An Analysis of Air Transport Results in the Sick Newborn Infant: Part I. The Transport Team

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An Analysis

of Air Transport

Results

in the Sick Newborn

Infant:

Part

I. The Transport

Team

MM Gary Pettett, MC, USA, LTC Gerald B. Merenstein, MC, USA, Frederick C.

Battaglia, M.D., L Joseph Butterfield, M.D., and Ruth Efird, R.N.

From the Departments of Pediatrics, Fitzs’imons Army Medical Center and University of Colorado Medical Center, the Newborn Center, Denver Children ‘s Hospital, and the Emergency Air Service, St. Anthony’s

Hospital, Denver

ABSTRACT. Regionalization of neonatal intensive care has necessitated air transport of the critically ill infant in sparsely populated areas. All newborn air transports to four

Denver area newborn intensive-care units over a 14-month

period were reviewed. An emergency-care nurse and a

neonatal intensive-care nurse provided the basic transport

team with physician assistance in selected cases. Infants were

evaluated and stabilized at the referring hospital before

moving the infant. The transports were analyzed for the type

of aircraft utilized, reason for referral, and mortality. The

results indicate that prior planning will permit the use of the

most appropriate aircraft and transport team. When using

well-trained transport personnel, the presence of a physician

may be limited to specific situations without adversely

affecting overall neonatal mortality. Pediatrics, 55:774, 1975,

AIR TRANSPORT, REGIONAL MEDICAL CARE, NEONATOLOGY.

and patient care can occur. In sparsely populated regions, long transport distances may be a neces-sary experience in meeting the needs of patients. The use of properly trained personnel and appro-priate transport equipment can make neonatal mortality independent of distance transported.2’4

The composition of transport teams has not been uniform. Recommendations vary from a nurse, physician (fully trained neonatologist or housestaff officer)6 and inhalation therapist7 to specially trained nurses under the direction of a neonatologist.4 This study was carried out to evaluate some of the criteria of importance in selecting an efficient, yet readily available, trans-port team.

MATERIALS AND METHODS

The development of specialized centers for

neonatal intensive care has brought with it

plan-ning for regionalized care and neonatal transport. While predelivery transport of the high-risk obstetrical patient is the preferred method of transport, this is not always possible. Utilization of transport systems to regional intensive-care

units has been shown to improve neonatal

mortal-ity.5 Location of the regional special-care unit

should be such that it is an integral part of an obstetrical unit and pediatric center to provide needed medical and paramedical expertise.2 Ideally, a major medical center may provide these facilities where integration of teaching, research,

All neonatal air transports to four Denver area newborn intensive-care units (NICUs) over a 14-month period were reviewed. The St. Anthony’s Hospital Emergency Air Service was used for

(Received August 30; revision accepted for publication

November 6, 1974.)

The opinions or assertations contained herein are the private

views of the authors and are not to be construed as official or

as reflecting the views of the Department of the Army or the

Department of Defense.

ADDRESS FOR REPRINTS: (G.B.M.) Chief, Newborn

Service, Fitzsimons Army Medical Center, Denver,

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these transports. The mode of transportation was helicopter (Alouette), fixed-wing propeller (Piper Cherokee, Piper Navajo) or executive jet (Lear). Selection of the aircraft depends upon weather, plane availability, distance, landing facilities at the destination, flying altitude (e.g., pressuriza-lion), number of members on the transport team, and number of patients transported. The heli-copter allows more versatility in mountain terrain and often closer landing to the hospital. However, the fixed-wing aircraft allows for pressurization, more room for personnel and equipment with less noise, and smoother flights at higher altitudes. Personnel for the aircraft were selected from the St. Anthony’s Emergency Care Nurses (ECN), Denver Children’s Hospital NICU nursing

per-sonnel, and physician housestaff of one of the four

Denver NICUs.

The ECNs receive intensive training in both adult and

pediatric

cardiopulmonary care for a period of ten weeks prior to utilization in

trans-port. Bimonthly in-services and case reviews of all

neonatal transports, along with attendance at local high-risk newborn courses, provide for continued training. Experienced NICU nures receive extended training in newborn intensive care, allowing them to perform necessary stabili-zation procedures (e.g., intravenous procedures, umbilical vein catheterization, and intubation).

Physicians were originally selected from the

housestaff

of

the receiving NICU. Currently, the

most senior housestaff officer (PL-3 with newborn

intensive-care experience at both the PL-1 and

PL-2 year) available from a volunteer list at Fitzsimons Army Medical Center is utilized. A neonatologist or neonatal fellow is available on a 24-hour basis to participate in or consult on any

transport. Utilization of senior house officers,

fellows, or a neonatologist began very early in this study. Comparative statistics of mortality rates for other physician attendants are therefore not available. We have found that senior housestaff

officers or subspecialty fellows are better able to

offer adequate consulting advice to referring

physicians and hospital personnel. This augments

ongoing statewide continued education programs for practicing physicians and hospital personnel.

Mobilization of the transport team begins with a call to an NICU from a referring physician. A brief history and summary of the infant’s current status is obtained. The referring physician is then requested to prepare all necessary materials, such as maternal blood, cord blood, chart, and x-rays. St. Anthony’s Emergency Air Transport Service is notified and arrangements are made to assemble the appropriate team members.

The basic team which has evolved during the period of study includes an ECN and NICU nurse. Utilization of physician staff on the team is based on the assessment by the NICU attending

staff of anticipated difficulties from available

information. The ECN may also request physician support.

The equipment used in transport is well outlined elsewhere,8’9 and will not be discussed here. Specific lists may be obtained on written request.

Evaluation and stabilization are carried out by the team at the referring hospital prior to moving

the infant. Consultation with the NICU by phone

or radio is always available. Having the infant

meet the transport team at the landing site is

strongly discouraged. On return, transportation is

via ground ambulance from the airport to the

receiving hospital.

RESULTS

A total of 105 newborns were transported by air to the Denver NICUs between November

1972 and December 1973 inclusive. This

repre-sents approximately 6% of all admissions to the Denver NICUs per year. The referrals originated from 51 different cities and 5 states (Fig. 1). Distribution of these transfers among three of the

NICUs where records were available for review is

shown in Table I. Figure 2 shows the relationship

between the total number of aircraft transports

and the Colorado statewide birth rate (Colorado

State Department of Public Health). While the

general trends of both transports and births tend

to parallel each other, the significant increase in

transports in the latter part of 1973 (P <

.01,

t-test) may also represent community awareness of the transport service as well as the impact of

continuing education programs. The correlation

between transports and the monthly birth rate is very low (r = +0.12).

AIRCRAFT UTILIZED

The criteria for selection of the proper aircraft

have been mentioned previously. Table II

demon-strates that well over one half of all transports

were accomplished by helicopter. Aside from the technical factors involved, the selection of the

proper aircraft is based on continuity of care

without unnecessary interruptions or exposure to

adverse environment. The mere proximity of a

helipad to a hospital cannot be a sole criteria for use of helicopter transport, while ignoring other

previously mentioned considerations. Table III

depicts 68 consecutive air transports between

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FIG. 1. Referral area for neonatal air transport.

NEONATAL AIR TRANSPORTS

TABLE I

(NOVEMBER 1972 TO DECEMBER 1973)

Total

Hospital Transfers % Survivors Deaths % Mortality

FAMC 5 3.9 5 0 0

Denver Children’s 64 62.1 47 17 26.6

UCMC 36 34.0 27 9 25.0

Total 105 100.0 79 26 24.9

differences in time of transport and time of

response are seen only for flights less than 70

miles or greater than 200 miles.

REFERRALS

The most common reasons for referral included

respiratory

distress syndrome (RDS) (4 1%),

prematurity and its attendant complications

(excluding RDS) 10%, congenital heart disease

(7.4%), and hyperbilirubinemia and

gastrointes-tinal dysfunction (5.5% each). Nearly one half of

all referred patients were identified within the

first eight hours of life. Table IV reflects the

frequency with which the various transport teams

were used. On 44% of the flights a physician was

in attendance, on 35% two specially trained

nurses (ECN and/or NICU), and on 21% a single

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OUTCOME

In order to assess the mortality possibly asso-ciated with problems in transport, all infants dying within 24 hours of transport were critically

reviewed for transport-related causes of death.

The fact that a certain portion of the infants died within this period of time after the transport does not necessarily implicate the transport in their death, nor does the fact they survived this period of time after the transport absolve the procedure from possibly contributing to it.

Mortality as a function of birthweight and gestational age is shown in Figure 3. The various teams are keyed with different symbols. Deaths within 24 hours of transport are marked. Not surprisingly, larger birthweight and longer gesta-tion are associated with an

increased

survival rate. Infants dying within 24 hours of transport were significantly smaller (P < .05, t-test) and

‘ younger (P < .01, t-test) than survivors. No

signi-ficant difference for distance

transported

is

seen.

Infants dying after 24 hours were not significantly

TABLE II

AIRCRAFT Uimizt

Aircraft

No. of

Transports % Total

Helicopter Fixed-wing Fixed-wing

(prop) (jet)

63 24 18

59 23 18

Total 105 100

different

from

survivors (P > .05 for weight, gestation, and distance transported, Table V).

Figure 4 shows that 50% of the transferred infants were identified within the first 24 hours of life. Their mortality rate was 30% as opposed to 14% in infants older than 25 hours. The cause of death in the 11 patients dying within 24 hours of transport included one newborn with severe congenital heart disease, one with diaphragmatic hernia, five with severe RDS (four with

intra-cranial

hemorrhage, one with disseminated

TABLE III

METhOD OF TRANSPORT AND TeiE INvoLvED

Data

Less Than 70 to

70 Miles 100 Miles

100 to 150 MIles

150 to

200 Miles

More Than

200 Miles

1. No.oftransports 15 11 17 10 15

2. Aircraft

Helicopter 15 10 13 1 1

Fixed-wing 0 0 3 6 7

Jet 0 1 1 3 7

3. Time in transport with infant on

aircraft (mean) 34.5 min 62.6 mm 80 mm 72.3 mm 99.5 mm

4. Time from referral call to ar-rival of team at referring

hospi-tal (mean) 48.7 min 134.7 min

(2’/4 hr)

143.7 mm

(2 hr 23 mm)

150 mm

(2’Ai hr)

195.5 mm

(3 hr 15 mm)

OP < .05, t-test.

TABLE IV

TRANSPORT TEs.M

No. of

Personnel Transfers % Total Deaths % Mortality

ECN only 22 21.0 3 13.6

Two nurses 37 35.2 1 1 29.7

ECN/physician 46 43.8 12 26.1

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20’

18

Is.

‘4’ 0. SI

12

,- 0

8’

SI

!

z

4,

2’

0’

II

3600

3400

3300

3200

3100

3000

2100

2800

of births per month

ridf

)11

411

aI Au. p OCT N PlC

FIG. 2. Number of neonatal air transports per month and number

(Colorado).

DISCUSSION

NOV OK FIS NM APR NAY

1972 1973 MONTHS

intravascular coagulation, and one with

gram-negative sepsis), two less than 1,000 gm with hypothermic shock, and two with massive meconium aspiration syndrome and gram-nega-five sepsis (Table VI). Careful review of these records revealed no specffic intratransport events or errors in stabilization by the transport team that could be directly related to the infant’s demise.

Transportation of newborn infants to regional care centers has become a key factor in reducing neonatal mortality. Successful outcome depends on proper transport after adequate stabilization.6

Stabilization requires meticulous attention to all

aspects

of supportive care.6’#{176}The personnel util-ized for transport must be well versed in neonatal care with appropriate skills needed to carry out the necessary stabilization. Continued updating of these skills by frequent in-service training sessions and case reviews are essential to good outcome.

A number

of authors

have

described effective transport systems utilizing air transport, but the

personnel used for transport have received only

passing

comment.4’6’7’1113

We have based the transport team on the least number of qualified people needed for each transport. This provides

maximum

efficiency without overcrowding the

transport unit or compromising care of the

trans-ported infant or infants in the NICUs.

Over a 14-month period, 105 infants have been transported via aircraft, utilizing specially trained emergency care nurses and NICU nurses as basic transport personnel. Approximately 70% of these neonates were premature and/or less than 2,500 gm in birthweight, which corresponds with the experience of other transport services.4’6 RDS was the most common referring diagnosis (40.7%), with a mortality rate of 34%. Of the 105 trans-ports, 11 died

within

24 hours of transport for a transport-related mortality rate of 10.5%. This is slightly lower than the 16.5% reported by Cunningham and Smith7 for a similar time period

utilizing a more complex transport team for short

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PRE-TERM

I

WEEKS OF GESTATION

GRAMS

FIG. 3. Newborn transports and deaths by birthweight, gestationab age, and presence of M.D. on transport team.

hours. Only one infant died in transport, a

severely

depressed

infant

with

diaphragmatic

hernia and subarachnoid hemorrhage. The

patient

was essentially refractory to resuscitation, including ventilation with intubation, vascular expansion, and alkali therapy. Two infants weighing less than 1,000 gm were hypothermic,

hypoglycemic, and in shock upon arrival of the

transport team at the referring hospital. While the hypoglycemia was corrected, shock and hypo-thermia proved refractory to vascular expansion, elevated ambient air temperature, heat shield, silver swaddler, and elevated aircraft tempera-hire. The hypothermia in these two infants was probably a significant factor in their deaths. Cyanosis was not an unexpected complication in the single infant with congenital heart disease

affecting pulmonary circulation. Of the five

infants dying with severe RDS, only one required

assisted ventilatory support in transfer (Pao2 of

less than 50 mm Hg in 80% to 100% oxygen, refractory apnea, or CO2 retention resulting in

persistent pHs of less than 7.20). None were

hypoxic upon arrival at the receiving NICU. The

two infants with massive aspiration did not

respond to tracheal aspiration prior to

trans-port.

For transport-related deaths, the most

signifi-cant factors correlated with outcome were

gesta-tional age and birthweight. There was no

differ-ence in the mean age at transport based on

gestational age or birthweight. Hence, reluctance

by the referring physician to transport the smaller

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50’

45

40’

35

3O 25’ 2O

IS

so

0 I

ft1

!-#{149} S-Is IY-z4 54s *-n >72,

v-SOS AOl (NOUNS) 53.8%

FIc. 4. Number of neonatal transports by age in hours and deaths in each group. TABLE V

OUTCOME OF TRANSPORTED INFANTS

Outcome No. Birthweight (gm) Gestational Age (wk) Distance Transfer (Miles)

Survivors 79 2,255 ± 772 34.7 ± 3.6 110.2 ± 87.5

Deaths > 24 hr

after transfer 15 1,828.1 ± 1,055.4 33.2 ± 4.4 160 ± 103.4

Deaths < 24 hr

after transfer 11 1,735.1 ± 965#{176} 31.5 ± 5.Ot 123 ± 65.7$

OP <.05 (t-test).

tP<.01 (t-test). $P >.05

procedures

prior

to transport

were

similar in all cases, although maintenance of temperature in very low birthweight infants in transport was

previously mentioned as a significant problem.

Outcome

was

independent

of

distance

trans-ferred, no matter what the time of death (Table V). Figure 3 shows the number of transports in relation to birthweight, gestational age, and trans-port team. The three blocked groups (I, II and III) are summarized in Table VII. No significant

4

I

difference

is seen

in the number of transports or

deaths

(transport-related

deaths)

with

or without

a physician. The correlation of transport-related deaths with the number of

ffights

without

a

physician on a monthly basis was extremely low (r = +0.007).

Shock, hypoxia, hypothermia or hypoglycemia, though looked for, were not found during or after

transport

beyond

that

mentioned

above,

reflect-ing appropriate attention to stabilization and

TAL TRAMPfl

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support prior to and during newborn transfer. TABLE VI

IMPLICATIONS

Ideal

management

of

the

high-risk

neonate

begins with the earliest identification possible. At present, only 50% of these infants can be iden-tified antepartum.1#{176} Previous authors have shown an improvement in neonatal mortality between hospitals not utilizing a referral system, those utilizing a referral system, and those with intra-mural intensive care units.’3 It therefore becomes

necessary

for centers

supplying

regional

medical

care to provide not only consultative services, but

also adequate transport services, giving the sick

neonate

access

to optimal

medical

care.

Certain-ly, a modern perinatal center should support in

active

fashion

a neonatal

transport

service

with

a

specific transport team as opposed to random

selection

of nurses

and physicians who happen to be available at the time of request for transports.

A

transport team which meets these needs without an extra burden on already busy neonatal

referral

centers

has been

described.

Proper

train-ing, supervision, and a rational approach to the

needs of each individual transport permit the

most appropriate team to be utilized. While no effort was made to review the neonatal mortality rates of referring hospitals in this study, one would hope that this approach to neonatal trans-port would help to narrow further the difference in neonatal mortality between those hospitals referring sick infants and those hospitals with intramural NICUs. While this paper describes a transport system utilizing aircraft, the general

principles

applicable

to the

transport

team

are

not specffic to the mode of transport. We are not

recommending

air

transport

as

a

method

of

choice except as required by terrain or distance.

When rationally approached, neonatal

trans-DEATHS WITHIN 24 HouRs OF TRANSPORT#{176}

No. Cause

1 Triscupid atresia

1 Diaphragmatic hernia

5 Severe RDS; 4 intracranial hemorrhage; 1

DIC; 1 gram-negative sepsis; none hypoxic

on arrival

2 < 1,000 gm were hypothermic; shock prior to

transport; unresponsive to therapy

2 Massive aspiration syndrome with

gram-nega-tive sepsis

#{176}Elevenof 26 deaths (42% of all deaths) < 24 hours

after transport.

port should lower neonatal mortality in referring

hospitals, not subject the sick infant to undue or

unnecessary risk, and the outcome should be

independent of distance transported. In order to

achieve these goals, an active, closely monitored, and properly staffed program specifically tailored to this need is recommended. The program must have retrospective case reviews, regular in-service education, on-the-job case discussions with the receiving hospital physicians to outline treatment plans, and on-the-job training by physi-cians when they are members of the transport team. The transport team should include properly trained emergency-care and neonatal intensive-care nurses. Utilization of a physician should reflect the needs of each specific case (e.g.,

assisted ventilation, multiple births, very low

birthweight infant [< 1,200 gm}, very premature [< 32 weeks gestational age]). Physicians utilized for this service need to be familiar with both newborn intensive care and transport support of the critically ill neonate.

TABLE VII

TRANSPORT-RELATED DEATHS, TRANSPORT TEAM, AND BIRTHWEIGHT AND GESTATIONAL AGE

Group#{176}

Total Transports

T ransports With M.D.

-Transports Withou

-t M.D.

No. Deaths % Mortality

No. Deaths

-% Mortality

I 47 19 4 21 28 5 17.2

II 34 17 0 0 17 2 11.7

III 20

bit

7 0

14.3 ± 5.2$ 1.3 ± 1.9$

0

9.3

13

19.3 ± 6.9$

1

2.7 ± 1.7$

7.7

13.7

#{176}SeeFigure 3.

tFour charts without record of team.

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REFERENCES

1. Usher, R. H.: The role of the neonatologist. Pediatr.

Clin. North Am., 17:199, 1970.

2. Swyer, P. R.: The regional organization of special care for the neonate. Pediatr. Clin. North Am., 17:761,

1970.

3. Scott, K. E.: Report of the committee on maternal and perinatal health of the province of Nova Scotia.

N.S. Med. Bull., 49:91, 1970.

4. Meyer, H. B. P., et al.: A regional system for transport of sick neonates in Arizona. Read before the Society for Pediatric Research, Atlantic City, New Jersey, April 1971.

5. Ellis, W. : The regional newborn center: The effect on neonatal mortality of referring hospitals. Presented at the annual meeting of the Medical Society of New Jersey, Atlantic City, May 6, 1972.

6. Stoirs, C. N., and Taylor, M. R.: Transport of sick

newborn babies. Br. Med. J., 3:328, 1970.

7. Cunningham, M. D., and Smith, F. R.: Stabilization and transport of severely ill infants. Pediatr. Clin. North

Am., 20:359, 1973.

8. Segal, S.: Transport of High-Risk Newborns. Canadian Paediatnc Society, 1972.

9. Committee on Fetus and Newborn: Hospital Care of

Newborn Infants, ed. 5. Evanston, Illinois: Amer-ican Academy of Pediatrics, 1972.

10. Klaus, M. H., and Fararoff, A. A.: Care of the High-Risk Neonate. Philadelphia: W.B. Saunders Co., 1973. 11. Shepard, K.: Air transportation of high-risk infants

utilizing a flying intensive care nursery. J. Pediatr.,

Th148, 1970.

12. Neonatal ICU reaches out via airlift. Hosp. Pract., 7: 115: 1972.

13. Amile, R., et al.: Transport of critically ill neonates to a regional medical center. Clin. Res., 22:237A, 1974.

WHAT

IS A GOOD

DOCTOR?

The issue of what makes a good doctor has perplexed men for a long time. To

all of the other characteristics Reinhard’ has added the quality of having

suffered himself in order to achieve empathy with his patients. He says, “...

healing in its broader context of restoring a sick and distraught person to

wholeness, requires a physician who has himself suffered, as only then can he

really understand and experience the suffering of others.”

REFERENCE

1. Reinhard, E. H.: Medicine and the crisis in confidence.

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1975;55;774

Pediatrics

Efird

Gary Pettett, Gerald B. Merenstein, Frederick C. Battaglia, L. Joseph Butterfield and Ruth

Transport Team

An Analysis of Air Transport Results in the Sick Newborn Infant: Part I. The

Services

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