Personnel and Training

As noted in Chapter 3, many types of providers serve on neonatal-pediatric transport teams (Table 4.1). Although many teams include physicians, nurses, and respiratory therapists, prehospital (emergency medical technicians and paramedics) providers, nurse practitioners, and physician assistants are also commonly included.

In addition, there may be differences in the level of training or experience among providers of the same general classification. For example, the term physician can refer to an attending or resident physician or to a fellow. Likewise, a nurse might be a nurse practitioner, a clinical nurse specialist, a nurse with specific advanced practice skills, or a staff nurse. No one team configuration is ideal for every situation, although there are minimum requirements that must be met for transport. The type of providers used is best determined by the team's mission(s) and clinical needs. Teams that respond to out-of-hospital emergencies will need personnel with prehospital experience, and those whose mission is restricted to the transport of critically ill neonates will need providers with extensive experience in neonatal medicine. In some cases, team configuration might be influenced by local statutes that, for example, might restrict the performance of procedures to certain licensed personnel. As a guideline, transported infants and children should receive the same level of care en route as will be provided in the unit to which they will be admitted, within the constraints of a transport environment.

Table 4.1: Transport Program Personnel: Potential Roles and Responsibilities (see Appendix A)

Program director

• Organization of the transport system

• Liaison between team and hospital administration

• Budget development

• Develop and implement quality improvement and safety programs

• Oversight of day-to-day transport team and supervisors

• In conjunction with transport team medical director, sets employment criteria and devises methods for continuing education to maintain and enhance skills

Transport team medical director

• Specialist in pediatric critical care, pediatric emergency medicine, or neonatology

• May function as program director and medical director

• May require codirector or other available expertise regarding specialty issues for combination neonatal- pediatric teams

• Partners with transport team coordinator regarding transport planning and operations

• Ensures consultation is available for pediatric trauma, surgical emergencies, and other required services

• Medical director or designee is available to transport team coordinator 24 hours a day, for online clinical expertise

• Participates in program fiscal planning and management

• Oversees and participates in design of the team training programs

• Oversees and participates in the selection and training of team members

• Develops and/or approves all transport policies and protocols

• Assists in development and implementation of outreach and follow-up programs

• Reviews transport cases, providing feedback to team personnel

• Conducts morbidity and mortality reviews with team members

• Reviews data and team statistics

• Designs research initiatives

• Serves as liaison with administration (base and referring facilities)

• Oversees and participates in quality reviews, and designs resulting education for staff

Transport team coordinator

• Health care professional (eg, nurse practitioner, registered nurse, respiratory therapist, paramedic)

• Coordinates day-to-day program activity

• Holds position equivalent to a manager for the transport team

• Partners with medical director regarding transport planning and operations

Transport team coordinator, continued

• Participates in design and implementation of the team training programs

• Develops and/or approves all transport policies and protocols, in conjunction with the medical director

• Oversees transport data collection

• Is responsible for equipment selection and maintenance

• Is responsible for budget management

• Is responsible for team scheduling and scheduling staff meetings and in-service offerings

• Participates in teaching and quality improvement reviews

• Assists the medical director in conducting morbidity and mortality reviews with team members

Table 4.1: Transport Program Personnel: Potential Roles and Responsibilities (see Appendix A), continued

Medical control physician

• Designated medical control physician(s) (sometimes known as medical control officer) or designee available 24 hours a day

• Responds promptly to transport or consultation requests for medical management of individual patients

• Reports to the medical director or may hold both positions

• Is competent in acute and critical care, including pediatric critical care, pediatric emergency medicine, pediatric surgery, neonatology, cardiology, and other specialties as appropriate

• Has demonstrated experience with medical and logistical aspects of transport services

• Triages transport requests and activates backup system when necessary

• Assists in determining team composition and mode of transport

• Provides medical management suggestions before the arrival of the transport team

• Communicates with team via online (eg, telephone, radio) and offline (eg, using written protocols) methods during transport

• Is kept informed of patient's clinical status

• Relays pertinent information to receiving unit for preparation for patient arrival

• Documents or ensures documentation of patient-related information and advice given

• Is knowledgeable of (or has immediate access to) available care resources (eg, area bed capacity, other transport team configuration, and therapy treatment options)

• Has the authority to accept transferred patients without further consultation

• Assists in admission to alternative receiving hospitals in region

• Has access to subspecialty consultation (eg, cardiology, nephrology, endocrinology, surgery)

• Is involved in quality improvement and safety programs (development and implementation)

Transport physician

• Licensed physician (attending, fellow, or resident status)

• Has the defined skill level for treatment of patient population

• Participates in the training program designed by the medical director and transport team coordinator using defined, established criteria

Transport physician

• Collaborates in stabilization and management of patient's condition during transport

• Documentation reflects assessment and required interventions during the transport

• Participates in teaching and quality improvement reviews

Transport nurse

• Licensed registered nurse

• Has the defined skill level for treatment of patient population

• Has specific experience and training in neonatal, pediatric, acute, intensive, and emergency care medicine

• Participates in training program designed by medical director and transport team coordinator using defined, established criteria

• Is responsible for coordinating stabilization and management of patient's condition; documenting assessments, communication, and care provided; and monitoring during transport

• Participates in teaching and quality improvement reviews

Table 4.1: Transport Program Personnel: Potential Roles and Responsibilities (see Appendix A), continued

Transport respiratory therapist

• Licensed respiratory therapist

• Has additional specific training and experience of seriously ill patients

• Has specific experience and training in neonatal-pediatric patient management during interfacility transport

• Participates in training program designed by medical director and transport team coordinator using defined, established criteria

• Assists team leader with stabilization and management of the patient's airway, pulmonary care, ventilator management, and other care according to license and privileges during transport

• Participates in teaching and quality improvement reviews

Transport paramedic

• Licensed paramedic

• Has additional specific training and experience with seriously ill pediatric patients

• Has specific experience and training in neonatal-pediatric patient management during interfacility transport

• Participates in training program designed by medical director and transport team coordinator using defined, established criteria

• Assists team leader with stabilization and management of the patient's condition during transport within scope of licensure and practice

• Participates in teaching and quality improvement reviews

Transport emergency medical technician (EMT)

• Licensed EMT

• Has additional specific training and experience with pediatric patients

• Has specific understanding of and training in neonatal-pediatric patient management during interfacility transport

Transport emergency medical technician (EMT)

• Participates in training program designed by medical director and transport team coordinator using defined, established criteria

• Assists team leader with stabilization and management of the patient's condition during transport within scope of licensure and practice

• Participates in teaching and quality improvement reviews

There is considerable debate about the role of physicians on the transport team.

At one time, many, if not most, transport teams included a resident or attending physician. However, recently, several factors have conspired to alter the resident’s role in transport medicine. First, resident work hours are now closely regulated. Training programs effectively have fewer resident hours available for noncore rotations. Second, subspecialty training program growth continues to accelerate. Tertiary care centers often have the option of including a neonatology, critical care, or emergency medicine fellow with the transport team rather than a resident. Not only are these individuals more experienced than resident physicians, they also occupy one of the limited number of available spaces in ambulances or helicopters, effectively eliminating the resident from the team. Finally, billing regulations force attending physicians to closely supervise residents in order to bill for patient care services. Advanced care providers, such as nurse practitioners and physician assistants, can often bill independently, making them more economical choices for the team and the hospital administration. Furthermore, limited research has demonstrated that well-trained nurses, respiratory therapists, and other professionals can function safely and effectively in the transport environment without the direct presence of a transport physician. Although this evidence suggests that the resident physician might not be a necessary member of the transport team, there is also evidence that participating in transport medicine provides an important educational experience for the resident. As previously mentioned, attending physicians and subspecialty (acute care) fellows can augment the skills of the transport team by providing additional expertise. Their technical and cognitive skills might be helpful in the care of certain critically ill infants and children. In addition, as members of the team, they can educate other team members and perform a quality assurance-quality improvement role.

Regardless of the type of practitioner, certain characteristics are vital for the effective practice of transport medicine. Team members must meet certain physical requirements (see Chapter 9 and Appendix A). Transport personnel might be asked to perform procedures and tasks not usually associated with their roles. They must be able to function relatively independently and as part of a multidisciplinary team.

When team members have been selected, they must be trained thoroughly. The scope of training will be largely dictated by law, the experience and background of the candidates, and the mission of the team. Some providers will require extensive initial cognitive and procedural training, but even highly experienced providers require significant orientation to the transport environment. Likewise, teams with a more restricted mission may need less extensive training than those with a broad mission. In many cases, transport personnel will be drawn from the ranks of experienced nurses and respiratory care practitioners. These staff members will need to undertake training designed to enhance their knowledge base and will need to learn and interpret certain assessments, techniques, studies such as laboratory and radiographic analyses, and procedures not usually expected in their standard positions. Initial cognitive training of large groups of providers can be conducted in a classroom environment. However, this approach might not be practical when training the 1 or 2 people needed to fill a periodic vacancy. Therefore, teams should consider alternative teaching methods. Examples include prerecorded lectures and self-learning modules. All candidates should be required to demonstrate that they have acquired the basic functional knowledge needed for the role (Table 4.2).

Most providers will need training to efficiently, expertly, and safely perform technical procedures in the transport environment. Suggested methods for acquiring these skills include actual practice with patients, use of manikins and simulators, and use of models.

Basic skill acquisition is only the first step. Continuing education is an essential component of team development for several reasons. First, advances in knowledge and changes in technology are likely to make some therapies less desirable or even obsolete. Second, certain vital technical skills are likely to be used only occasionally, if ever, in actual practice. Prudence dictates that teams should always be prepared to use these skills, making competency and proficiency assurance mandatory. Finally, some important disease entities are rare. Practice sessions and continuing education allow team members to rehearse the management of unusual conditions in advance of need.

Some programs or their sponsoring organizations may require that team members be licensed or credentialed to perform their transport role. These requirements can be different for different providers. For example, attending physicians are likely to be board certified in a primary specialty (usually pediatrics) and may also have subspecialty certification in neonatology, critical care medicine or another discipline. They will also almost certainly have hospital privileges that delineate a scope of practice. Such privileges can easily be structured to include interfacility patient transport. On the other hand, nurses will have passed state licensure and nursing board examinations, and many will have additional credentials such as “Certified Critical Care Nurse” (CCRN). Specialty certification like CCRN might be mandatory for participation on some teams. The National Certification Corporation (NCC) offers a certification examination in Neonatal Pediatric Transport. The examination is open to physicians, nurses, nurse practitioners, physician assistants, respiratory care professionals, and paramedics. Although the organization recommends that candidates have a minimum of 2 years' experience before attempting the examination, any of the aforementioned providers may apply for the examination as long as they have an active license.

Successful

Table 4.2: Sample Diagnosis-Based Educational Checklist for Neonatal Transport

Neonatal Diagnosis	Date Learning Module Completed
Cardiac
Cardiac arrhythmia
Congenital heart disease (ductal-dependent defect)
Congenital anomalies
Ambiguous genitalia
Bladder or cloacal exstrophy
Choanal atresia
Cleft lip and/or palate
Down syndrome
Genitourinary (renal, hydronephrosis, prune belly)
Hygroma
Multiple congenital anomalies
Myelomeningocele
Syndrome (enter specifics)
Teratoma
Metabolic, Medical
Infant of diabetic mother
Hydrops
Hyperbilirubinemia
Sepsis
Neurologic
Hematoma (epidural, subdural, subgaleal); skull fractures
Intraventricular hemorrhage
Neurologic defect other than meningomyelocele (encephalocele, hydrocephalus, anencephaly)
Neuromuscular defect
Seizures
Respiratory
Long-term ventilation or tracheostomy
Prematurity, RDS
Term RDS (TTN, pneumonia, PPHN, MAS, asphyxia)

Table 4.2: Sample Diagnosis-Based Educational Checklist for Neonatal Transport, continued

Surgical
Bowel obstruction (abdominal distension, bilious emesis, malrotation, pyloric stenosis, volvulus)
Diaphragmatic hernia
Gastroschisis or omphalocele
Esophageal atresia or tracheal-esophageal fistula
Imperforate anus
Intestinal perforation
Masses (chest, abdominal)
Necrotizing enterocolitis
Skills used
Arterial puncture, blood gas analysis
Venous access, antibiotic administration
Intraosseous access, fluid bolus, resuscitation medications
Intubation, ventilator management, inhaled nitric oxide
Needle aspiration, chest tube insertion and management
Umbilical artery or vein cannulation
Surfactant administration

RDS indicates respiratory distress syndrome; TTN, transient tachypnea of the newborn; PPHN, persistent pulmonary hypertension; MAS, meconium aspiration syndrome.

candidates can also participate in the maintenance of certification process through the NCC.

Finally, teams may wish to have their own internal credentialing, certification, and skill maintenance program. Teams that perform these functions are strongly encouraged to keep careful records and to insure that criteria are applied uniformly and fairly.

In addition to initial training and continuing education, all teams should incorporate a program of quality improvement into their educational offerings (see Chapter 8). Such programs can take many forms, but most include several basic components. All sentinel, serious, and adverse events and near misses, as defined by the by The Joint Commission, and critical incidents, including death during transport, medical errors, compromised care, injury or death of personnel, and care conflicts, should be carefully reviewed, as should all unexpected outcomes and procedural complications. In addition, most programs include mandatory review of certain types of transports, such as of patients with certain diagnoses or patients with a certain degree of illness as assessed by objective parameters.

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Source: AAP. Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients. 4th edition. — American Academy of Pediatrics,2015. — 488 p.. 2015

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