SUBMITTED TO SUBMITTED BYDr. Mrs. GANDHIMATHI Miss. M. SATHYAPROFESSOR OF NURSING II yr M.Sc (N)RMCON RMCON

Inter-hospital

Intra-hospital

MEANING:

The transport service gives high – risk patients timely

access to the appropriate services without interrupting their

care.

HISTORY OF NEONATAL EMERGENCY TRANSPORT SERVICES:

The development of specialized neonatal intensive care units (NICUs) providing an evolving “package” of care began in North America, Europe, and Australia in the late 1960s. ‘Regionalization of care’ that paralleled the establishment of tertiary centers influenced the pattern of infants transported, with increases in the number of in – utero transfer, particularly in North America.

In 1966, the first newborn with respiratory distress syndrome was transported to university of California, San Francisco by its NICU staff.

L

evel I [Basic Care] – Relatively minor problems

L

evel II [Speciality Care] – Low birth weight babies (1500 to 2500 gm, 32 to 36 weeks of gestation)

L

evel III [Subspeciality Care] – Maternal and Neonatal those at high risk (less than 1500 gm birth

weight or less than 32 weeks gestation)

1 2 3Basic Specialty Subspecialty

Level I to Level II:Complicated cases not

requiring intensive care.

Level II to Level III:Complicated cases requiring

intensive care. L

abor less than 34 weeks gestation S

evere isoimmune disease S

evere medical complications A

nticipated need for neonatal surgery

Level III to Level II:For growth and development

of infants no longer requiring intensive care.

Reasons for transport

Commonest reason is transport for advanced level of care such a

situation may arise due to non availability of:

Pediatric subspecialty (Neurology, nephrology)

Specific investigation (MRI, 24 hours EEG etc), specific facility

(Advanced ventilation, plasmapheresis or it may be due to non

availability of continuous monitoring in the referring hospital).

Preparation for transport

Each hospital should be ready with plan for transport of

critical child long before such need arises.

Each institute should have list of hospitals in the

surrounding area which offer specialized facility.

Staff:

Call from referral hospital/pediatrician/physician.

Staff should have the ability to assess the need and to perform procedures.

Before leaving, clinically relevant information regarding the patient should be communicated to the receiving unit.

Expected time of arrival should be notified to the receiving unit.

Equipment:

The transport ambulance should be equipped like a mini NICU and should have a vital sign monitor, portable ventilator, resuscitation bags, oxygen, life saving drugs and disposables.

Record:

Before leaving from referring hospital a set of vital signs.

Clinical condition and main interventions

An informed consent

Patient:

The condition of the baby should be assessed before transfer.

a. Airway Stable, if intubated – secured, position confirmed

b. Breathing Well supported, put on transport ventilator and settings confirmed by blood gas

c. Circulation Heart rate and blood pressure controlled, peripheral circulation stable, hemoglobin concentration adequate, blood volume near normal.

d. Metabolic Temperature well maintained, blood glucose, calcium, potassium in normal range

e. Neurology Seizures controlled, raised ICP controlled.

Stabilization during transport

Responsibilities of transport team – stabilization phase

Quick assessment of patient statusStabilization of patient for transportAnticipation of problems likely encountered on

transportSecure all lines and tubesObtain consent and talk to parents/family

Transport is easy if we concentrate on the basics of airway, breathing and circulation and anticipate problems.

Trauma – cervical spine stabilized, pneumothoraces drained, intra – abdominal, intra – thoracic bleeding controlled, intra – abdominal injuries well investigated, long bones/pelvic fractures secured.

Once the transport team has stabilized the child and is ready to move, it has to ensure that the patient is safety moved in and out of the vehicle.

Care and monitoring during transport

Ideally transport vehicles should have monitoring and treatment facilities like those available in PICU. There should be an ongoing monitoring of major organ systems including vital parameters, invasive and non – invasive blood pressure monitoring, end – tidal CO2 temperature, oxygen saturation.

In case an emergency arises it is better to stop transport vehicle and perform stabilization procedures as it is difficult to perform intubation (or) pneumothorax drainage in a moving vehicle.

Responsibilities of transport team – transport phase

Safe movement of patient in and out of vehicle

Ongoing monitoring of major organ systems during transport.

Prompt recognition and treatment of problems on route.

Provision of detailed report to admitting personnel.

Detailed documentation of events during transport.

Handing over the patient

All the reports, x – rays and copies of medical records should be handed over. The changes in clinical scenario and events occurred during the transport should be carefully logged and notified to the physician in tertiary care center.

Communication

Effective communication at all points during transport is the key to a successful retrieval.

The information exchanged in the first communication between the referring and transport teams should be relevant to the transport. That is whether the patient requires critical care transport, how quickly should the team reach the patient; and what equipment is required.

Communication with the family is as important as with the referring and receiving units. Families should receive updates on their child’s condition and directions to the receiving unit.

General curriculum for all transport teams include

Training in:Interpretation of x – raysInterpretation of common laboratory investigations

PharmacotheraphyFluid therapy

Equipment trainingLegal issuesDocumentationInfection controlVehicle safetyPublic relationsContinuous quality improvement

Technical skills

Proficiency in following proceduresEndotracheal intubationBag – mask ventilationIntraosseous line placementDefibrillation and cardioversionAerosol treatmentUse of oxygen therapy devices

Preferred technical skillsCentral venous line placement

Chest tube placement Arterial puncture

Cognitive skills

Ability to recognize and treat:Cardiopulmonary arrestAir leakShockSepsisIntestinal obstruction/perforationBirth injuriesSeizures

Toxic ingestionsAirway obstructionDrowning and other hypoxic ischemic

injuriesMetabolic disordersCongenital heart disease

Status epilepticusStatus asthmaticus

Larger equipmentTransport incubator or stretcher if weight

of patient is >5kgVentilator and humidification apparatus

Monitor:o Heart rate, ECG and respiratory rateo Blood pressure

o Pulse oximeter

o Temperature probe

o Defibrillator, cardioverter infusion pumps with high (1000ml/H) and low (0.1 ml/H) flow.

o Portable oxygen cylinder

Smaller transport equipment (may be packed or placed in a tray)

Various size of

Oral / nasal airway

Laryngeal mask airway

Laryngoscope

Self – inflating resuscitation bag

Endotracheal tubes

Suction catheters

Emergency tracheostomy

set

Intravenous cannulae

Central line sets (double

and triple lumen)

Heparinized saline

Intravenous fluids

Normal saline

Ringers lactate

Dextrose 5%, 10%, 25%

Isolyte P

Various medicationsEpinephrineVolume expandersDopamineSodium bicarbonateNaloxone

Other medicationsEptoinAdrenalineLasixHeparinCalcium gluconate,Potassium chloride

Gas Expansion Insert orogastric or nasogastric tubes open to air in every

infant and in any child who may experience gastrointestinal symptoms or may be at risk for vomiting.

Avoid use of cuffed endotracheal tube. If cuff is used consider using water for filling the cuff.

Ensure that chest tube, endotracheal tubes and other artificial vents are patent.

Suction airway well before and during transportReevaluate for extrapulmonary air. Carry a transillumination

device and have a needle thoracentesis device available.Request if possible to fly at a lower attitude for patients with

trapped gases (pneumothorax, pneumoperitoneum, bowel obstruction)

Decreased partial pressure of oxygen

1. Before leaving the referral hospital

a. Ensure that the child is as optimaaly oxygenated as possible

b. Correlate oxygen saturation with PaO2

c. Check placement and stabilization of the endotracheal tube.2. E

n routea. Increase FiO2 to keep saturation of more than 95%b. FiO2 required can be calculated as follows: FiO2 required = (FiO2 X BP1/BP2) FiO2 = current FiO2 BP1 = current barometric pressure BP2 = altitude barometric pressure

Stresses of flight

Following stresses have been identified by several authors and various organizations.

Hypoxia

Temperature

Dehydration

Noise

Vibration

Fatigue

Fluid leakage out of intravascular spaces

Transport team members are equally affected with these stresses as is patient. Ear plugs and plenty of fluids for the transport personnel and earplugs as a applicable, adequate fluid therapy, close attention to pneumothorax, pneumoperitoneum, warming and extra oxygen can usually overcome these stresses.

Role of nurse in transport

1. The nurse who accompanies in transport of neonates must possess advanced pediatric assessment skills.

2. The nurse should be comfortable with and have significant experience using medications commonly used in a critical care setting.

3. Explanation about the patient condition and need of transport should given to the family members.

4. Before leaving the referring hospital a set of vital signs such as oxygen saturation, heart rate, blood pressure and temperature should be documented.

5. Informed consent should be obtained from parents.

6. Baby should be well covered.

Working condition of the equipment should be assessed and should be prepared for transport.

Condition of the baby during transport should be documented.

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