outlying hospital requires an Fro2 of more than to TO%, mechanical ventilation or PAP should be instituted reduce the incidence of hypoxic e ergencies at higher altitudes. This seems to provide a protecti effect without concomitantly increasing the risk of pn~~m~t~o~ax.~6 Another phenomenon that results from the reduction in barometric pressure with increasing altitude is the expansion of extraneous trapped gases within the body.46,47 The accompanying rise in pressure within the cavities in which these gases are entrapped may result in physiologic dysfunction, such as in the case of pneumothorax, where tension may cause further lung compression and diminished venous return to the heart. Pneumothorax is a treatable condition, but air leak, which may result in interstitial emphysema, ~~e~momediastiu~m, or pneumopericardium, may be exacerbated by air transport and not easily remedied. Even with pressurization to 8,000 feet, there may be an increase in the volume of intrathoracic trapped gas by as much as 3O%.48 Likewise, gastrointestinal air beyond the pylorus may expand by as much as SO%, resulting in distention of the bowel and further compromise in respiratory function. This may be alleviated to some extent by the placement of an orogastric tube to prevent further accumulation of swallowed air. The expansion of gas caused by iminished barometric pressure at higher altitudes must also e considered in therapeutic maneuvers. For instance, the adm istration of IV fluids must utilize a system which is either sealed un r a vacuum (plastic bags) or the bottles must be ven the development of a positive pressure system wbic IV fluids into the baby at a rate greater than that anticipated or prescribed. Similarly, a negative pressure system may result on descent of the 45

aircraft if the vent is not functioning. Under these circumstances, the possibility of blood backing up into the infusion tubing may create the potential for thromboembolic phenomena. Air expansion also makes it necessary to ensure that any medication vials used during transport are completely filled. The withdrawal of medications from such vials does not require the injection of an isovolemic quantity of air, as is usually done at sea level. To do so raises the possibility that the plunger of the syringe may be forcefully e’ected, causing the loss of medication and potential body injury. d Noise and Vibration The potential of noise and handling to produce hypoxemia in preterm newborns is well known. As described previously for ground transportation, the same holds true for transport done by either fixed-wing aircraft or helicopter, and probably to a greater extent. Sound levels in the cockpit of a standard medical evacuation helicopter (Fig 1.2) may approach 100 decibels, which exceeds the presumed safe level. We have attempted to deal with the situation by placing cotton plugs in the external auditory canals of the infants we transport by helicopter. The cotton plugs are secured with an elasticized mesh hat that prevents slippage of the plugs in flight. The effectiveness of this technique will require clinical investigation. Thermoregulation The difficulty in maintaining thermoneutrality is exacerbated in neonatal air transport because of the reduction in ambient temperature with increasing altitudes. This may result in the loss of cabin heat to the exterior of the vehicle and thereby require increases in the amount of heat provided by the incubator

Fig 12.-Typical dates incubator, 46

crew

helicopter of three,

used for neonatal and pilot.

air transport.

Vehicle

accommo-

in order to maintain the infant’s body temperature (unless the beater in the plane is able to keep the cabin temperature stable). This places an additional burden on the power sources which are used to produce heat, and in tbe event of problems with power conversion or inversion, incubator batteries may be rapidly discharged. LeBlanc has suggested the use of a chemically hea mattress to reduce the power consumption required during transport. He has also demonstrated that routine transport incubators display wide swings in air temperature even during periods of stable operation5’ We have observed one ad itional complication of thermoregulation, the overheating of e incubator and resultant hyperthermia in the infant. This has occurred during daytime helicopter transport, in which the helicopter cabin functions like a greenhouse. Internal cabin temperatures as high as 110” F may occur if the helicopter has been sitting in tbe sun, and this heat is not dissipated until the vehicle is in full flight. In addition, a second greenhouse effect occurs if incident sunlight strikes the incubator window during the flight. This problem can be alleviated by covering the incubator with a sheet of aluminum foil. The aluminum will reflect the sunlight from the incubator, but it will also obscure complete view of the patient. Care must be taken to maintain adequate patient observation without the subsequent development of hy

Most of the monograpb to this point has dealt with the transfer of a critically ill newborn from a community hospital to a tertiary center. Neonatal intensive care units, however, must be reserved for the care of the sickest newborns within the region. Distance also limits the involvement of the family with the infant. Accordingly, arrangements must be made for the timely disposition of the convalescent infant who is no longer truly in need of intensive care. Several investigations have demonstrated not only the feasibility of the back-transfer of infants to local community hospitals, but also the safety and cost-effectiveness of such transfers.“r, 52 On the other hand, the potential dangers of such transfers were made evident by Clarke and eolleagues, who reported four cases of necrotizing enterocolitis in nine stable, growing preterm infants weighing less than 1,300 gm and returned to community hospitals, in whom disease began within 60 hours of transfer. They concluded that early feeding following transport may have been responsible for the development of disease.s3 As this report indicates: convalescent infants should not be retransferred to community hospitals unless an adequate program of well-developed policies and procedures has been implemented. 47

Regionalization of perinatal health care has led to the development, within a specific geographic area, of a cooperative and well-coordinated system of maternal, perinatal, and neonatal health. This accomplishes the following objectives: quality care for all pregnant women and their newborns, maximal utilization of highly trained perinatal and neonatal personnel and their facilities, and the assurance of reasonable cost-effectiveness. Within the neonatal component of regionalized perinatal care, it may be both desirable and appropriate to retransfer selected newborns from the neonatal intensive care unit to a newborn nursery when the infant is no longer in need of intensive care. Such transfers may reduce the ultimate cost of infant care, increase the availability of services and facilities to critically ill infants, and enhance family-centered perinatal care. It is expected that the newborn nursery to which the infant is transferred can provide the care and support to the infant and parents following resolution of the acute problems, and that continued growth of the infant, developmental assessment, and family-centered care can be fostered. The Michigan Department of Public Health5* has designed a model to assist hospitals in the preparation of transfer plans for the return of a convalescent infant from a tertiary care center to a selected newborn nursery. This model includes suggested policies and procedures that each hospital will have to adapt to its own needs, facilities, and programs. In this model, only hospitals that have been identified by the medical directors of the neonatal intensive care units as able to care for a convalescent infant can be considered for continued care of the infant and family. Prior to writing a plan for the transfer of convalescent infants, a multidisciplinary team from the regional neonatal facility should be identified. Ideally, this team should include nurses and physicians from both obstetric and neonatal areas. This team accepts responsibility for the initial evaluation of a potential receiving unit an the writing of the plan and contract between referring and receiving hospitals. Within the receiving hospital, a similar team should be identified to review and accept the plan. Of course, consultation may be sought from other disciplines involved in perinatal care whenever necessary. Several steps need to be accomplished in the preparation of a transfer plan. First, there needs to be acceptance of a policy in the regional center that infants may be transferred from the neonatal intensive care unit to a specific newborn nursery. This nursery may be within the regional center or in an outlying community hospital. Second, there needs to be acceptance of a policy in the receiving hospital that infants may be transferred into the newborn nursery from an outside neonatal intensive 48

TABLE

7.-ASSESSKENT

OF A RECEIVING

Physical plan Staffing (physicians, nurses, support personnel) Equipment Nursery policies, procedures, orders Infection control (preparation; decontamination, Personnel competencies Availability and response of x-ray, lab, respiratory Family-centered care and flexibility Parent teaching and family support Attitude toward return of infants Inservice and educational facilities Clinical skills of professionals Philosophy of patient care

UNIT

surveillance,

isolation)

therapy

care unit. Factors to considered in this assessment are listed in Table 7. Third, a ansfer plan must be developed that includes criteria for and an outline of approval for the medical, nursing, tals. Fifth, the plan mus state health direc ented to the policy and proce he preceding steps are completed, the plan may The following paragraphs e plan. The examples given are not intended to be all-inclusive, and factors will obviously vary in individual hospital plans. Nevertheless, this may be useful to hospitals that have not yet adopted such a policy.

INTRODUCTION

Regionalization of perinatal care involves the referral of mother and/or infant to a regional center when complex care is required. It may also involve the selective transfer of a convalescent infant to the newborn nursery of the regional center or the originating hospital in accordance with rules developed by the state Department of Wealth. Infant transfer requires shortand long-term planning to assure the benefits for both the infant and the family. Part of this planning is a multidisciplinary assessment of the rece’ . unit by the regional center health care team. The regional r and the receiving unit share responsibilities for establishing and maintaining communication. The primary goal for all involved is t e provision of safe physical and psychological care of the infant and family. 49

HOSPITAL POLICIES 1. A hospital policy must be adopted within the regional center allowing for the selective transfer of a convalescent infant. Within the neonatal component of perinatal care and under state Department of Health rules, it may be appropriate to transfer a convalescent infant from the neonatal intensive care unit to a newborn nursery when the infant no longer requires intensive care. Prior to transfer, the receiving nursery will have been evaluated and a determination made by the regional center that the receiving unit can provide comprehensive health care to the infant and his family. 2. A hospital policy within the receiving unit must be adopted to allow the admission of convalescent infants from the regional center. RESPONSIBILITIES OF HEALTH CARE PERSONNEL IN THE REFERRING HOSPITAL These responsibilities should be clearly delineated. 1. Initial assessment of the hospital newborn nursery by a multidisciplinary team: A. Determination of the unit’s ability to provide care and support to the infant and parents after the acute problems have been resolved. B. Determination of the unit’s ability to provide continued growth and developmental surveillance and foster familycentered maternity care. 2. Facility reassessment immediately prior to infant transfer: At least 24 hours prior to the anticipated transfer of the infant, the receiving unit should be assessed again for specific verification of A. Adequate staffing. B. Availability of nursery space. C. Ability to meet the infant’s and family’s care needs. D. Availability of necessary equipment. 3. Definition of criteria indicating convalescence: This list will vary according to the receiving hospital’s capabilities and will differ from one plan to another. It is recommended that the following be considered: A. Stable vital signs. B. Feeding without difficulty. C. Able to be in an incubator or crib and maintain thermoneutrality. D. No longer in need of cardiorespiratory monitoring. E. No longer requiring supplemental oxygen. F. Free of infection. 4. Physician responsibilities: A. Assessment of the infant. B. Medical assessment of the receiving units. 50

units, C. Coordination of with receiving physician as to the in1. Communicati tent to transfer the infant. 2. Obtaining permission from the parents for the transfer. 3. Written orders for t e transfer of the infant and preparation of a medical summary. D. Maintenance of communication and consultation with the receiving hospital following the transfer. 5. Nursing Responsibilities: A. Assessment of the infant. B. Nursing assessment of the receiving unit. C. Coordination of the transfer: 1. Order from the physician authorizing the transfer. 2. Making all necessary transportation arrangements. 3. Preparing nursing summaries of the current status of the infant and family, including history, parent teaching plan, and comprehensive care p!an 4. Initiation of appropriate referrals. D. Maintenance of communization and consultation with the receiving hospita following transfer of the infant. This may be accompli ed by visit or telephone contact. RESPONSIBILITIES OF RECEIVING HOSPITAL

EALTM &IRE PERSONNEL INTHE NE~~~~~ NURSERY

The responsibilities of the health care personnel within the bospital’s newborn nursery receiving the convalescent infant should be clearly defined. 1. Physician responsibilities: A. Assumption of primary medical supervision of the convalescent infant. B. Provision of continue ieal supervision of the convae (and preferably thereafter). lescent infant until d C. Communication with the neonatal intensive care referring physician: 1. Progress reports. 2. Consultation when nee 2. Nursing responsibilities A. Admission of the baby to the unit with proper legal identification. x3. plementation of the musing care plan. view of medical orders with the attending physician c. within 8-12 hours of admission. D. Discharge planning, which includes continued parent teaching, continuity of referrals, and initiation of additional referrals E. Maintenance of communication with the neonatal intensive care unit through the use of weekly progress notes and discharge plans 51

AGREEMENT BETWEEN HOSPITALS A statement of policy related to selective transfer of convalescent infants between the referring and receiving hospitals should be adopted. The final plan should be submitted to the state health director for approval. The final policy should be in the form of a written contract between referral and receiving hospitals. The implementation and success of such a program depends on continued efforts by both referral and receiving hospitals to comply with all facets of regionalized perinatal care. The role of ongoing outreach education cannot be overstressed and will be addressed in a later section. OTHER iSSUES SAFETY Fatal accidents involving neonatal transport teams have been reported with both ground ambulances and helicopters. Since the actions of other drivers carmot be controlled, the possibility of accidents cannot be removed. All possible steps to improve safety and decrease risk that are under the control of the transport team should be taken. As has been stressed previously, adequate stabilization of the infant should preclude the need for excessive speed. Meticulous maintenance of the vehicle and equipment should prevent dangerous mechanical failures. Ground vehicles should have a low enough center of gravity to ensure stability on sharp turns and should have at least two tires on each side of the drive axle to minimize instability should a tire rupture at high speed (Fig 13). Weather and road conditions may necessitate selection of alternate routes or different transporation modes. All equipment should be firmly anchored before putting the vehicle in motion, and all personnel as well as the patient should be secured in their seats or incubator with appropriate restraints. Steps to prevent flames and sparks from causing inadvertent combustion in the presence of the often oxygen-enriched atmosphere of the patient compartment should be routine. Communications equipment should be well-protected so that function will be preserved in the event of an accident and help can be promptly obtained. More than one exit should be available in the event that the transport vehicle rolls over and the main exit is blocked. Routine inclusion of fire extinguishers and flares is essential. MOTION SICKNESS Motion transport 52

sickness is an occupational hazard among team members. Although some individuals

neonatal are more

Fig 53.-Remnant of tire which ruptured at high speed, causing a severe ambulance accident. Vehicle was not equipped with dual rear wheels on each side.

susceptible than others, eve ened and rugged individual will occasionally e rience motion sickness. Vibration, sudden stops and starts, a hanges in speed may produce vestibular overstimulation w coupled with certain psychological factors, may result in nausea. Some individuals may experience nausea before the vehicle has even started to move; individuals with such sensiti are advised not to participate in neonatal transport. Indivi 1s who only infrequently encounter the problem find that sensation can often be avoided or minimized by facing in the direction that the van is going, looking out a window, taking occasional slow deep breaths, or temporarily lying down. A variety of other empirical maneuvers have been suggested whose effectiveness vary with the individual. A variety of antiemetics (e.g., dimenhydrinate, phenothiazines) are available for the treatment of motion sickness, but their use during neonatal transport is controversial. These agents may cause drowsiness and may have adverse effects on asthma, glaucoma, or prostatic hypertrophy.55 They should never be used by vehicle ors and should be used only as a means of last resort for eitating motion sickness among the other transport team members Emesis bags or basins should be provided for this unfortunate malady.

I~YFECT~~NCONTROL Careful possibility

handwashing an common sense should decrease the of inadvertent transmission of nosocomia! infection. 53

All equipment in contact with potentially infected secretions should be disposed of or appropriately sterilized between patient use. Transport incubators serve as an adequate means of isolation for most infants. Handwashing en route is facilitated by the use of individually packaged tissues impregnated with alcoholic benzalkonium chloride. A generous supply of paper towels is desirable. If the infant is known to have an infection with a significant transmissible pathogen (e.g., rubella, staphylococcal pyoderma) additional appropriate steps can be implemented. Prior appropriate immunizations (especially rubella) are desirable for all transport personnel. MEDICOLEGAL CONCERNS Firm rules dictating the legal responsibility for the patient by the transport team cannot be made; each clinical situation must be judged independently. In some circumstances, responsibility may be perceived to begin when advice for stabilization is given over the phone to the referring physician. In other circumstances, responsibility may not begin until the patient leaves the referring hospital. In many jurisdictions, joint responsibility by the transport physician and the referring physician may be assigned once the call is made. Even though one or the other of these individuals may not be present at the time that an untoward event occurs, vicarious responsibility may be incurred and liability assigned.56, 57 The referring physician cannot assume that his responsibilities are discharged once he has made the transport request. The transport team may be considered liable if adequate instructions for stabilization were not communicated over the phone. The wisest approach, of course, is for neither party to worry about liability, but for both to do the best possible job in caring for the infant. If a physician is not physically present as part of the team, the physician responsible for the transport team must have devised well-delineated protocols for the management of problems during transport, taken all reasonable steps to ensure that the personnel on the transport team are capable of fulfilling those protocols, and ascertained that either he or another appropriate delegated physician is available for communication. If any malpractice judgment is rendered, it should be recognized that legal responsibility may not necessarily equate with fiscal responsibility. Neonatal transport contracts may be negotiated with referring hospitals that delineate the distribution of fiscal responsibilities no matter who is judged liable. Even though the referring physician or hospital may be judged legally responsible for an act of malpractice, the transport contract may specify that the regional center contribute to the financial settlement. The converse is also possible. Details of individual trans54

port contracts will depend, of course, on the needs of both institutions, their insurance status, interhospital relationships, and a host of other factors. Such contracts are obviously not essential for neonatal transport to occur from a referring hospital, but are often useful for both parties when a referring hospital sends a substantial number of babies to the center every year. The structure of the contract may serve to encourage transports and back-transfers while protecting both institutions from catastrophic losses. Obtaining informed consent from the parents or guardians is essential for the proper conduct of a neonatal transport. The consent process should include a discussion of potential risks, benefits, and alternatives. Care should be taken to make no guarantees of outcome, clinical course, or treatment modalities. A signed consent form does not guarantee the absence of litigation, but carefully witnessed and doeume consent for transport and delivery of necessary emergency may go far in defusing potential problems. Informed consent for neonatal transport should be obtained only by the responsible member of the transport team who can best expl relative risks and benefits, but the referring physician sho previously have discussed with the parents the necessity for ansport of their infant to an institution with appropriate facilities. Circumstances may occasionally arise in which parents are unavailable or refuse transport. Under these circumstances, most states have legal provisions permitting necessary emergency care, and all states provide 24-hour availability of Child Protection Services to ensure delivery of such care to minors. The importance of carefully documenting all discussions with the referring hospital and the family concerning all procedures, medications, laboratory results, and thougbt processes that went into the evaluation and care of the child cannot be overemphasized. Although some individuals blissfully feel they are protecting themselves from self-indictment by minimizing documentation, many court decisions view lack of documentation as an attempt to hide something, or as proof of substandard care. The major purpose of documentation is to facilitate provision of care by permitting an accurate review of prior events, but the inherent protection it may provide against unwarranted litigation cannot be overlooked. Patient misidentification is a frequent source of medicolegal difficulties in all health fields. pite the urgency of the infant’s clinical circumstance an e perceived need to return the infant to the regional center as soon as possible, it is important to identify the infant properly. Appropriate identification bands must be securely attached to the infant and must be double-checked by personnel at both receiving and referring hospitals. 55

COSTS

A substantial investment may be required by the regional center to establish and properly maintain the vehicles, equipment, and personnel necessary for expert neonatal transport. Once the initial investment is made, a busy unit will usually have no difficulty generating adequate revenue to make the service self-sustaining. Third-party insurance carriers have variable policies about reimbursement for neonatal transport; most provide 80% or more coverage for the transport to the regional center, and a smaller number provide for return transport to the referring hospital for convalescent care. For indigent families, the cost of neonatal transport will be defrayed by Medicaid in most states. Many state legislatures appropriate funds to permit neonatal transport in areas that have insufficient resources to pay for such services. Air transport services by helicopter or fixed-wing aircraft often operate under different circumstances than ground ambulances, and may function independently from regional centers. The independent companies may demand payment before transport occurs, and in this event a social worker or hospital financial officer may be helpful for rapidly identifying resources. If the family’s insurance does not cover such vehicles or the family has no insurance, payment may have to be made out of pocket, or the receiving or referring hospital may have to guarantee payment and arrange repayment over time from the family. It is morally indefensible to deny necessary urgent services on the basis of lack of funds. The social work or business office at the regional center can expect to run into such circumstances occasionally and should be prepared to expend whatever time and effort are necessary to secure transfer of the infant. The actual costs generated will usually depend on the distance traveled and services rend.ered. UNRESOLVED

ISSUES

The development of regional centers and the creation of neonatal transport services have not always resulted in the smoothly functioning scheme that was outlined at the beginning of this article. At least two major problems have been identified. First, some referring hospitals (particularly those with relatively few deliveries) have not acquired the necessary equipment or developed the requisite skills for resuscitation and stabilization of the sick neonate, despite existing guidelines. Even the speediest ambulance or helicopter requires some time to arrive at the referring hospital, and lack of resuscitation during this critical interval can further compromise the infant. Perhaps even more tragic is the circumstance in which the hospital has 56

the necessary equipment, the referring physician assumes his responsibility is over o the transport has been requested. He may leave the infant to the care of nursery personnel who are ready and willing to help in the stabilization of the infant but cannot do so without his supervision. Properly conducted perinatal outreach education programs can help overcome this deficit. The physician should be strongly encouraged to stay to transmit necessary information to the transport team and to observe and discuss appropriate management and stabilization of the infant on their arrival. Failure to provide adequate attention to the infant cannot be condoned or overlooked, or it may become self-perpetuating. The second problem is the curious position of the level II nurseries. In many regions there either are no level II centers or the existing ones are poorly utilize . Level I hospitals often rationalize that there is no me to settle for a level II nursery when they could have “the b t.” In many situations level II centers have been developed to serve almost exclusively as special care nurseries for infants born at their own institution. This may work very well, but on occasion results in lack of available resources for needy level I infants or failure to transfer infants who truly require level III services. Some of the roblems of such level II centers have been discussed by Paneth. iTi3Efforts to better integrate level II centers in-to the regionalization scheme are warranted. Good relations with level III centers and an active back-transfer program will encourage more appropriate referral to level III centers. Level III centers can also help channel appropriate patients to level II centers when receiving incoming transfer requests. Encouragement of such referrals by the level III center may ultimately facilitate the establishment of more appropriate referral patterns irectly to the level II center. The actual practice of neonatal transport often reflects a regionalization program that is very different from the theoretical structure. To optimize use of resources and decrease geographic and financial stresses to the family, continual efforts to approach. this ideal model are warranted. RESPONSIBILITIES COMMUNITY HOS

In addition to providing neonatal intensive care to patients referred from the regional community hospitals, the primary responsibilities of the tertiary center must include the development of ongoing continuing professional education programs, establishment of a consultation/resource role, and the conduct of periodic performance reviews, quality assurance, and overall evaluation of the delivery of perinatal health care within the region. The perinatal center should provide regional leader&i

in the development of standards for practice and the establishment of networks among care providers for the improvement of patient outcome.

OUTREACH EDUCATION To be effective, outreach education in the community hospital must encompass all facets of health care delivered within the community hospital.5g’ 6o Educational programs and goals must be extended, not only to physicians and nurses, but to respiratory therapists, social workers, and laboratory technologists as well, for example, who must be kept aware of changes in practice and technology in their respective fields. Many different strategies have been proposed for carrying out education in community hospitals, and most of these have been objectively demonstrated to be effective.61‘63 The effectiveness of any program depends on an understanding of a number of principles of outreach education to avoid the obstacles inherent in the relationship between a primary and tertiary center. First, the establishment of a collegial relationship is mandatory. Mutual trust and reciprocal communication are essential to the success of joint problem-solving. Health care providers in community hospitals must not feel that members of the outreach education team are passing judgment on community medical practices, but that they are genuinely concerned with providing an educational service aimed at improving health care delivery. Second, as eloquently stated by Philip and colleagues, “the most important consideration is not whether a message is heard but whether this results in a change in behavior.“61 To accomplish both of these goals, we have incorporated several different strategies into our own outreach education program. We feel that these methods address both institutional and individual needs for members of the health care team and also allow personal preferences for ongoing professional education.

MICHIGAN PERINATAL EDUCATION PROJECT The Michigan Perinatal Education Project was implemented in 1978. The project consists of a large collection of audiovisual aids encompassing the entire spectrum of perinatal care. These include videotapes, slide and tape combinations, instructional pamphlets and booklets, and self-assessment examinations. The entire program was placed in the community hospitals within our referral region, and it was demonstrated by pretesting and posttesting that significant changes in cognition were brought about by use of the materials.63 All of the programs were updated in 1983 and remain available for purchase or rent, in whole or in part. This approach facilitates self-study in a nonthreatening manner, but requires either individual motivation

58

or administrative dir ability of appropriate

project also requires 1 equipment.

the avail-

COMMUNITY PERINATAL EDUCATION P~ocx04 This program consists of a series of l-day seminars that address timely aspects of ~eri~ata~ care. The lectures are designed primarily for nursery and obstetric nurses, though the scope is sufficiently broad that physicians or paramedical personnel might also find them of interest. The selection of topics is developed from an interest survey done at the community hospitals. Each l-day seminar consists of a series of different lectures given by obstetricians and perinatologists, neonatologists, nurses, pediatric respiratory therapists, perinatal and neonatal social workers, and related health care personnel, such as genetic counselors, teratologists, pathologists, and ethicists. Health care personnel from community hospitals are invited to come to the tertiary center for t e day. In addition to the didactic presentations, sufficient time is available for discussion and interaction, and tours of the obstetric and neonatal intensive care units are integrated into the program so that the visiting personnel may become familiar with the tertiary facilities. We have found that an assembly of nurses from the different community hospitals in our region has provided a useful forum for discussion of common problems and solutions. Participants are encouraged to share the contents of the seminars with fellow workers, and an effort is made to send a different participant to each of the seminars. These rograms have been approved for nursing continuing educatio 1 units, which makes them even more attractive to the partie SITE VISITS The Perinatail Outreach Coordinator meets often with coLmmunity hospital personnel at their respective institutions. These visits may include discussion groups, need assessments, equipment/facilities review, chart audit, or an educational program. At programs in the community hospital the material is adapted to meet specific needs. VISITING FELLOWSHIP Several years ago a visiting fellowship program was instituted in our neonatology division to allow practicing physicians to return to the tertiary center for a I- or 2-week rotation in neonatal medicine. The physicians are integrated into the pediatric house officer program in neonatology and are encouraged to have a “hands-on” experience. They may accompany house officers on rounds, attend high-risk deliveries, assist in the performance of 59

manual procedures, attend teaching rounds and conferences, accompany fellows on transports, and assume any aspect of patient care, under the direct supervision of a neonatologist or fellow. Participants have found this to be a useful experience in relearning procedures done infrequently in private practice, such as umbilical catheterization, endstracheal intubation, or thoracostomy tube placement, and for updating their knowledge of neonatology. The program enables the practitioner to have direct interaction with tertiary care providers, furnishes a setting which is free of the distractions of private practice, and helps foster an understanding of the scope of neonatal medicine as it is presently practiced. This program has been approved for continuing medical education credits and allows the participant to receive 1 credit hour per hour spent in the program. On occasion, a senior pediatric house officer can be made available under a locum tenens arrangement to cover the pediatrician’s office during the time he is in the visiting fellowship program. This has been useful for the solo practitioner who would otherwise have to give up vacation time to participate in the program.

TRANSPORT REVIEW CONFERENCE The Transport Review Conference is the primary tool of outreach education. Several studies have demonstrated the impact of direct educational programs within the community hospital on modifying behavior and improving the delivery of perinatal and neonatal health care in community hospitals. Philip and colleagues demonstrated the value of the transport conference as an educational tool.61 Lazzara and colleagues demonstrated the ability of such programs to reduce the incidence of intracerebral hemorrhage in the transported premature infant.64 Maisels and colleagues showed the positive effect on medical care practices and the pattern of transfer in hospitals in which such an educational program had been implemented.62 An important aspect in the review process is the establishment of an appropriate data base, aimed at establishing current care practices in referral hospitals. This can be done retrospectively, as in Philip’s study, by a review of maternal and infant hospital records.61 An alternative approach is to collect data prospectively. We have devised a transport review/evaluation form (Fig 14) whi ch is completed immediately on transfer of each infant. The form has been devised so that information entered can be directly fed into a computer, enabling the subsequent retrieval of information according to community hospital, diagnosis, birth weight, or any other selected parameter. This has enabled us to identify care trends, problems, and changes implemented through transport review conferences, for either any individual community hospital or for the region as a whole. All forms are evaluated at a monthly multidisciplinary meeting

60

Fig 14.--Transport sician front;

immediately B, back.

after

review/evaluation each iransport.

form, which is completed by transport phyData are entered into computer analysis.

of the physicians, nurses, respiratory therapists, ambulance personnel, and emergency services administrators from our tertiary center. Transport review conferences are held approximately every 6 months in each of our community hospitals. Two factors contribute heavily to the value of these conferences. They are multidisciplinary, and they focus on mutual problem-solving. Prese a neonatologist, perinatal outreach nurse coordinator, and p atric respiratory therapist visit the community hospitals, which ricians, pediatricians, family practiare represented by ob tioners, obstetric and iatric nurses, respiratory therapists, and social workers. D g the first portion of the conference, the case of each patient transferred from the community hospipast 6 months is reviewed. This tal to the tertiary center in t includes a brief history, a s mary of the clinical course, and relevant follow-up information Any problems encountered are also discussed at this time, and can include items such as delayed departure or arrival of the transport team, manage in the community hospital, appropriateness of referral, o quacy of feedback to the community hospital. This aspect of the transport conference is general concluded with a comparison posiof data collected over the prece ng 6 months illustrating tive aspects in improvement in perinatal-neonatal care over that period of time. Any preexisting nroblems that have not yet been resolved receive further discussion and recommendations. Fol61

lowing the review of cases, a didactic presentation is offered, usually one which has been preselected by the community hospital to meet its needs. We have found that the most effective means of encouraging attendance at these conferences is to schedule them as a noon conference, dinner conference, or in conjunction with the hospital’s monthly pediatric staff meeting. This imposes the least inconvenience on the practicing physician and in some instances assures the attendance of those who would otherwise not voluntarily come. It is very important that these conferences be held on a regular and scheduled basis to minimize anxiety that the purpose of the conference is to pass judgment and condemn the medical practices of the community hospital. We have found that the collegial nature of these conferences increases dramatically after the first several conferences. QUALITY

ASSURANCE

AND PERFORMANCE

REVIEW

Since the ultimate goal of regionalization of perinatal care is the improvement of perinatal health care within the region, it is the obligation of the tertiary center to monitor the effectiveness of perinatal health care within its region. The first step in any such endeavor is the formulation and compilation of a regional data base. Statistics alone are probably not an adequate assessment but do indicate patterns of referral and offer a means of comparison among different tertiary centers. Prospective comparisons of data obtained over sequential time periods also allow a single center to determine its impact on regional perinatal health care. For instance, a pattern demonstrating an increase in maternal referrals, decreased perinatal mortality rates in community hospitals, and increasing perinatal mortality rates in tertiary centers suggests that there is better recognition of perinatal risk factors and a modification of behavior in community hospitals prompting earlier referral. On the other hand, an increasing number of neonatal transports, especially if accompanied by increasing mortality rates in community hospitals, suggests failure to recognize and act on obstetric or neonatal risk factors. The ultimate effectiveness of regionalization of perinatal care will best be judged by the long-term outcomes of infants delivered or cared for by such programs. The responsibility for organized and longitudinal follow-up of such infants rests with the tertiary center. A multidiscipline developmental assessment program should be established in order to periodically assess neurodevelopmental outcomes, diagnose early handicaps, and make referrals to early intervention programs. As short-term outcomes are most often the results of changes in mortality, long-term issues should focus on morbidity as a consequence of obstetric and/or neonatal complications. 62

The tremendous growth in the use of computers in medical practice should greatly facilitate data processing and analysis. This will enable each center to effectively monitor the performance of its own region and will allow comparisons with the performance of other centers. This should also make possible a computation of the true cost-effectiveness of regionalization of perinatal care. REFERENCES 1. American Academy of Pediatrics/American College of Obstetrics and Gynecology: Guidelines for Perinatal Care. Washington, D.C., AAPIACOG, 1983, pp. 1-13. 2. Harris T.R., Isaman J., Giles HR.: Improved neonatal survival through maternal transport. Obstet. Gynecoi. 52:294, 1978. C.L.. Aladiem S., Avuste 0.. et al.: An analvsis of maternal trans3. Anderson port within a suburban metropolitan region. Am. J. Obstet. Gynecol. 140:499, 1981. 4. Modanlou H.D., Dorchester W.L., Tkorosian A., et al.: Antenatal versus neonatal transport to a regional nerinatal center: A comparison between matched pa&s. Obstet. Gynecol. 53:725, 1979. T.C., Densberger M., Krogman J.: Maternal transport and the peri5. Miller natal denominator. Am. J. Qbstet. Gynecol. 147:19, 1983. 6. Auld P.: Maternal transport is not the answer. Perinatol. Neonatol. 2:8, 1978. 7. Cohen R.S.. Stevenson D.K.. Malachowski N.. et al.: Favorable results of neonatal intensive care for very low birth weight infants. Pediatrics 69:621, 1982. N., Kiely J.L., Wallenstein S., et al.: Newborn intensive care and 8. Paneth neonatal mortality in low birth weight infants: A population study. N. Engl. J. Med. 307:149, 1982. 9. Sims D,G., Wynn J., Chiswick ML.: Outcome for newborn babies declined admission to a regional neonatal intensive care unit. Arch. Dis. Child. 57:334, 1982. 10. Chance G.W., Matthew J.D., Gash J.: et al.: Neonatal transport: A controlled study of skilled assistance. J. Pediatr. 93:662, 1978. 11. Hood J.L., Cross A., Hulka B., et at.: Effectiveness of the neonatal transport team. Crit. Care Med. 11:419, 1983. 12. Sumners J., Harris H.B., Jones B., et al.: Regional neonatal transport: Impact of an integrated community/center system. Pediatrics 65:910, 1980. 13. Cook L.J., Kattwinkel J.: A prospective study of nurse-supervised versus physician-supervised neonatal transport. JOGN Nurs. 12:371, 1983. 14. Bose C.L., Jung A.L., Thornton J.W.: Neonatal transport: The practical issues. Perinatol. Neonatol. 8161, 1984. 15. Ferrara A.; Harin A.: Emergency Transfer of the High-Risk Neonate. St,. Louis, C.V. Mosby Co., 1980, pp. 110-114. 16. Thompson T.R.: Neonatal transport nurses: An analysis of their role in the transport of newborn infants. Pediakics 65:887, 1980. 17. Greene W.T.: Organization of neonatal transport services in support of a regional referral center. Clin. Perinatol. 7:187, 1980. 18. Segal S.: Transport of High-risk Newborn Infants. Quebec, Canadian Paediatric Society, 1972, pp. 23-2’7. 19. Nielsen B.C., Jung A.L., Atberton S.O.: Evaluation of the porta-warm mattress as a source of heat for neonatal transport. Pediatrics 58:500, 1976. 20. Bell E.F., Weinstein M.R., Oh W.: Heat balance in premature infants: comparative effects of convectively heated incubator and radiant warmer, with and without plastic heat shield. FJ. Pediatr. 96:460, 1980. 21. Srikasibhandha S., Cats B.P.: Transport of the newborn. 2. Geburtshilfe Perinatol. 181:460, 1977. 63

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43.

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Unfer S.M., Bozynski M.E.: Solid-state oxygen for use in emergency evacuation of neonates. Crit. Care Med. 12:475, 1984. Clarke T.A., Zmora E., Chen J.H., et al.: Transcutaneous oxygen monitoring during neonatal transport. Pediatrics 65884, 1980. Donn S.M.. Kuhns L.R.: Pediatric Transillumination. Chicago.Year Book Medical Publishers, Inc., 1983. Versmold H.T., Kitterman J.A., Phibbs R.H., et al.: Aortic blood pressure during the first 12 hours of life in infants with birth weight 610 to 4,220 grams. Pediatrics 67:607, 1981. Shipman S., Robinson D.: Neonatal protocols: Normal newborn care, in Perez B. (ed.): Protocols for Perinatal Nursing Practice. St. Louis, C.V. Mosby Co., 1981, pp. 239-256. House M. and Dombkiewicz M.: Patient care in the ICN, in Avery G. (ed.): Neonatology: Pathophysiology an,d Management of the Newborn. Philadelphia, J.B. Lippincott Co., 1981, pp. 62-66. Perez R.: Protocols for Perinatal Nursing Practice. St. Louis, C.V. Mosby Co., 1981, pp. 257-268. Korones S.: High Risk Newborn Infants: The Basis for Zntensive Nursing Care. St. Louis, C.V. Mosby Co., 1976, pp. 150, 155. Donn S.M., Kuhns L.R.: Mechanism of endotracheal tube movement with change of head position in the neonate. Pediatr. Radiol. 9137, 1980. Kee J.L.: Fluids and Electrolytes with Clinical Application: A Programmed Approach. New York, John Wiley & Sons, Inc., 1978, pp. 276-278. Bliss-Holtz J.: Renal and metabolic crises, in Vestal K., McKenzie C. (eds.): High Risk Perinatal Nursing. Philadelphia, W.B. Saunders Co., 1983, pp. 429-435. Stephenson K.: Neonatal and maternal transport, in Vestal K., McKenzie C. (eds.): High Risk Perinatal Nursing. Philadelphia, W.B. Saunders Co., 1983, pp. 49-59. Bednarek F.J., Kuhns L.R.: Endotracheal tube placement in infants determined bv suprasternal palpation: A new technique. Pediatrics 56:224, 1975. Raffensperger J.G.: Swenson’s Pediatric Surgery. New York, Appleton-Century-crofts, 1980, p. 736. Faix R.G., Donn S.M.: Immediate management of the traumatized infant. Clin. Perinatol. 10:487, 1983. Lewis A.B., Takahashi M., Lurie P.R.: Administration of prostaglandin El in neonates with critical congenital cardiac defects. J. Pediatr. 93:481, 1978. Shenai J.P.: Sound levels fo;neonates in transit. J. Pediatr. 90:811, i977. Weiss C.E., Pickering D.E., Morros J.S.: Exposure of high-risk neonates to noise. Folia Phoniatr. 30:225, 1978. Campbell A.N., Lightstone A.D., Smith J.M., et al.: Mechanical vibration and sound levels experienced in neonatal transport. Am. J. Dis. Child. 138:967, 1984. Shenai J.P., Johnson G.E., Varney R.V.: Mechanical vibration in neonatal transport. Pediatrics 68:55, 1981. Honeyfield P.R.: General conditions of air transport, in Graven S.N. (ed.): Newborn Air Transport. Evansville, Mead Johnson Nutritional Division, 1978, pp. 1-3. Cunningham M.D.: Newborn air transport by helicopter, in Graven S.N. (ed.): Newborn Air Transport. Evansville, Mead Johnson Nutritional Division, 1978, pp. 4-6. Wyman M.L.: Management of respiratory emergencies during air transport, in Graven S.N. (ed.): Newborn Air Transport. Evansville, Mead Johnson Nutritional Division, 1978, pp. 61-63. Hackel A.: Ventilation, in Graven S.N. (ed.): Newborn Air Transport. Evansville, Mead Johnson Nutritional Division, 1978, pp. 52-54. Pickering D.E.: One state-of-the-art design solution for continuing intensive care of distressed infants during land and air transport, in Graven S.N. (ed.): Newborn Air Transport. Evansville, Mead Johnson Nutritional Division, 1978, pp. 27-37. 64

47.

Cunningham M.D.: Aspiration pneumonitis and newborn a.ir transport, m Graven S.N. (ea.): Newborn. Air Transport. Evansville, Mead Johnson Nutritional Division, 1978, pp. 64-66. 48. Oxer H.F.: Aeromedical evacuation of the seriously ill. Br. Med. J. 3:692, 1975. 49. Sherman N.: Fluid and drug administration, in Graven S.N. (ea.): Newborn Air Transport. Evansville, Mead Johnson Nutritional Division, 1978, p, 44. M.H.: Evaluation of two devices for improving thermal control of 50. LeBlanc premature infants in transport. Grit. Care Med. 12:593, 1984. 51. Leake R.D., Loew A.D., Oh W.: Retransfer of convalescent infants from newborn intensive care to community intermediate care nurseries. Clilz. Pediatr. 15:293, 1976. 52. Jung A.L., Bose CL.: Back transport of neonates: improved efficiency of tertiary nursery bed utilization. Pediatrics 71918, 1983. 53. Clarke T.A., Maniscalco W.M., Emmens R.W.: Necrotizing enterocolitis in premature infants transferred back to a community hospital. Am. J. Wis. Child. 137:563, 1983. 54. Michigan Department of Public Health, personal communication. 55. American Society of Hospital Pharmacists: American Hospital Formulary Seruice: Drug Information 1984. Bethesda, Md., American Society of Hospital Pharmacists, Inc., 1984. 56. King J.H. Jr.: The Law of Medic& Malpractice in a Nutshell. St. Paul, Minn., West Publishing Co., 1977, pp. 225-242. 57. Peters J.D., Fineberg KS., Kroll S.A.: The Law of Medical Practice in Michigan. Ann Arbor, Health Administrative Press, 1981, pp. 177-180. 58. Paneth N., Kiely J.L., Susser M: Age at death used to assess the effect of interhospital transfer of newborns. Pediatrics 73~854, 1984. 59. Duxbury M. (ea.): Outreach Progmms: Their Integral Parts and Processes. White Plains, N.Y.! March of Dimes Birth Defects Foundation, 1978. 60. Raff B. (ea.): Perinatal Outreach Education: Methods, Evaluation, and Financing. White Plains, N.Y., March of Dimes Birth Defects Foundation, 1981. 61. Philip A.G.S., Little G.A., Luceg J.F.: The transport conference as a teaching stratenv: evaluation in the Vermont/New Hamoshire regional oerinatal urogram.‘erinatol. Neonatol. 8:63, 1984. * S 62. Maisels M.J., Morrow D., Fernsler S., et al.: Care of low-birthweight and sick newborn infants in community hospitals: Effect of an education program. Am. J. Perinatol. 1~247, 1984. 63. Harlan W.R., Hess G.E., Borer B.C., et al.: Impact of an education program on perinatal care practices. Pediatrics 66:893, 1980. 64. Lazzara A., Kanto W.P.: Continuing education in the community hospital and reduction in the incidence of intracerebral hemorrhage in the transported preterm infant. J. Pediatr. 101:757, 1982.

3. c 4. d 5.

c

4.1. a, b 12. a, b, d 13. a, d 14. a, b, d

8. e 9. 10.

b a,

b,

e

15.

b, d

65