Medical Advances Studied for Transport
Transport Risk Scores
Many teams have used the Pediatric Risk of Mortality (PRISM), Score for Neonatal Acute Physiology (SNAP and SNAP-II), and Glasgow Coma Scale (GCS) in their clinical practice; however, except for the Glasgow Coma Scale score, these assessment tools were developed primarily for in-hospital use.
Several recent transport studies1,2 used the PRISM instrument to account for case severity, thus illustrating the utility of a scoring tool in transport research. In 2001, Lee et al3 reported the development and application of the Transport Risk Index of Physiologic Stability (TRIPS) instrument. This specific infant transport assessment tool, used on arrival of the transport team at the referring hospital and again after arrival at the referral center, includes clinical signs such as temperature, blood pressure, respiratory status, and response to noxious stimuli. These investigators report that their scoring model was a reliable predictor of short-term mortality (Although not specifically studied in the transport environment, the results of several inpatient studies suggest that preterm infants treated early with surfactant during a brief period of intubation followed by nasal continuous positive airway pressure (CPAP) have improved outcomes and decreased need for mechanical ventilation.8,9 The reduction in need for mechanical ventilation may be particularly advantageous in the transport setting, where monitoring for changes in lung compliance is difficult and may lead to an increased risk of hyperventilation and pneumothorax. If administration of surfactant prior to transport is not available or deemed not to be safe, the SUPPORT study group found that early CPAP reduced the need for intubation and was associated with a shorter duration of ventilation, suggesting that early CPAP should be considered as an alternative to intubation and surfactant in preterm neonates.10Extracorporeal Membrane Oxygenation During Transport
Extracorporeal membrane oxygenation (ECMO) is a well-established method of providing cardiopulmonary support to neonates with life-threatening cardiac and/or respiratory failure.
In general, safe performance of ECMO requires a team of medical professionals, including neonatologists, intensivists, pediatric surgeons, perfusionists, and NICU/PICU nursing and respiratory therapy staff. Because of the complexity of the equipment and the need for anticoagulation, only a few transport programs have developed the capability to initiate ECMO and transport patients during ECMO to tertiary centers. Two large descriptive studies report over a 20-year experience of interhospital transport of neonates and pediatric patients following ECMO cannulation.11,12 These studies suggest that transport ECMO is feasible and can be safely performed in critically ill children, with survival rates comparable to those of in-house ECMO patients.The number of critically ill neonates and pediatric patients requiring interhospital transport for ECMO has decreased over the last decade since the availability of inhaled nitric oxide (iNO) and high-frequency ventilation for treatment of patients with severe pulmonary disease. Mainali et al13 demonstrated that high frequency jet ventilation with or without iNO was a safe and effective alternative for transporting pre-ECMO neonates.
Most ECMO centers encourage early identification and transport of patients with progressive respiratory failure who may require ECMO to prevent the patient's condition from becoming too unstable for travel. If an ECMO center is considering offering ECMO services during transport, it is essential to understand the potential morbidity of ECMO transports and the added number of specialists and specialized vehicles that will be required.
Inhaled Nitric Oxide
iNO has become the standard of care to treat severe hypoxic respiratory failure associated with pulmonary hypertension in term and near-term neonates. Nitric oxide is a selective pulmonary vasodilator with minimal systemic adverse effects. After reviewing many multicenter neonatal studies, the US Food and Drug Administration approved the use of iNO in term and near-term neonates older than 34 weeks' gestation.
Although the off- label use of iNO has increased dramatically in the past decade,14 a Cochrane systematic review found that iNO as a rescue therapy for respiratory failure in preterm neonates had no significant effect on mortality or bronchopulmonary dysplasia.15A retrospective study by Lowe et al16 suggests that initiating iNO at the referring hospital and continuing the administration during transport decreases the number of hospital days for surviving neonates with severe hypoxic respiratory failure who do not require ECMO. Further prospective, randomized controlled studies are needed to validate these findings.
Commercial equipment is available to provide iNO in conjunction with many transport ventilators and manual ventilation systems. Delivery of inhaled nitric oxide during transport can be technically challenging, and the consequences of increased or interrupted delivery can be dangerous. The American Academy of Pediatrics has published some key references detailing its clinical use.17 Teams contemplating the use of iNO during transport should ensure the following: (1) training of personnel on the delivery of iNO in the NICU before transport; (2) availability of equipment for measuring dosage and monitoring for environmental exposure of personnel to gas byproducts; and (3) a protocol developed with neonatal experts to determine whether patients are appropriate candidates for iNO therapy.
Therapeutic Hypothermia
Therapeutic hypothermia is a relatively new, evolving therapy for improving neurodevelopmental outcomes in term newborn infants with acute perinatal hypoxic-ischemic encephalopathy (HIE). Several randomized clinical trials have demonstrated both safety and efficacy of therapeutic hypothermia (cooling to a rectal or core temperature of 33°C-34°C for 72 hours) in improving neurodevelopmental outcomes in newborn infants with moderate to severe HIE. Because institution of hypothermia within 6 hours of birth is critical for optimal neuroprotection, cooling prior to or during transport is often necessary.
Fairchild et al18 reported a 4-year experience with therapeutic hypothermia on transport. Several smaller studies and case reports also discuss the initiation of passive cooling (withholding external heat sources) while awaiting transport or during interfacility transport.19,20 Because a substantial risk of unintended overcooling may develop, these studies highlight the need for established protocols and education of referral and transport personnel as well as continuous monitoring of core temperature when passive cooling is used. Randomized-Controlled trials are needed to further evaluate the safety and efficacy of therapeutic hypothermia on transport.Neonatal Transport Team Workforce
A national survey of neonatal transport teams (NTTs) in the United States described characteristics of this workforce and evaluated whether there were any differences between unit-based and dedicated teams with regard to team training and a subset of complex procedures allowed on transport.21,22 A total of 398 NTTs were located in the United States, and 335 completed the survey, for a total response rate of 84.2%. Two hundred twenty-nine (68.4%) of the NTTs were unit-based, and 106 (31.6%) were dedicated teams. Using the chi-square test, no differences were found between unit-based and dedicated teams for most of the items pertaining to orientation and procedures allowed on transport. However, statistically significant differences (P partially explained by the much lower percentage of unit-based teams that transported neonates by helicopter (34.5% compared with 74.5% of the dedicated teams) or airplane (20.5% versus 67% of the dedicated teams). When the annual transport volume exceeded 200 neonates, the type of team was more likely dedicated in structure. Only 27.4% of the dedicated teams transported fewer than 200 per year, whereas 85% of the unit-based teams indicated this was their transport volume. The median transport volumes reported in this study suggests that as many as 68 797 critically ill neonates are transported each year, with dedicated teams transporting 58% and unit-based teams transporting 42% of the infants.21,22
King et al1 reported no difference in mortality, transport-related morbidity, and outcome (success) of procedures after changing from a nursephysician team to a nurse-only team configuration.
Transport nurses provided care equivalent to a team that included a resident or fellow physician; however, it should be noted that during the study period, a physician did accompany the nurse-only transport team to retrieve 15 patients with anticipated increased severity of illness; 4 of those patients died. Overall, team response time improved and transport times were significantly shorter with the nurse-only team compared with the prior transport structure of a physician-nurse team.Pediatric Transport Team Workforce
Orr et al2 evaluated survival rates and unplanned events during the transport process when patients were transported by either a pediatric critical care specialized team or by nonspecialized teams. Nonspecialized teams were identified as transport generalists, although it should be noted they were personnel from 4 competing air medical transport services, and all 4 services were fully accredited by the Commission on Accreditation of Medical Transport Systems. The nonspecialized teams had limited pediatric training and experience with pediatric emergencies, whereas pediatric critical care specialized teams were those with extensive training and experience in pediatric critical care. To estimate severity of illness, the PRISM score was calculated at 2 time points: at the referring hospital and during transport. Although 94% of the patients (n=1021) were transported by a pediatric specialty team, unplanned events occurred significantly more often among the 64 patients transported by nonspecialized teams. These morbidities included airway-related events, cardiopulmonary arrest, equipment failure, sustained hypotension, loss of intravenous access while inotropic support was required, and pneumothorax. The authors commented that the only variable that differed between the 2 populations was the transporting personnel. When patients were transported by nonspecialized teams, the transport times were shorter, which may have represented emphasis on a speedy transport rather than taking the time to perform an adequate stabilization.
Death occurred significantly more often amongst patients transported by nonspecialized teams compared to specialized teams (23% versus 9%; P The Section on Transport Medicine and other national transport organizations have recently increased their focus on efforts to improve quality of care using evidenced-based research. Because transport proposals have not constituted a large percentage of granting agency requests for research study applications through Requests for Applications, many qualified projects have not been conducted because of lack of funds. Funding may be available through private foundations, national transport or pediatric health care organizations (Table 17.2), and some private corporations.Table 17.2: Sources of Possible Grant Information and Support for Neonatal-Pediatric Transport Research
| Name | Address |
| American Academy of Pediatrics Association of Air Medical Services National Association of EMS Educators National Institutes of Health Emergency Services for Children March of Dimes | http://www.aap.org http://www.aams.org http://www.naemse.org http://www.nih.gov http://www.ems-c.org http://www.modimes.org |
In part because most transport programs have been primarily focused on the provision of clinical care, there has not been a strong emphasis on research and research funding. It is clear, however, that to improve the clinical care, quality, skilled, and funded research and researchers are required. Clinical research training (eg, study design, grant writing, biostatistics, and epidemiology) may be obtained at local medical schools or universities. In fact, many medical centers have established clinical research facilities and staff to support personnel in obtaining skills and conducting clinical studies.
References
1. King BR, King TM, Foster RL, McCans KM. Pediatric and neonatal transport teams with and without a physician: a comparison of outcomes and interventions. Pediatr Emerg Care. 2007;23(2):77-82
2. Orr RA, Felmet KA, Han Y, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics. 2009;124(1):40-48
3. Lee SK, Zupancic JA, Pendray M, et al. Transport risk index of physiologic stability: a practical system for assessing infant transport care. J Pediatr. 2001;139(2):220-226
4. Broughton SJ. The Mortality Index for Neonatal Transportation Score: a new mortality prediction model for retrieved neonates. Pediatrics. 2004;114(4):e424-e428
5. Costakos D, Allen D, Krauss A, et al. Surfactant therapy prior to the interhospital transport of preterm infants. Am J Perinatol. 1996;13(5):309-316
6. Mildenhall LFJ, Pavuluri NN, Bowman ED. Safety of synthetic surfactant use before preterm newborn transport. J Paediatr Child Health. 1999;35(6):530-535
7. Biniwale M, Kleinman M. Safety of surfactant administration before transport of premature infants. Air Med J. 2010;29(4):170-177
8. Rojas MA, Lozano JM, Rojas MX, et al. Very early surfactant without mandatory ventilation in premature infants treated with early continuous positive pressure: a randomized, controlled trial. Pediatrics. 2009;123(1):137-142
9. Dani C, Corsini I, Bertini G, Fontanelli G, Pratesi S, Rubaltelli FF. The INSURE method in preterm infants of less than 30 weeks' gestation. J Matern Fetal Neonatal Med. 2010;23(9):1024-1029
10. Finer NN, Carlo WA, Walsh MC, et al. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research. Early CPAP versus surfactant in extremely preterm infants. N Engl JMed. 2010;362(21):1970-1979
11. Coppola CP, Tyree M, Larry K, DiGeronimo R. A 22-year experience in global transport extracorporeal membrane oxygenation. J Pediatr Surg. 2008;43(1):46-52
12. Clement KC, Fiser RT, Fiser WP, et al. Single-institution experience with interhospital extracorporeal membrane oxygenation transport: a descriptive study. Pediatr Crit Care. Med. 2010;11(4):509-513
13. Mainali ES, Greene C, Rozycki HJ, Gutcher GR. Safety and efficacy of high-frequency jet ventilation in neonatal transport. J Perinatol. 2007;27(10):609-613
14. Clark RH, Ursprung RL, Walker MW, Ellsbury DL, Spitzer AR. The changing pattern of inhaled nitric oxide use in the neonatal intensive care unit. J Perinatol. 2010;30(12):800-804
15. Barrington KJ, Finer N. Inhaled nitric oxide for respiratory failure in preterm infants. Cochrane Database Syst Rev. 2007;(3):CD000509
16. Lowe CG, Trautwein JG. Inhaled nitric oxide therapy during the transport of neonates with persistent pulmonary hypertension or severe hypoxic respiratory failure. Eur J Pediatr. 2007;166(10):1025-1031
17. American Academy of Pediatrics, Committee on Fetus and Newborn. Use of inhaled nitric oxide. Pediatrics. 2000;106(2 Pt 1):344-345
18. Fairchild K, Sokora D, Scott J, Zanelli S. Therapeutic hypothermia on neonatal transport: 4-year experience in a single NICU. J Perinatol. 2010;30(5):324-329
19. Hallberg B, Olson L, Bartocci M, Edqvist I, Blennow M. Passive induction of hypothermia during transport of asphyxiated infants: a risk of excessive cooling. Acta Paediatr. 2009;98(6):942-946
20. Anderson ME, Longhofer TA, Phillips W, McRay DE. Passive cooling to initiate hypothermia for transported encephalopathic newborns. J Perinatol. 2007;27(9):592-593
21. Karlsen KA. National Survey to Describe the Workforce of Neonatal Transport in the United States. Dissertation. University of Utah; 2007. Accessed at www.Proquest.com: http://gradworks.umi.com/32/87/3287722.html
22. Karlsen KA, Trautman M, Price-Douglas W, Smith S. National survey of neonatal transport teams in the United States. Pediatrics. 2011;128(4):685-691
23. Killion C, Stein HM. The impact of air ambulance transport on neonatal outcomes. Newborn Infant Nurs Rev. 2009;9(4):207-211
Selected Readings
American Academy of Pediatrics. HIPAA: A How To Guide for Your Medical Practice. Elk Grove Village, IL: American Academy of Pediatrics; 2004
Day S, McCloskey K, Orr R, Bolte R, Notterman D, Hackel A. Pediatric interhospital critical care transport: consensus of a national leadership conference. Pediatrics. 1991;88(4):696-704
Hulley SB, Cummings SR, Browner WS, et al. Designing Clinical Research: An Epidemiologic Approach. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001
Woodward GA, Insoft RM, Pearson-Shaver AL, et al. The state of pediatric interfacility transport: consensus of the second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference. Pediatr Emerg Care. 2002;18(1):38-43