Essential Components of Neonatal-Pediatric Transport Services
Like other parts of the emergency medical and critical care systems, a neonatal-pediatric transport program must be tailored to the specific needs and resources of the region served.
Nevertheless, most of the larger transport services have certain organizational features in common. The most important is a dedicated team of trained health care professionals proficient at providing neonatal and/or pediatric critical care at the referring facility and in a mobile environment. Along these lines, there must be a sufficient number of critically ill and injured patients to enable team members to maintain their skills and to permit staff to be used optimally. Other key components include: (1) online (real-time) medical control by qualified medical command physicians; (2) well-equipped ground and/or air ambulances; (3) communications and dispatch capabilities; (4) prospectively written clinical and operational guidelines; (5) a comprehensive database allowing for quality and performance improvement activities; (6) medical and nursing direction; (7) administrative resources; and (8) institutional endorsement and financial support. Subsequent chapters discuss these components and other clinical and organizational factors in more detail.In most programs, the transport team's composition is determined by preexisting policies and procedures, with modifications made depending on an individual patient's anticipated needs. For example, a neonatal team may typically dispatch 2 nurses but may add a respiratory therapist if inhaled nitric oxide therapy is likely to be initiated. Transport staff may include physicians, nurse practitioners, physician assistants, nurses, paramedics, and/or respiratory therapists. A team member's professional degree is less important than his or her ability to provide the level of care required in the transport environment.
Providing critical care under transport conditions is significantly different from practicing in an intensive care unit (ICU) or ED. One cannot assume that a health care professional who is competent in the ICU will function equally well in the patient compartment of an ambulance or in an unfamiliar hospital ED.In addition to their clinical expertise, team members must possess excellent interpersonal skills as well as the ability to improvise and solve problems. Moreover, additional training in transport medicine is mandatory. A senior member of the program who is experienced in transport and talented at teaching should oversee the training. The transport curriculum should include didactic as well as practical instruction in clinical and operational aspects of transport medicine. When supplementing the core transport team with staff who do not typically work with the team, some focused “just in time” training should be provided to orient the new personnel to the transport environment and familiarize them with essential safety procedures.
The referring physician is responsible for determining the resources needed during interfacility transport, according to federal regulations that govern the transfer of patients with emergency medical conditions. However, it is advisable that this decision be informed by input from the medical command physician, the transport team, and/or the vehicle operator, as appropriate. Ideally, a transport program should be able to provide or arrange transport by ground ambulance, helicopter, or fixed-wing aircraft. The recommendation for a specific mode of transport is based on factors such as patient condition and acuity; current and available levels of medical care; number of transport staff required; distance to the referring institution; traffic congestion; and weather conditions, among others. Although speed may be perceived as the highest priority, the safety of the crew and patient remains of paramount importance.
The number of team members dispatched for a transport is constrained by the size and spatial configuration of the vehicle used. Ground ambulances can typically carry up to 3 or 4 caregivers, helicopters can carry 2 to 4, and fixed-wing aircraft can carry 2 to 5. Whenever possible, the mode of transport should allow for the presence of at least 1 adult family member during the transport. Regardless of mode, the team must be able to mobilize and depart from its base quickly. Teams may be stationed at hospitals or strategic off-site locations.
A clear delineation of tasks performed by non-health care personnel from those performed by health care personnel optimizes safety, efficiency, and response time. The health care professionals on the team must be able to provide medical care without inordinate concern for the technical aspects of the transport. Similarly, the pilot or emergency vehicle operator must be permitted to function free of any distractions or emotive patient data that might impair his or her judgment. At the same time, adequate understanding of each team member's role can improve communication and teamwork.
Providing intensive care in a mobile environment can be challenging. Transport teams must function despite limitations in resources, mobility, and/or space. In addition, it may be difficult — sometimes even impossible — to assess a patient or perform certain procedures while working in a moving vehicle, especially a small helicopter. Therefore, major therapies needed to stabilize the patient's condition or to prevent decompensation en route should be considered or performed before departure from the referring facility. The provider's threshold for performing interventions, such as airway management, may be lower than if the patient were already at the tertiary care center because of the differences in environment and resources during transport.
Consideration should be given to establishing policies that support the transport of infants and children back to their referring facilities when further inpatient care remains necessary but the specialized resources of the tertiary center are no longer required. Transfer agreements specific to each referring institution can be useful, especially if these include criteria for patient acceptance and return transport. Reverse transport encourages efficient use of the region's neonatal and pediatric critical care resources and promotes cooperation among institutions. One potential problem with this practice is that third-party payers may challenge the necessity or benefit of back transport and deny payment for the cost of the return trip. Lack of insurance coverage can put undue stress on the referring and/or receiving hospital or ultimately become the nonreimbursed responsibility of the patient's family.