Clap1605 02

Neonatal transport
in developing
country settings:
a systematic review
Montevideo
2016
Also published in [Español 2016]
Transporte neonatal en el entorno de los países en desarrollo: revisión sistemática
ISBN: 978-92-75-31917-8
PAHO HQ Library Cataloguing-in-Publication Data
Pan American Health Organization Latin American Center for Perinatology, Women and Reproductive Health
Neonatal transport in developing country settings: a systematic review. Montevideo : CLAP, 2016.
(CLAP/WR. Scientific publication, 1605-02).
ISBN 978-92-75-11917-4 (NLM Classification: WX215)
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Table of contents
Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Results and systematic review references. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Future directions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
General references. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Appendix 1. PRISMA 2009 Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Appendix 2. Search strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Coordination:
Suzanne Serruya
Pablo Durán
Authors:
Susan Niermeyer
Gretchen Domek
External Review Committee:
José Ceriani Cernadas

Fernando Espinosa
Roseli Calil
Guilian Birchwood
Joanna Laurent-Blaize
Valeska Stempliuk
Gonzalo Giambruno
Anabela Santoro
Mara Castro
Pablo Durán
Fernando Silvera
Gerardo Martínez
Ana Noble
Eduardo Castañeda
Lauren Arnesen
Abstract
Background: Reduction in neonatal mortality is central to achieving global child survival targets
in the coming decades. Efforts to prevent the primary causes of neonatal death (prematurity,
asphyxia, severe infections, congenital anomalies) must be complemented by development of
systems to care for sick newborns, including safe neonatal transport.
Objectives: This systematic review identifies and analyzes the evidence on neonatal transport
in developing countries in order to highlight important conclusions and gaps in knowledge in
preparation for development of clinical guidelines and practical tools to support safe neonatal
transport.
Methods: The electronic search strategy included terms related to transport, access, and referral
of neonates. Data sources included MEDLINE, Embase, CINAHL, Web of Science, the Cochrane
Library, LILACS, SciELO, and African Index Medicus. Eligible studies utilized a randomized, quasi-
randomized or non-randomized prospective design with a comparison group. Cross-sectional,
caseseries, case-control, or cohort studies that identified modifiable outcomes were included
when there were defined comparison groups or comparison with established standards or
guidelines. The review focused on transport of infants with an age 28 days or less from the
community or a primary care facility to a center with specialty neonatal care, as well as inter-
facility patient transfers between two neonatal specialty care centers and intra-facility patient
transfers to/from a neonatal specialty care unit. Articles were evaluated for strength of study
design, selection bias, control for confounders, and data collection methods.
Results: Forty studies met inclusion criteria. There were no randomized controlled trials and five
quasi-experimental pre/post studies; most studies were of moderate to weak quality. Fourteen
studies examined physiologic stability during transport and identified potentially modifiable risk
factors associated with clinical deterioration and mortality or differential outcomes between
inborn and outborn (transported) neonates. Six studies compared management of neonatal
transports with norms for performance or formal regional guidelines. Six studies examined the
effect of team training/composition on knowledge and skills, physiologic indicators of stability,
and/or mortality. Three studies reported trails of equipment (transport carriers or incubator).
Eleven studies considered the role of neonatal transport in providing access to the health system.
Conclusions and implications: Evidence supported the need for establishment of neonatal
transport services to provide equitable and widespread access to high-quality care for infants
in the first month of life. Improvement in the outcome of transported neonates can be readily
achieved by focusing on issues of basic physiological stability. Specific training in patient
assessment and management can improve outcome, but must be accompanied by necessary
systems changes, including proper equipment, norms, and oversight.
Abbreviations
AAP American Academy of Pediatrics

CFT capillary ﬁlling time
CLD chronic lung disease
EMS emergency medical service
EPHP Effective Public Health Practice Project
GA gestational age
HIE hypoxic-ischemic encephalopathy
IV intravenous
nCPAP nasal continuous positive airflow pressure
NICU neonatal intensive care unit
NR not reported
OR odds ratio
RR risk ratio
SIMV synchronized intermittent mandatory ventilation
SNAP-II Score for Neonatal Acute Physiology II
SNAPPE-II Score for Neonatal Acute Physiology Perinatal Extension-II
S.T.A.B.L.E Sugar, Temperature, Airway, Blood pressure, Lab
work, and Emotional support (training program)
TBA traditional birth attendant
TOPS Temperature, Oxygenation, Perfusion, and blood Sugar
TRIPS Transport Risk Index of Physiologic Stability
TTN transient tachypnea of the newborn
VLBW very low birth weight
Introduction
Aims and rationale
Mortality occurring in the neonatal period, defined as the first 28 days of life, accounts for
over 40% of deaths in children under the age of 5 years globally, according to The Millennium
Development Goals Report 2013 (United Nations 2013). Leading causes of mortality in neonates
include prematurity, asphyxia, severe infections, and congenital anomalies. The majority of
births in developing countries take place in rural settings, often in the home, and with providers
(such as traditional birth attendants) with limited formal training and minimal equipment.
Additionally, specialty neonatal care facilities are often few in number, transport modes are
limited, and transportation routes are difficult and time-consuming. Many neonatal deaths
could be avoided and morbidity reduced with the ability to safely transfer a sick newborn to a
health facility with a higher level of care. In order to improve the procedures related to neonatal
transport and to improve the quality of care under these critical conditions, it is necessary to
provide technical guidelines supported by scientific evidence to the organizations, facilities, and
health care professionals in charge of setting health system priorities and policies surrounding
the transport of neonates.
The specific aim of this review is to analyze the evidence and experience on neonatal transport in
developing countries in order to establish a practical guideline that would help those responsible
for coordinating the transport of neonates to perform it in the most effective manner and with
the highest standards of quality.
Objectives
Neonatal transport in developing country settings: a systematic review
The overall objective is to perform an assessment of referral systems in developing countries

to transfer neonates to higher levels of care in a timely and effective manner. The specific
objectives include:
1. To perform a review of the scientific evidence on neonatal transport, focusing on the

assessment of basic conditions, stabilization, requirements for a quality transport
(equipment, human resources, etc.), and differences or specificities depending on the
transport media.
2. To analyze the evidence identified.
3. To consolidate the results, identifying the main observations and also those critical
aspects for which there is no clear evidence. The document will be the background for
developing clinical guidelines to be used in health facilities.
4. To propose further steps in the design and validation of a clinical guideline and the
practical tools to support safe neonatal transport.
Conceptual framework
The “three delays” model (Thaddeus and Maine, 1994) describes a conceptual framework for the
factors and subsequent phases of delay that influence the timely accessibility of specialty care in
obstetric emergencies and ultimately contribute to maternal deaths. The model has been adapted
10 for analysis of obstetric referral interventions (Hussein 2012), perinatal deaths (Mbaruku 2009),
and neonatal deaths (Waiswa 2010). We have adapted this conceptual framework for the phases
of delay that affect transport and the timely arrival to specialty neonatal care. Such critical delays
are a major contributing factor to neonatal mortality. These delays include: (I) delays in deciding
to seek care for reasons that include socioeconomic and cultural factors, (II) delays in reaching
an appropriate medical facility, and (III) delays in receiving adequate care once at an appropriate
medical facility due to poorly staffed, equipped, and managed facilities. For the purpose of this
review, the interventions that we examine will address primarily Phase II delays that pertain to
the accessibility of appropriate health services. The issues confronted in Phase II include the
ability to reach an appropriate facility, the time spent to reach an appropriate facility, and the
morbidity/mortality associated with reaching the facility. Specific factors considered include the
distribution and location of appropriate medical facilities and health care providers, established
referral patterns, travel distances and times, availability of transportation and transportation
routes, costs of travel, and availability/quality of medical treatment during transport. These
delays are most common and often severe in developing countries, especially in rural settings,
where specialty medical facilities, trained health care providers, and modes of transportation
are limited. Phase III relates to delay or compromised quality of care of transported neonates at
the medical facility. The issues considered in Phase III that are relevant to this review include
morbidity associated with poor communication before/upon arrival at the medical facility and
morbidity associated with intra-facility transport of neonates for diagnostic/ surgical procedures.
/ Introduction
Distance of transport
Household / Community First-level health facility Referral health facility
Figure 1. Conceptual model of neonatal transport. Neonatal transport most often occurs from a first-
level health facility to a referral center; however, transport may occur from the community to a
health facility or within a facility (intra-facility transport).
11
Methods
13
Protocol and registration
A review protocol (available upon request from the authors) was created prospectively to conform
with the objectives of the systematic review. Methods followed the PRISMA 2009 Checklist
(Appendix 1). The systematic review was not publicly registered. Because of the absence of
randomized controlled trials and controlled clinical trials, meta-analysis was not undertaken.
Eligibility criteria
Participants
This review includes neonates, defined as newborn infants with a chronological age of 28 days or
less irrespective of the postmenstrual age at birth, who are referred from the community or from
a primary care facility to a center where specialty neonatal care is available. It will also include
inter-facility patient transfers between two neonatal specialty care centers (e.g., for specialized
services such as pediatric surgery or ventilation) and intra-facility patient transfers to/from a
neonatal specialty care unit (e.g., from a neonatal intensive care unit to the operating room or
an imaging facility). Exclusion criteria include pregnant and post-partum women referred for an
obstetric complication or emergency and infants or children transferred or referred beyond the
neonatal period.
Interventions and observations
All interventions to improve the emergency referral of infants during the neonatal period are
relevant to this review. These may include, but are not limited to, interventions that provide
training, communication, or incentives pertaining to neonatal referral or transport as well as
interventions that improve already existing methods of transport, provide new methods or
equipment for transport, improve physiologic stability and care during transport, enhance
monitoring and assessment during transport, create new referral facilities, or improve linkages
between referral levels. Cross-sectional, case series, case-control, or cohort studies that
identified modifiable outcomes were included when there were defined comparison groups or
comparison with established standards or guidelines for performance.
Outcome measures
Primary outcome measures for the review were neonatal morbidity and mortality. Morbidity
includes physiologic factors such as thermal stability (hypothermia), glucose control
(hypoglycemia), and oxygen saturation (hypoxia). Secondary outcome measures include factors
such as travel time, referral rates, type of transportation, type/timing of communication,
utilization of services, costs (direct and indirect), provider knowledge and skills, and the family’s
satisfaction with a service or intervention.
Settings
Studies included come from developing countries, limited to countries classified by the World
Bank as low-income, lower-middle-income, and upper-middle-income economies (http://
14
data.worldbank.org/about/country-classifications/country-and-lending-groups). Studies from
developed countries are not included.
Study designs
Study designs eligible for inclusion in this review are randomized or quasi-randomized studies with
a control or comparison group, non-randomized prospective studies with a comparison group,
controlled before-after studies, and interrupted time series analyses of neonatal emergency
referral systems. Cross-sectional, case series, case-control, or cohort studies that identified
modifiable outcomes were included when there were defined comparison groups or comparison
with established standards or guidelines for performance. Studies without a comparison group
were excluded, as were editorials, comments, letters, historical articles, and case reports.
/ Methods
Identification of relevant studies
Search strategy
The electronic search strategy was based on terms related to transport, access, and referral of
neonates. The search strategy (Appendix 2) was run in MEDLINE on the Ovid platform. The search
strategy was then adapted for Embase, CINAHL, Web of Science, and the Cochrane Library as
well as LILACS, SciELO, and African Index Medicus. Reports and studies from the gray literature
were also considered for relevance.
Searches were conducted between March and June 2013. Adaptation for other databases was
accomplished by selecting appropriate subject heading or keywords from the respective thesauri;
no date or language restrictions were employed. Electronic search citations were downloaded
using EndNote X7 (Thompson Reuters). Reference lists from retrieved papers were screened.
Non-indexed and gray literature was included.
Screening studies
Inclusion and exclusion criteria were applied successively to titles, abstracts, and full articles.
Abstracts were obtained and reviewed for those titles that appeared to meet the specified
inclusion criteria, and full articles were obtained and reviewed for those abstracts that appeared
to meet the criteria or when information was insufficient to exclude articles based on title and
abstract alone. The inclusion and exclusion criteria were then reapplied to the full reports by
two separate reviewers in order to determine the articles included in the final review.
15
Data extraction, quality assessment, and analysis
Quality assessment was guided by the Effective Public Health Practice Project quality assessment
tool for quantitative studies (EPHPP 2009). For non-randomized studies, the components rated
were limited to estimates of selection bias, description of study design, confounders, data
collection methods, and analyses. Two reviewers independently assigned quality scores and
compared assessments. Uncertainties were resolved by arbitration with an independent third
reviewer.
Synthesis of the studies began with categorization of the scope and intent of the studies and their
outcomes. For each study a tabular summary entry was created that included author, year, and
country; study design; setting (levels of care); participants; dates of study; comparison groups;
outcomes; and conclusions/recommendations. In the absence of randomized controlled trials
or a sufficient number of quasi-experimental studies, further analysis of size/direction of effect
was not possible. Studies within each category were summarized in narrative fashion for their
common themes and notable differences. The implications for development of guidelines for
neonatal transport in developing countries were identified and discussed, gaps in the available
evidence were highlighted, and directions for future research suggested.
Results and
systematic review
references
17
Study selection
Search results and study selection are summarized in Figure 2. Forty studies met inclusion
criteria of having a defined comparison and measured outcomes. Complete citations are listed in
the “References Included in the systematic review” section at the end of this chapter, begining
on page 36 (reference citations for the other chapters of this book are given in the “General
references” chapter, which begins on page 55).
Figure 2.
Records from databases searched:

MEDLINE/in-process n=728, Embase
n=464, Web of Science n=78, CINAHL
n=489, Cochrane n=1, LILACS n=951,
Records from other sources SciELO n=12,034, African Index Medicus n=80
(cited references) n=36
Records n=14,825
Abstracts selected n=470
Abstracts selected Excluded (did not meet

after screening n=2 criteria) n=340
Full-text articles
assessed n=132 Full-text articles excluded:
Review n=33
No comparison n=6
Poster/case study/letter n=5
No relevant outcomes n=7
Articles included n=40 High-income n=41
18
Study characteristics and quality assessment
Table 1, which is given on page 22, summarizes the quality assessment of the included studies.
There were no randomized controlled trials of interventions related to neonatal transport. Five
studies employed a quasi-experimental pre/post design around educational interventions or
significant changes in health system structure. The majority of studies reported on prospective
or retrospective cohorts, analysis of cross-sectional samples, or case series. Assessment of
whether the participants in studies were representative of the target population and the extent
to which missing data introduced selection bias was difficult because of lack of details on the
conduct of studies. Data collection tools were described primarily in studies of physiological
scoring systems for risk classification and comparisons with established guidelines for transport.
Analyses were often limited to descriptive statistics on comparison groups and Chi-square or
t tests to define differences in outcome. Logistic regression analysis was employed in a small
number of studies.
Results of individual studies
Characteristics of included studies are summarized in Table 2, which begins on page 23. According
to the conceptual framework for the systematic review, the studies focused on Phase II and
Phase III delays, that is, respectively, reaching an appropriate medical facility and obtaining
adequate and appropriate medical treatment. Studies relating to the processes, conditions of
/ Results and systematic review references
clinical care, equipment, systems, and training of personnel directly involved in the activity
of neonatal transport are presented in sections entitled: 1) “Transport Results physiology and
care,” 2) “Adherence to norms and guidelines,” 3) “Team training and composition,” and 4)
“Equipment.” A fifth section, entitled “Access/Health system,” contains studies relating to the
broader organization of neonatal transport within the health care system and issues of access to
health care as impeded/facilitated by neonatal transport or modifications of the health structure.
Active interventions focused on transport team training, application (during transport) of scoring
tools for assessment of physiologic stability and prediction of mortality, and changes in health
coverage or health services available at the population level.
Synthesis of results
1) Transport physiology and care
Fourteen prospective and retrospective cohort studies examined physiologic stability

during transport and identified the potentially modifiable risk factors associated with
clinical deterioration and mortality or differential outcomes between inborn and outborn
(transported) neonates. Eleven of the studies identified hypothermia as a factor strongly
associated with deterioration/mortality (Buch 2012, Goldsmit 2012, Lucas da Silva 2012,
Mathur 2005, Mathur 2007, Sehgal 2001, Silveira 2003, Singh 1996, Vieira 2011a,b,c). Other
risk factors associated with adverse outcomes included hyperthermia, hypoglycemia, poor
perfusion, and length of time in transport. One study (Chung 2009) demonstrated a higher
risk of chronic lung disease as a notable difference between transported very low birth 19
weight (VLBW) preterm infants and matched inborn controls. Three studies (Goldsmit 2012,
Lucas da Silva 2012, Mathur 2007) examined the utility of illness severity scores (SNAP-II,
SNAPPE-II, TRIPS, TOPS) in assessment, triage, and prediction of mortality. One small study
of intra-hospital transports (Carsi-Bocanegra 2001) found that high-, moderate-, and low-
acuity patients could be transported safely with adequate technology and trained personnel.
A series of three studies (Vieira 2011a,b,c) examined the clinical complications associated
with intra-hospital transports and developed and validated a predictive score to identify
neonates at risk of such complications.
Several studies documented the high percentage of transports accomplished by family

members and the low proportion of transports performed by trained personnel with adequately
equipped transport vehicles and appropriate communication surrounding the transport.
Reported mortality rates for neonates after inter-facility transport were exceptionally high
in several reports and often correlated with the degree of hypothermia. Even with well-
trained and -equipped teams, the lack of specific expertise in respiratory care of infants was
associated with higher rates of chronic lung disease.
2) Adherence to norms and guidelines
Six studies compared management of neonatal transports with norms for performance or
formal regional guidelines. Four cohort studies (Albuqerque 2012, Hadley 2001, Mutlu 2011,
Nakhshab 2010) described poor conformity with regional norms. The key deficiencies identified
were: communication before and during transport, adequacy of the team and transport unit,
stabilization before transport, continuation of basic supportive care, equipment maintenance
and function, and documentation of patient status. A case-control comparison of referred

infants with and without hypoxic-ischemic encephalopathy (HIE) noted that only 11% of
neonates were accompanied by a referral letter, and infants with HIE were no more likely to
have a referral letter despite the central importance of such information to planning patient
management and defining prognosis (Butt 2007). A case series of 15 transported neonates
highlighted the disparity between provincial and private ambulance transfers, with lower
quality of private inter-hospital transports (Roux 1989).
3) Team training and composition
Six studies examined the effect of team training on knowledge/skills and physiologic indicators
of stability and the effect of team training/composition on physiologic indicators and mortality
of transported neonates. In a series of three studies (Kumar PP 2008, 2010, 2011), care by a
specially trained neonatal team was associated with improved physiologic stability, whether
transport covered long or short distances. The third study in the series (Kumar PP 2011)
again showed decreased complications of glucose and thermal control, hypoxia, and apnea
among infants transported by a specialized team and reported that survival was significantly
higher (96 vs. 89%) among those infants accompanied by the specialized team. Two before-
and-after studies delivered the S.T.A.B.L.E. program to medical and paramedical transport
personnel (Martinez Veronica 2011, Spector 2009), with improvement in physiological
variables and equipment use as well as decreased mortality post-intervention in one study,
but more limited improvement in thermal control only, without change in mortality in the
other setting. A third before-and-after study (Chandy 2007) trained community and facility
20
providers in the Delivery Life Support program as an extension of a trauma life support/
transport initiative and demonstrated improvement in knowledge, skills, confidence, and
teamwork, but did not report infant outcomes.
4) Equipment
Three studies reported trials of transport carriers designed to provide thermoregulation

for neonates. One study examined infant temperatures before and after transport in a
commercially available styropor box (Gosavi 1998) and found that the environment prevented
hypothermia during inter-facility transport between urban hospitals. Comparison of a
custom-crafted insulated carrier with warm wraps showed improved temperature stability
during short transfers between a neonatal care ward and the operating room (Joshi 2010).
A comparison of premature infants cared for in a prototype non-electric incubator vs. a
commercial incubator showed stable, equivalent vital signs in the two groups (Khodadadeh
2001); however, observations took place among non-distressed infants in the neonatal care
unit.
5) Access/Health system
Eleven studies examined the role of neonatal transport in providing access to the health
system. Five studies compared inborn and outborn (transported) neonates with respect to
intermediate physiological outcomes and/or mortality (Araújo 2011, Dicko 2010, Enweronu-
Laryea 2008, Kumar M 2002, Ndiaye 2003) and showed that outborn status was consistently
associated with higher mortality. Improvements in neonatal intensive care unit (NICU)
facilities in one of these study areas resulted in increased survival of very low birth weight
(VLBW) outborns, but a large increase in referrals of infants >2500 grams (Enweronu-
Laryea 2008). Two studies utilized the Three Delay Model to analyze verbal and social
autopsies(Upadhyay 2013, Waiswa 2010) and reported that half or more of overall mortality
was due to Phase II and III delays. One before-and-after study (Lu 1999) documented the
impact of implementation of national health insurance on transported neonates, including
decreased mortality and discharge against medical advice. Another single study (Wang
1997) examined the effect of referral from obstetric clinics to either a district hospital or
tertiary center and found higher mortality for all infants referred to the level II center and
specifically for ventilated infants. Large-scale implementation of transport with a structured,
specialized neonatal transport service resulted in reduction in early neonatal mortality rates
in areas served by the dedicated team (Woodward 1997). Another before-and-after study of
the implementation of a package of improvements in neonatal transport (Uslu 2011) showed
decreased physiologic complications, improved Transport Risk Index of Physiologic Stability
(TRIPS) scores, and greater compliance with guidelines in the post-intervention period.
21
Table 1. Quality assessment summary ( EPHPP 2009) 1
Control of Strength of Control for Data Collect.

Author Year
Selection bias Study Design Confounders Methods
Transport physiology and care
Buch 2012 Weak Moderate Strong Weak
Carsi-Bocanegra 2001 Weak Weak Weak Weak
Chung 2009 Weak Moderate Strong Weak
Goldsmit 2012 Moderate Moderate Strong Strong
Karagol 2011 Moderate Moderate Weak Weak
Lucas da Silva 2012 Moderate Moderate Strong Strong
Mathur 2005 Weak Moderate Strong Strong
Mathur 2007 Weak Moderate Weak Weak
Sehgal 2001 Weak Moderate Strong Weak
Silveira 2003 Weak Moderate Strong Weak
Singh 1996 Weak Moderate Weak Weak
Vieira 2011a Weak Moderate Strong Weak
Vieira 2011b Weak Moderate Strong Weak
Vieira 2011c Weak Moderate Strong Strong
Adherence to norms and guidelines
Albuquerque 2012 Weak Moderate Weak Weak
Butt 2007 Weak Moderate Weak Weak
Hadley 2001 Moderate Moderate Weak Weak
Mutlu 2011 Weak Moderate Weak Weak
22 Nakshab 2010 Moderate Moderate Weak Weak
Roux 1989 Weak Weak Weak Weak
Team training and composition
Chandy 2007 Weak Moderate Weak Weak
Kumar PP 2008 Weak Moderate Weak Weak
Martínez Verónica 2011 Moderate Moderate Weak Weak
Spector 2009 Moderate Moderate Weak Weak
Equipment
Gosavi 1998 Weak Moderate Weak Weak
Joshi 2010 Weak Weak Weak Weak
Khodadadeh 2001 Weak Moderate Weak Weak
Access/Health system
Araújo 2011 Weak Moderate Weak Weak
Dicko 2010 Weak Moderate Weak Weak
Enweronu-Laryea 2008 Weak Moderate Weak Weak
Kumar M 2002 Weak Moderate Weak Moderate
Lu 1999 Moderate Moderate Weak Weak
Ndiaye 2003 Moderate Moderate Weak Weak
Upadhyay 2013 Moderate Moderate Weak Moderate
Uslu 2011 Moderate Moderate Weak Moderate
Waiswa 2010 Moderate Moderate Weak Strong
Wang 1997 Weak Moderate Weak Weak
Woodward 1997 Strong Moderate Weak Weak
1
Effective Public Health Practice Project (2009) http://www.ephpp.ca/Tools.html.
Table 2. Summary of characteristics of included studies
Dates of
Author/Country Study Design Levels of Care Participants Comparison Results Recommendations
Study
Transport physiology and care

Physiologic factors significantly
associated with mortality
included:
-Hypothermia Mortality can be improved by
Transport from 149 referred
Prospective promoting institutional deliveries,
homes, primary neonates (48 -CFT > 3 seconds
cohort of proper regionalization of newborn
Buch 2012 health centers, deceased, 51 8/2010- Deceased and -RR > 60/minute
referred care, appropriate pre-referral
/ India public and survived, 50 left 1/2011 surviving neonates
neonates over 6 Only 26.8% of transports stabilization, communication during
private hospitals against medical
months used an ambulance, 11.4% transport, and adequate equipment
to a NICU advice)
had an accompanying skilled and staff at the referral facility.
attendant, and 33% sought
advice regarding care during
transport.
Intra-facility
Prospective Complications
transport of 26 transported Complications during intra-facility
Carsi-Bocanegra cohort of during transport in No statistical differences in
NICU patients neonates (9 high 12/1998- transport of NICU patients can be
2001 transported high, medium, and complications were found
(i.e. for surgical risk, 11 medium 12/1999 minimized with proper transport
/ Mexico neonates over low risk groups of among risk groups.
and imaging risk, 6 low risk) procedures.
1 year neonates
procedures)
Case-control
Complications of
study of referred Respiratory outcomes in transported
Inter-facility 68 VLBW prematurity in
VLBW preterm Risk of CLD in the outborn neonates can be improved by
Chung 2009 transports from neonates (34 transported VLBW
neonates and 1999-2003 group was 4.4-fold higher than including a respiratory therapist
/ Taiwan (China) hospitals to a inborn, 34 preterm neonates
matched inborn in the inborn group. in the transport team and with the
NICU outborn) and matched
controls over 4 timely administration of surfactant.
inborn controls
years
Newborn infants who are less
critically ill still require the
Clinical deterioration was
optimization of care during
Prospective Inter-facility seen in 57% of transports,
transport to prevent complications
cohort of transport Pre and post- independent of patient
Goldsmit 2012 160 referred 7/2009- of hypothermia and hypoglycemia.
referred from various transport TRIPS characteristics, type or
/ Argentina neonates 5/2010 severity of their condition. Tools or scores to systematically
neonates over institutions to a scores
10 months NICU measure the quality of transport
Thermal and respiratory status
(such as TRIPS) can be useful
showed most instability.
to audit and optimize neonatal
transport services.

23
24
Dates of
Study
Transport from outside

compared to within the city led
to significantly worsened illness
variables, including admission
208 referred time to NICU (13.6 hours v. 6.6),
term neonates intubations during transport
Retrospective Illness variables Long-distance land-based transport
with TTN (105 (10 v. 3), respiratory support
cohort of Transport from of neonates in neonates with TTN increases
Karagol 2011 transferred from 1/2005- in NICU (nCPAP 42 v. 27; SIMV
referred term hospitals to a transferred from the severity of illness and requires
/ Turkey within the city, 12/2009 26 v. 3), duration of antibiotic
neonates with NICU within the city and appropriate respiratory equipment
103 transferred treatment (7.2 v. 5.5 days),
TTN over 4 years outside the city and trained transport staff.
from outside the presence of pulmonary air leak
city) syndrome (20 v. 4), duration of
hospitalization (8.4 v. 6.1 days),
development of pneumothorax
(20 v. 4), and blood gas
parameters at admission.
Prospective TRIPS score at admission had
Inter-facility
cohort of good performance in predicting TRIPS might be a useful triage and/
Lucas da Silva transport from 175 referred 3-year TRIPS, SNAP-II,
referred high-risk patients for 7-day or evaluation tool for transport
2012 / Brazil hospitals to a neonates period SNAPPE-II scores
neonates over 3 mortality and was similar to services.
NICU
years SNAP-II and SNAPPE-II.
Mortality was 39.3% in mildly
hypothermic neonates, 51.6%
in moderately hypothermic,
and 80% in severely WHO classification of severity of
hypothermic. Mortality was hypothermia correlates with the risk
Transport from increased significantly for of fatality but should also include
the community all groups in the presence of
Prospective 100 referred Mortality rates the presence of associated illness
Mathur 2005 (homes and associated illness, physiologic
cohort of neonates with in neonates with (birth asphyxia, neonatal sepsis, and
/ India health facilities) derangements, and weight
referred hypothermia NR mild, moderate, respiratory distress), physiological
to a referral <2.0kg.
neonates with (temperature and severe derangements (hypoxia,
neonatal unit
hypothermia <36.5°C) hypothermia 36% of neonates were hypoglycemia, and shock), and
of a teaching
transported naked, only 5% weight <2.0kg as adverse factors
hospital
had their head covered with a that should classify hypothermia in
cap, and all were transported in the next higher category of severity.
open vehicles (cycle-rickshaw,
auto-rickshaw, public bus, and
scooter).
Transport from TOPS
the community (Temperature, All the TOPS variables had TOPS has an equally good prediction
Prospective
(homes and Oxygenation, significant correlation with for mortality as SNAP-II and can be
cohort of 175 referred
Mathur 2007 health facilities) 3/2003- Perfusion, and fatality on univariate analysis. used as a simple and useful method
referred neonates with
/ India to a neonatal 12/2003 blood Sugar) The total correct classification of assessment of risk of fatality
neonates over weight >1.0kg
nursery of and SNAP-II as rate for TOPS was 81.7%, while immediately upon admission of a
10 months
a teaching predictors of that for SNAP-II was 83.4%. referred neonate.
hospital mortality
36% of patients died (70%
within 6 hours of arrival).
Factors significantly Feeding during transport is
contributing to mortality important to help regulate
included: lower birth weight, hypoglycemia, a contributing factor
Transport prematurity, hypothermia, to mortality.
from homes, hypoglycemia, poor perfusion, Low-cost transportable devices that
Prospective primary health and longer transport time. help with the application of heat
95 referred
cohort of centers, public (transparent insulating bags, Saran
Sehgal 2001 neonates (35 8/1999- Deceased and Only 5% of patients were
referred and private wrap, plastic heat shield) will help
/India deceased, 60 11/1999 surviving neonates transferred by ambulance (the
neonates over 4 hospitals to an reduce mortality.
survived) others were brought by various
months emergency unit
vehicles such as cars, jeeps, Communication with referral centers
of a children’s
auto-rickshaw, and bicycle- is critical so that they are able to
hospital
rickshaws). prepare for the needs of the arriving
No referrals were accompanied neonate.
by trained health personnel.
No patients were fed during
transport.
320 referred Risk of death was higher
Transport
Prospective neonates (61 Mortality in (RR = 3.09) in the neonates Hypothermia on admission is an
from homes or
cohort of with moderate neonates with exposed to moderate independent risk factor for neonatal
Silveira 2003 health centers 3/2000-
referred hypothermia, moderate hypothermia (temperature death and thermal control should
/ Brazil to the Instituto 6/2000
neonates over 3 259 controls and mild/no between 32.5°C-35.99°C) than be an important part of neonatal
Materno Infantil
months with mild or no hypothermia in the non-exposed group transport.
de Pernambuco
hypothermia) (temperature >36°C).

25
26
Dates of
Study
Mortality was significantly

higher in hypothermic (56.2%)
and hyperthermic (52.4%)
neonates compared to
110 referred euthermic (12.3%) neonates. Methods to regulate temperature
Neonates
Prospective Transport from neonates (73 instabilities of neonates during
with normal Transport vehicles included car
Singh 1996 cohort of “various places” with normal transport need to be improved and
NR temperature, (73.6%), open jeep (6.4%), bus
/ India referred to a tertiary temperature, 16 open vehicles should not be used
hypothermia, and (5.4%), ambulance (3.6%) and
neonates level hospital hypothermia, 21 because temperature maintenance
hyperthermia rickshaw (10.8%). No transport
hyperthermia) in these vehicles is not possible.
involved medical personnel
or monitoring. Methods
for thermal control were
inadequate in all cases.
Hypothermia occurred in
15.3% of transports and was
640 transported associated with weight at
Cross-sectional neonates transport <1.0kg (OR 3.7),
Intra-hospital
study (nested submitted to weight at transport 1.0-2.5kg Intra-hospital transports present
Vieira 2011a transport of Neonates with
in a prospective 1191 intra- (OR 1.5), pre-transport axillary an increased risk for hypothermia
/ Brazil NICU patients 1/1997- and without
cohort) of hospital temperature <36.5°C (OR and should be conducted by skilled
(i.e. for surgical 12/2008 hypothermia
referred transports 2.0), central nervous system transport teams with adequate
and imaging (<36.0°C)
neonates over (182 with malformation (OR 2.8), use equipment.
procedures)
12 years hypothermia, of supplemental oxygen (OR
1009 without) 1.6), mechanical ventilation
prior to transport (OR 2.5), and
transport for surgeries OR 1.7).
Clinical complications occurred
641 transported
in 27.3% of transports and
neonates
Intra-hospital were associated with CNS
Prospective submitted to Intra-hospital transports are
transport of malformations (OR 1.6),
cohort of 1197 intra- Neonates with and associated with increased risk of
Vieira 2011b NICU patients 1/1997- surgery (OR 4.0), pre-transport
referred hospital without clinical clinical complications and should
/ Brazil (i.e. for surgical 12/2008 supplemental oxygen (OR
neonates over transports (327 complications be conducted by skilled transport
and imaging 4.0), pre-transport assisted
12 years with clinical teams with adequate equipment.
procedures) ventilation (OR 5.0), and
complications,
duration > 120 minutes (OR
870 without)
1.6).
Variables included in the final
multiple logistic regression
model for clinical complications
during intra-hospital transports
Neonates admitted included gestational age, pre-
during even transport body temperature,
Cross-sectional
Intra-hospital 695 transported years (used as a underlying disease, transport
study (nested
transport of neonates (301 derivation cohort destination, and type of Predictive scores can be developed
in a prospective
Vieira 2011c NICU patients during even 1/2001- to determine respiratory support. and validated to identify infants at
cohort) of
/ Brazil (i.e. for surgical years, 394 12/2008 relevant variables risk of clinical complications during
referred At least one clinical
and imaging during odd for a predictive intra-hospital transports.
neonates over 8 complication occurred
procedures) years) score) and odd
years during 22.9% of transports
years (used as a
validation cohort) (hypothermia in 12.7%,
hyperoxia in 5.6%, desaturation
in 4.1%, and the need for
increased respiratory support
in 2.3%).
Adherence to norms and guidelines

24% of transports had high
High, average, and conformity, 46.7% average Neonatal transport systems need
low conformity conformity, and 29.3% low
Prospective improvement in following existing
Transport from to existing norms conformity.
cohort of norms, especially with regards to
Albuquerque secondary 75 referred 7/2004- (based on an
referred ~70% of newborns were pre-transportation communication,
2012 / Brazil health units to a neonates 12/2004 arithmetic mean
neonates over 6 transported in an inadequate the adequacy of the team and
NICU calculated for
months manner, and no newborn was transport unit, and clinical
each neonatal
transported in full accordance conditions on arrival.
transport)
with the existing norms.
Only 11.1% of neonates
Transport from carried a referral letter; those Maintaining good standards in
Case-control homes, primary with v. without HIE were not medical note keeping and referral
study of referred health centers, 340 referred Neonates with significantly more likely to carry documentation is an important
neonates public hospitals, neonates (153 HIE and matched a referral (14.4% v. 8.6%).
Butt 2007 3/2005- aspect in planning further patient
with HIE and and private cases with HIE, controls without
/ Pakistan 6/2005 Neonates seen by a physician management and counseling
matched health facilities 187 controls HIE admitted on
were statistically more likely parents about their infant’s
controls over 4 to a NICU in without HIE) the same day
to carry a referral letter than prognosis. Such practices should be
months the Children’s
those seen by other health care regularly audited.
Hospital Lahore
providers (17.3% v. 2.8%).

27
28
Dates of
Study
Of those patients with a Educational interventions are likely

nasogastric tube in place to have a greater impact than
Inter-facility upon arrival, 19% were non- further technological advances.
transport from functioning (due to spigotting
several hospitals Maintaining simple interventions
Retrospective 126 referred or knotting).
and some intra- Compliance and during transport, such as
cohort of surgical Of those patients arriving with intravenous fluid replacement,
Hadley 2001 facility transport 1/1999- non-compliance
referred surgical neonates (21 an intravenous cannula, 28% nasogastric drainage, and the
/ South Africa from the 9/1999 with a standard of
neonates over 9 intra-facility had the drip turned off and 28% administration of oxygen, should be
obstetric ward care
months transports) had non-functioning infusions. made priorities in the management
to a surgical
nursery at a of surgical neonates.
Only 64% of patients had
tertiary hospital radiographs with them upon Transport personnel should be
arrival (resulting in 36% having trained specifically for neonatal
to repeat imaging). transfer.
The most common errors Transport equipment should be

before and during referral continuously checked to make sure
were absence of IV line and/or it is functioning properly.
inappropriate type or amount of
Infants with IV fluid (61%) or errors related Transport vehicles should be
referrals that to respiratory support (20%) prepared for the requirements of a
were informed (obstruction or dislocation of sick neonate.
Inter-facility and previously and intubation tube or inadequate
Prospective Experience and training of
intra-facility not informed oxygen supply).
cohort of accompanying health care workers
Mutlu 2011 (emergency 216 referred 1/2007- previously
referred No transport vehicle was should be appropriate to care for a
/ Turkey department) neonates 12/2007
neonates over observed to have a mechanical sick neonate.
transport to a Conformity with
12 months ventilator, monitor, or neonatal
NICU regional norms Accurate and timely communication
pulse oximeter. between referring providers and a
Premature and
term neonates Only 58% of accompanying neonatologist at the referral facility
medical personnel had received should help eliminate unnecessary
neonatal resuscitation training. referrals.
71% of neonates carried a Detailed referral notes should

referral note. accompany patients.
Only 50% of patients had an

Inter-facility arterial blood gas, chest x-ray, The current neonatal transport
Cohort of
transport from and blood sugar checked before system needs to be improved
Nakhshab 2010 referred 148 referred 6 months Conformity with
various regional transport. (including regionalization,
/ Iran neonates over 6 neonates (NR) regional norms
hospitals to a communication, optimal equipment,
months 10.1% were hypothermic upon
NICU and skilled personnel).
arrival to NICU
Quality of inter-hospital
15 referred transports, especially by
Lack of equipment in ambulances
Case-series neonates (11 private ambulance, was
increases the risk of neonatal
Roux 1989 of referred Inter-hospital by private 5/1987- Conformity with not up to standard and
transport. Staff development
/ South Africa neonates over 2 transports ambulance, 4 6/1987 transport norms included deterioration of
and a national control body are
months by provincial body temperature, heart and
recommended.
ambulance) respiratory rates, and serum
glucose values.
Team training and composition

Self-rated skills,
Training of care 305 providers Significant improvement The Delivery Life Support program
confidence, and
providers from (160 TBAs, 96 occurred in overall knowledge, trains rural care providers (TBAs,
Prospective quality of team
a rural region village trauma confidence, hands-on skills, midwives, paramedics, medical
Chandy 2007 cohort of trained work before and
(villages, several first helpers, 30 2004-2006 and quality of team work as assistants, and physicians) to regard
/ Cambodia care providers after completing
health centers, midwives, 19 assessed by a user-skill survey delivery as a potential trauma
over 2 years a delivery life
3 referral doctors/medical at the completion of the requiring stabilization and possible
support training
hospitals) assistants) training course. transport.
course
Physiologic Significant improvement
Transport
Prospective characteristics of in rates of hypoglycemia, Proper training and adequate
from pediatric,
cohort of neonates pre- and hypothermia, hypoxia, pre-transport stabilization by
Kumar PP maternity 151 referred 3/2008-
referred post-stabilization and hypotension occurred a specialist transport team
2011 / India centers to a neonates 3/2009
neonates over by a specialized after being stabilized and can decrease transport-related
tertiary pediatric
13 months neonatal transport transported by a specialist morbidity.
hospital
team transport team.
Biochemical Biochemical and physiologic

Transport
Retrospective 1015 referred and physiologic characteristics (arterial pH,O2
from various
cohort of neonates (795 characteristics saturation, core temperature) Long-distance road transfer of
maternity
Kumar PP 2010 referred within-city 7/2004- of neonates and 24- hour mortality rates neonates by a trained and qualified
and pediatric
/ India neonates by transports, 6/2008 transported short were not significantly different team can lead to results comparable
centers to a
land transport 220 out-of-city (within city limits) between neonates transferred to short-distance transport.
tertiary pediatric
over 4 years transports) and long distances for short versus longer
hospital
(outside city limits) distances.

29
30
Dates of
Study
Incidence of hypo/
hyperglycemia, hypo/
hyperthermia, hypoxia, and
288 referred Neonates apnea were significantly higher
Transport in neonates transported on
neonates transported by
Retrospective from various their own compared to those Specialized neonatal transport
(160 with a a specialized
cohort of maternity transported by a specialized services could improve survival
Kumar PP 2008 specialized 7/2004- neonatal
referred and pediatric neonatal transport service. rates and decrease biochemical
/ India neonatal 3/2007 transport service
neonates over centers to a abnormalities of transported
transport and neonates Significantly more neonates
33 months tertiary pediatric neonates.
service, 128 on transported on who were transported by a
hospital
their own) their own specialized transport service
survived (96.2%) compared to
those transported on their own
(89%).
More patients had normal body
Program criteria temperature (post 87% v. pre
pre- and post- 59%), normal range of blood
Transport from glucose values (93% v. 45%), The S.T.A.B.L.E. program training
Before and S.T.A.B.L.E. (Sugar
the interior incubator use (97% v. 52%), course for medical and paramedical
after (quasi- 3,277 neonates and Safe Care,
Martínez of the state and pulse oximetry monitoring transport personnel was highly
experimental) (384 pre- Temperature,
Verónica 2011 of Jalisco and 2005-2009 (89% v. 61%) in the post v. pre- effective, easy to implement,
study of referred intervention, Airway, Blood, Lab
/ Mexico metropolitan intervention group. and resulted in a significant
neonates over 4 2,893 post) work, Emotional
Guadalajara to a improvement in neonatal morbidity
years support) training Decreased mortality (post 14%
NICU rates.
for medical and v. pre 22%) occurred during
paramedical staff hospitalization in the post-
intervention group.
Program criteria
pre and post- Significantly more neonates in
Before and S.T.A.B.L.E. (Sugar the post-intervention group had
after (quasi- 282 referred and Safe Care, temperatures within a normal Implementation of a neonatal
Transport from
experimental) neonates Temperature, range (post 56% v. pre 36%). provider educational program
Spector 2009 10 outlying 11/2006-
study of referred (136 pre- Airway, Blood, Lab (S.T.A.B.L.E.) can be used to improve
/ Panama birthing centers 1/2008 No statistical difference was
neonates over intervention, work, Emotional thermal control of transported
to a NICU observed in serum glucose
two separate 146 post) support) training neonates.
7-month periods course for medical levels, length of stay, or
and paramedical mortality.
staff
Equipment
Temperatures of
Prospective neonates pre- and It is possible to maintain normal
Inter-facility
cohort of high- post-transfer using No neonate became temperatures of neonates during
Gosavi 1998 transport 32 high-risk 10/1994-
risk referred a commercially hypothermic or required transportation by using a styropor
/ India between 3 neonates 2/1995
neonates over 5 available styropor resuscitation during transport. box and bubbling oxygen into the
urban hospitals
months box as an box to maintain oxygenation.
incubator
No significant temperature
Intra-facility differences were reported
transport Temperature of pre- and post-transport with A cheap and easily fabricated
Prospective
between a neonates pre- and neonatal carrier. cardboard neonatal carrier (40 x
Joshi 2010 cohort of ~60 transferred
neonatal care NR post-transfer using 40 cm2) can be used to transport
/ India transferred neonates Temperature difference
ward and a neonatal carrier neonates short distances (~100m)
neonates was significantly less with a
operating room and warm wraps with effective thermal control.
(~100 m) neonatal carrier (< 0.5°C) than
with warm wraps (1.0°C).
45 non-
distressed
premature
(<37 week
Vital signs of A non-electric transport incubator
GA) neonates No significant difference
Prospective neonates using was shown to be safe and effective
weighing was observed in vital sign
cohort of Neonates a prototype non- in providing thermal regulation for
between 1.5- measurements taken for 2
Khodadadeh non-distressed admitted to a 12/1999- electric transport non-distressed premature babies
2.5kg (25 tested hours (oxygen saturation, heart
2001 / Iran premature neonatal care 5/2000 incubator and over a 2-hour period and could
in a prototype rate, respiratory rate, rectal
neonates over 6 unit neonates using be used to transport neonates to
non-electric temperature) between the two
months a commercial higher levels of care in developing
incubator, 20 groups.
electric incubator. countries.
tested in a
commercial
electric
incubator)

31
32
Dates of
Study
Access/Health system
Transport of
Sistema Único
de Saúde Transported
Prospective patients from neonates and Transport group had a greater
cohort of hospitals of the 184 neonates neonates born in incidence of hyperglycemia Perinatal care and transport
Araújo 2011 8/2008-
referred preterm northeast region (61 outborns, the maternity ward (RR=3.2), hypoglycemia should be better organized in the
/ Brazil 7/2010
neonates over 2 of Rio Grande 123 inborns) of the reference (RR=2.4), hyperthermia (RR=2.5), northeastern region of Brazil.
years do Sul and hospital (paired and hypoxemia (RR=2.2).
inborns from the according to GA)
maternity ward
to a NICU
Transport
from the
Cross-sectional
community to 1072 neonatal Factors related to neonatal
study of Reduction of neonatal morbidity and
Dicko 2010 a neonatology admissions (760 10/2006- Inborns and mortality included maternal
neonatal mortality requires an improvement
/ Mali unit at a outborns, 312 1/2007 outborns illiteracy, small weight at birth,
admissions over in the reference system.
teaching inborns) and outborn birth.
3 months
hospital (and
inborns)
Pre and post-

upgrade in NICU Investments in NICU facilities
facilities from should be accompanied by
Transport improvements in emergency
Before and level I to level 4-fold increase took place in
from homes, obstetric services, human resources,
after (quasi- 465 outborn IIIA (improved outborn referrals for infants
primary health neonatal resuscitation practices,
Enweronu- experimental) neonates (178 infant care area, >2.5kg.
facilities, public 10/2003- and referral/transport systems.
Laryea 2008 study of pre-upgrade, handwashing
hospitals, and 9/2005 Survival improved significantly
/ Ghana neonates 287 post- facilities, radiant [This article was included as an
private hospitals for inborn neonates <2.5kg and
admitted over 2 upgrade) warmers, intervention affecting Phase III
to a NICU and outborns <1.5kg.
years incubators, delays. Increased outborn referrals
inborns
physiological occurred after improvements in
monitoring, and NICU facilities.]
lab equipment)
Prevention of deaths due to birth
asphyxia and prematurity (primarily
Admissions to 56 deaths (0.8%) occurred occurring in the first week of life)
a subdistrict among inborn group and 70 should include the promotion of
hospital (first deaths (18.2%) in outborn institutional deliveries or care by
Retrospective level referral group. a skilled attendant at birth while
cohort of facility for 7137 neonates
Kumar M 2002 Inborns and Main causes of death in prevention of deaths due to sepsis
neonates essential (6746 inborns, 1994-1999
/ India outborns the inborn group were (primarily after the first week of
admitted over 6 newborn care 385 outborns)
birth asphyxia (37.5%) and life) should include training health
years services) from
prematurity (46.4%) and main care workers in early detection of
the community
cause of death in the outborn sepsis and sepsis management.
and the
group was sepsis (71.4%). An effective referral system from
obstetric ward
the community and to secondary/
tertiary specialty care is a necessity.
Transport from
Level I units 733 referred The incidence of hypoglycemia Improved outcomes of transported
Before and (obstetric clinics neonates 7/1991- (pre 26.8% v. post 13%), neonates are related to the
after (quasi- providing care (260 before 5/1992 acidemia (35.3% v. 26%), infant establishment of a network of
Pre- and post-
experimental) for normal implemen- mortality (19.7% v. 9.3%), and perinatal services, including
Lu 1999 implementation
study of referred neonates) to tation of discharge against medical educating providers to identify high-
/ Taiwan (China) of National Health
neonates during Level II (district National Health advice (4.2% v. 0.4%) decreased risk neonates and perform neonatal
8/1997- Insurance
two separate or regional Insurance, 473 in the second period after resuscitation, training transport
time periods hospitals) and after implemen- 3/1999 implementation of National teams, and improving consultation
Level III (NICU) tation) Health Insurance. and communication.
units
686 low birth Outborn mortality ratio was
Transport from Inborn and
weight (<2.5kg) 65% and inborn 34.5%.
public or private outborn low birth
Retrospective neonates Improvement in the capacity for
health facilities weight neonates Delay of admission, methods of
cohort of low resuscitation and stabilization in
in Dakar and 506 low birth transport, maternal age, parity,
Ndiaye 2003 birth weight 1/1998- Deceased and community hospitals and creation of
surrounding weight inborns and Apgar scores did not differ
/ Senegal neonates 12/1999 surviving low birth a more organized neonatal transport
areas to a (112 deceased) significantly between deceased
referred over weight outborn system to the regional hospital are
neonatology and surviving outborns.
one year 180 low birth neonates needed.
service at a
regional hospital weight outborns Ambulance transport was used
(117 deceased) in only 10% of cases.

33
34
Dates of
Study
44% overall mortality was due

to Phase I, 34% due to Phase II,
50 deceased and 28% due to Phase III delays
Cross-sectional neonates (22 (some deaths were not due to
study of due to Phase I Mortality in any delays and some due to Delays in deciding to seek care and
deceased delays, 17 Phase Phase I, Phase multiple delays). transport-related delays are major
Upadhyay 2013/ neonates Home visits in II, 14 Phase III, 2010 II, and Phase III
41.2% of Phase II delays contributors to newborn deaths and
India during a 1 year 28 rural villages and 13 with no deaths delays (as defined
were due to absence of an efforts to improve newborn survival
period by verbal delay—5 deaths by Thaddeus &
accompanying family member, need to address both concurrently.
autopsy and had all 3 delays Maine, 1994)
social audit and 13 deaths 23.5% to unavailability of
had 2 delays) transport, 23.5% to long
distance to health facility, and
11.8% to lack of funds.
Pre- and post-
neonatal transport Incidence of hypothermia,
improvements hypoglycemia, and hypotension
(including were decreased after
educational transport improvements were
sessions for implemented.
healthcare
TRIPS score (pre 20.07 v. post
3/2007- personnel, Improvements in neonatal transport
Before and 2452 referred 11.53) and mortality rate (18.4%
Transport from 8/2007 purchases of conditions (educational programs
after (quasi- neonates v. 14.1%) were significantly
external centers ambulances for providers, improved vehicles
Uslu 2011 experimental) (1525 pre- higher in infants in the pre-
in 15 different and transport and equipment, and official and
/ Turkey study of referred intervention, intervention group.
provinces to a equipment, compulsory documentation and
neonates over 927 post- 1/2008-
NICU neonatal Higher incidence of pre- reporting) can lead to decreased
1 year intervention) 4/2008 resuscitation transport communication, neonatal morbidity and mortality.
programs, presence of a detailed discharge
compulsory use and birth reports, ambulance
of a “Neonatal and incubator use, proper
Transport Form”, use of intravenous fluids, and
and official intubation characterized the
reporting of post-intervention group.
referrals)
Retrospective
Mortality in
cohort study Efforts to improve newborn survival
Phase I, Phase 50% of overall mortality was
of deceased 16 rural health need to address concurrently
Waiswa 2010 64 deceased 1/2005- II, and Phase III due to Phase I delays, 20% due
neonates by facilities (52 household and health facility-
/ Uganda neonates 12/2008 delays (as defined to Phase II delays, and 30% due
verbal and social health providers) related delays in seeking
by Thaddeus & to Phase III delays.
autopsy over 4 appropriate care.
Maine, 1994)
years
Transport from Transport morbidity and mortality
Prospective 51 obstetric 254 referred Overall mortality rates were could be improved by better
cohort of clinics (level neonates (180 Infants transferred 1.5 times higher and mortality recognition in level I units of
Wang 1997 7/1991-
referred I) to 8 district to level II units, to level II and rates for ventilated neonates appropriate level of referral,
/ Taiwan (China) 6/1992
neonates over hospitals (level 74 to level III level III units were 3 times higher in level II v. improved capability of level II units
1 year II) and 1 tertiary units) level III units. to treat sick neonates, and increased
center bed capacity in level III units.
Inter-facility 716,853 live

transport births (298,504
Mortality rates were
Before and from various in area with Early neonatal
significantly lower in an area
after (quasi- hospitals, dedicated mortality rate
with a dedicated neonatal A structured and specialized
Woodward 1997 experimental) imaging transport (0-6 days) in areas
1990-1995 transport team (6.9 per 1000 neonatal transport service can lead
/ Hungary study of live facilities, or team, 418,349 with and without
live births) compared to a to decreased neonatal mortality.
births over 6 surgical centers in control a dedicated
control area without a transport
years to 5 NICUs and area without transport team
team (7.7 per 1000 live births).
one cardiac care dedicated
unit transport team)
CFT = capillary filling time; CLD = chronic lung disease; GA = gestational age; HIE = hypoxic ischemic encephalopathy; IV = intravenous; NICU = neonatal intensive care unit; NR = not reported; RR = risk
ratio; SNAP-II = Score for Neonatal Acute Physiology II; SNAPPE-II = Score for Neonatal Acute Physiology Perinatal Extension-II; TBA = traditional birth attendant; TOPS = Temperature, Oxygenation,
Perfusion, and blood Sugar; TRIPS = Transport Risk Index of Physiologic Stability; TTN = transient tachypnea of the newborn; VLBW = very low birth weight.

35
References included in the systematic review
Albuquerque AMA, Leite ÁJM, de Almeida NMGS, da Silva CF. Avaliação da conformidade do transporte
neonatal para hospital de referência do Ceará / An evaluation of the extent to which the transportation of
newborns to a referral hospital conforms to existing norms in the Brazilian State of Ceará. Rev. Bras. Saúde
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Discussion
39
Summary of evidence and recommendations
The evidence included in this systematic review substantiates the need for establishment of
neonatal transport services to provide equitable and widespread access to high-quality care
for infants in the first month of life. Infants born in the community or in first-level facilities
who require transport to higher levels of care continue to experience disproportionately high
mortality and morbidity compared to infants born in a center capable of delivering needed
care. However, improvement in the quality and organization of transport systems alone is
insufficient. Implementation or improvement of a transport system must be accompanied by a
system for regionalization of care within a referral network and strengthening of the capacity
to deliver high-quality care to meet the demand at every level of the perinatal health system.
Unanticipated consequences, such as increased referral of neonates who should be able to
receive adequate care in their facility of birth, can limit the overall impact of transport and
health system improvements. Similarly, referral of acutely ill neonates to a facility inadequately
prepared (either with personnel or equipment) to care for them also results in suboptimal
outcomes. Structural changes in the health system, such as implementation of universal health
coverage for pregnant women and newborns, can result in improvements in quality of perinatal
care, transport, and access to services.
Improvements in outcomes of neonatal transport can be achieved readily by focusing on the

critical, yet basic, issues of physiological stability. In order to accomplish improved quality of
care during transport, there is a need for proper equipment and vehicles, training and availability
of personnel, and norms for organization, administration, communication, and clinical care.
Oversight of national-level authorities or professional bodies may be necessary to achieve
adherence to established regulations and guidelines.
Specific training in patient assessment and management of common problems of transported
neonates is likely more important than the particular professional composition of the team.
Scores for severity of illness and specifically developed scales for monitoring physiologic stability
in transport can improve quality of care and may be useful in triage of patients to appropriate
referral centers. The impact of educational programs may not be uniform, however, because
education must be accompanied by necessary systems change and must result in sustainable
change in behavior.
Limitations and gaps in research
The evidence available for review reflects a lack of well-controlled, active intervention trials to
improve the quality of care during transport, the vehicles and equipment used during transport,
and the administration and management of transport services. There were no studies designed to
provide the highest level of evidence (randomized controlled trials, cluster-randomized trials, or
controlled clinical trials). Few studies carefully examined packages of interventions, combining,
for example, team training with improved equipment and vehicles and more rigorous transport
guidelines. No studies reported on systematic assessment of need for transport integrated with
comprehensive health system planning.
There were notable gaps in certain areas of the evidence identified for the systematic review.
Although hypothermia was identified in multiple studies as a major morbidity encountered
during neonatal transport, there were few studies identified that evaluated equipment or
modalities such as skin-to-skin care to provide thermal support during transport. There were no
40
studies identified from developing countries that compared different modes of medical transport
(ground, water, air ambulance (fixed wing, helicopter), bicycle ambulance, backpack/carrier).
Evaluations of equipment and operational functions may reflect publication bias or publication
of such studies in journals not included in the databases searched.
Identification of related articles by authors of included studies was hampered by inconsistent

application of conventions for indexing author names. Disproportionate difficulty accessing
literature from certain regions of the world may result from several factors. These include
variability in the order of surnames and given names (especially in studies from China), confusion
created by inconsistent use of paternal and maternal surnames (as in Spanish and Portuguese), and
uncertainties in alphabetization and indexing for authors whose surnames include “da” or “de.”
Conclusions
The studies included in this review highlight the scarcity of high-level evidence relating to
neonatal transport in developing countries. The findings from non-randomized studies without
control groups should be interpreted with caution and do not provide an independently sufficient
evidence base for formulation of guidelines. However, the available studies do reveal the
prevalence of inadequate systems for neonatal transport in low- and middle-income countries of
all regions of the world. Difficulty in maintaining thermal stability is the fundamental challenge
that most directly impacts neonatal morbidity and mortality. The capacity to provide additional
condition-specific care for respiratory distress and prematurity, surgical conditions, and sepsis
and its complications also directly influences neonatal morbidity and mortality. Even where
norms or guidelines exist, adherence to such standards of performance is low. Training of
/ Discussion
personnel to adequately and continuously assess the physiologic stability of neonatal patients
and correctly employ basic equipment and techniques to stabilize patients before and during
transport can improve outcome. Diffusion of innovation in equipment designed for neonatal
transport in resource-limited settings is limited. Planning for development of neonatal transport
systems must be integrated not only with similar efforts directed toward pregnant/postpartum
women and pediatric patients, but also with development of a coordinated system of perinatal
and maternal-child care. To realize the potential life-saving value of neonatal transport, three
steps are essential: (1) strengthening capacity for prevention/recognition/stabilization at the
community and first-level health facilities; (2) designing systems for ready access and effective
triage and transport of patients to higher levels of care; and (3) increasing capacity in terms of
skills and volume at the higher levels of care.
41
Future directions
43
Areas for future research
As efforts to improve neonatal survival expand, the demand for access to safe and effective
neonatal transport will only increase. Educational programs for neonatal resuscitation, essential
newborn care, and prematurity prevention/care all currently incorporate messages around
formulation of an emergency plan, including transportation and communication to a health
facility. This situation presents an opportunity to design controlled intervention trials for
effectiveness in reducing morbidity and mortality associated with neonatal transport. Ideally,
trials will incorporate packages of interventions shown to have impact on infant outcomes,
including such elements as:
• Pre-referral stabilization at site of origin of transport
•• surfactant administration
• Referral documentation
• Communication between referring site and receiving (referral) facility
•• to initiate transport
•• to direct transport to appropriate receiving facility
•• during transport (advice for patient management)
•• post referral follow-up to referring site
• Transport vehicles and equipment
•• Requirements for minimum equipment and for specific equipment for each
medical facility, e.g., incubator, infusion pump, feeding tube, nasogastric suction,
cardiorespiratory monitoring, oximeter, non-invasive blood pressure monitoring,
temperature monitoring and feedback control, blood glucose monitoring, intravenous
fluids, antibiotics, anticonvulsants
•• vehicle selection, operating characteristics, critical maintenance
• Team composition and training

•• staffing
•• professional role (physician, nurse, respiratory therapist, emergency medical
technician)
•• training in resuscitation and stabilization, assessment
• Kangaroo care and other alternative methods for maintaining thermal stability (aluminum
foil, silver swaddler, chemical warming mattresses, low-cost incubators)
• Triage and evaluation tools
• Quality improvement efforts focused on transport
•• critical incident analyses
•• case reviews
•• monitoring
• Cost-benefit analysis (DALYs, life-expectancy)
•• sources of financing for transport
• Family satisfaction
Specific strategies to promote rigorous research directed toward development of low-cost,

technologically appropriate equipment for neonatal transport might take advantage of the
fact that technology is currently a strong global funding priority. Grant programs such as the
Gates Foundation Grand Challenges series support such development, as do multiple university
partnerships among medical, nursing, and bioengineering faculty. The mechanism of the Global
44
Development Alliance, such as the public-private partnerships organized by the United States
Agency for International Development, also offers opportunities to collaborate with industry in
the development of appropriate technology and purpose-built devices.
Development of guidelines
Development of guidelines for neonatal transport has generally occurred by incorporation

of specific practices and principles from the various fields that contributed to its genesis:
neonatology, pediatric critical care and emergency medicine, pediatric surgery, trauma, and
emergency medical services for children. Guidelines must meet the needs of policymakers,
hospital and health system administrators, communications personnel, and the clinicians
directly involved in patient care. Previous guidelines have relied heavily on expert opinion and
consensus. However, the available evidence can be incorporated to support recommendations,
especially for developing countries seeking to improve or establish neonatal transport systems.
Neonatal transport must be situated in the larger context of regionalized perinatal care,
encompassing care of the pregnant woman and the fetus as well as the newly delivered mother
and her infant. Timely referral of the pregnant woman and in utero transport of the undelivered
fetus has been shown to improve outcome for a variety of neonatal medical conditions in the
developed world, including extreme prematurity and complex congenital malformations. Timely
referral for cesarean section can prevent morbidity and mortality from intrapartum-related
events (asphyxia). After delivery, transport of mother and infant together is critical to support
exclusive breast-feeding and employ skin-to-skin care as a means of thermal control during
transport. However, admission of both the mother and baby to the referral facility requires
changes in policy, financing, and capacity.
/ Areas for future research
The evolution of a neonatal transport system naturally moves from an initial focus on the most
common reasons for referral (including moderate prematurity, hypoxic-ischemic encephalopathy,
sepsis, and surgical conditions) to increasingly sophisticated interventions for complex, high-
acuity conditions (such as extreme prematurity with respiratory distress, pulmonary hyper
tension, and critical congenital heart disease). This progression in sophistication ideally parallels
that occurring in the health system as a whole. Rational use of transport calls for basic care
for infants 1800–2500 grams and above to occur in first-level centers close to the community.
Referrals to level II centers are indicated for moderate illness, and tertiary centers are reserved
for management of the highest-risk infants, as predicted by illness severity scores or need for
mechanical ventilation or surgical intervention. As the severity of illness increases, the need for
a centralized transport system also increases in order to assure full availability of appropriate
trained personnel, equipment, and protocols. With increasing complexity of disease come difficult
decisions on investment of resources in intensive care rather than primary prevention and care.
Resources for development of guidelines
Existing guidelines for neonatal transport in the developed and developing world can serve as
useful models for development of regional guidelines. The Section on Transport Medicine of the
American Academy of Pediatrics (AAP) updated Guidelines for Air and Ground Transport of Neonatal
and Pediatric Patients in 2007 and also recently issued the results from a national consensus
conference on pediatric and neonatal interfacility transport (Stroud 2013). The Asociación
Española de Pediatría also recently issued updated recommendations on neonatal transport
(Moreno Hernando 2013). Guidelines from the Brazilian Ministry of Health (Brasil, Ministério
de Saúde 2010) and Argentinian Ministry of Health (Argentina, Ministerio de Salud 2012) also
45
provide recent templates for implementation.
Additional resources to support the development of transport infrastructure globally include the
Handbook of Pediatric and Neonatal Transport Medicine (Jaimovich and Vidyasagar 2002) and white
papers on transport from the World Bank (Babinard and Roberts 2006) and the International
Forum for Rural Transport Development (Lema 2009).
Framework for practical implementation of a neonatal transport system
Organization of a neonatal interfacility transport service
Prior to the organization of a neonatal transport system, planning and coordination at the
national and regional level are necessary to align the goals and objectives of transport with
those of the larger health system. Such a planning process includes:
• Alignment of targets for outcome improvement in health system and priority conditions
(and exclusions) for transport
• Estimation of demand for care, by target condition and by region (met and unmet need)
• Development of primary and referral centers to meet demand for care (appropriate
population-based distribution)
• E
stimation of demand for transport to achieve equitable access to care (accounting for
population distribution)
• Establishment of referral networks by target condition and by region (based on available
subspecialties)
• Determination of administrative and governance model for transport system (governmental
or private, independent organization or affiliate of hospital system)

• Definition of financial operating plan and revenue flows (alignment with covered benefits
of health insurance plans, financial responsibility of sending and receiving hospitals [e.g.
personnel], provision for uninsured patients or those with conditions outside covered
benefits)
Transport program structure and administration
Transport may originate in the community, with local emergency services and a community
health care provider accompanying the patient; however, transport vehicles in the community
seldom have adequate equipment for care of neonates. Origination of the transport from the
referral center enables more efficient use of appropriately equipped vehicles and offers the
additional advantage that primary care providers remain in their assigned role and available
to other persons needing services in the community. Delivering medical care in the context
of transport requires a specific skill set; hence it is undesirable to use staff nurses (even very
experienced intensive care nurses), residents, or fellows who do not have specific training in
transport medicine.
The volume of transported neonates may not be sufficient to support a single-purpose transport
team and system. Configuring teams to come together on an as-needed basis introduces delay;
however, maintaining a 24/7 team exclusively for neonatal transports is usually cost-prohibitive.
Many teams are structured to transport both neonatal and pediatric patients. Coverage between
adult and neonatal/pediatric transport is difficult because of the very disparate diagnoses and
46 skill sets, but it may be feasible to share transport vehicles. Sharing of communications and
administrative infrastructure with adult transport is virtually mandatory.
Transport team members: mobile and in-facility clinicians and administrative support
Personnel are the most valuable element in a transport system. Trained personnel with the
ability to provide appropriate care during transport are crucial to reducing mortality associated
with long transport distances and optimizing outcome. Typical roles within a neonatal transport
system include:
Medical director – pediatric/neonatal specialist with training in critical care and transport
medicine, responsible for developing and reviewing policies and protocols, selecting and training
personnel, approving equipment and therapeutic strategies, providing case review and oversight
as well as outreach education, and managing quality improvement programs.
Transport coordinator (administrative director) – a health professional who is responsible for

the daily activities of the transport team, including scheduling, selection and maintenance of
equipment, data collection, budget management, training and compliance.
Coordinating (control) physician – pediatric/neonatal specialist with training in critical care who
obtains information about the patient, offers advice on patient management before arrival of
the team, provides supervisory contact during transport, and documents clinical data for use by
the receiving facility. The coordinating transport physician also assures availability of bed space,
appropriate team composition, and notification of other needed sub-specialists.
Transport team members - physicians, nurses, paramedic/emergency medical technicians,
respiratory therapists, and pilots/drivers. Dedicated, specially trained nurses or advanced practice
nurses may offer advantages over physicians in terms of cost, flexibility between inpatient/
transport duties, familiarity with equipment, and specific training in monitoring/supportive
functions. Physicians can participate effectively through regular communication with the on-
site team throughout the transport as well as immediate availability for consultation in case of
emergency. Emergency medical technicians are vital to the logistics of patient transfer (equipment
functionality, vehicle loading and securement systems) and may also serve as drivers. When
patients with respiratory conditions are transported under mobile NICU conditions, respiratory
therapists can assume responsibility for air way and ventilator management, in conjunction with
nurse specialists and supervising physicians.
Transport program personnel management, training, and assessment
The transport environment implies a degree of autonomy for clinicians and so the most valuable
transport team members have considerable expertise. However, traits that support a high
level of performance under demanding conditions are equally important, such as leadership,
flexibility, independence, excellent communication skills, and ability to solve problems. The
composition and training of the clinicians on the transport team should be matched to the mission
and clinical scope of the team. A diagnosis-based educational checklist (based on the target
conditions for transport) along with a curriculum in transport medicine/physiology can serve as
a guide for development and maintenance of cognitive knowledge. There is usually a need for
additional training to develop procedural skills to the level required for efficient, safe, successful
performance under field conditions. Maintenance of skills and renewal of the knowledge base
47
is critical, as is training of new staff members when turnover occurs. Transport team members
should be directly involved in ongoing quality monitoring and quality improvement initiatives.
Communications and dispatch center/integration with EMS
Effective communication is required to coordinate the multiple parties involved in interfacility

transport. A communication system should provide a standardized mechanism and routine for:
• Access to services by the referring provider
• Notification, briefing, and mobilization of the transport team
• Response to the referring facility
• Contact among the transport team, medical control physician, referring and receiving
health providers, and communication center
• Follow-up to the referring facility/provider
Emergency transport medical communications systems may follow a number of models,

including: (1) public safety and emergency dispatch centers (e.g., 911 system); (2) hospital-
based communications centers (usually affiliated with and emergency department); (3)
freestanding communications centers serving one or more transport programs; and (4) unit-
based communications site (such as a NICU).
A communication center must operate 24 hours a day, 7 days a week with trained communications
specialists. These specialists obtain patient information and assess the logistical aspects of
transport to select the appropriate mode and coordinate each step according to policies and
procedures. Phone systems and two-way radio systems (in the event of phone outages) form the
nucleus of the communications center; data links to emergency services, weather, and traffic/
flight control centers characterize more sophisticated and larger systems.
Modes of transportation
Modes of transport vary from one region to another and depend upon patient acuity, geographical
features, distance, transit time, weather patterns, and population density. Attention to the safety
of the transport team and patient are the foremost considerations determining the mode of
transport. All transport vehicles should provide oxygen and air in concentrations from 21% to
100%. Adequate lighting, climate control, and electrical power/outlets are especially important
for assessment and care of neonatal patients. Expensive modes of transport, such as fixed-wing
aircraft or helicopter, may be shared by several institutions. Vehicle operation (including fueling,
maintenance, insurance, required licensure of drivers/pilots, etc.) may be core functions of the
medical entity or of a contractor, or a hybrid approach.
Equipment and medications
Equipment and medications for neonatal transport differ to a great extent from the equipment
and medications used in adult care. This requires a parallel but separate set of equipment and
medications in services that care for both age groups. Equipment used in transport must meet
several general characteristics:
• Appropriate for the age group and set of medical conditions to be addressed
48
• Lightweight, portable, rugged, easy to clean
• Secured in the transport vehicle for patient and team safety
• Tested in the transport environment (temperature, altitude, vibration)
Equipment to provide complete monitoring of heart rate, respiratory rate, temperature,

blood pressure, and oxygen saturation is essential to achieving good patient outcomes.
Thermoregulation and impact protection are especially important considerations for neonates,
as is the ability to provide glucose-containing fluids (enterally or parenterally) and measure
blood glucose. Portable suction is necessary for clearing the airway and gastric decompression.
Ability to administer blended oxygen is standard. Ventilator care requires highly specialized
equipment for operation under the conditions of transport.
Medications required in transport are dictated by the diseases encountered. In neonatal transport,
certain medications such as prostaglandins and surfactant require refrigerated storage. Their use
may be infrequent but the lifesaving nature of treatment justifies the expense of maintaining
current stock where transport of infants with congenital heart disease or respiratory distress
is part of the portfolio. Analgesics, sedatives, and other controlled substances require specific
security and documentation; all medications must be routinely logged, restocked, inventoried,
and replaced when outdated. Neonatal dosage references and dosage calculation aids are useful
and improve safety of neonatal care.
Legal and compliance issues and safety
Transport involves the transfer of responsibility from the referring to the accepting providers
and facility. The lines of responsibility and applicable laws, regulations, and administrative
guidelines must be clearly defined. Legal issues can arise around violations of regulatory or
licensure standards, as well as medical malpractice. Transport of non-patients (e.g. mothers and
other family members of sick newborns) also raises issues of liability.
Quality improvement/data collection/accreditation
Continuous monitoring and evaluation of a transport program are vital to providing quality
patient care. Transport must address the six characteristics of quality care: effective, timely,
efficient, patient-centered, equitable, and safe. In addition to routine case review and review
of patient care guidelines, quality improvement involves specific activities at every level of
the transport enterprise, following the PDSA (Plan, Do, Study, Act) cycle or a similar program.
Data collection is central to quality improvement, as is the feedback of results to the transport
team/administrators. Accreditation is a voluntary process in which a board of experts evaluates
a program or institution against measurable standards or criteria. Accreditation for medical
transport is generally separate from accreditation of hospital services.
Transport physiology and stress
Providing care in a mobile environment involves understanding of the stresses placed on both
49
patient and care providers. Noise, vibration, temperature swings, exposure to high humidity
and/or dehydration can worsen patient condition and stress transport team members physically
and emotionally. Air medical transport requires thorough understanding of physical gas laws,
hypoxia, and flight physiology. Transport team members may face long, irregular duty hours
under stressful circumstances. Stress management, debriefing and team health are important
considerations to support continued quality of patient care.
Family-centered care
Family-centered care recognizes the important role of the family in the lives of children. For
neonates, the role of the mother is central as a source of nourishment (breast milk) and warmth
(skin-to-skin care). However, the acuity of a patient’s condition and the need for rapid mobilization
may lead to parental separation. Parents should be given the opportunity to accompany the
transport when possible. At all times, parents should be given the opportunity to discuss their
child’s condition and management with transport team members.
Outreach education
An outreach education program should be incorporated into transport activities, with the goal of
improving patient outcome. Outreach education can improve recognition of conditions requiring
transport and stabilization before arrival of the transport team. Development of relationships
between referring and receiving health care providers can also improve follow-up care and
coordination of care.
Ethical considerations
Consent to administer medical treatment is generally obtained prior to transport. National law
and cultural norms surrounding this process may vary significantly. However, minors generally
do not have the legal authority to give consent, and thus a parent or legal guardian has this
responsibility. In the case of an emergency that threatens life or health when a parent or
guardian is not available, emergency services may be provided if the doctrine of implied consent
is applicable.
Practical tools to support safe neonatal transport
There are a variety of resources that offer practical tools for education and job aids for safe
neonatal transport in developing countries. Below are descriptions of several key texts, as well
as a range of materials that pediatric professional organizations have developed for transport-
team training and capacity-building of staff in neonatal care units.
Handbook of Pediatric and Neonatal Transport Medicine
The second edition of this book (Jaimovich and Vidyasagar 2002) includes extensive chapters
on the medical conditions most commonly encountered in neonatal transport as well as sample
forms and reference materials. The table of contents of the text is given below:
50
I. General Considerations
1. Organization of a Pediatric-neonatal Transport Program
2. Transport Management Considerations
3. Organization of a Neonatal Transport Program
4. Aviation Physiology in Pediatric Transport
5. General Neonatal Physiologic Considerations
6. Transport Safety
7. Administrative Pearls
II. Cardiovascular System
8. Pediatric Cardiology in Transport Medicine
9. Cardiopulmonary Resuscitation of Newborns during Transport
10. Pediatric Cardiopulmonary Resuscitation
11. Shock
III. Respiratory System
12. Airway Management
13. Respiratory Failure Management during Transport
14. Transport Issues in Neonates with Respiratory Problems

15. Transport Management of Acute Pediatric Asthma
16. Transport of Neonatal and Pediatric Patients Requiring Extracorporeal Life Support
17. High-Tech Respiratory Care on Transport
IV. Central Nervous System
18. Neonatal Neurological Problems
19. Transportation of the child with Seizures
20. Near-Drowning
V. Endocrine System and Metabolism
21. Endocrine and Metabolic Emergencies
22. Evaluation and Management of Renal Emergencies
23. Poisoning, Ingestion, and Overdose
VI. Trauma
24. Initial Stabilization and Transport of the Pediatric Trauma Patient
25. Central Nervous System Injuries
26. Cardiothoracic Injuries in Children
27. Abdominal Anomalies
28. Skeletal Injuries 51

29. Burns and inhalation Injuries
VII. Infectious Disease
30. Infectious Disease
VIII. Special Topics
31. Temperature Regulation and Management
32. Common Radiologic Findings in Pediatric and Neonatal Transport Patients
33. Transport Equipment and Techniques
Appendix I: Laboratory Values

Appendix II: Treatment Algorithms and Charts
Appendix III: Drug Therapy
Appendix IV. Pediatric Transport Protocols
Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients
This extensive text, from the American Academy of Pediatrics (AAP), includes valuable practical
tools for the operational aspects of a neonatal transport service. Other resources for initial
stabilization prior to transport, management during transport, and emergency care are available
through the AAP Division of Life Support.
www.aap.org
ACoRN, Acute Care of at-Risk Neonates
The ACoRN Neonatal Society, a Canadian society of volunteer professionals, publishes this book
(ACoRN Editorial Board 2005), which provides health care professionals with a step-by-step
framework to guide management of the sick newborn. The newest English-language update was
published in 2012. There is also a Spanish-language eBook edition available from Amazon.com.
www.cps.ca/en/acorn
The National Neonatology Forum of India
This organization offers clinical practice guidelines for transport of a sick neonate and teaching
aids for newborn care during neonatal transport.
http://bit.ly/29LREsi
Neonatal Resuscitation Program (NRP)
This AAP educational program in neonatal resuscitation for health professionals incorporates
the guidelines and consensus on science of the International Liaison Committee on Resuscitation
(ILCOR) as well as adult learning techniques utilizing simulation and skills practice to achieve
competency.
http://www2.aap.org/nrp/
52
Helping Babies Breathe (HBB)
Based on the same science and guidelines as NRP, this educational program targets birth
attendants in resource-limited settings and equips them with the skills to protect healthy babies
and help those babies who do not breathe at birth through stimulation, clearing the airway, and
bag and mask ventilation with air.
http://www.helpingbabiesbreathe.org/
Perinatal Continuing Education Program (PCEP)
A series of four workbooks provides educational tools for physicians, nurses, nurse midwives,
respiratory therapists, and other providers of care for pregnant women and newborns.
Content and activities are aimed at improving perinatal care policies, as well as practices and
procedures,through establishing organization-wide care goals and routines.
Book I – Maternal and Fetal Evaluation and Immediate Newborn Care
Book II – Maternal and Fetal Care
Book III – Neonatal Care
Book IV – Specialized Newborn Care
S.T.A.B.L.E.
This neonatal education program focuses on the post-resuscitation/pre-transport stabilization

care of sick infants. The title stands for the six assessment and care modules in the program:
Sugar, Temperature, Airway, Blood pressure, Lab work, and Emotional support. A seventh module,
Quality Improvement, stresses the professional responsibility of improving and evaluating care
provided to sick infants.
The S.T.A.B.L.E. instructional materials include a Learner/Provider Manual and and also
an Instructor Manual. An accompanying slide program (Post-resuscitation/ Pre-transport
Stabilization Care of Sick Infants, Guidelines for Neonatal Healthcare Providers) can be used
for self-study or instructor-led presentations. These illustrations, photos, and animations are
available on DVD or flash drive. A second slide set (Physical and Gestational Age Assessment of
the Newborn) is available on CD-ROM or flash drive. An advanced module on care of the patient
with congenital heart disease (Recognition and Stabilization of Neonates with Severe CHD) is
available as a student handbook and slide program on CD-ROM.
www.stableprogram.org
PSSAT
Pre-transport Stabilization Self-Assessment (PSSAT) is a tool for quality improvement in

S.T.A.B.L.E. The tool records data useful to assess the stabilization care provided to neonates
requiring transport or transfer to another unit. Data are recorded from three time periods: Time
A – at the time the transport is requested; Time B – upon arrival of the transport team in the
referring nursery; and Time C – upon departure of the transport team. By using the recording
of stabilization actions at each time period, nursing and medical review teams can assess the
adequacy of pre-transport (or transfer) stabilization care.
http://www.stableprogram.org/stabilizationtool.php
53
Scores for severity of illness and transport physiologic stability
Scores for severity of illness and transport physiologic stability (SNAP-II, SNAPPE-II, TRIPS, TRIPS-
II) are described in studies included in the systematic review and in the literature describing their
development and refinement (Richardson 2001, Lee 2001, Lee 2013).
General references
55
ACoRN Editorial Board, Solimano A , Littleford J. ed. ACoRN: acute care of at-risk newborns.
ACoRN,Vancouver, 2005. (2010 update in 3rd printing).
American Academy of Pediatrics. Section on Transport Medicine. Guidelines for air and ground transport
of neonatal and pediatric patients. 3 ed. Elk Grove Village, 2007. [Access July 8, 2015]. Available at: http://
tinyurl.com/o6rj948
Argentina. Ministerio de Salud. Dirección Nacional de Maternidad e Infancia. Área de Neonatología.

Recomendaciones para la práctica del traslado neonatal. Buenos Aires: Ministerio de Salud, 2010. 115p.
[Access July 8, 2015]. Available at: http://bit.ly/1NRe5qE
Babinard J, Roberts P. Maternal and child mortality development goals: what can the transport sector do?
Washington: World Bank, Aug 2006. 40 p. Transport Papers TP-12. [Access September 2, 2013]. Available
at: http://www.worldbank.org/transport/
Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e

Estratégicas. Manual de orientações sobre o transporte neonatal. Brasília, 2010. 40 p. (Série A. Normas e
Manuais Técnicos). [Access July 8, 2015]. Available at: http://tinyurl.com/paoax3p
Effective Public Health Practice Project. Quality assessment tool. 2009. [Access August 27, 2013]. Available
at: http://www.ephpp.ca/tools.html
Gould JB, Danielsen BH, Bollman L, Hackel A, Murphy B. Estimating the quality of neonatal transport in
California. J Perinatol. 2013; 33:964-970.
Hussein J, Kanguru L, Astin M, Munjanja S. The effectiveness of emergency obstetric referral interventions
in developing country settings: a systematic review. PLoS Medicine. 2012; 9(7):e1001264. [Access July 8,
2015]. Available at: http://tinyurl.com/p9yr2dk
Jaimovich DG , Vidyasagar D, Ed. Handbook of pediatric and neonatal transport medicine. 2 ed. Philadelphia:
Hanley, 2002.
Lee SK, Zupancic JAF, Pendray M, et al. Transport risk index of physiologic stability: a practical system for
assessing infant transport care. J Pediatr 2001;139(2):220-226.
Lee SK, Aziz K, Dunn M, et al. Transport risk index of physiologic stability, version II (TRIPS-II): a simple and
practical neonatal illness severity score. Am J Perinatol. 2013 May 30;30(5):395-400.
Lema VM. Maternal and newborn health and emergency transport in Sub-Saharan Africa. Nairobi: IFRTD,
2009, 38 p. [Access July 8, 2015]. Available at: http://tinyurl.com/pl53osn
Mbaruku G, van Roosmalen J, Kimondo I, Bilango F, Bergstrom S. Perinatal audit using the 3-delays model
in western Tanzania. Int J Gynaecol Obstet. 2009;106(1):85-88. [Access July 8, 2015]. Available at: http://
tinyurl.com/oxd7yf5
Moreno Hernando J, Thió Lluch M, Salguero Garcia E, et al. Recomendaciones sobre transporte neonatal.
Anales de Pediatría. 2013, 79(2): 117.e1–117.e7. [Access July 8, 2015]. Available at: http://tinyurl.com/
of59zqw
Richardson DK, Corcoran JD, Escobar GJ, et al. SNAP-II and SNAPPE-II: simplified newborn illness severity
and mortality risk scores. J Pediatr. 2001;138(1):92-100.
Stroud MH, Trautman MS, Meyer K, et al. Pediatric and neonatal interfacility transport: results from a
national consensus conference. Pediatrics. 2013;132(2):359-66. [Access July 8, 2015]. Available at: http://
tinyurl.com/o2vhu3m
Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994 Apr; 38(8):1091-110.
[Access July 8, 2015]. Available at: http://tinyurl.com/noka893
United Nations. The millennium development goals report 2013. New York, 2013. [Access September 2,
2013]. Available at: http://www.un.org/millenniumgoals/reports.shtml.
56
Appendices
57
Appendix 1. PRISMA 2009 Checklist
Section/topic # Checklist item
TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both.
ABSTRACT
Provide a structured summary including, as applicable: background; objectives;

data sources; study eligibility criteria, participants, and interventions; study
Structured summary 2
appraisal and synthesis methods; results; limitations; conclusions and
implications of key findings; systematic review registration number.
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known.
Provide an explicit statement of questions being addressed with reference to

Objectives 4
participants, interventions, comparisons, outcomes, and study design (PICOS).
METHODS
Indicate if a review protocol exists, if and where it can be accessed (e.g.,

Protocol and
5 Web address), and, if available, provide registration information including
registration
registration number.
Specify study characteristics (e.g., PICOS, length of follow-up) and report

Eligibility criteria 6 characteristics (e.g., years considered, language, publication status) used as
58 criteria for eligibility, giving rationale.
Describe all information sources (e.g., databases with dates of coverage,

Information sources 7 contact with study authors to identify additional studies) in the search and
date last searched.
Present full electronic search strategy for at least one database, including any
Search 8
limits used, such that it could be repeated.
State the process for selecting studies (i.e., screening, eligibility, included in
Study selection 9
systematic review, and, if applicable, included in the meta-analysis).
Describe method of data extraction from reports (e.g., piloted forms,

Data collection
10 independently, in duplicate) and any processes for obtaining and confirming
process
data from investigators.
List and define all variables for which data were sought (e.g., PICOS, funding
Data items 11
sources) and any assumptions and simplifications made.
Describe methods used for assessing risk of bias of individual studies (including
Risk of bias in
12 specification of whether this was done at the study or outcome level), and how
individual studies
this information is to be used in any data synthesis.
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means).
Describe the methods of handling data and combining results of studies, if

Synthesis of results 14
done, including measures of consistency (e.g., I2) for each meta-analysis.
Risk of bias across Specify any assessment of risk of bias that may affect the cumulative evidence
15
studies (e.g., publication bias, selective reporting within studies).
Describe methods of additional analyses (e.g., sensitivity or subgroup analyses,

Additional analyses 16
meta-regression), if done, indicating which were pre-specified.
/ Appendices
RESULTS
Give numbers of studies screened, assessed for eligibility, and included in the
Study selection 17
review, with reasons for exclusions at each stage, ideally with a flow diagram.
For each study, present characteristics for which data were extracted (e.g.,
Study characteristics 18
study size, PICOS, follow-up period) and provide the citations.
Risk of bias within Present data on risk of bias of each study and, if available, any outcome level
19
studies assessment (see item 12).
For all outcomes considered (benefits or harms), present, for each study: (a)
Results of individual
20 simple summary data for each intervention group (b) effect estimates and
studies
confidence intervals, ideally with a forest plot.
Present the main results of the review. If meta-analyses are done, include for
Synthesis of results 21
each, confidence intervals and measures of consistency.
Risk of bias across

22 Present results of any assessment of risk of bias across studies (see Item 15).
studies
Give results of additional analyses, if done (e.g., sensitivity or subgroup

Additional analysis 23
analyses, meta-regression [see Item 16]).
DISCUSSION
Summarize the main findings including the strength of evidence for each main
Summary of
24 outcome; consider their relevance to key groups (e.g., healthcare providers,
evidence
users, and policy makers).
Discuss limitations at study and outcome level (e.g., risk of bias), and at review-
Limitations 25
level (e.g., incomplete retrieval of identified research, reporting bias).
Provide a general interpretation of the results in the context of other evidence,

Conclusions 26
and implications for future research.
59
FUNDING
Describe sources of funding for the systematic review and other support (e.g.,
Funding 27
supply of data); role of funders for the systematic review.
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting
Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6):
e1000097. doi:10.1371/journal.pmed1000097
For more information, visit: www.prisma-statement.org.
Appendix 2: Search strategy
Neonatal Transport – keyword and MeSH – Ovid Search

May 27, 2013
Concepts Transport/access/referral Neonatal conditions Location

exp Developing
(evacuation or stabilization or
countries/
neonatal transport$ or neonatal
or Medically
retrieval$ or transport team$ or
underserved area/
transport service$ or (bicycle or
or exp Africa/
bicycles or bicycling or bike$)
Key Words or exp Central
or (car or cars or ambulance$ limited to birth to 1 mo America/ or exp
or donkey$ or backpack$
Latin America/ or
or pouch$) or (phone$ or
exp South America/
telephone$ or cellphone$)).
or exp Asia/ or exp
ti,ab.
Carribean region/
exp Transportation of patients/ Hypothermia, induced/ or

or Transportation/ or Health Hypothermia/ or Respiratory
services accessibility/ or exp distress syndrome, newborn/
"Referral and consultation"/ or Pneumonia/ or Hypoxia-
or Patient transfer/ or ischemia, brain/ or Hypoxia,
Telemedicine/ or Remote brain/ or Asphyxia neonatorum/
consultation/ or Bicycling/ or or Asphyxia/ or Sepsis/ or
Motorcycles/ or Ambulances/ Hypotension/ or Hyaline
or Air ambulances/ or Aircraft/ membrane disease/ or
or Taxi/ or Helicopters/ or Respiration, artificial/ or exp Developing
Stretchers/ or Motor vehicles/ Fetal growth retardation/ countries/
60 or Hypoglycemia/ or or Medically
or Telecommunications/ or
Satellite communications/ Pneumothorax/ or Apnea/ underserved area/
or Radio/ or exp telephone/ or Airway obstruction/ or or exp Africa/
MeSH or Cellular phone/ or exp Respiratory insufficiency/ or or exp Central
Emergency medical services/ Continuous positive airway America/ or exp
or Health services, indigenous/ pressure/ or Infant mortality/ or Latin America/ or
or Emergency treatment/ Body temperature regulation/ exp South America/
or Delivery of health care, or Resuscitation/ or Infant, or exp Asia/ or exp
integrated/ or Life support premature, diseases/ or exp Carribean region/
care/ or exp Emergency Infant, newborn, diseases/
responders/ or Incubators, or Congenital anomalies/ or
infant/ or Regional medical Intensive care, neonatal/ or
programs/ or regional health Infant, premature/ or Infant,
planning/ small for gestational age/ or
Infant, low birth weight/ or
Infant, very low birth weight/
or Infant, extremely low birth
weight/
Filters Limited to birth to 1 mo

Publication CLAP/SMR Nº 1605-02 2016
ISBN 978-92-75-11917-4

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Neonatal transport

Transporte neonatal en el entorno de los países en desarrollo: revisión sistemática

PAHO HQ Library Cataloguing-in-Publication Data

(CLAP/WR. Scientific publication, 1605-02).

ISBN 978-92-75-11917-4 (NLM Classification: WX215)

© Pan American Health Organization, 2016. All rights reserved.

Av. Brasil 2697 - Ap.4

Results and systematic review references. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Future directions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

Appendix 1. PRISMA 2009 Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Appendix 2. Search strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

External Review Committee:

José Ceriani Cernadas

AAP American Academy of Pediatrics

Aims and rationale

The overall objective is to perform an assessment of referral systems in developing countries

1. To perform a review of the scientific evidence on neonatal transport, focusing on the

2. To analyze the evidence identified.

Household / Community First-level health facility Referral health facility

Protocol and registration

Data extraction, quality assessment, and analysis

Records from databases searched:

Abstracts selected n=470

Abstracts selected Excluded (did not meet

Study characteristics and quality assessment

Results of individual studies

1) Transport physiology and care

Fourteen prospective and retrospective cohort studies examined physiologic stability

Several studies documented the high percentage of transports accomplished by family

2) Adherence to norms and guidelines

and function, and documentation of patient status. A case-control comparison of referred

3) Team training and composition

Three studies reported trials of transport carriers designed to provide thermoregulation

Control of Strength of Control for Data Collect.

Transport physiology and care

/ Results and systematic review references

Transport from outside

/ Results and systematic review references

Mortality was significantly

Adherence to norms and guidelines

/ Results and systematic review references

Of those patients with a Educational interventions are likely

The most common errors Transport equipment should be

71% of neonates carried a Detailed referral notes should

Only 50% of patients had an

Team training and composition

Biochemical Biochemical and physiologic

/ Results and systematic review references

/ Results and systematic review references

Pre and post-

/ Results and systematic review references

44% overall mortality was due

Inter-facility 716,853 live

/ Results and systematic review references

Khodadadeh Y, Nili F, Nayeri F, Wickramasinghe Y. Comparative clinical evaluation of a prototype

for Neonatal Deaths in Rural Haryana, India. J Trop Pediatr. 2013;59(2):100-105.

Summary of evidence and recommendations

Improvements in outcomes of neonatal transport can be achieved readily by focusing on the

Limitations and gaps in research