Neonatal Critical Care Transport Research Articles

A national retrospective review of neonatal critical care transfers in dedicated critical care transport services in the private sector

South Africa (SA) has a shortage of dedicated neonatal critical care services, which are mostly concentrated in urban areas, thus illustrating the need for neonatal critical care transport (CCT) services. Neonates who are transported by teams without the requisite experience and knowledge in neonatal care are at risk of severe adverse events during transport. This has led to the development of dedicated CCT teams by some emergency medical services. There is a paucity of national literature describing the neonatal population who undergo CCT in dedicated services.To describe a sample of neonates who underwent CCT transfer by dedicated CCT services in the private sector in SA.This observational cohort study with a retrospective descriptive design sampled all neonatal transfers completed during 1 year (1 January 2017 - 31 December 2017) from the dedicated CCT of the two largest national emergency medical services in SA. Data were extracted from patient report forms by trained data extractors, and subjected to descriptive analysis.A total of 444 neonates were transferred between the two services. A total of 760 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent diagnosis was respiratory distress syndrome (n=139, 31%), followed by congenital heart defects (n=123, 28%) and prematurity (n=81, 18%). Patients had an average of ~4 attachments, with the most prevalent being patient monitoring (n=677, 152%). Just under half (n=182, 41%) of patients required ventilatory support. A total of 422 medications were required during transport, yielding a rate of ~1 medication or infusion per neonate transported. The most common infusion was maintenance (n=199, 45%), while almost 1 in 10 neonates required inotropic support (n=33, 7%).This study provides insight into the demographics, most prevalent diagnoses, and interfacility transfer monitoring needs of neonates being transported in SA by two private dedicated CCT services. The results of this study should be used to inform future specialised neonatal CCT courses and qualifications, as well as the scopes of practice of providers transporting neonates.

New Formula for Nasal Endotracheal Intubation in Extremely Low–Birth Weight Infants in the Emergency Transport Setting: The “Genoa Formula”

ObjectiveThe purpose of this study was to find a predictive equation for estimating the optimal nasal endotracheal tube insertion depth in extremely low–birth weight infants (ELBWs) requiring invasive ventilation in the critical care interfacility transport setting. MethodsWe retrospectively calculated the optimal tube insertion depth in a cohort of neonates ≤ 1,000 g born at our neonatal intensive care unit and nasally intubated within the first 24 hours of life from January 2019 to May 2020. ResultsA total of 75 ELBW infants were included, with a median gestational age of 26.6 weeks (range, 22.1-32.6 weeks) and a median birth weight of 780 g (range, 410-990 g). The linear regression of the estimated optimal endotracheal tube insertion depth showed a good correlation when plotted against weight (R2 = 0.491); thus, a new weight-based formula was obtained. ConclusionThe proposed weight-based formula (the “Genoa formula”) may help in predicting optimal insertion depths for nasal intubation in ELBW neonates, especially when a prompt radiologic confirmation of the tube position is not available, as during neonatal critical care transport.

A Novel Simulation Based Method For Training Pediatric & Neonatal Critical Care Transport Teams

A Novel Simulation Based Method For Training Pediatric & Neonatal Critical Care Transport Teams

A Pediatric and Neonatal Critical Care Transport Team’s Standard of Care for Suspected Stroke of a Pediatric Patient

BACKGROUND A 314 bed free standing Children’s Hospital is the region’s first and only dedicated pediatric stroke center offering comprehensive, individualized treatment protocols for children (Children’s Mercy, 2018). The WHO estimates 1-2/210,000 children will have a stroke. Mortality is 2-11% but persistent neurological deficit will occur in 68-73% of children who experience a stroke (Bernard Ann Neurol 2008). “Recognition and early intervention are critical to minimizing brain damage” (Mutka Sharma, MD). Depending on the length of time since the stroke, treatment options …

A Novel Simulation Based Method For Training Pediatric & Neonatal Critical Care Transport Teams

Background: Critically ill pediatric patients often require care in tertiary/quaternary institutions, necessitating transport from community hospitals to these specialized centers. Such inter-facility transport is accomplished using specially trained critical care transport teams. These teams manage and support critically children in a resource limited environment prior to the stabilization that advanced ICU care can provide. Because support on transport impacts both short- and long-term outcomes for these patients, ongoing training is essential and …

A Pediatric and Neonatal Critical Care Transport Team’s Standard of Care for Suspected Stroke of a Pediatric Patient

A Pediatric and Neonatal Critical Care Transport Team’s Standard of Care for Suspected Stroke of a Pediatric Patient

Noninvasive Ventilation During Pediatric and Neonatal Critical Care Transport: A Systematic Review*

Noninvasive ventilation is increasingly used in neonatal and pediatric patients, but the intensive care transport setting is lagging in terms of availability of noninvasive ventilation for children. The objective of this systematic review of the literature was to answer the question: In children 0 days to 18 years old, who are hospitalized with acute respiratory distress and require critical care transport, is noninvasive ventilation effective and safe during transport? MEDLINE via PubMed, EMBASE (via Scopus), Cochrane Central Register of Controlled Trials, African Index Medicus, Web of Science Citation Index, and the World Health Organization Trials Registry. Two reviewers independently reviewed all identified studies for eligibility and quality. Data were extracted independently by two reviewers using piloted data extraction forms. Data were not synthesized due to nature of studies included. A total of 1,287 records were identified; no randomized or quasi-randomized controlled trials were found. Eight observational studies, enrolling 858 patients were included, of these 60.4% were neonatal ICU and 39.6% were nonneonatal ICU patient transports. The mode of noninvasive ventilation during transport was continuous positive airway pressure in seven studies (708 patients) and high-flow nasal cannula in one study (150 patients). During transport on noninvasive ventilation, three of 858 patients (0.4%) required either intubation or escalation of noninvasive ventilation. In the 24 hours following transfer, 63 of 650 children (10%) transferred on noninvasive ventilation were intubated. The odds of intubation within 24 hours were significantly higher for continuous positive airway pressure transfer 60 of 500 (12%) compared with high-flow nasal cannula three of 150 (2%): odds ratio (95% CI) 6.68 (2.40-18.63), p value equals to 0.00003. Minor adverse events occurred in 1-4% of noninvasive ventilation transports. This review found observational study evidence of a rate of intubation or escalation of 0.4% during noninvasive ventilation transport of children 0-18 years old, with an in-transport adverse event rate of 1-4%. Further studies are required. If randomized trials are not possible, it is suggested that well-conducted observational studies are reported in a more standardized manner.

A Pediatric and Neonatal Critical Care Transport Team's Standard of Care for Suspected Stroke of a Pediatric Patient

Background A 314 bed free standing Children's Hospital is the region's first and only dedicated pediatric stroke center offering comprehensive, individualized treatment protocols for children (Children's Mercy, 2018). The WHO estimates 1-2/210,000 children will have a stroke. Mortality is 2-11% but persistent neurological deficit will occur in 68-73% of children who experience a stroke (Bernard Ann Neurol 2008). Recognition and early intervention are critical to minimizing brain damage (Mutka Sharma, MD). Depending on the length of time since the stroke, treatment options can vary. Rapid identification and treatment can be lifesaving and/or potentially improve neurologic outcomes (Children's Mercy 2018). Objectives To provide a Pediatric and Neonatal Critical Care Transport team the training, job aides and standardization for the recognition and treatment of a pediatric patient with stroke symptoms requiring transport to a Pediatric Stroke Center. ●Identify pediatric patients with symptoms concerning for stroke ●Initiate a Stroke Alert Protocol if child has focal neurologic deficit and meets criteria for activation ●Aid in the pre Pediatric Stroke Center triage process and stroke evaluation ●Provide rapid assessment, stabilization, and transport of children with stroke-like symptoms to pediatric center ●Initiate neuroprotective measures designed to minimize secondary neurologic injury IMPLEMENTATION ●Clinical Practice Guideline ●Suspected Stroke Checklist ●tPA Administration and Monitoring Guidelines Results Because symptoms of a pediatric ischemic stroke can vary greatly from an adult ischemic stroke, our Critical Care Transport Team is specially trained and prepared to transport a pediatric patient with stroke symptoms from anywhere in the area. If a pediatric ischemic stroke is suspected by a referral and/or our transport team, our collaborative team of Medical Control Physicians (MCP), Transport Personnel, Referral Physicians and Emergency Room Physicians are all specially trained to activate our stroke protocol immediately should a patient present with stroke symptoms. Since implementation we have transported and treated 2 patients with basilar artery stroke. Both patients had successful clot retrieval and full neurological recovery! Several other critical diagnosis as a result of being a stroke mimicker were made during the stroke alert and/or stroke activation procedure including brain tumor, HSV encephalitis, brain abscess, Schawannoma and Moya Moya disease. Conclusion There has been an increase in rapid diagnosis, early recognition and treatment of pediatric patients with acute ischemic stroke and other stroke mimickers that required emergent intervention following implementation of our Stroke Alert Protocol, Clinical Practice Guideline, Suspected Stroke Checklist and tPA Administration and monitoring Guideline for Pediatric and Neonatal Critical Care Transport.

Development of a novel reference nomogram for endotracheal intubation in neonatal emergency transport setting.

Neonatal endotracheal intubation is a challenging procedure during transport. The aim of this study was to evaluate the effectiveness of the emergency intubation guidelines followed by our Neonatal Emergency Transport Service (NETS). Our transport intubation guidelines follows a weight-based nomogram for nasal intubation, and the tube position is clinically verified after intubation, while the postintubation chest X-ray is postponed to Neonatal Intensive Care Unit (NICU) admission. Data on postnatal age, weight and tube insertion depth were obtained from the online NETS clinical database, and the postintubation chest X-ray images were assessed. During the study period, 161 newborn infants were nasally intubated during transport, and received a postintubation radiograph at NICU admission. A total of 130 neonates (80.7%) had the endotracheal tube (ETT) correctly positioned between T1 and T2 vertebrae, while 12 (7.5%) was at C7 vertebrae level and 19 (11.8%) at T3. No patients had ETT tip positioned at T4 vertebrae level or below. No adverse events related to intubation were observed. Our intubation procedure showed a good reliability and safety in neonatal critical care transport, although chest X-ray to confirm the tube placement is postponed to NICU arrival. Based on our results, we suggest a revised version of weight-based nomogram for nasal intubation.

Benchmarking Pain Assessment Rate in Critical Care Transport

The purpose of this study is to determine the rate of pain assessment in pediatric neonatal critical care transport (PNCCT). The GAMUT database was interrogated for an 18-month period and excluded programs with less than 10% pediatric or neonatal patient contacts and less than 3 months of any metric data reporting during the study period. We hypothesized pain assessment during PNCCT is superior to prehospital pain assessment rates, although inferior to in-hospital rates. Sixty-two programs representing 104,445 patient contacts were analyzed. A total of 21,693 (20.8%) patients were reported to have a documented pain assessment. Subanalysis identified 17 of the 62 programs consistently reporting pain assessments. This group accounted for 24,599 patients and included 7,273 (29.6%) neonatal, 12,655 (51.5%) pediatric, and 4,664 (19.0%) adult patients. Among these programs, the benchmark rate of pain assessment was 90.0%. Our analysis shows a rate below emergency medical services and consistent with published hospital rates of pain assessment. Poor rates of tracking of this metric among participating programs was noted, suggesting an opportunity to investigate the barriers to documentation and reporting of pain assessments in PNCCT and a potential quality improvement initiative.

Improving Standardized Hand-Off Communication Through Education for a Pediatric Neonatal Critical Care Transport Team

Introduction: The Critical Care Transport Team at University of California Davis Medical Center Children's Hospital provides safe and expedient transport of critically ill children and neonates through collaboration with a Pediatric or Neonatal ICU attending physician (MCP). Clear and concise communication is essential in the care of these fragile patients. According to JCAHO, a standardized hand-off communication tool is necessary. It was determined that there was a need for a practice change and therefore an educational quality improvement project was initiated.

Intubation in Pediatric/Neonatal Critical Care Transport: National Performance

Background: There are nearly 200,000 US infants/children transported annually for specialty care and there are no published best practices in transport intubation. Objective: Respiratory interventions are a priority in pediatric and neonatal critical care transport (PNCCT). A recent Delphi study identified intubation performance as an important PNCCT quality metric, though data are insufficient. The objective of the study is to determine multi-center rates of first attempt intubation success in pediatric/neonatal transport and identify practice processes associated with higher performing centers. Methods: Retrospective chart review where data was collected from the 9 participating centers over a 6-month period from January–June 2013. Data describing intubation training and practices were gathered using SurveyMonkey® (Palo Alto, CA). Data were tabulated in Microsoft Excel (Redmond, WA) and analyzed using descriptive statistics. Through the determination of 1st intubation success rate across multiple pediatric/neonatal critical care transport programs, we hypothesized that the features of higher and lower performing centers can be identified to inform practice. Results: 9 of 14 invited institutions participated. The median (IQR) 6-month transport volume for neonates(neo) was 289(35-646) and pediatric (ped) 510(122-831). On average, 7%(+/−3.0) of neo and 1.6%(+/−0.7) of ped transport patients required intubation. Individual centers had their initial success rate calculated and a 95% confidence interval was determined for those centers satisfying the np > 5 and n(1-p) > 5 sample size requirement for normality assumption of proportions. Since the overall success rate was 64%, it was determined that n = 14 initial intubation attempts would be the minimum number needed per center in order to fulfill the sample size requirement for normality assumption. Centers whose 95% confidence interval did not contain the initial overall success rate were identified. Conclusion: This represents the first multi-center neo/ped intubation dataset in PNCCT. First attempt intubation success lags behind reported anesthesia intubation rates but parallels pediatric emergency department intubation success rates. Training and operational processes are variable in PNCCT, though top performing teams require live-patient intubation success to achieve initial intubation competency.

Measure, Report, Improve: The Quest for Best Practices for High-Quality Care in Critical Care Transport

There has been increasing attention nationally to the quality of care provided by critical care transport teams. Much of this has been fostered by benchmarking work done in overlapping fields of medicine. Another important catalyst has been the landmark work by the Institute of Medicine— Crossing the Quality Chasm . Organizations such as the Cystic Fibrosis Foundation have mature and transparent processes for measuring quality of care at different hospital systems, allowing these programs to compare themselves to others and learn from the high performers. The field of pediatric and neonatal critical care transport strives to do the same but has only recently begun to develop the performance measures and benchmarking strategies necessary to do this work. This article describes examples of quality improvement measurement and benchmarking, reviews important concepts related to continuous quality improvement, and introduces the reader to the consensus quality metrics established by the Ohio Neonatal/Pediatric Transport Quality Improvement Collaborative and by the American Academy of Pediatrics' Section on Transport Medicine.

The Impact of Postintubation Chest Radiograph During Pediatric and Neonatal Critical Care Transport

Tracheal intubation is necessary in the setting of pediatric/neonatal critical care transport but information regarding usefulness and efficiency of a confirmatory postintubation chest radiograph is limited. We hypothesize that routine postintubation chest radiograph to confirm tracheal tube position is not informative and can be eliminated to improve efficiency without compromising safety in transport. This was a prospective observational study. The primary study outcome was the rate of tracheal tube repositioning after postintubation chest radiograph and the secondary outcome was the on-scene time. Additional data obtained included the initial accuracy of tracheal tube depth based on Pediatric Advanced Life Support and Neonatal Resuscitation Program guidelines. A children's hospital-based pediatric/neonatal critical care transport team in northeastern Ohio. All pediatric/neonatal patients intubated by the transport team during the 18-month study period (January 2009-July 2010). There were 77 patients enrolled (43 pediatric, 34 neonatal). A postintubation chest radiograph was obtained 85.7% of the time and showed tracheal tube malposition in 47% of cases. No difference was seen in the rate of malpositioned tracheal tubes in the neonatal group compared with pediatric group (51.7% vs. 43.2%, p = 0.54). The calculated tracheal tube depth based on the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines was correct in 50% of the neonates and 41.9% of the pediatric patients. In patients with appropriate initial tracheal tube depth by calculations, the tracheal tube was repositioned at similar rates after postintubation chest radiograph in both neonatal and pediatric patients (50% vs. 41.9%, p = 0.48). When comparing mean onscene times for patients with/without a postintubation chest radiograph, the neonatal patients saved 33 minutes on average when no chest radiograph was obtained (mean ± sd: 60.6 ± 35.8 min vs. 93.8 ± 23.8 min, p = 0.01). There was no statistical difference in on-scene time for pediatric patients whether they did or did not receive a postintubation chest radiograph. Although postintubation chest radiographs may extend the overall on-scene transport times in select patients, our data show that the postintubation chest radiographs remain informative in pediatric/neonatal critical care specialty transport and should be obtained when feasible.

Pediatric and Neonatal Interfacility Transport Medicine After Mass Casualty Incidents

Pediatric and neonatal interfacility transport medicine is a relatively young but a rapidly evolving specialty. Transport teams are essential for the safe interfacility movement of critically ill patients. A mass casualty incident (MCI) can present major challenges for a critical care transport team. This article will examine the capabilities and limitations of pediatric and neonatal critical care transport teams. The predicaments brought about by Hurricane Katrina that hindered the evacuation of pediatric and neonatal patients out of ravaged hospitals are also reviewed. From these experiences, recommendations to improve the efficiency and efficacy of interfacility transport of pediatric patients will be presented.

Pediatric and neonatal critical care transport: A comparison of therapeutic interventions

To compare the therapeutic interventions provided to newborn and pediatric patients by a dedicated combined neonatal pediatric critical care transport team. From November 1987 through December 1989 we prospectively compared the number of therapeutic interventions performed by the critical care transport team on newborns and pediatric patients. The transport team (critical care physician [PL3 or greater], pediatric respiratory therapist, critical care nurse), recorded all therapeutic interventions, including both procedural and pharmacologic, for 213 newborn and 149 pediatric consecutive transports. Data were analyzed by analysis of variance or chi 2 statistic. All patients were admitted to either the pediatric or the neonatal intensive care unit, and over 80% of both age groups received assisted ventilation. Newborns commonly suffered from respiratory diseases (159/213), while pediatric patients suffered from respiratory (52/149), central nervous system (28/149), and traumatic conditions (37/149). Airway maintenance procedural interventions (intubation, ventilation) were the commonest in both groups, although more frequent in neonates. Neonates received antibiotics and morphine (P < 0.05) while pediatric patients received anticonvulsants and respiratory drugs (P < 0.05) more frequently. Newborns received significantly more interventions than pediatric patients (average 3.56 vs 2.93, P < 0.05). Newborns also received significantly more procedural interventions (2.06 vs 1.36, P = < 0.05) including intubation (34.7% vs 15.4%, P < 0.05) and the initiation of mechanical ventilation (38% vs 22%, P < 0.05). Overall, newborns received more interventions, including intubation, and ventilation from the transport team than did pediatric patients. Our data suggest that combined pediatric neonatal transport teams should be prepared to intervene in a wide range of conditions from preterm respiratory distress to the multiply traumatized adolescent.