Medical Insight: Neonatal patient transport

Copyright EMBRACE
Ian Braithwaite and Dr Cath Harrison, both members of The Yorkshire and Humber Infant and Children’s Transport Service (Embrace), discuss the requirements of neonatal air transportation, outlining some of the conditions and factors which affect the systems already in place
 
Transporting neonatal patients by air 
Neonatal transport is common in the UK. Around 15,000 babies move between UK hospitals each year, the majority by road1. A baby born prematurely may not necessarily be unwell, but may require an increased level of support which cannot be provided locally. Where possible, high-risk pregnancies are managed in tertiary centres with neonatal intensive care facilities, usually located in major cities. If babies are delivered in local district hospitals, they may require transport to specialist centres where they can receive life-saving therapies. An otherwise normal pregnancy may proceed uneventfully but during or shortly after birth, problems may become apparent requiring specialist input. Some congenital defects, such as some disorders of the heart or metabolism, are challenging or sometimes impossible to detect by antenatal screening and only become evident after birth, where the appropriate treatment centre and the patient are separated by distance. After appropriate and specialist treatment, once medically and socially able, the health system may organise repatriation of the baby back to their local hospital, for care to be continued closer to home. This article will focus on the baby who requires a flight transport between healthcare facilities rather than the child who is born compromised outside hospital and requires a primary response.
 
In the UK, only around one per cent of all neonatal transports are performed by air
 
Why fly?
Although the majority of babies moved by the authors’ transport service go by road, any of our patients may be flown if they need definitive emergency treatment within a specific time window, or when their clinical condition requires the journey time to be minimised. Journey times have the potential to be extended if there is no local bed or specialist treatment availability and if the service needs to transfer patients out of their normal geographical region. When done by road, these journeys can be physiologically demanding for the patients and logistically complex for the transport service; air transport can make these transfers much easier and quicker. Location plays a part too; international and over-water flights are usually always considered for air transport. Around the world, differences in geography and healthcare organisation lead to global variations in neonatal air transportation. In the UK, only around one per cent of all neonatal transports are performed by air1. Both authors have previously worked in Australia where, in contrast, air transport accounts for an estimated 30 per cent of neonatal transfers2.
 
Rotary and fixed wing
The choice between rotary and fixed-wing may be a pragmatic one based on the aircraft and experience available, the route and the weather. The importance of infrastructure cannot be underestimated – if the helicopter landing sites require secondary road transport, the team is faced with a longer, more complicated transfer, which reduces the utility of air transport. The number of hospitals in the UK with on-site helicopter landing sites are increasing – thanks in no small part to the efforts of the HELP Appeal: a UK based charity supporting hospital helipad development3 – yet still remain a relative rarity. In other countries such as Australia, the helipad infrastructure is more advanced. In a remote and rural context, fixed-wing aircraft may be the primary transport vehicle. However, they may not start to demonstrate benefit for neonatal transport until the destinations are at least 200 miles apart (depending on how close to the airports the hospitals are).
 
patient care may be provided by a generalist medical flight crew who are experts in flight medicine and familiar with the aviation environment. These personnel would have received additional training to facilitate the safe transfer of neonatal patients
 
Service models
Globally, excepting the occasional neonatal transport service that operates both their own aircraft and medical teams, a clear division in organisation falls between the use of specialist and non-specialist teams to move patients. Specialist teams are dedicated neonatal transport services that provide occasional air transport alongside predominantly ground-based transfers. Medical teams undergo regular training and familiarisation with an air operator, but are classed as medical passengers for the flight, with no aviation responsibilities. Team members would replace or supplement the air operator’s regular medical crew for the journey.  
Alternatively, patient care may be provided by a generalist medical flight crew who are experts in flight medicine and familiar with the aviation environment. These personnel would have received additional training to facilitate the safe transfer of neonatal patients.
Local circumstances will dictate the choice between the model used, and it will always be a balance between aviation and neonatal experience. Despite training and competency challenges for both models, either can provide safe and effective care. Accreditation with an organisation that has standards for neonatal transport is a useful way of demonstrating a commitment to safety and quality. In the UK, NHS commissioned, geographical neonatal transport services have agreed a set of standards for the transport of the neonatal patient by air. Due to the small numbers of neonatal air transports undertaken, the need to benchmark services against other providers increases in importance. The Ground Air Medical qUality Improvement Collaborative (GAMUT) database is another governance tool allowing international comparisons on agreed performance indicators4. 
Neonates should not be considered small children, or even tiny adults – they are physiologically distinct and physically fragile. The premature infant requires a stable environment in the hospital setting that takes huge effort to replicate in the air. The integration of their required medical equipment into an appropriate flight-worthy system is a challenge. The appropriate composition, training and experience of the medical team is crucial, especially if neonatal transport is considered a low-frequency, high-risk event in your context. When undertaking neonatal air transfers we must strive to match the quality and characteristics of the care the patient receives on ground transfers. 
 
Equipment
The scope of neonates that may be transported by air may range from the term infant with an isolated medical complaint, who can feed and receive cuddles in the air, to the extreme premature baby who weighs less than 500 grams, and requires complex and intensive support. The catalogue of equipment available to a neonatal transport team overlaps with that routinely taken for adult transports, but the technology required for some neonates can seem out of proportion with the tiny patient that it surrounds. The best equipment available on a neonatal intensive care unit may not be appropriate for the transport environment in terms of size, weight, power requirements, medical gas usage or fixation. 
Babies are a vulnerable group requiring protection from their surroundings. A warm environment is critical, especially given the exposed nature of landing sites – all but the most robust infants will require some type of incubator. A lightweight, carbon fibre ‘pod’ is a popular choice for babies weighing over two kilograms, which is supplemented with electrical or chemical warming technology. For smaller babies, a more complex incubator becomes necessary: one that can maintain a warm, humid environment irrespective of the external climate. This complexity comes at the price of weight and power requirement, ruling out many smaller airframes as being suitable for neonatal transport. An appropriate means of patient restraint is an essential component of any transport system and is no different for neonates. This requirement generally precludes the possibility of transporting twins inside one incubator (certainly in the UK). However, this may be the only option available in some international situations, depending on local resources. 
 
A capable ventilator is also essential – one that offers intelligent support to the smallest lungs
 
A capable ventilator is also essential – one that offers intelligent support to the smallest lungs. It is desirable to have a means of actively heating and humidifying the inspired gas. This is essential when non-invasive respiratory support modes such as High Flow or Continuous Positive Airway Pressure (CPAP) are used. High concentrations of oxygen in the youngest and smallest neonates can lead to over-vascularisation of the retina, with long term visual complications. Therefore, all modes of ventilation and resuscitation must be available with variable oxygen concentrations. This may require pressurised air cylinders or a compressor, both of which add weight and complexity to the transport system. 
Neonatal medication volumes are tiny in comparison to adult therapies. Fluids require precise and measured dosing, so it is not acceptable to hang a bag of intravenous fluid up and allow gravity to deliver it to the patient. The number of medical devices – such as syringe pumps – required for a sick infant often seems to be inversely proportional to their weight. Safely securing these to a stretcher is a design and certification challenge.
 
Forces
It must be assumed that neonates are at least as susceptible to the physical forces experienced in transport as adults – potentially more susceptible. Practitioners should consider how acceleration and vibration forces of all modes of transport might affect their patients. Acceleration forces in a helicopter are lower than those experienced in road transport or a fixed-wing take-off and landing, but the vibration exposure is greater. The dose of forces that is acceptable to patients is a complex equation to which there is no easy guide. The greater noise and vibration amplitudes of air transport must be balanced against shorter journey times, and thus reduced period of exposure. 
Pilots should consider how they can minimise the effects of vibration and acceleration on their charges through judicious choice of flight routing, cruise speed and take-off and landing profiles. These variables should be discussed with the medical crew with the aim of optimising the patient’s comfort. Every effort should be made to load and unload the patient in sheltered conditions – such as in a hangar, if at an airport. The next development in transport research and equipment design will hopefully involve mitigating the physical effects of the journey on these vulnerable patients. Vibration damping and hearing protection tailored to the most vulnerable patients would be high on most flight teams’ wish-list. 
 
an aspect of neonatal transport that must not be overlooked is their family
 
Family
Finally, an aspect of neonatal transport that must not be overlooked is their family. There are often two patients to consider; the mother and the baby. Mothers may be unwell post-delivery and also require transfer. In a remote setting, the transport system may be configured for mother and baby to be flown in the same vehicle. Alternatively, a return trip or additional resource may be required; family separation, especially soon after birth, should be minimised. Where this cannot be avoided, information about the medical condition, the journey and the destination hospital should be provided. 
The transportation of neonatal patients by air is challenging. It relies on the right combination of airframe and equipment, as the sickest and smallest of these patients can present considerable technical challenges; they also demand a high level of training and experience from those on the transport team. The care of neonates in the air requires a distinct mix of aviation and medical skills that should work together to make the transition from hospital, to aircraft, to hospital as smooth and uneventful as possible.

About the authors
Ian Braithwaite (MSc BEng RN(CH))
Ian has been a children's transport nurse for 16 years. He is currently a Nurse Educator at Embrace, the Yorkshire and Humber Infant and Children's Transport Service. He is involved nationally in promoting best practice and assisting services with development of their paediatric and neonatal flight programmes. 
Dr Cath Harrison (BM BS BMedSci DTM&H MRCP FRCPCH)
Cath Harrison has been a consultant neonatologist in Leeds since 2004, with training and experience from the UK, Australia and South Africa. She is the lead neonatologist for Embrace, a combined neonatal and paediatric transfer service in the UK, carrying out both road and air transfers. Prior to the setting up of Embrace in 2009, she was the lead clinician for the Yorkshire Neonatal Network Transport Service. In this role she was involved in the design, development and introduction of Embrace and currently works for the service in both a clinical and managerial role, leading on quality improvement and research. 

Resources

1.Data from the UK Transport Interest Group - ukntg.net
2. Estimate extrapolated from data obtained from www.nets.org.au
3. helpappeal.org.uk 
4. gamutqi.org 
 
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