TRANSPORTING INFANTS TO AN NICU

As regionalization and specialization of care for newborn infants have developed, a special type of
team has been created for transport of these infants from a referring hospital to a level III center
(neonatal intensive care unit [NICU]). Policies and procedures will reflect the unique characteristics
of each region (eg, size, geography, economics, sophistication of medical services). Lines of
communication must always be open between the referring hospital and the NICU at all levels (ie,
administrators, physicians, nurses) and with ambulance or air services. Ideally, the mother would be
transferred to the level III center before delivery of a high-risk infant, but this is not always possible.

I. Transport team. The team may include physicians and nurses. Special training must be provided
in the care of sick infants. A specific medical protocol is established. The team should be able to
contact the attending neonatologist at any time during transport. Appropriate insurance coverage is
necessary for team members, and questions of liability must be worked out with legal consultation
among hospitals, ambulance services, and aircraft services.

At the referring hospital, team members should conduct themselves as professional representatives of
the NICU, avoiding conflict with or criticism of the referring hospital staff. Questions about transport
protocol should be worked out directly between the referring physician and the attending
neonatologist.

II. Equipment. Each transport team should be self-sufficient. Medications and equipment can be
chosen according to published lists. Special emphasis is placed on maintaining thermal neutrality
(eg, plastic swaddling or heated, humidified inspired air mixtures). Noise and vibration often
compromise auditory and visual monitoring, and well-calibrated blood pressure and trancutaneous
monitors may be useful.

III. Protocol for stabilization and transfer. The goal of stabilization is to make the transfer
uneventful.

A. General procedures. Attention to the details of stabilization is important! Unless active

resuscitation is underway, the team's first task at the referring hospital is to listen to the history and
assessment of the infant's status. The vital signs are then obtained. At this point, a precise diagnosis
of all the infant's problems may be less important than predicting what the infant will need during
transport. It is prudent to initiate anticipated interventions before leaving the referring hospital. For
example, an infant with increasing work of breathing and increasing needs for inspired oxygen who
faces a 2-h journey probably should be placed on mechanical ventilation and have an intravenous
catheter in place before transfer begins. In most cases, an infant is not ready for transport until
basic neonatal needs are met: thermoneutrality, acceptable cardiac and respiratory function,
and blood glucose levels in the normal range. Vital signs must be stable, and catheters and tubes
should be appropriately placed. Problems that may occur during transport should be anticipated. The
NICU should be given an expected arrival time. The parents should be allowed to see and touch the
infant before transport. During transport, vigilant monitoring should continue for unexpected changes
in the infant's status. Respiratory rate, heart rate, blood pressure, and oxygen levels should be
monitored. After transfer is completed, the team should talk with the parents and, if possible, with the
referring physician.

B. Prophylactic antibiotic therapy. Infants at risk for sepsis and those with indwelling catheters
should probably receive antibiotic therapy. Culture of blood samples may be performed at the
referring hospital or at the NICU.

C. Gastric intubation. If the infant has a gastrointestinal disorder (including ileus accompanying
critical illness) or diaphragmatic hernia or if continuous positive airway pressure is administered
through the nose or a mask, venting of the stomach with a nasogastric or orogastric tube is indicated,
especially if airplane or helicopter transport will be used. Venting should be performed before
transport because the air trapped in the gastrointestinal tract will expand in volume as atmospheric
pressure decreases.

D. Temperature control and fluid balance. Special attention to temperature and fluid balance
is required for infants with open lesions (eg, myelomeningocele or omphalocele). A dry or moist
protective dressing over the lesion can be covered by thin plastic wrap to reduce radiant heat loss.

IV. Evaluation of transport. Each transport should have a scoring system that reflects the "before"
and "after" status of the infant. For example, vital signs and glucose oxidase measurements taken
when the team first arrives at the referring hospital should be compared with the same measurements
taken on admission to the NICU. This system provides quality control of transports and is useful in
outreach education to convey constructive criticism to referring hospitals. It is also important to
review on a regular basis such things as team response time, referring hospital satisfaction, difficult
transports, safety updates, team credentialing, and medical protocols.

V. Outreach education. Transport team members (including neonatologists and administrators)

should meet with professionals from each referring hospital. Such a forum for discussion of transport
issues and specific transported patients provides mutual feedback and stimulates interhospital
protocol decision making (ie, should surfactant be instilled before the transport team arrives).

VI. Special considerations in air transport. Each region should develop protocols for choosing
ground or air transport, based on distance, nature of the terrain, location of landing sites, and
availability of aircraft and ambulances.

A. Safety guidelines. Clear guidelines should be established regarding air transport. Decisions
regarding flight safety should be made according to weather and other flight conditions (ie, the pilot
should not be given information on the age of the patient or the severity of the illness before making
decisions on flight safety). Controlled landing sites familiar to the pilot should be used. Loading and
unloading of the aircraft should not take place while engines are running; an idling helicopter is
dangerous.

B. Dysbarism. In helicopters and unpressurized aircraft, dysbarism (imbalance between air

pressure in the atmosphere and the pressure of gases within the body) causes predictable problems.
Partial pressures of inspired gases decrease as altitude increases, so infants will require an increased
concentration of inspired oxygen. Trapped free air in the thorax or intestines will expand in volume
and may cause significant pulmonary compromise. A cuffed tube or catheter should be evacuated
before takeoff.

Note: Because blood pressure varies with changing gravitational force, fluctuations noted during
climbing or descent should not be cause for alarm.