Chakradhar Maddela*
Neonatologist, Department of Neonatology, ESIC Medical College, Hyderabad, Telangana, India.
*Corresponding Author: Chakradhar Maddela, Neonatologist, Department of Neonatology, ESIC Medical College, Hyderabad, Telangana, India.
DOI: 10.31080/ASPE.2022.05.0505
Received: February 14, 2022; Published: February 25, 2022
Citation: Chakradhar Maddela. “Organization of Neonatal Transport Service with Regional Perspective - Review Article”. Acta Scientific Paediatrics 5.3 (2022): 19-24.
Neonatal transport system is primitive in India. High risk deliveries are not always anticipated. Many sick neonates are transferred to higher care centre by attendants on two wheelers, three wheelers, vans, buses, and ill-equipped general ambulances. As a result of which, these sick babies are prone to develop morbidities like hypothermia, hypoglycemia, hypoxaemia, hyper-carbia and multi organ dysfunction even when they reached higher care centre. This may result in higher morbidity and mortality leading to high infant mortality. Hence, there is an urgent necessity to establish dedicated neonatal transport service system in the country. Organized patient transport system always yields better health outcomes than self-transport system.
Keywords: High-Risk New-Born; Neonatal Transport Service; Organization.
ASHA: Accredited Social Health Activist; BP: Blood Pressure; CPAP: Continuous Positive Airway Pressure; EMRI: Emergency Management and Research Institute; IMR: Infant Mortality Rate; INR: Indian Rupee; MRI: Magnetic Resonance Imaging; NMR: Neonatal Mortality Rate; NTS: Neonatal Transport Service; NICU: Neonatal Intensive Care Unit; PDF: Portable Document Format.
India has got still high infant mortality rate (IMR) - 29/1000 live births in 2021, when compared to western countries (figure of < 6/1000 births). Neonatal deaths contribute to two thirds of the IMR and most neonates are dying during 1st week of life [1]. Neonatal mortality rate (NMR) in India is 20.4/1000 live birth in 2020, Unicef data (IMR 34/1000 in 2016) [2]. This reflects the existing perinatal care and services in the country. The figures are better in some states especially in south states. Delivery of high-risk pregnancies should occur at tertiary care hospital for better perinatal like premature births. Hence, there is need of neonatal transfer from primary care centre to tertiary care centre through neonatal transport system (NTS).
Dedicated NTS does not exist in public sector at our place. Our main transport system is by road transport with 108 EMRI ambulances [3]. It is the one for all types of patients. Many babies are transferred by two wheelers (10-25 km), car, van, jeep and ill-equipped private ambulances. These high-risk babies are succumbing to develop hypothermia, hypoglycaemia, hypoxia and hypotension during neonatal transfer and contribute to significant neonatal morbidity and mortality even when they reached tertiary care centre. Organized transport showed better neonatal outcome than self-transport [4].
Our place is situated on national highway 62 with twin towns, Korutla and Metpally (Approximately 118,000 urban populations together) separated by 11km and approximately 180 surrounding villages spread in 40km radius. The population density at Metpally and Korutla is 1900/Km2 or 4900/sq.mi and 2900/Km2 or 7500/ sq.mi [5]. Ten to fifteen percent of villages are outreach (tribal Thandas) and not well connected with all seasonal roads.
Approximately > 5000 deliveries per annum are taking place in our area. Out of this, 60-65% deliveries taking place in two government regional area hospitals and the remaining 35-40% deliveries occurring in local maternity nursing homes. It is good to have a level 3 NICU for regional needs. There is a high scope and need for establishing a neonatal transport service (NTS), at least two. There is a necessity for creating public awareness and optimum utilization of NTS services.
There is regional shortcoming of resource deficiency - men, machines and money. The NTS should be patient friendly and cost effective.
Types of neonatal transport: can be classified as follows
Affordable cost-effective vehicles for a journey upto 200 km. The disadvantage of these vehicles is lesser space available for placing transport incubator, neonatal equipment, patient attendants and performing procedures
These vehicles have advantage over minivans like - more space available for staff, patients, equipment and performing procedures. A longer journey upto 300km or more can be done. Initial purchase cost is relatively high for these vehicles. Example -
The ambulance vehicles should pass and withstand 10G force in all directions. Ambulances are allowed to drive at higher speed than permissible road limits by NHS (but not more than 20kmph) [6]. The transport incubator trolley is positioned on offside for space management and well utilisation.
Transport team leader is usually a neonatal physician. The other members include neonatal advanced nurse practitioner or neonatal transport coordinator, neonatal transport nurse, respiratory therapist and ambulance crew. Neonatal nurse/transport nurse/ respiratory therapist is deficit in number and can be substituted with a trained neonatal transport nurse, male or female/midwife/ ASHA (Accredited Social Health Activist -by Government of India) worker from community and ambulance crew.
A transport vehicle should be provided with specified weight, fixations, power and gas provisions (two cylinders that last for more than two hours). Power from two alternate modes like generator and inverter should be available to run the equipment. Ambulance should be fitted with cot rails and fixations, fastening belts for equipment, adequate power adapters, ambient environment with thermal control, permissible noise and vibration, infection control, safety measures and insurance coverage for all passengers [8].
Transport incubators - cost effective, indigenously made ones are preferred -
Other essential equipment
Power backup from alternate sources should be available like electric generator/inverter, electric adapters in sufficient number and minimum of two oxygen gas cylinders.
Normal saline, ringer lactate, 10% and 25% dextrose, calcium gluconate, phenobarbitone, adrenaline - prefilled syringe in 1:10,000 dilution, dopamine, dobutamine, midazolam, morphine, fentanyl, sodium bicarbonate and surfactant.
This can be achieved with following - (a) training and assessment (b) communication and documentation (c) stabilization and care (d) quality governance and (e) legal issues.
Training and education should be central theme for personnel involved in neonatal transfers. Training should include the following [9]
The supporting staff at referring and receiving units should prepare necessary documents/PDF files [10]
It is exchange of information between persons and parties - referring unit, receiving unit including transport team and patient’s family. The success of NTS depends on effective communication between the referring and receiving units. This is specially important when transport is taking place from remote and rural place (11). A dedicated telephone line or mobile phone should be maintained for this purpose.
Communication with the referring unit: Should include introduction of team leader and members, name and address of receiving unit, patient details in a structured form [11]
Communication with family and parents: The following things should be discussed with parents
Physiological stabilisation of sick infant should be carried out by the transport team at referring centre by structured protocols - ‘TABCDE’ or ‘STABLE’ (16). The aim is to restore physiological equilibrium like normothermia, euglycemia, management and prevention of hypoxia, acidosis and hypotension, surfactant administration, assisted ventilation and improving organ perfusion [12].
Infant should be assessed with STABLE or TABCDE protocol
Handover - should be carried out in conducive atmosphere in presence of both teams (referring and receiving) and parents, initially with verbal consent at bedside and later with written consent.
While transferring the infant into the transport incubator, the following precautions should be taken
The team leader should be available to referring, receiving units and parents throughout journey by mobile phone. He should update the clinical status of infant and communicate any emergency/ untoward incident to all the three groups.
Once the infant reached the receiving centre, the team leader should communicate the clinical status of the infant, probable diagnosis, prognosis, hospital stay, finances, insurance, further management and probable date and time of reverse transport.
Parents should be given an opportunity to see the baby. They should be given liberty to ask any questions and concerns regarding the status and care of the baby. They should be explained about the state of illness and need for further care and invited to accompany the transport team in the ambulance.
FCC may not possible be in transport environment due to reasons like severity of sickness of infant and need for fast transfer to level 3 care unit. Invite parents to accompany the baby in ambulance.
This is not a main transport system at our place but occasionally used for transporting babies with specific clinical conditions like infant cardiac surgeries at distant cities after initial road transport. Whereas neonatal air transport is an integral part of sick patient transport system in many developed countries especially Australia, USA and UK (Scotland, Wales and England). Both pressurized (fixed wing aircrafts) and unpressurized aircrafts (Helicopters) can be used for air transport. There are concerns need to be mentioned here specific to air transport like [13]
Air transport is costly
In spite of optimum care during transport, emergency situation, infant death, accidents can occur [14]. These incidents should be reported and resolved with policy guidelines. Quality assurance and incident review should be submitted to state review bodies [15].
Medico-legal issues arise due to inadequate information and poor communication between the clients and care givers. Anticipate legal issues when baby dies during transport. When the baby is rapidly deteriorating during transport, ambulance should be taken to the nearest and highest care level hospital and stabilised or if baby dies, death certificate should be issued.
There are no conflicts of interest.
There are no sponsors for study article.
Copyright: © 2022 Chakradhar Maddela. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
ff
© 2024 Acta Scientific, All rights reserved.