Transporting the Critically III Infant or Child

With regionalization first of neonatal intensive care and later of pediatric intensive care, emergency interhospital transport systems were developed to provide rapid, safe, and effective transfer of critically ill children from community hospitals to regional intensive care facilities. Transfer of women with identifiable high-risk pregnancies to regional obstetric perinatal centers has been instituted to provide maximal surveillance and support at the time of delivery. The philosophy of transport systems is not only to provide a means of transferring a sick patient to a more appropriate facility but also to institute appropriate intensive care monitoring and treatment in the patient before leaving the referring hospital. This aspect of care begins as soon as the referring physician telephones the intensive care physician at the referral hospital. The patient is presented to the ICU physician, who offers advice regarding immediate treatment and then mobilizes the transport team and alerts the appropriate consultants and hospital resources required for the incoming patient. The transport team usually consists of a physician and nurse specially trained in neonatal or pediatric intensive care and transport. Support personnel may include respiratory therapists, anesthesiologists (particularly in the case of a pediatric upper airway problem), emergency medical technicians, or additional nursing or physician trainees. Portable intensive care equipment must include cardiovascular monitoring devices, an infant transport device to maintain a neutral thermal environment during transport, resuscitation equipment (including airway and breathing devices), and additional equipment to institute intensive care on arrival at the referral hospital.

Problems that may arise during transport must be anticipated and treated before the patient is transported, which usually requires a careful assessment of the airway, breathing, and the adequacy of gas exchange along with monitoring the adequacy and stability of the circulation. Because procedures are so difficult to perform in transit, such interventions as intubation and placement of venous or arterial catheters are completed at the referring hospital if there is any question that they will be required. Possible medications required during transport should be anticipated and made immediately available. Transport can be carried out by ambulance, helicopter, or fixed-wing aircraft, depending on local circumstances. In general, the environment provided by helicopter transport is the most difficult one in which to provide surveillance and treatment because of poor temperature and noise control, as well as limited operating space. Communication with the transport team and regional center is essential to facilitate consultation with senior staff members and to help the accepting ICU anticipate the nature and degree of illness. The most serious flaws in the transport system are usually the response time of the transport team once a referral call is made and the availability of on-call transport team members who are adequately trained. An institutional commitment of funds, personnel, and equipment, along with excellent organization, can ensure that neonatal and pediatric transport systems have a significant impact on patient care, community physician education, and regional hospital referrals.^{[361] [362]}