Introduction

Journal of Neonatology

0973-21870973-2179

National Neonatology Forum

jn-19-4-007

REVIEW ARTICLE

Establishing national advisory group for neonatal transport

Gupta

Samir

Senior Research FellowSinha

Sunil

Professor of Paediatrics & Neonatal Medicine*

Department of Neonatal Medicine, The James Cook University Hospital, Middlesbrough, TS4 3BW, UK

*E-mail: sunil.sinha@stees.nhs.uk

10–122005

194332335

Introduction

Neonatal transport is an integral part of networking. The need for transfer is determined by the requirement for support or treatment beyond that is available locally. Babies who are premature, require surgery or are not improving on conventional intensive care are transferred to centers that can provide the required modality of treatment. The priorities of neonatal transport vary widely depending on the geography, priorities, resources and expertise available for the management of neonatal problems in that area. India witnesses 26 million childbirths and 1.2 million neonatal deaths per year (1). This accounts for a global share of 20% and 30% respectively. It also accounts for 40% share of 20 million Low Birth Weight (LBW) babies born globally. As three fourths of total neonatal deaths occur in LBW babies hence targeting this vulnerable group is of paramount importance. Neonatal sepsis, Birth Asphyxia and premature deliveries account for 52%, 20% and 15% neonatal deaths respectively. The highest Estimated Neonatal Mortality rate is observed in states of Orissa (61), Madhya Pradesh (59) and Uttar Pradesh (53) where the national average is 32 per 1000 live births.

It is now well accepted that the outcome of newborn babies in terms of survival and long term morbidity is better if appropriate care is provided in the neonatal period. The ‘high cost and low volume’ neonatal intensive care can not be provided at every delivery site and hence for the rapid and effective transport of high risk newborns, the link between neonatal intensive care and good transport services is important.

Development of neonatal transport service

India is a country with wide geographic variations and different ethnic and cultural background. The Neonatal transport service standard model of developed countries can not be transcribed to the framework of India. This is because of the fact that economic state of S outh Asia cannot be compared with developed countries. Compared to developed countries where 12% of central government expenditure is allocated to health, South Asia gets only 2% and the fact that 40% of population lives on less than $1 per day (2). The development of such services would need a staged long term plan and formulizing a model targeting the needs at Urban as well as Rural sector.

The bigger picture

A national body of transport service with representation from every state and union territory would provide a backbone to formulate, develop, integrate and assess the future developments of this service. This national group could set up the following key areas:

Capital and Budget allocation

Identifying and integrating the neonatal intensive care units

Setting standards of care & development of clinical guidelines

Modes of transport

Equipment, Communication and Documentation

Training of medical and paramedical personal

Strong infrastructure and uniformity of approach with ongoing data collection and audit of practice would help in early identification and rectification of problems.

The smaller picture

Until the long term development of national neonatal transport service framework, the regional integration of services at state and district level would be important for India. This service should work in association with national framework. The Teaching (Level 3) and District (Level 2) perinatal centers could identify a Pediatrician with interest in transport who could organize, supervise and develop the existing practices. In the first stage of improving neonatal transport, targeting the big killers and providing appropriate care at appropriate centers is important. This includes identifying low birth weight babies, and babies with neonatal sepsis, and transferring them with the aid of existing transport services. This should have the following components:

Improving communication and liaison with the primary health centers

Teaching and training to identify high risk babies

Stressing the need for early and safe transfer

Formulating the basic guidelines like maintenance of temperature, early treatment of sepsis and establishing feeding and nutrition

Considering the mother and family support during transport

The feasibility of smaller picture is evident from the Srilankan experience where the neonatal mortality rate could be brought down below 20 per 1000 live births because of good primary level perinatal services (3). Another example of effective perinatal care is the SEARCH model where the good antenatal and perinatal care reduced NMR from 62 to 26 per 1000 live births in just 3 years in the Gadchiroli district of India (4).

Such micro level approach for targeting and organizing neonatal transport development would be more suitable for initiation and build up of future effective service.

The long term vision

Despite the fact that the micro level smaller picture approach is more suitable to target at the initial stages, the long term infrastructure development and consolidation is equally important. The three tier structure model of neonatal care is pivotal to the development of neonatal transport service in future. The various key issues that are important for service organization and provision are:

Prioritizing transport

It is important to identify and appropriately use the funds for the transport of babies who would benefit from the service provision rather than being left at the whim of a clinician. This would require setting the “standards” of care and this would vary from one geographic location to other. Rather than generalizing the gestation or weight criteria across the country it would be more important to audit the regional needs and upgrade the services over period of time. The Neonatal transfer index (NTI) (NTI = number of newborns transferred/total live births × 100) would be useful to compare the transport services across the states and regions (5).

Mode of transport

Choice of the mode of transport depends on geography (distance, topography), weather, the newborn condition, safety and costs. The range of options (ambulance, helicopter, fixed wing aircraft or ferries) is dependant on local factors and should be individualized in each case. As a guide, for short distances of up to 1–2 hr driving time, road transport is quicker. These guidelines are for developed country and should be amended based on cost implication and availability of service framework and expertise (6).

Human resources

This comprises of Medical director, Manager and transport coordinator. The medical director oversees the development, implementation and monitoring of patient care and transport standards (policies, protocols, procedures, patient and transport documentation). The manager looks after the budget, equipment, data collection and works closely with the medical director. Transport coordinator has the authority to make the decisions regarding transfer and admission.

In addition the team members comprise of different types of health personals. Physicians are added to basic team based on the needs of the patient and competency of team members. The team members comprise of Registered nurse, and paramedics.

It is important that all team members are properly trained and competent. In emergency transport two trained members are highly desirable of which one needs to be delegated as a team leader. The study of different models of transport has shown that where volumes were high and transports long, the paramedic model was the least costly (8).

Acute and reverse neonatal transports

With the development of neonatal intensive care service and organization of transport services, it becomes important to consider reverse transfers to level 2 neonatal units for continuation of intensive care and free beds in level 3 units to accommodate babies requiring more intensive care. The data from various developed countries has shown that eventually the reverse transfers outnumber acute transfers. This stage along with appropriate in utero maternal transfers signifies maturity of the neonatal transfer service provision.

Education and training

The education and training standards are the key to successful transfers. Uniform national training program is helpful for a high quality service with better inter region association. The education is required in the following areas:

Practical transport management

Ambulance and Equipment training

Pre transport stabilization and check.

There are various training program like STABLE which provide basic training in transport. The local transport groups continually assess, audit and improve the practices. Monthly meetings can be used to monitor and discuss case scenarios.

Documentation and quality assurance

It is important to document the details from the point of receiving the transport call. The regional units can have the hot line to coordinate with the smaller hospitals of the region. The details of baby and the clinical condition should be documented with time along with the advice given on designated form. The integrated care pathway can be developed on the neonatal transport system which prompts and keeps the data record of the details of documentation before and during the transport.

For quality purposes each transport should be evaluated at the end of the transport. Using a transport validated physiological score such as ‘TRIPS’ (to evaluate patient status before, during and after transport) one can assess team and transport performance.

Budget allocation and development of neonatal intensive care

It is recommended that there should be one level in neonatal intensive care unit (NICU) bed per 1000 live births (8). Accordingly, India would need about 26000 NICU beds (or 1300 NICUs, each with 20 beds).10 years ago India had only 10 level III units for a population of one billion and 26 million births per annum (9).

It is important to increase the budget allocation with development of neonatal intensive care and expansion of NICU beds to optimize and rationalize the service provision.

In summary, the concept of developing neonatal transport service in India is important to improve the practice and reduce the mortality. Before targeting this framework nationally it is important to strengthen the infrastructure of neonatal intensive care in a three tier system. Till then improving the basic and timely transport at peripheral micro level would be of paramount importance for decreasing the mortality and morbidity.

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