In New York City in 1973, there were 70 acute-care facilities that maintained maternity and newborn services. In the past few years, approximately 100,000 live babies per year have been delivered in these services (Table 1). The decline in fertility rates and accrued birth rates has been attributed to increased utilization of family-planning services and the liberalization of abortion laws.1,2 For many years, it has been recognized that in any live-birth population, because of maternal, paternal, labor, delivery, or intrinsic newborn factors, a percentage will be at risk of increased mortality or morbidity.3 It has been estimated that 5 to 6 per cent of any live-birth population in urban areas such as New York City is at risk and in need of special newborn care or neonatal intensive care.4-6
Many of these infants at risk are being delivered in institutions with newborn intensive-care units (NICUs). However, there will always be infants born at institutions that lack specialized care. Since these infants will need access to special facilities, transportation becomes a necessity. Based on the experience in New York City, it is apparent that many urban centers share similar needs. These needs are complicated in rural areas by the necessity to transport over long distances.
FEDERAL AND STATE GUIDELINES
In the past few years, there have been attempts to regionalize maternal-child health services. This is based upon documentation of decreased morbidity and mortality of neonates cared for in NICUs. 4,7,10 Federal guidelines have been promulgated as expansions of Title V of the Social Security Act of 1935" (under provisions of maternal and child health services). Specifically, Public Law 92-345 stipulated that each maternal and child health crippled children's plan must include five programs by 1975: maternal and infant care, family planning, children and youth program, dental care, and intensive infant care. These guidelines required each state to create legislation on intensive infant care and to include the location of the centers, the type of care given to infants, the transport systems employed, and regional aspects of planning. The centers were also to function as resources for referrals and to establish education and counseling services for parents and for the community. A follow-up program was implied in the guidelines.
NEW YORK CITY LIVE BIRTHS (BY YEAR)
STATE HEALTH DEPARTMENT RESPONSE TO REGIONALIZATION OF PERINATAL CARE: 38-STATE SURVEY (COLLATED IN 1975)
The response from the individual states has been encouraging. Many states or groups of states have updated their intensive-care services for infants. The California Medical Association (Committee on Maternal and Child Care and Subcommittee on Perinatal Mortality) has created guidelines for intensive-care units, high-risk obstetric units, and infant transport services. With stimulus from the state's Crippled Children Bureau, California has designated a number of primary, secondary, and tertiary care centers.12 Maryland is now serviced regionally. All neonates who need special or intensive care are transported to Baltimore City Hospital or the University of Maryland Hospital. In the Midwest, area -wide planning has also been implemented by the Great Plains Organization for Perinatal Health, organized in 1970. It includes North Dakota, South Dakota, Minnesota, Wisconsin, Iowa, and Nebraska. These states contain at least 14 perinatal centers, with an additional five being planned. Continuing west, the Inter-Mountain Regional Newborn Intensive Care Unit in Salt Lake City, Utah, serves a six-state region (Utah, Idaho, Wyoming, Nevada, Montana, and northern Arizona) and draws from a live-birth population of 80,000; Colorado has regionalized for its urban and suburban areas. Arizona has a historic 1967 project that did indeed show a decrease in neonatal mortality when regionalization of NICUs occurred. As a result, the entire state has regionalized its NICU facilities.
On the East Coast, the Massachusetts Department of Public Health13,14 is establishing centers while standardizing formats and guidelines for categorizing infants with low birth weight, congenital anomalies, respiratory distress syndrome, etc. Based on these guidelines, the state will create primary, secondary, and tertiary care centers. Georgia, under RMP, also has organized nursery care at several levels.15
Professional organizations and conferences have discussed and stated the goals of regionalization of perinatal care.6,16 The New York City Infant Transport Service recently conducted a survey to determine each state's response to the need for regionalization. The results are shown in Table 2.
NEWBORN TRANSPORT SERVICES
Once a commitment to perinatal care has been made and the necessity for regionalization realized, the questions of transportation and communication become paramount. The efficiency of any program attempting to meet the needs of ill newborns in a particular area will depend on the exchange of information and prompt, proper care.
TABLE OF ORGANIZATION
A great many newborns at risk can be recognized before birth.17 Ideally, these babies should be delivered at perinatal centers, but for various reasons they are not. Often the potential risk is not realized or not deemed likely enough to warrant the mother's inconvenience. Patterns of seeking medical care are often influenced by the patient's perception of a problem or by the advice of a friend. Added to these predictable problems are the unexpected cases: mothers with acute toxemia or thirdtrimester bleeding, precipitous premature delivery, and neonates with such disorders as sepsis, congenital anomalies, and asphyxia. Even under the best of circumstances, then, newborns at risk will be born at facilities that cannot provide the fullest range of care. In order to give these infants optimal care, adequate transportation to centers must be provided.
The first step in the care of newborns must be taken in the first few minutes of life. No facility with a maternity service should be without personnel (physician and nursing) trained in the resuscitation of the newborn and early supportive care. Part of the role of a transport service is to provide continuing education and information so that the personnel of smaller hospitals can acquire such knowledge and maintain skills. An example of information that can be distributed to hospitals that will need a transport service is given in Table 3.
Once the medical decision to transfer a newborn is made, the method of transportation must be decided. Why is it important that newborns, especially low-birth-weight or ill newborns, require special means of transport? Obviously newborns, especially those of low birth weight, are small, and most standard emergency equipment is just too large. The neonate also has special needs of environmental control, isolation from possible sources of infection, oxygen (with or without assisted ventilation), and small volumes of parenteral fluid. No emergency service geared for adults or children can begin to meet these needs.
The necessities of an infant transport service can be discussed by considering the three major components: (1) vehicle, (2) equipment, and (3) personnel. Each of these will have to be tailored to meet the particular requirements of the region being served, the type of infants being moved, and the resources available.
Vehicles range from ambulances to jet aircraft.18 All types of ambulances are used (hearse type, standard van, specially designed van, etc.), as are helicopters, fixed-wing aircraft, and boats. If all transporting to be done is within a relatively small area, such as an urban center, some type of ground vehicle is best. If transports are made over long distances (greater than 50 to 75 miles), aircraft will be fastest, with coordinated ground transportation to transfer the neonate from the landing site to the receiving hospital. Since some services will handle both intracity and longdistance transports, they will favor a completely portable carrier with all monitors and life-support equipment attached so that it can be used in any type of vehicle without requiring utilization of outside power sources.
According to federal specifications for ambulances,19,20 there are three basic vehicles that meet government standards for emergency vehicles: (1) conventional cab chassis with modular ambulance body; (2) standard van, forward-control integral cabbody ambulance; and (3) specialty van, forward-control integral cabbody ambulance. In spite of the extensive coverage of all ambulance specifications in the government publications, there is no mention of guidelines for infant transport vehicles. Some suggestions, specific for infant ambulances, are discussed in the Canadian Paediatric Society handbook on transport of the newborn21 and the American Academy of Pediatrics "Standards and Recommendations for Hospital Care of Newborn Infants."22 The former also discusses problems peculiar to other means of infant transport.
Ambulance design will depend primarily on the ambulance and the equipment used, accommodations for personnel, and the type of power source. For instance, as a power source, generators are heavy, break down easily, cause vibration problems, and present design difficulties in achieving automotive balance. However, they produce a great deal of energy, especially important if much of the equipment on board has to be electrically operated. As a solution to the generator problem, some services have substituted inverters and battery packs.
Some of the potential and real problems encountered with ground vehicles are as follows:
1. A properly balanced heavyduty chassis is necessary to handle the large load of equipment and assure a smoother, safer ride. In addition, urban streets are particularly hard on tires, shock absorbers, etc.
2. Vibration and noise preclude the use of such standard equipment as stethoscopes and some types of monitors.
3. Weather and traffic conditions will delay transport significantly. Motor vehicle operators with a wide knowledge of routes are most useful.
4. Frequent repairs and maintenance are necessary, and a backup vehicle must be available.
5. Possible adverse effects of ground transport on newborns have not been clearly defined.
6. Motion sickness can be a significant discomfort to personnel.
Helicopters are a dramatic means of transportation but also present problems. The vibration and noise levels in a helicopter are considerably greater than those in ground vehicles. It is virtually impossible to do much with a neonate in a helicopter, and it cannot "pull over"; therefore, a newborn must be stabilized carefully and all problems anticipated before helicopter transport. A complication of aircraft transport, especially by helicopter, is rapid change in pressure, leading to abdominal distention and unrecognized hypoxia. Sudden increases in altitude will also aggravate any condition with trapped air, such as pneumothorax or pneumoperitoneum. (Control should be established by tube and three-way stopcock before takeoff.)
Since aircraft can land only where proper airstrips and clearance are available, ground transportation must also be used and carefully coordinated. For long distances (over 200 miles) fixed-wing aircraft become the method of choice.
Vehicles can be bought and modified to a transport service's needs or used by contract. Whatever the arrangement, the vehicle operator should have a basic knowledge of the vehicle, the equipment used, the geography of the hospitals visited, and the fastest routes, as well as alternative routes. All vehicles should have some means of two-way communication.
The equipment that should be taken on transport will depend on in-transit needs and the availability of equipment at the hospital of origin. The basic unit will be a portable infant carrier, with oxygen and good visibility, capable of providing environmental control. Easy access to the infant should be available for stimulation, suction, and assisted ventilation. The carrier must have its own power source and be of weight and bulk that make it possible to Lift. Oxygen supply can be provided on the carrier, but the amount and weight of the tanks should be considered. Heat should be carefully controlled, and the design of the carrier must minimize heat loss. When the carrier is not attached to a power source, heat is usually provided by heavy batteries. Monitoring equipment can be either present on the carrier or easily available for connection to the infant. Also basic to any transport will be the portable emergency kit: a collection of equipment and drugs necessary for emergencies. Our basic kit includes:
1. Laryngoscope with infant- and premature-size blades; extra lights and batteries
2. Endotracheal tubes with adapters, sizes 10 and 12
Calcium gluconate, 10 per cent
Sodium bicarbonate, 8.4 and 4.2 per cent
Dextrose, 50 per cent
4. Syringes: 2½-cc, 10-cc, 20-cc.
5. Needles, size 23, 20, 18
6. Three-way stopcock
7. Alcohol swabs
8. Airways: sizes for infant and premature
Other equipment to be carried will depend on the availability of equipment at the sending hospital and the expected duration of the trip. If the sending hospital is poorly stocked, equipment can be provided in kits that are kept sterilized and ready and can be easily used when needed. Suggested kits include:
Lumbar puncture kit
Combined umbilical catheterization, vessel cut-down, and suture kit
Parenteral fluid kit
Bacteriologic sampling kit
Details and other suggestions are given in "The Manual for the Transport of High-Risk Newborn Infants."21
Personnel can be classified as administrative, clerical, nursing, physician, and vehicle operator. Most transport services, including personnel, are part of a neonatal intensivecare facility.
All calls must be answered and processed rapidly and efficiently. When there are many calls, priorities should be established by a physician. The support services of a hospital (supplies, oxygen therapy, infection control, laundry, etc.) are used as with any other special care facility, usually under the coordination of nurses.
Basic skills and knowledge are necessary. Any person who accompanies a neonate must be experienced in observation, use of monitors, suctioning, assisted ventilation (at least with bag and mask), and use of the equipment at hand. The transport staff should have the ability to ventilate during apnea spells and recognize and assist in managing deteriorating conditions. Deciding which level of medical training is needed to accompany the infant will depend on the severity of the infant's condition and the duration of the trip. Trained infant care technicians (nurses' aides with previous NICU experience and special training in transport) can skillfully move most stable low-birth-weight infants. They are equally capable of accompanying stable full-term newborns who have need of exchange transfusion, surgical procedures, diagnostic workups, etc. Trained NICU nurses familiar with equipment can handle most of the more complicated cases. Physicians are best utilized for the most serious cases (e.g., those requiring the use of respirators) and complicated circumstances. It should be emphasized, however, that a physician with limited newborn experience can offer little help to the sick newborn. More important than any one person transporting the newborn is the team: dispatcher, vehicle operator, medical staff, and consultants. Their approach and attitude will, in the long run, provide the most comprehensive care for the infant.
When deciding on choice of vehicles, transit time is the major criterion. This can be estimated by the distance to be traveled, road conditions, weather, and the vehicles available for use. Several principles, however, hold true for all transports:
1. The importance of being ready, with all equipment functioning at all times, cannot be overemphasized. Disposable items are best, since they require no stabilization or servicing and can be left at smaller hospitals when proper equipment is scarce or unavailable.
2. Oxygen hoods are available that fit into transport incubators. They allow more efficient use of a limited oxygen supply as well as higher concentrations. Most oxygen analyzers give an accurate report of concentration even in a moving vehicle.
3. Intravenous solutions must be administered with a pump, since flow cannot be dependably regulated in a moving vehicle.
4. The use of monitors is recommended, since heartbeat and breath sounds usually cannot be heard with a stethoscope.
5. Glass equipment is best replaced by lightweight plastic.
6. Neonates are best transported without endotracheal tubes if bagging is sufficient, since the trauma of the tube on the larnyx is aggravated by vehicular motion. If it is anticipated that the baby cannot be intubated once in transit (in a helicopter in bad weather, for instance) and deterioration is a real possibility, it is safer to intubate before transport. An alternative to endotracheal intubation and ventilation is the use of continuous positive airway pressure.23 In addition, mechanical ventilation is possible if the vehicle provides sufficient space and if personnel have expertise in the machine's use. Obviously, blood gas measurements should be taken often. A minimum requirement would be a blood gas measurement on a stabilized infant just before transport and immediately upon arrival at an NICU.
If the trip is of short duration (up to 15 minutes*), it is best to stabilize as necessary but to postpone more invasive procedures for a few minutes until they can be done under better conditions at the center. Umbilical catheters, intravenous fluid lines, and tubes dislodge with ease during transport.
For longer trips (15 minutes to one and a half hours), ground transportation works well. For trips that would take longer than two hours by ground travel, helicopters provide more rapid transportation, especially if road traffic is heavy or road conditions are poor.
NEW YORK CITY EXPERIENCE
For the past 25 years, the transport of preterm newborns had been carried out by the New York City Department of Health. In 1970, the Health Services Administration of the City of New York reorganized the Infant Transport Service (ITS) at the New York University-Bellevue Medical Center. Utilizing a 24-hour operational telephone number, ITS dispatches and transports infants to centers. The calls are answered by technicians, nurses, or neonatal consultants, who evaluate the request before placement. The need for a physician to accompany the infant is determined at this time, based on key questions and ITS policy. These questions will include birth weight, Apgar score, relevant maternal history, temperature, age of baby, color, respiratory status, activity, anomalies, rashes, injuries, etc., and equipment attached to -the infant. Usually the necessity for physician accompaniment can be anticipated. If in the interim, however, the infant's condition deteriorates, a consultant neonatologist is immediately called to arrange for a physician. Physicians should always accompany (1) infants under 1,000 gm., (2) neonates requiring assisted ventilation, (3) newborns with chest tubes in place, (4) infants with a history of apnea spells or those with moderate to severe respiratory distress, and (5) any infant whose referring doctor requests physician accompaniment. A request for physician assistance by one of the transport nursing staff is never denied.
An NICU bed at one of 15 centers is reserved for the neonate, and the transport is carried out. The van's special equipment includes a radiant heater over a work area, large oxygen tanks, wall electricity (supplied by a generator), suction apparatus, oxygen analyzers, cardiac monitors, intravenous fluid pumps, umbilical catheterization set, and other accessory supplies as well as the emergency kit (see above). No facilities for blood gas analysis or mechanical ventilation are currently available.
Some problems have been encountered in obtaining the proper level of care for high-risk neonates. Some relate to organization of newborn services; others have to do with the distribution of facilities, including transport services. For instance, the level of newborn care in New York City is influenced by many factors - ownership of the hospital (municipal, voluntary, or proprietary), the patients served (from medically indigent to middle class), and the existence of training programs. Moreover, at least four medical centers have instituted their own neonatal transport services, without considering the utilization of the other existing centers in New York City. An additional problem is the maldistribution of centers relative to the newborns in need of service (population density).
Lack of interdepartmental communication in a hospital is another problem. For example, often two or three departments are involved with mother and child before hospital discharge. Care becomes uncoordinated, often to the detriment of the family. Added to this, in many small hospitals, is the lack of sufficient knowledge to care for the sick or compromised infant. Basic accepted concepts of temperature control, metabolic problems, feeding, etc., are not understood or applied. The ITS staff of physicians, nursing personnel, ambulance drivers, and administrative personnel have transported over 1,000 neonates annually m the first three years of operation. An organizational chart will detail the interrelationships (Table 3). The activities of the New York City ITS are outlined in Figures 1 through 7.
Figure 1. Number of infants, transported per 1 ,000 live births in New York City.
Figure 2. Frequency distribution of transported infants, by weight. Over the past three calendar years, the peak weight distribution of transported neonates continues to be in the 1,501-2,000 gm. and the >2,500 gm. weight categories.
Figure 3. Percentage of transported infants accompanie physician. Comparing two calendar years (1 972 and 1 97 is obvious that the number of physician-assisted transp have almost doubled.
All transported infants are followed up by telephone until discharge OT expiration; a summary is then collated with the transport data sheets for long-term analysis.
Ongoing surveillance and internal control are carried out by daily review of all calls, frequent staff meetings, and nvservice education. An Infant Transport Service Advisory Group, composed of neonatologists and health department and hospital administrators, is a further stimulus for quality operational control. A more structured auditing procedure has been developed for the nursing personnel, who handle the bulk of calls. Ongoing community education has been carried out by workshops, visits to nurseries, and individual instruction.
To determine the number of nursing personnel needed for ITS, a formula has been devised:
Figure Fiscal year 1973:
Fiscal year 1973:
4. Percentage of live births transported in New York City by ITS, by weight distribution.
Figure 5. Cumulative percentage of transported infants, by weight, compared with the cumulative percentage of live births, by weight, in New York City (calendar year 1 973).
ESTIMATION OF NEEDED NURSING PERSONNEL
H=N (dispatching + transport + charting + maintenance + in-service + follow-up + miscellaneous).
H = Number of nursing personnel needed to 40 transport total of infants per year.
H = Total number of nursing hours per week.
N = Average number of calls per week.
40 = Forty-hour work week.
To obtain a true estimate, one must add nursing time to cover seven-day adjustment, sick leave, and vacation time.
In any discussion of transit time, the exact definition must be clear. For instance, if one considers the time from when ITS is first called until the newborn is in an NICU, this span will rarely exceed three hours. However, the time spent by the ITS staff in moving a newborn from the hospital of birth to an NICU is less than one hour and often less than half an hour.
Cost factors should always be considered in any program for planning purposes. Simple unit cost (per transport) can be calculated by dividing the total budget by the number of calls. In New York City, unit costs per year were:
Figure 6. Survival rate of transported infants.
Fiscal year 1972:
Fiscal year 1973:
More accurate formulas include the variable costs per transport, and this would increase the unit cost to a truer estimate. Most transport services that function as part of an NICU, and transport babies only to that center, do not take into account physician and nursing salaries when calculating their cost per transport.
Medical economists also make use of the benefit-cost ratio for program analysis. In this framework, present dollar value of future benefits (for example, prevention of one case of neonatal mortality or morbidity) and costs, direct and indirect, are compared. When the benefit-cost ratio is greater than 1:1, the program is deemed praiseworthy. This method is being applied in NICTJs.
Figure 7. Mortality of transported infants - frequency distribution, by weight.
1. Harris, D., et al. Legal abortion, 1970-1971 - The New York City experience. Am. J. Public Health 63 (1973). 409.
2. Pakter, J., et al. Two years experience in New York City with the liberalized abortion law - Progress and problems. Am. J. Public Health 63 (1973), 524.
3. Pierog, S. H.. and Ferrara, A. Approach to the Medical Care of the Sick Newborn. St. Louis: C. V. Mosby Company, 1971.
4. Bellevue Hospital Center, Infant Transport Service, First Annual Report, April, 1971 -March, 1972, New York.
5. Ontario Council on Health, Report of the Subcommittee on Perinatal Problems (Monolog #2), 1971.
6. Regionalization of Perinatal Care. Report of the 66th Ross Conference on rePediatric Research. Columbus, Ohio: Ross Laboratories, 1974, pp. 74-78, 90.
7. Rawlings, G., et al. Changing prognosis for infants of very low birth weight. Lancet 1 (1971), 516.
8. Teberg, A. J., Wu, P., and Hodgman, J. E. Developmental and neurologic outcome of infants with birth weight under 1500 grams (abstract). Clin. Research 21 (1973), 322.
9. Vapaavouri. E., and Raiha, N. C. R. Intensive care of small premature infants. I: Clinical findings and results of treatment. Acta Paediatr. Scand. 59 (1970), 353.
10. Drillien, C. M. Later development and follow-up of tow birth weight babies. Pediatric Annals 1 .1 (1972), 44.
11. Hutchins, V. (director. Bureau of Community Health Services, Public Health Service, Department of Health, Education, and Welfare). Personal communication, 1974.
12. Standards for Infant Intensive Care Units. California State Department of Public Health, Bureau of Crippled Children's Services. 1 972.
13. Regulations Governing Newborn Services in Hospital. Massachusetts Department of Public Health. 1970.
14. Massachusetts Department of Public Health. New regulations for newborn services. N. Engl. J. Med. 286 (1972), 1363.
15. Blackmon, L., and Brown, A. Recommended Standards for Hospital Nursery Services. Georgia Regional Medical Program, June, 1973.
16. Report of the Joint Committee on the Regional Approach and Reproductive Care of the Society of Obstetricians and Gynecologists of Canada and the Canadian Paediatric Society, 1971.
1 7. Quilligan, E. J. The obstetric intensive care unit. Hosp. Practice 7 (1973), 61.
18. Shepard, K. S. Air transportation of high-risk infants utilizing a flying intensive-care nursery. J. Pediatr. 77 (1970). 148-149.
19. Ambulance Design Criteria. Washington, D.C.: U.S. Department of Transportation, National Highway Traffic Safety Administration. 1973.
20. Federal Specification Ambulance Emergency Medical Care Vehicle KKK-A-1822. Washington. D.C.: General Services Administration, 1974.
21. Segal. S. (ed). Manual for the Transport of High-Risk Newborn Infants. Canadian Paediatric Society, 1972.
22. Standards and Recommendations for Hospital Care of Newborn Infants. Fifth Edition. Evanston, III.: American Academy of Pediatrics, 1971.
23. Gregory, G. A., et al. Treatment of the idiopathic respiratory distress syndrome with continuous positive airway pressure. N. Engl. J. Med. 284 (1971 ), 133-140.
NEW YORK CITY LIVE BIRTHS (BY YEAR)
STATE HEALTH DEPARTMENT RESPONSE TO REGIONALIZATION OF PERINATAL CARE: 38-STATE SURVEY (COLLATED IN 1975)
TABLE OF ORGANIZATION
Figure 6. Survival rate of transported infants.