- Email: [email protected]
Nurse-led neonatal transport
Semin Neonatol 1999; 4: 265–271
Nurse-led neonatal transport Andrew Leslie* and Carl Bose† *Nottingham Neonatal Service, City and University Hospitals, Nottingham, UK; and †University of North Carolina at Chapel Hill, Medical Director, Pediatric Transport Service, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA Key words: neonatal transport, nurse practitioner
Although the North American experience of nurse-led neonatal transport indicates that neonatal nurses can effectively lead transfers in the role traditionally taken by doctors, nurse-led transport has been slow to evolve in Europe. This article explores the issues in setting-up a nurse-led neonatal transport service in the UK, learning from the American experience. Key issues are discussed, including the structure of nurse-led services, training and education, triage of transfers, supervision, prescribing, communication and cost. Nurse-led transport is now a practical possibility, but warrants further investigation before widespread adoption. 1999 Harcourt Publishers Ltd
Neonatal care in the developed world is invariably provided in hierarchical referral systems that involve transferring selected babies for specialist care. Organization of transport services varies substantially between countries [1,2]. It is clear that transport may behazardous for vulnerable, sick babies [3,4], and the evidence points to significantly improved outcomes when transfers are supervised by staff who are trained in neonatal transfer, and whose skills are maintained [5,6]. The professional configuration of these teams varies and good outcomes have been reported for transport teams led by doctors and also by nurses [5,7,8]. In the USA many transport teams are nurse-led, but this model has not been widely adopted elsewhere. In the UK the evolution of the Advanced Neonatal Nurse Practitioner (ANNP) role has made nurse-led transport a potentially viable option. This paper discusses the evidence that nurses may effectively lead transfers and some issues in service configuration and management.
Background The TINA guidance [9] recommends that staff attending transfers are appropriately trained and Correspondence: Andrew Leslie, Nottingham Neonatal Service, City Hospital, Nottingham, UK. Email: [email protected]
1084–2756/99/040265+07 r12.00/0
experienced. There are a number of difficulties in running quality services, with trained and experienced staff, when the core personnel are junior doctors as they are numerous and in post only for limited periods. Nurse-led transport programmes have not emerged in the UK despite ANNPs becoming established on many British NICUs. Anecdotally, many ANNPs undertake transport as part of their role, but it is not clear if they are trained specifically in transport, or are acting in a similar capacity to untrained Specialist Registrars (SpRs). At least one UK centre is proposing to shift to a partly ANNPled transport service, and is putting an appropriate training programme in place. The first report of a nurse-led transport program in the USA appeared in 1950 [10]. This program was developed by the New York Department of Health in collaboration with area hospitals, and included nearly all of the features of contemporary neonatal transport programmes. Most importantly, in-transit care was provided by specially-trained paediatric nurses. This remarkable programme transported 1209 patients during a 2-year period [11]. However, this programme was unique; the widespread development of nurse-led transport programmes did not occur until a much later date. The evolution of neonatal transport in the USA is closely linked to the regionalization of neonatal © 1999 Harcourt Publishers Ltd
266
intensive care. This phenomenon occurred throughout the USA between the mid-1970s and the early 1980s. Centralization had two effects on transport: the number of infants being transferred declined because infants were more often delivered in a hospital capable of providing appropriate neonatal care, and the responsibility to provide transport shifted to the regional centres. In 1983, the American Academy of Pediatrics (AAP) formally assigned this responsibility in their Guidelines for Perinatal Care [12]. A number of factors influenced the change in personnel for transport. As the number of transports increased, it became less practical to send physicians on transport. Neonatologists were in relatively short supply, and reimbursement usually did not adequately support their professional effort. Although participation in transport was considered by many to be very educational, in high-volume programmes time spent on transport by physicians in training often competed with other aspects of training. In addition, in the late 1980s, many transport programmes came under closer financial scrutiny. Most high-volume programmes chose to use non-physician personnel as attendants during transport. The use of neonatal nurse practitioners (NNPs), nurses with training and credentials similar to British ANNPs, offered an attractive alternative to physician attendance [13]. Nurse practitioners generally were highly skilled, provided consistent expertise and were licensed in most states to perform all the diagnostic and therapeutic procedures required during transport. However, their greatest disadvantage was, and continues to be, their scarcity and relatively high salaries. As an alternative to NNPs, many centres have chosen to train NICU staff nurses to participate in transport. This often is a very practical alternative because salaries of staff nurses are less than those of NNPs, and they generally are more available. In addition, in most states, they are permitted to perform invasive procedures and administer medication in a closely regulated expanded role. Because of these advantages, transport teams led by specially trained NICU nurses have become the most common configuration of neonatal transport programs in the USA. Unfortunately, in recent years, regionalized perinatal care has deteriorated rather dramatically in the USA, with neonatal intensive care now being provided in many smaller hospitals. One consequence has been that the responsibility for
A. Leslie and C. Bose
transport has followed the site of care for infants. The net result has been the distribution of transports over many more programmes which individually transport fewer patients. It is assumed, although not proven, that this deregionalization of transport services has resulted in a decrement in the quality of care during transport.
The evidence that nurses can effectively lead transfers Data regarding the effectiveness of nurse-led transport teams are all from the USA, and most were collected some years ago, at the time that nurse-led teams were being established. Cook and Kattwinkel [7] evaluated the transfers of 234 neonates. Fiftyfive of these were transferred by a nurse-led team and the rest were by various grades of junior physician. Babies were selected according to which team was on-call, without regard to the nature or severity of illness. They found that babies in all groups were in comparable condition on completion of transfer, despite similar pre-transfer illness severity. Thompson [8] reported early results of the effectiveness of using selected, specially trained, NICU nurses as team leaders in neonatal transfers. This study retrospectively compared 443 nurse-led with 189 physician-led transfers. Allocation to either group was by availability of doctor or nurse. The groups were similar for proportion of premature babies transferred, prevalence of a primary respiratory disorder and proportion ventilated in transit, although significantly more babies with congenital heart disease were transferred by physician-led teams. There were no significant differences in survival between the two groups and the author concluded that ‘. . . NICU nurses who have completed a comprehensive didactic and practical educational program can effectively assume the transport team leadership role for ill newborns.’ There are no studies which have evaluated the abilities of British ANNPs in providing effective transport for sick babies, and it is essential that such work is undertaken by centres proposing such a change.
Organizing a service In the UK at present there are no transport services which are wholly nurse-led. Interested centres are
Nurse-led neonatal transport
dealing with the different issues and constraints which apply in the UK, many of which are not entirely resolved. This section outlines these issues and suggests strategies that may be appropriate in managing them. Experience from the USA regarding these issues has been added when this might provide helpful insight. Structure of the service Organized transport services have been evolving for longer in the USA than the UK, and so this section concentrates on that experience. In the USA, transport programmes have common features in terms of their administrative organization, independent of the size and financial structure of the program or of the sponsor hospital [14]. These components can be generally categorized into those related to medical care and those related to non-medical factors, e.g. transportation, communications and finances. The medical components of a neonatal transport programme should be the responsibility of a neonatologist. Direction of the non-medical components is generally the responsibility of a member of the hospital administration. Often a collaborative effort exists that takes advantage of the expertise of professionals in all disciplines. The role of the medical director is vital in nurse-led programs because of the assumption of responsibility and liability for the quality of care provided by the transport team. In this capacity, the medical director is responsible for developing training programmes and patient care protocols. The medical director, in conjunction with the co-ordinator of non-physician personnel, must ensure that all personnel have completed training requirements successfully and have satisfied the regulations of the agencies that govern the various professional groups. The director also must develop and maintain a system for reviewing the quality of care provided during transport. Each group of professionals (e.g. nurses and often respiratory therapists in the USA) on the transport team should have a person who is designated as the co-ordinator of that group. The co-ordinator should supervise the selection and training of personnel and develop a system of peer review. This person should be responsible for scheduling and identifying needs of team members. It is also advisable to designate a single person to co-ordinate team activities who will interface
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Table 1. Outline of additional training required for ANNPs to manage transfers Basic training Demonstrate ability to recognize and manage potentially life-threatening conditions. Clinical issues for transfer — additional transport considerations in stabilizing airway, breathing, circulation, blood sugar, temperature. Priorities for transfer; logical systems-based approach. Transport issues — attention to placement, security and patency of tubes and lines; additional challenges to vital signs caused by transport; what constitutes acceptable stability for transfer; effective use of transport equipment. Interpersonal issues — working effectively with referring staff and parents. Supervision and documentation. Continuing education Discussion of recent transfers — audit of team performance; formulate plans for improving future performance. Problem-solving scenarios. Review of recent transport research. Revision of basic issues. Equipment updates.
closely with the medical director. Most often, this person will be the nurse co-ordinator of the team. Transport training Nurse-led transport in the UK is likely to use neonatal nurses with the Advanced Neonatal Nurse Practitioner (ANNP) qualification. Newly-qualified ANNPs need substantial further training to become able to lead transfers effectively. Transport training may include didactic elements along with supervised transfers. It is essential that centres who are interested in this route are committed to the training and able to offer sufficient transfers, as well as quality supervision, to enable students to gain experience. Continuing education is necessary for all staff undertaking transfers. Major issues to be covered in basic and continuing training are outlined in Table 1. In the wake of the TINA document, it is no longer acceptable for some transfers to be led by junior doctors in non-neonatal jobs who do few transfers each year. Many junior doctors in the UK need transport experience as part of their paediatric training, and it may be possible to provide structured training programs for smaller numbers of interested doctors.
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Although there are no nationally adopted standards in the USA for training transport personnel, the American Academy of Pediatrics (AAP) has established general principles and guidelines for training programs [15]. These cover similar issues to those outlined above. They also recommend didactic and practical teaching, and suggest laboratory simulation of practical skills, such as intubation, umbilical catheterization, and chest tube placement. Demonstration of proficiency in all areas is ensured by examination or observation by a qualified supervisor. After this initial preparation, a period of training should be provided during which the trainee accompanies a more experienced team member on transport. Final certification of competence should be awarded by both the medical director of the transport program and the co-ordinator for the trainee’s professional group. Completion of several nationally sponsored advanced life support training courses is also recommended. Who should go on a transfer? It is not desirable to triage transfers at the time of referral and then allocate them to doctors or ANNPs on the basis of disease severity. Information provided at the time of request for transfer is usually incomplete and sometimes unreliable. Although a number of scoring systems have been developed for critically ill older paediatric patients in an attempt to determine an appropriate team configuration, their reliability remains in doubt and they are untested in neonatal patients [16]. The team leader, whether a physician or nurse, must be capable of managing emergencies, both predicted and unpredicted. As a minimum, an ANNP who is sent on a transfer must be as able as the person providing care in the referring hospital. The small number of neonatal transfers which involve moving babies with critical highly unstable conditions, such as transfers for ECMO, may be properly staffed by two transport team leaders, ANNPs, physicians or both.
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when they should seek guidance. Some of these will be related to drug initiation (see below). Other occasions when ANNPs may be required to discuss a case should include any situation where stabilizing for transfer is not straightforward, where a baby is possibly too sick for transfer or where there is significant disagreement over management with the referring unit staff. The environment for contacting base for advice should be a facilitative one, where contact is encouraged. ANNPs cannot certify death, and there should be clear discussion of the difficulties this raises before nurse-led transport starts. Good transport management includes not attempting transfer when the prognosis is hopeless and death may be imminent. This situation requires close discussion with the referring unit staff and with the consultant at base so that, if appropriate, the death can be managed in a controlled way by the referring unit. In the event of serious decompensation of a baby in transit it is necessary for the ANNP to institute appropriate emergency treatment to attempt to stabilize the situation. Resuscitation should continue until the baby can be reviewed by a doctor. In the USA, governance of the professional activities of nurses is the responsibility of each state, usually through a board of nursing and regulations known as nurse practice acts. Although these acts vary between states, a common feature is the requirement for direct communication between a supervising physician and a nurse practising in an ‘expanded role’. Many of the activities required during neonatal transport are defined as expanded practice, for example invasive procedures or administration of medications. Although not mandated by law, it is also advisable for an experienced physician to provide consultation when a physician in training attends transport. The logical person to provide such consultation is the one who will receive the patient upon return to the receiving hospital. For this reason, the advice should usually be from a neonatologist or comparably trained subspecialist. Prescribing
Supervision Supervision should always be available for whoever is leading a transfer. This should be provided by a Consultant Neonatologist/Paediatrician from the referral centre. ANNPs doing nurse-led transfers should be governed by agreed protocols for
For ANNPs to be able to function on neonatal transfers in the team leader role, they must be able to initiate drug therapy. In the UK, this area has proved particularly problematic to ANNPs in all areas of practice. The problem is rooted in the Medicines Act, which makes no provision for
Nurse-led neonatal transport
Table 2. Summary of the recommended content of a group drug initiation protocol [10] Group protocols should include clear statements on the following: (1) Clinical condition or situation to which the protocol applies Clear and unambiguous description of which patients and clinical conditions are included and excluded, and action to be taken. (2) Characteristics of staff authorized to take responsibility for the supply or administration of medicines under a group protocol Details of the professional and specialist qualifications, training, experience and competence relevant to the clinical condition and medicines involved. Details of the necessary training and continuing education for staff involved. (3) Description of treatment available under a group protocol Names and legal status, details of dose to be given, route, frequency and total permissible dose of all medicines to be supplied and administered. Details of adverse effects and drug interactions and instructions for managing these; when to refer for medical advice. Audit trail. (4) Management and monitoring of group protocols The names of the authors of the protocols and the approving committees and managers. Review date.
neonatal drugs to be prescribed by nurses. However, the act has been interpreted as apparently allowing nurses to initiate drug therapies if they do so under an agreed protocol. Further weight has been added to this interpretation by publication of the ‘Crown Report’ [17]. The report aims to facilitate good practice in this area and protect patients. For this reason, the protocols required are extensive and comprehensive. Any activity nurses undertake in this area is not ‘prescribing’, but is ‘drug initiation under protocol’. The contents of a group protocol are outlined in the Crown report and are summarized in Table 2. Potential authors of group protocols must refer to the whole report. Any neonatal unit using ANNPs in a role where they may need to ‘prescribe’ will need to write protocols. For transport, where the drug initiation activity may take place in hospitals other than the ANNPs base, a number of further steps may be necessary. The major points needing attention are outlined in Table 3. In particular, it is essential that
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Table 3. Major steps necessary in preparing group protocols for initiating drugs during nurse-led neonatal transport (1) Identify necessary drugs. (2) Ensure the venture has the support of all relevant Consultants. (3) Form a writing committee — must include Consultant Neonatologist and senior pharmacist. (4) Draft protocols according to Crown Report guidance. (5) Submit protocols to review by senior personnel unconnected with the writing process. (6) Submit final version for the approval of the hospital board and drugs and therapeutics committee. (7) Discuss the change to nurse-led transfer with referring hospitals. (8) Undertake audit and review process.
the hospital board approves this activity, and accepts the liability for the actions of the transport team, however it is constituted and wherever it is working. The move from medical to nurse-led transfer is a significant change, and the hospital must be assured that it is not being placed at risk. The drugs protocols should include information on when an ANNP may initiate each drug, the dose which may be given, and guidance on when the dose may be varied. Information on pharmacology, potential side-effects and action to be taken should also be included. Limits to the independent opportunities for ANNPs to initiate drugs should be built-in, to ensure that appropriate discussions with a supervising consultant happen in particular situations. For example, it might be appropriate to insist that such discussion occurs before inotropes are started. Drugs protocols alone give no guidance on the management of individual problems, and so they need to be cross-referenced to relevant clinical guidelines. If these are not in place or up-to-date, they may need to be prepared. It is important for good relations with local units that they are informed of this role for ANNPs, and given the opportunity to discuss any misgivings they may have. A common fear is that the referring unit may be liable for the mistakes of a nurse-led transport team while the team is in their hospital. If this matter has been discussed with the transport teams’ hospital board, and they have agreed to ‘cover’ the team wherever they are working, then this issue can be quickly resolved. Audit of ANNP drug initiation is necessary, and the protocols should include audit points. It is sensible to insist that ANNP drugs protocols aim for the highest standard of ‘prescribing’ practice.
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For example, whenever a drug is initiated by an ANNP, this should be documented in the notes, along with the relevant clinical findings, indication and plan. This issue is somewhat more complicated in the USA because the governance of medical care, including the practice of nurses, is the responsibility of each state. However, there is general uniformity in the rules promulgated by most states. As in the UK, nurses are permitted to prescribe under established written guidelines. These are usually written as protocols for the care of problems (e.g. hypotension) or diagnoses (e.g. sepsis); they should be approved by the medical director of the programme. Some protocols include detailed decision trees, often termed critical pathways. When an individual patient requires care other than that specified by a protocol, approval of a consulting physician is usually required. Transport team members function as agents of their sponsor hospital; they are not independent practitioners. In this capacity, they must conform to the protocols and procedures authorized by the hospital. Team members may be liable if they do not perform within the scope of their employment, or if they do not abide by protocol. Communication The transport of patients by nurse-led teams is facilitated by the availability of a communication system, which permits direct contact between the team and the consulting physician at all times [18]. This level of communication is mandated by the nurse practice acts in some US states. This is a trivial problem while the team is in the referring hospital. During transit, the problem can be minimized by the use of a variety of devices. The use of cellular phones is ideal during ground transport, except in areas where coverage is incomplete, because of the general familiarity with this type of communication. The use of VHF and UHF radios with patching devices to phone lines is an alternative during flight or in areas where cellular service is not available. In the future, it seems likely that telemedicine technology will permit the real time transfer of video images and other digital information to support the capabilities of consulting physicians. Financial issues No data are available in the UK regarding costs of nurse-led transport compared to established
A. Leslie and C. Bose
systems. The issues involved are complex and depend on a range of other, often local, factors. The difficulty in identifying the costs associated with a transport program increases if its finances are integrated into the operation of the NICU, as is usually the case [19]. For example, personnel costs often are difficult to quantify because, except in very high-volume programmes, transport personnel usually contribute to in-patient services during transport duty time. Therefore, the cost assigned to the transport programme should be discounted based on this contribution. The proportion of time devoted by the medical director may increase in nurse-led programmes. This time contribution is difficult to quantify, and is often ignored in the financial analysis. A potential economy may be to combine services, either within a hospital or between hospitals. An example of the former would be to cross-train members of specialty transport teams, e.g. paediatric, neonatal, and adult, such that the total number of personnel can be reduced. This strategy invariably results in some loss of expertise, but may be necessary to insure financial viability. Collaboration between hospitals may include the sharing of vehicles or teams. Smaller units may benefit from outsourcing entirely; that is, contracting with larger medical centres for the provision of all transport services.
Conclusion There are similar conditions in British neonatal care at present to those which influenced the change to nurse-led transfer in the USA. The TINA document and the forthcoming European Standards Organisation guidance on transport may mitigate against every neonatal unit owning and operating an inter-hospital transport facility, as is the case at present. This may lead to responsibility for transport shifting further to the tertiary units, with a consequent increase in the workload for those centres. The number of junior doctors available to these centres is not increasing, and the hours they work are becoming fewer. At the same time, the political climate appears to favour a facilitative atmosphere regarding nurse-specialization. Furthermore, anecdotally, many nurse-practitioners in tertiary centres are frustrated in their roles, and this option may provide an opportunity for genuine specialization.
Nurse-led neonatal transport
A change to nurse-led transport in the UK will not be without problems, and important lessons can be learned from the USA. Issues there included the lack of evaluation by a physician and potential liability of the referring unit. These questions were typically satisfied by clear delineation of the technique of selection and training of personnel, and the demonstration of competence. The support and endorsement of an involved medical director was also critical. Initially, referring physicians found relinquishing care of a critically ill patient to non-physician personnel unacceptable. However, most referring physicians were concerned only with transferring their patients in a safe and timely fashion, and this concern was satisfied with the demonstration of competence and efficiency. Early local experience in the UK has found these issues to be highly pertinent, and the solutions similar. The preparation of British ANNPs is extensive, costly and time-consuming, and mitigates against UK centres becoming reliant on ANNPs for transport, due to the time taken to train replacements. It is unlikely that a US-style model which uses nurses not trained to ANNP level will be acceptable in the UK at present. Hybrid services, using both ANNPs and a smaller number of junior doctors may be the best option. Quality in transport may be consequent more on using trained and interested staff than on their professional backgrounds. Centres shifting to nurse-led transport must prospectively evaluate the effects of the change. References 1 Shenai JP, Mayor CW, Gaylord MS, Blake WW, Simmons D, DeArmond D. A successful decade of regionalised perinatal care in Tennessee: the neonatal experience. J Perinatol 1999; 11: 137–143. 2 Leslie AJ. Formation of a Neonatal Transport Team. Paediatr Nurs 1994; 6: 18–22. 3 Harding JE, Morton SM. Adverse effects of neonatal transport between level iii centres. J Paediatr Child Health 1993; 29: 146–149. 4 Hood JL, Cross A, Hulka B, Lawson EE. Effectiveness of the neonatal transport team. Crit Care Med 1983; 11: 419–423.
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5 Leslie AJ, Stephenson TJ. Audit of neonatal intensive care transport — closing the loop. Acta Paediatr 1997; 86: 1253–1256. 6 Chance GW, Matthew JD, Gash J, Williams G, Cunningham K. Neonatal transport: a controlled study of skilled assistance. J Pediatr 1978; 93: 662–666. 7 Cook LJ, Kattwinkel J. A prospective study of nurse-supervised versus physician-supervised neonatal transports. JOGN Nurs 1983; 12: 371–376. 8 Thompson TR. Neonatal transport nurses: an analysis of their role in the transport of newborn infants. Paediatrics 1980; 65: 887–892. 9 Medical Devices Agency. Transport of Neonates in Ambulances. London: Department of Health, 1995. 10 Losty MA, Orlfsky I, Wallace H. A transport service for premature babies. Am J Nurs 1950; 50: 10. 11 Wallace HM, Losty MA, Baumgartner L. Report of two years experience in the transportation of premature infants in New York City. Pediatrics 1952; 22: 439. 12 American Academy of Pediatrics, Committee on the Fetus and Newborn, and American College of Obstetricians and Gynecologists, Committee on Obstetrics. Maternal and fetal medicine: guidelines for perinatal care. Evanston, IL: American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 1983:45. 13 Mitchell A, Watts J, Whyte R, Blatz S, Norman GR, Guyatt GH, Southwell D, Hunsberger M, Paes B. Evaluation of graduating neonatal nurse practitioners. Pediatrics 1991; 88: 789. 14 Bose CL. Neonatal transport. In: Avery GB, Fletcher MA, MacDonald MG (eds). Neonatology: pathophysiology and management of the newborn. Philadelphia: JB Lippincott Co., 1994: 42. 15 American Academy of Pediatrics, Task Force on Interhospital Transport. In: Mhairi G, MacDonald MD (eds). Guidelines for air and ground transport of neonatal and pediatric patients. Elk Grove Village, IL: American Academy of Pediatrics, 1999. 16 Orr RA and Karr VA. Assessing severity of illness before transport. In: McCloskey KAL, Orr RA (eds). Pediatric Transport Medicine. St. Louis: Mosby, 1995: 123. 17 Dr June Crown (Chairman). Review of Prescribing, Supply and Administration of Medicines — A Report on the Supply and Administration of Medicines under Group Protocols. Department of Health, London, 1998. 18 Conn AKT, Bowen CY. The communications network for perinatal transport. In: MacDonald MD, Miller MK (eds). Emergency transport of the perinatal patient. Boston: Little, Brown & Co., 1989: 92. 19 Risemberg HM. Financing a perinatal transport program in the United States. In: MacDonald MA, Miller MK (eds). Emergency transport of the perinatal patient. Boston: Little, Brown & Co., 1989: 85.
Nurse-led neonatal transport Andrew Leslie* and Carl Bose† *Nottingham Neonatal Service, City and University Hospitals, Nottingham, UK; and †University of North Carolina at Chapel Hill, Medical Director, Pediatric Transport Service, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA Key words: neonatal transport, nurse practitioner
Although the North American experience of nurse-led neonatal transport indicates that neonatal nurses can effectively lead transfers in the role traditionally taken by doctors, nurse-led transport has been slow to evolve in Europe. This article explores the issues in setting-up a nurse-led neonatal transport service in the UK, learning from the American experience. Key issues are discussed, including the structure of nurse-led services, training and education, triage of transfers, supervision, prescribing, communication and cost. Nurse-led transport is now a practical possibility, but warrants further investigation before widespread adoption. 1999 Harcourt Publishers Ltd
Neonatal care in the developed world is invariably provided in hierarchical referral systems that involve transferring selected babies for specialist care. Organization of transport services varies substantially between countries [1,2]. It is clear that transport may behazardous for vulnerable, sick babies [3,4], and the evidence points to significantly improved outcomes when transfers are supervised by staff who are trained in neonatal transfer, and whose skills are maintained [5,6]. The professional configuration of these teams varies and good outcomes have been reported for transport teams led by doctors and also by nurses [5,7,8]. In the USA many transport teams are nurse-led, but this model has not been widely adopted elsewhere. In the UK the evolution of the Advanced Neonatal Nurse Practitioner (ANNP) role has made nurse-led transport a potentially viable option. This paper discusses the evidence that nurses may effectively lead transfers and some issues in service configuration and management.
Background The TINA guidance [9] recommends that staff attending transfers are appropriately trained and Correspondence: Andrew Leslie, Nottingham Neonatal Service, City Hospital, Nottingham, UK. Email: [email protected]
1084–2756/99/040265+07 r12.00/0
experienced. There are a number of difficulties in running quality services, with trained and experienced staff, when the core personnel are junior doctors as they are numerous and in post only for limited periods. Nurse-led transport programmes have not emerged in the UK despite ANNPs becoming established on many British NICUs. Anecdotally, many ANNPs undertake transport as part of their role, but it is not clear if they are trained specifically in transport, or are acting in a similar capacity to untrained Specialist Registrars (SpRs). At least one UK centre is proposing to shift to a partly ANNPled transport service, and is putting an appropriate training programme in place. The first report of a nurse-led transport program in the USA appeared in 1950 [10]. This program was developed by the New York Department of Health in collaboration with area hospitals, and included nearly all of the features of contemporary neonatal transport programmes. Most importantly, in-transit care was provided by specially-trained paediatric nurses. This remarkable programme transported 1209 patients during a 2-year period [11]. However, this programme was unique; the widespread development of nurse-led transport programmes did not occur until a much later date. The evolution of neonatal transport in the USA is closely linked to the regionalization of neonatal © 1999 Harcourt Publishers Ltd
266
intensive care. This phenomenon occurred throughout the USA between the mid-1970s and the early 1980s. Centralization had two effects on transport: the number of infants being transferred declined because infants were more often delivered in a hospital capable of providing appropriate neonatal care, and the responsibility to provide transport shifted to the regional centres. In 1983, the American Academy of Pediatrics (AAP) formally assigned this responsibility in their Guidelines for Perinatal Care [12]. A number of factors influenced the change in personnel for transport. As the number of transports increased, it became less practical to send physicians on transport. Neonatologists were in relatively short supply, and reimbursement usually did not adequately support their professional effort. Although participation in transport was considered by many to be very educational, in high-volume programmes time spent on transport by physicians in training often competed with other aspects of training. In addition, in the late 1980s, many transport programmes came under closer financial scrutiny. Most high-volume programmes chose to use non-physician personnel as attendants during transport. The use of neonatal nurse practitioners (NNPs), nurses with training and credentials similar to British ANNPs, offered an attractive alternative to physician attendance [13]. Nurse practitioners generally were highly skilled, provided consistent expertise and were licensed in most states to perform all the diagnostic and therapeutic procedures required during transport. However, their greatest disadvantage was, and continues to be, their scarcity and relatively high salaries. As an alternative to NNPs, many centres have chosen to train NICU staff nurses to participate in transport. This often is a very practical alternative because salaries of staff nurses are less than those of NNPs, and they generally are more available. In addition, in most states, they are permitted to perform invasive procedures and administer medication in a closely regulated expanded role. Because of these advantages, transport teams led by specially trained NICU nurses have become the most common configuration of neonatal transport programs in the USA. Unfortunately, in recent years, regionalized perinatal care has deteriorated rather dramatically in the USA, with neonatal intensive care now being provided in many smaller hospitals. One consequence has been that the responsibility for
A. Leslie and C. Bose
transport has followed the site of care for infants. The net result has been the distribution of transports over many more programmes which individually transport fewer patients. It is assumed, although not proven, that this deregionalization of transport services has resulted in a decrement in the quality of care during transport.
The evidence that nurses can effectively lead transfers Data regarding the effectiveness of nurse-led transport teams are all from the USA, and most were collected some years ago, at the time that nurse-led teams were being established. Cook and Kattwinkel [7] evaluated the transfers of 234 neonates. Fiftyfive of these were transferred by a nurse-led team and the rest were by various grades of junior physician. Babies were selected according to which team was on-call, without regard to the nature or severity of illness. They found that babies in all groups were in comparable condition on completion of transfer, despite similar pre-transfer illness severity. Thompson [8] reported early results of the effectiveness of using selected, specially trained, NICU nurses as team leaders in neonatal transfers. This study retrospectively compared 443 nurse-led with 189 physician-led transfers. Allocation to either group was by availability of doctor or nurse. The groups were similar for proportion of premature babies transferred, prevalence of a primary respiratory disorder and proportion ventilated in transit, although significantly more babies with congenital heart disease were transferred by physician-led teams. There were no significant differences in survival between the two groups and the author concluded that ‘. . . NICU nurses who have completed a comprehensive didactic and practical educational program can effectively assume the transport team leadership role for ill newborns.’ There are no studies which have evaluated the abilities of British ANNPs in providing effective transport for sick babies, and it is essential that such work is undertaken by centres proposing such a change.
Organizing a service In the UK at present there are no transport services which are wholly nurse-led. Interested centres are
Nurse-led neonatal transport
dealing with the different issues and constraints which apply in the UK, many of which are not entirely resolved. This section outlines these issues and suggests strategies that may be appropriate in managing them. Experience from the USA regarding these issues has been added when this might provide helpful insight. Structure of the service Organized transport services have been evolving for longer in the USA than the UK, and so this section concentrates on that experience. In the USA, transport programmes have common features in terms of their administrative organization, independent of the size and financial structure of the program or of the sponsor hospital [14]. These components can be generally categorized into those related to medical care and those related to non-medical factors, e.g. transportation, communications and finances. The medical components of a neonatal transport programme should be the responsibility of a neonatologist. Direction of the non-medical components is generally the responsibility of a member of the hospital administration. Often a collaborative effort exists that takes advantage of the expertise of professionals in all disciplines. The role of the medical director is vital in nurse-led programs because of the assumption of responsibility and liability for the quality of care provided by the transport team. In this capacity, the medical director is responsible for developing training programmes and patient care protocols. The medical director, in conjunction with the co-ordinator of non-physician personnel, must ensure that all personnel have completed training requirements successfully and have satisfied the regulations of the agencies that govern the various professional groups. The director also must develop and maintain a system for reviewing the quality of care provided during transport. Each group of professionals (e.g. nurses and often respiratory therapists in the USA) on the transport team should have a person who is designated as the co-ordinator of that group. The co-ordinator should supervise the selection and training of personnel and develop a system of peer review. This person should be responsible for scheduling and identifying needs of team members. It is also advisable to designate a single person to co-ordinate team activities who will interface
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Table 1. Outline of additional training required for ANNPs to manage transfers Basic training Demonstrate ability to recognize and manage potentially life-threatening conditions. Clinical issues for transfer — additional transport considerations in stabilizing airway, breathing, circulation, blood sugar, temperature. Priorities for transfer; logical systems-based approach. Transport issues — attention to placement, security and patency of tubes and lines; additional challenges to vital signs caused by transport; what constitutes acceptable stability for transfer; effective use of transport equipment. Interpersonal issues — working effectively with referring staff and parents. Supervision and documentation. Continuing education Discussion of recent transfers — audit of team performance; formulate plans for improving future performance. Problem-solving scenarios. Review of recent transport research. Revision of basic issues. Equipment updates.
closely with the medical director. Most often, this person will be the nurse co-ordinator of the team. Transport training Nurse-led transport in the UK is likely to use neonatal nurses with the Advanced Neonatal Nurse Practitioner (ANNP) qualification. Newly-qualified ANNPs need substantial further training to become able to lead transfers effectively. Transport training may include didactic elements along with supervised transfers. It is essential that centres who are interested in this route are committed to the training and able to offer sufficient transfers, as well as quality supervision, to enable students to gain experience. Continuing education is necessary for all staff undertaking transfers. Major issues to be covered in basic and continuing training are outlined in Table 1. In the wake of the TINA document, it is no longer acceptable for some transfers to be led by junior doctors in non-neonatal jobs who do few transfers each year. Many junior doctors in the UK need transport experience as part of their paediatric training, and it may be possible to provide structured training programs for smaller numbers of interested doctors.
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Although there are no nationally adopted standards in the USA for training transport personnel, the American Academy of Pediatrics (AAP) has established general principles and guidelines for training programs [15]. These cover similar issues to those outlined above. They also recommend didactic and practical teaching, and suggest laboratory simulation of practical skills, such as intubation, umbilical catheterization, and chest tube placement. Demonstration of proficiency in all areas is ensured by examination or observation by a qualified supervisor. After this initial preparation, a period of training should be provided during which the trainee accompanies a more experienced team member on transport. Final certification of competence should be awarded by both the medical director of the transport program and the co-ordinator for the trainee’s professional group. Completion of several nationally sponsored advanced life support training courses is also recommended. Who should go on a transfer? It is not desirable to triage transfers at the time of referral and then allocate them to doctors or ANNPs on the basis of disease severity. Information provided at the time of request for transfer is usually incomplete and sometimes unreliable. Although a number of scoring systems have been developed for critically ill older paediatric patients in an attempt to determine an appropriate team configuration, their reliability remains in doubt and they are untested in neonatal patients [16]. The team leader, whether a physician or nurse, must be capable of managing emergencies, both predicted and unpredicted. As a minimum, an ANNP who is sent on a transfer must be as able as the person providing care in the referring hospital. The small number of neonatal transfers which involve moving babies with critical highly unstable conditions, such as transfers for ECMO, may be properly staffed by two transport team leaders, ANNPs, physicians or both.
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when they should seek guidance. Some of these will be related to drug initiation (see below). Other occasions when ANNPs may be required to discuss a case should include any situation where stabilizing for transfer is not straightforward, where a baby is possibly too sick for transfer or where there is significant disagreement over management with the referring unit staff. The environment for contacting base for advice should be a facilitative one, where contact is encouraged. ANNPs cannot certify death, and there should be clear discussion of the difficulties this raises before nurse-led transport starts. Good transport management includes not attempting transfer when the prognosis is hopeless and death may be imminent. This situation requires close discussion with the referring unit staff and with the consultant at base so that, if appropriate, the death can be managed in a controlled way by the referring unit. In the event of serious decompensation of a baby in transit it is necessary for the ANNP to institute appropriate emergency treatment to attempt to stabilize the situation. Resuscitation should continue until the baby can be reviewed by a doctor. In the USA, governance of the professional activities of nurses is the responsibility of each state, usually through a board of nursing and regulations known as nurse practice acts. Although these acts vary between states, a common feature is the requirement for direct communication between a supervising physician and a nurse practising in an ‘expanded role’. Many of the activities required during neonatal transport are defined as expanded practice, for example invasive procedures or administration of medications. Although not mandated by law, it is also advisable for an experienced physician to provide consultation when a physician in training attends transport. The logical person to provide such consultation is the one who will receive the patient upon return to the receiving hospital. For this reason, the advice should usually be from a neonatologist or comparably trained subspecialist. Prescribing
Supervision Supervision should always be available for whoever is leading a transfer. This should be provided by a Consultant Neonatologist/Paediatrician from the referral centre. ANNPs doing nurse-led transfers should be governed by agreed protocols for
For ANNPs to be able to function on neonatal transfers in the team leader role, they must be able to initiate drug therapy. In the UK, this area has proved particularly problematic to ANNPs in all areas of practice. The problem is rooted in the Medicines Act, which makes no provision for
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Table 2. Summary of the recommended content of a group drug initiation protocol [10] Group protocols should include clear statements on the following: (1) Clinical condition or situation to which the protocol applies Clear and unambiguous description of which patients and clinical conditions are included and excluded, and action to be taken. (2) Characteristics of staff authorized to take responsibility for the supply or administration of medicines under a group protocol Details of the professional and specialist qualifications, training, experience and competence relevant to the clinical condition and medicines involved. Details of the necessary training and continuing education for staff involved. (3) Description of treatment available under a group protocol Names and legal status, details of dose to be given, route, frequency and total permissible dose of all medicines to be supplied and administered. Details of adverse effects and drug interactions and instructions for managing these; when to refer for medical advice. Audit trail. (4) Management and monitoring of group protocols The names of the authors of the protocols and the approving committees and managers. Review date.
neonatal drugs to be prescribed by nurses. However, the act has been interpreted as apparently allowing nurses to initiate drug therapies if they do so under an agreed protocol. Further weight has been added to this interpretation by publication of the ‘Crown Report’ [17]. The report aims to facilitate good practice in this area and protect patients. For this reason, the protocols required are extensive and comprehensive. Any activity nurses undertake in this area is not ‘prescribing’, but is ‘drug initiation under protocol’. The contents of a group protocol are outlined in the Crown report and are summarized in Table 2. Potential authors of group protocols must refer to the whole report. Any neonatal unit using ANNPs in a role where they may need to ‘prescribe’ will need to write protocols. For transport, where the drug initiation activity may take place in hospitals other than the ANNPs base, a number of further steps may be necessary. The major points needing attention are outlined in Table 3. In particular, it is essential that
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Table 3. Major steps necessary in preparing group protocols for initiating drugs during nurse-led neonatal transport (1) Identify necessary drugs. (2) Ensure the venture has the support of all relevant Consultants. (3) Form a writing committee — must include Consultant Neonatologist and senior pharmacist. (4) Draft protocols according to Crown Report guidance. (5) Submit protocols to review by senior personnel unconnected with the writing process. (6) Submit final version for the approval of the hospital board and drugs and therapeutics committee. (7) Discuss the change to nurse-led transfer with referring hospitals. (8) Undertake audit and review process.
the hospital board approves this activity, and accepts the liability for the actions of the transport team, however it is constituted and wherever it is working. The move from medical to nurse-led transfer is a significant change, and the hospital must be assured that it is not being placed at risk. The drugs protocols should include information on when an ANNP may initiate each drug, the dose which may be given, and guidance on when the dose may be varied. Information on pharmacology, potential side-effects and action to be taken should also be included. Limits to the independent opportunities for ANNPs to initiate drugs should be built-in, to ensure that appropriate discussions with a supervising consultant happen in particular situations. For example, it might be appropriate to insist that such discussion occurs before inotropes are started. Drugs protocols alone give no guidance on the management of individual problems, and so they need to be cross-referenced to relevant clinical guidelines. If these are not in place or up-to-date, they may need to be prepared. It is important for good relations with local units that they are informed of this role for ANNPs, and given the opportunity to discuss any misgivings they may have. A common fear is that the referring unit may be liable for the mistakes of a nurse-led transport team while the team is in their hospital. If this matter has been discussed with the transport teams’ hospital board, and they have agreed to ‘cover’ the team wherever they are working, then this issue can be quickly resolved. Audit of ANNP drug initiation is necessary, and the protocols should include audit points. It is sensible to insist that ANNP drugs protocols aim for the highest standard of ‘prescribing’ practice.
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For example, whenever a drug is initiated by an ANNP, this should be documented in the notes, along with the relevant clinical findings, indication and plan. This issue is somewhat more complicated in the USA because the governance of medical care, including the practice of nurses, is the responsibility of each state. However, there is general uniformity in the rules promulgated by most states. As in the UK, nurses are permitted to prescribe under established written guidelines. These are usually written as protocols for the care of problems (e.g. hypotension) or diagnoses (e.g. sepsis); they should be approved by the medical director of the programme. Some protocols include detailed decision trees, often termed critical pathways. When an individual patient requires care other than that specified by a protocol, approval of a consulting physician is usually required. Transport team members function as agents of their sponsor hospital; they are not independent practitioners. In this capacity, they must conform to the protocols and procedures authorized by the hospital. Team members may be liable if they do not perform within the scope of their employment, or if they do not abide by protocol. Communication The transport of patients by nurse-led teams is facilitated by the availability of a communication system, which permits direct contact between the team and the consulting physician at all times [18]. This level of communication is mandated by the nurse practice acts in some US states. This is a trivial problem while the team is in the referring hospital. During transit, the problem can be minimized by the use of a variety of devices. The use of cellular phones is ideal during ground transport, except in areas where coverage is incomplete, because of the general familiarity with this type of communication. The use of VHF and UHF radios with patching devices to phone lines is an alternative during flight or in areas where cellular service is not available. In the future, it seems likely that telemedicine technology will permit the real time transfer of video images and other digital information to support the capabilities of consulting physicians. Financial issues No data are available in the UK regarding costs of nurse-led transport compared to established
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systems. The issues involved are complex and depend on a range of other, often local, factors. The difficulty in identifying the costs associated with a transport program increases if its finances are integrated into the operation of the NICU, as is usually the case [19]. For example, personnel costs often are difficult to quantify because, except in very high-volume programmes, transport personnel usually contribute to in-patient services during transport duty time. Therefore, the cost assigned to the transport programme should be discounted based on this contribution. The proportion of time devoted by the medical director may increase in nurse-led programmes. This time contribution is difficult to quantify, and is often ignored in the financial analysis. A potential economy may be to combine services, either within a hospital or between hospitals. An example of the former would be to cross-train members of specialty transport teams, e.g. paediatric, neonatal, and adult, such that the total number of personnel can be reduced. This strategy invariably results in some loss of expertise, but may be necessary to insure financial viability. Collaboration between hospitals may include the sharing of vehicles or teams. Smaller units may benefit from outsourcing entirely; that is, contracting with larger medical centres for the provision of all transport services.
Conclusion There are similar conditions in British neonatal care at present to those which influenced the change to nurse-led transfer in the USA. The TINA document and the forthcoming European Standards Organisation guidance on transport may mitigate against every neonatal unit owning and operating an inter-hospital transport facility, as is the case at present. This may lead to responsibility for transport shifting further to the tertiary units, with a consequent increase in the workload for those centres. The number of junior doctors available to these centres is not increasing, and the hours they work are becoming fewer. At the same time, the political climate appears to favour a facilitative atmosphere regarding nurse-specialization. Furthermore, anecdotally, many nurse-practitioners in tertiary centres are frustrated in their roles, and this option may provide an opportunity for genuine specialization.
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A change to nurse-led transport in the UK will not be without problems, and important lessons can be learned from the USA. Issues there included the lack of evaluation by a physician and potential liability of the referring unit. These questions were typically satisfied by clear delineation of the technique of selection and training of personnel, and the demonstration of competence. The support and endorsement of an involved medical director was also critical. Initially, referring physicians found relinquishing care of a critically ill patient to non-physician personnel unacceptable. However, most referring physicians were concerned only with transferring their patients in a safe and timely fashion, and this concern was satisfied with the demonstration of competence and efficiency. Early local experience in the UK has found these issues to be highly pertinent, and the solutions similar. The preparation of British ANNPs is extensive, costly and time-consuming, and mitigates against UK centres becoming reliant on ANNPs for transport, due to the time taken to train replacements. It is unlikely that a US-style model which uses nurses not trained to ANNP level will be acceptable in the UK at present. Hybrid services, using both ANNPs and a smaller number of junior doctors may be the best option. Quality in transport may be consequent more on using trained and interested staff than on their professional backgrounds. Centres shifting to nurse-led transport must prospectively evaluate the effects of the change. References 1 Shenai JP, Mayor CW, Gaylord MS, Blake WW, Simmons D, DeArmond D. A successful decade of regionalised perinatal care in Tennessee: the neonatal experience. J Perinatol 1999; 11: 137–143. 2 Leslie AJ. Formation of a Neonatal Transport Team. Paediatr Nurs 1994; 6: 18–22. 3 Harding JE, Morton SM. Adverse effects of neonatal transport between level iii centres. J Paediatr Child Health 1993; 29: 146–149. 4 Hood JL, Cross A, Hulka B, Lawson EE. Effectiveness of the neonatal transport team. Crit Care Med 1983; 11: 419–423.
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5 Leslie AJ, Stephenson TJ. Audit of neonatal intensive care transport — closing the loop. Acta Paediatr 1997; 86: 1253–1256. 6 Chance GW, Matthew JD, Gash J, Williams G, Cunningham K. Neonatal transport: a controlled study of skilled assistance. J Pediatr 1978; 93: 662–666. 7 Cook LJ, Kattwinkel J. A prospective study of nurse-supervised versus physician-supervised neonatal transports. JOGN Nurs 1983; 12: 371–376. 8 Thompson TR. Neonatal transport nurses: an analysis of their role in the transport of newborn infants. Paediatrics 1980; 65: 887–892. 9 Medical Devices Agency. Transport of Neonates in Ambulances. London: Department of Health, 1995. 10 Losty MA, Orlfsky I, Wallace H. A transport service for premature babies. Am J Nurs 1950; 50: 10. 11 Wallace HM, Losty MA, Baumgartner L. Report of two years experience in the transportation of premature infants in New York City. Pediatrics 1952; 22: 439. 12 American Academy of Pediatrics, Committee on the Fetus and Newborn, and American College of Obstetricians and Gynecologists, Committee on Obstetrics. Maternal and fetal medicine: guidelines for perinatal care. Evanston, IL: American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 1983:45. 13 Mitchell A, Watts J, Whyte R, Blatz S, Norman GR, Guyatt GH, Southwell D, Hunsberger M, Paes B. Evaluation of graduating neonatal nurse practitioners. Pediatrics 1991; 88: 789. 14 Bose CL. Neonatal transport. In: Avery GB, Fletcher MA, MacDonald MG (eds). Neonatology: pathophysiology and management of the newborn. Philadelphia: JB Lippincott Co., 1994: 42. 15 American Academy of Pediatrics, Task Force on Interhospital Transport. In: Mhairi G, MacDonald MD (eds). Guidelines for air and ground transport of neonatal and pediatric patients. Elk Grove Village, IL: American Academy of Pediatrics, 1999. 16 Orr RA and Karr VA. Assessing severity of illness before transport. In: McCloskey KAL, Orr RA (eds). Pediatric Transport Medicine. St. Louis: Mosby, 1995: 123. 17 Dr June Crown (Chairman). Review of Prescribing, Supply and Administration of Medicines — A Report on the Supply and Administration of Medicines under Group Protocols. Department of Health, London, 1998. 18 Conn AKT, Bowen CY. The communications network for perinatal transport. In: MacDonald MD, Miller MK (eds). Emergency transport of the perinatal patient. Boston: Little, Brown & Co., 1989: 92. 19 Risemberg HM. Financing a perinatal transport program in the United States. In: MacDonald MA, Miller MK (eds). Emergency transport of the perinatal patient. Boston: Little, Brown & Co., 1989: 85.