Importance of specialized paediatric and neonatal transport. Current situation in Spain: Towards a more equitable and universal future 夽

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www.analesdepediatria.org

SPANISH ASSOCIATION OF PAEDIATRICS

Importance of specialized paediatric and neonatal transport. Current situation in Spain: Towards a more equitable and universal future ^夽

Nuria Millán García del Real

^a,b,c,^∗

, Laura Sánchez García

^d,e,f

, Yolanda Ballesteros Diez

^g,h

, Raquel Rodríguez Merlo

^i,j

,

Alberto Salas Ballestín

^c,k,l

, Raquel Jordán Lucas

^m,n

, Nieves de Lucas García

^j,o

aServiciodeEmergenciasMédicasPediátricas,Catalu˜na,Spain

bUnidaddeCuidadosIntensivosPediátricos,HospitalSanJuandeDios,Catalu˜na,Spain

cGrupodeEstabilizaciónyTransportedelNi˜noyNeonatoCríticodelaSociedadEspa˜noladeCuidadosIntensivosPediátricos (SECIP)

dServiciodeNeonatologíadelHospitalUniversitarioLaPaz,Madrid,Spain

eEquipodeTransporteNeonataldelaComunidaddeMadrid,Madrid,Spain

fGrupodeTransporteNeonataldelaSociedadEspa˜noladeNeonatología,Spain

gServiciodeUrgenciasdelHospitalUniversitarioCruces,Bilbao,Spain

hGrupodetrabajodePacienteCríticodelaSociedadEspa˜noladeUrgenciasdePediatría

iSUMMA112Madrid,Madrid,Spain

jGrupodeEmergenciasyUrgenciasPediátricasdelaSociedadEspa˜noladeMedicinadeEmergencias

kUnidaddeTransportePediátricodeBaleares,IslasBaleares,Spain

lUnidaddeCuidadosIntensivosPediátricosdelHospitalUniversitarioSonEspases,PalmadeMallorca,Spain

mServiciodeNeonatologíadelHospitalUniversitariValld’Hebron,Barcelona,Spain

nGrupodeTransporteNeonataldelaSociedadEspa˜noladeNeonatología

oSAMUR-ProtecciónCivildeMadrid,Madrid,Spain

Received1June2021;accepted14June2021 Availableonline29November2021

KEYWORDS Neonataltransport;

Paediatrictransport;

Interfacility transport;

Criticalcare

Abstract Specializedpaediatricandneonataltransportisausefulandessentialresourceinthe interhospitaltransferofthesepatients.Itallowsbringingthematerialandpersonalresources ofanintensivecareunitclosertotheregionalhospitalswherethepatientcanbefound.The benefitsoftheseteams areverywelldemonstratedintheliterature.Theseunitsshouldbe partoftheemergencysystems,whileitwouldberecommendedthattheybestaffintegrated inthetertiaryhospitals,inordertomaintainthenecessaryskillsandcompetencies.Theteam,

夽 Pleasecitethisarticleas:MillánGarcíadelRealN,SánchezGarcíaL,BallesterosDiezY,RodríguezMerloR,SalasBallestínA,Jordán LucasR,etal.Importanciadeltransportepediátricoyneonatalespecializado.SituaciónactualenEspa˜na:Haciaunfuturomásequitativo yuniversal.AnPediatr(Barc).2021;95:485.

∗Correspondingauthor.

E-mailaddress:[email protected](N.MillánGarcíadelReal).

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madeupofphysicians,nursesandemergencymedicaltechnicians,mustmasterboththepatho- physiologyoftransportandthatofthecriticalpatientinthisagerange.Ahighqualityofboth humanandcareisimportant,socontinuoustrainingandperiodicrecyclingwillbeessentialto becompliantwiththequalityindicatorsintransport.Likewise,itisessentialtohavespecific vehiclesadaptedtothisfunction,whichallowcarryingthewidevarietyofnecessarymaterial, aswellastheelectromedicinethatisrequired.However,inSpainthispaediatricandneona- taltransportmodelisnotstandardizedandthereforeisnothomogeneous:therearedifferent modelsthatdonotalwaysprovideadequatequality,makingitnecessarytoimplementspecial- izedunitsthroughoutthecountrytoguaranteesanitarytransportqualitytoanycriticalchild orneonate.

4.0/).

PALABRASCLAVE Transporteneonatal;

Transporte pediátrico;

Transporte interhospitalario;

Cuidadoscríticos

Importanciadeltransportepediátricoyneonatalespecializado.Situaciónactualen Espa˜na:Haciaunfuturomásequitativoyuniversal

Resumen Eltransportepediátricoyneonatalespecializadoesunrecursoútilyesencialenel trasladointerhospitalariodeestospacientes.Permiteacercarlosrecursosmaterialesyperson- alesdeunaunidaddecuidadosintensivosaloshospitalescomarcalesdondesepuedaencontrar elpaciente.Losbeneficiosdeestosequiposestánmuybiendemostradosenlaliteratura.Estas unidades deberíanformarpartedelossistemasdeemergencias,al mismotiempoquesería recomendablequefueranpersonalintegradoenloshospitalesterciarios,conelfindemantener lashabilidadesycompetenciasnecesarias.Elequipo,compuestopormédicos,enfermerosytéc- nicosdeemergenciassanitariastienequedominartantolafisiopatologíadeltransportecomola delpacientecríticoenesterangodeedad.Esimportanteunaaltacalidadtantohumanacomo asistencial,porloquelaformacióncontinuadayelreciclajeperiódicoseránimprescindibles parapodercumplircorrectamenteconlosindicadoresdecalidadentransporte.Asímismo,es fundamentalcontarconvehículospropiosyadaptadosasufunción,quepermitanllevarlagran variedaddematerialnecesario,asícomolaelectromedicinaqueserequiere.Sinembargo,en Espa˜naestemodelodetransportepediátricoyneonatalnoestáestandarizadoyporlotanto noeshomogéneo:existendiferentesmodelosquenosiempreaportanunaadecuadacalidad, siendonecesariolaimplantacióndeunidadesespecializadasentodoelpaísparagarantizarun transportesanitariodecalidadacualquierni˜nooneonatocrítico.

Introduction

Thetransportofcriticallyillchildrencontinuestobeanarea to improve in Spanish emergency medical services (EMS) systems. At present, the human and material resources allocated to this process are inadequate to address the specific needs of children, and transports are frequently performed under significantly lacking conditions. This has motivated 4 scientific societies in Spain, the Sociedad EspañoladeCuidados IntensivosPediátricos(Spanish Soci- etyofPaediatricIntensiveCare,SECIP),SociedadEspañola de Neonatología(Spanish Society of Neonatology, SENeo), SociedadEspañoladeUrgencias Pediátricas (Spanish Soci- etyofPaediatricEmergencyCare,SEUP)andtheSociedad EspañoladeMedicinadeUrgenciasyEmergencias(Spanish SocietyofEmergencyandUrgentCare,SEMES)tostartcol- laborating inpursuitof asharedgoal:theoptimization of paediatric and neonataltransport(PNT) in Spain in every agerange.Thefirststepinthiscollaborationtookplacea

fewmonthsagowiththepublicationofapositionstatement regarding the need to create PNT units for interhospital transport(IHT).¹

In Spain, paediatric primary transport (generally from transferofpatientsfromsiteofillnessorinjurytothenear- esthospital)isusuallycarriedoutbytheEMSsystemofeach autonomouscommunity in Spain and coordinated through aswitchboard.The unitsthatprovide thisinitialcareand transportarebasicoradvancedlifesupportunits(Table1) thatalsotransportcriticallyilladults.Atpresent,thereare nostandardisedrequirements regardingequipmentor the traininginpaediatricsofthestaffintheseunits.

SecondarytransportinvolvesIHT,andinthespecificcase ofcriticallyillchildrenusuallyinvolves transportfromthe hospitalwherestabilizationisinitiatedtoanotherhospital withgreater resources tomanage the patient’s condition and,insomeinstances,transportbacktotheoriginalhospi- tal.ItisduringIHTthatpaediatricequipmentshouldnever belacking,asthisallowstoinitiatethe careat thesend- 485.e2

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Table1 CharacteristicsoflifesupportunitsofemergencymedicalservicessystemsinSpain.

Basiclifesupportunit Advancedlifesupportunit

Team 1o2EMT EMT+Nurse+Physician

EMT+Nurse EMT+Physician

Airtransport No Helicoptermostfrequently

Fixed-wingaircraftinsomecases

Groundtransport Yes(ambulance) Ambulance

Rapidinterventionvehicle

Numberofunits Greater Limited

Distancetositeofincident Usuallyshorter Usuallylonger

EMT,emergencymedicaltechnician.

inghospital(SH)thatthechildren willbereceivinginthe receivingunit(mostlikelyapaediatricintensive careunit [PICU]orneonatalintensivecareunit[NICU])withaware- ness and anticipation of the potential complications that couldemergeduringtransport.^2,3Thebenefitsofitarewell documentedintheliterature,^4---7someshort-term(decrease inmorbidity,mortalityandlengthofstay)andotherslong- term (cost-effectiveness in child health and reduction in healthcarecosts).

Ouraimwastoreviewtheadvantagesofusingspecialised PNT,provideanupdatedperspectiveonthesituationofPNT in Spain and highlight the human and material resources requiredforthisservice.

Current situation of PNT in Spain

Attheinternationallevel,noparticularmodeloftransport team has been established in terms of its composition,^8,9 andmultipleoptionsapply:respiratorytherapistandnurse, nurse and adjunct physician or nurse and resident physician,amongothers,inadditionto1or2technicians.Spain hasoptedfor amodelconsisting ofanemergencymedical technician(EMT),nurseand/orphysician.

The composition is the same in PNT teams, with the added requisite that every member of the team (paediatrician/neonatologist,nurseandEMT) shouldhave specific traininginpaediatric/neonatalcareandmedicaltransport, althoughthisisnotalwaysthecaseinreal-worldpractice.

AvarietyofmodelscanbefoundthroughoutSpain(SENeo 2018nationwidesurvey)thatdifferinhowtransportisman- agedandinthecompositionofthetransportteam(Fig.1, Tables2A,2Band2C).Thisheterogeneityispartlyexplained bythecharacteristicsofeachautonomouscommunity(eco- nomic,sociodemographicandgeographical).However,since childrenhavetherighttoreceivethebestpossiblecaredur- ingmedicaltransport,asestablishedbyarticles3and24of theDeclaration oftheRightsof Children¹⁰ andarticles20 and 30 of the Spanish Constitution of 1978,¹¹ we believe thatthefollowingiswarranted:

- Forallchildrenofanyagetobeextendedtherighttothis service.

- Forstaffintheseteamstohaveextensiveknowledgeand skillsinpaediatricandneonatalcriticalcareandexperi- enceandknowledgeofmedicaltransport.

- All medicaldevices andstabilization supplies should be available andideally locatedinthe vehiclesof thespe- cialisedteam.

What is the contribution of PNTs to the EMS system?

Thetransportofacriticallyillpaediatricpatientdoesnot consist solely of moving a patient from one location to another,butisamorecomplexprocessthatallowsadequate stabilizationandinvolves theSH, thetransportteam,the receivinghospitalandthecoordinatingfacilitythroughtheir collaboration.Thus, PNT makes available the human and materialresources ofaPICUor NICUtopatientswherever theyhappentobe.Thus,PNTteams:

- Provide equipment and medication not available in lower-level hospitals and health care workers trained in their use: central vascular access line insertion and use, surfactant administration both postintubation and throughminimally invasivemethods; setup anddelivery of nitric oxide¹²; non-invasive ventilation^13,14 (high-flow nasalprongs,continuouspositiveairwaypressure[CPAP]), which reduces the proportion of patients intubated for transport;ventilationinterfacesappropriatefor thesize of paediatric/neonatal patients that are intubated or requirehigh-frequencyoscillatoryventilation¹⁵ (amodal- ityappliednearlyexclusivelyinneonatology/paediatrics and which requires experience for correctimplementa- tion).

- Allowtransportofpatientswithpaediatricillnessesthat require specific management: late preterm infants^16,17 (careful management in the first hours post birth can have an impact on long-term outcomes: prevention of hyperoxia/hypo- or hypercapnia, hypothermia, damage to the developing lung caused by the use of respira- tory support, abrupt haemodynamic changes carrying a risk of cerebrovascular insult, etc); hypoxic-ischaemic encephalopathy^18,19(withaspecifictimewindowforiniti- ation oftherapeutic hypothermiatoimproveneurologic outcomes and requiring careful management of fluids, electrolytes and haemodynamic support); cardiac dis- eases,bothcongenitalandacquiredin thefirstyearsof life,etc.

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Specialised neonatal transport Specialised paediatric and neonatal transport

Other models (involving paediatricians Transport by EMS

Figure1 PaediatricandneonataltransportmodelsinSpain.

EMS,emergencymedicalservices.

- Allowstransportofpatientsthatneedcarethatrequires highlyspecifictraining,suchasextracorporealmembrane oxygenation (ECMO)^20,21 with the added peculiarities of infants and children compared to adults, and always withparticipationofotherteams(surgeons,perfusionists, security/police,civilguardorarmedforces).

- Allowstransfer backtoSH of patients that stillrequire specialised care during transport. This type of transfer contributestotheoptimizationofhealthcare resources andtoimprovingthequalityoflifeofpatientsandtheir families.

Other waysinwhich severelyillchildrenwouldbenefit fromtheavailabilityofPNTincludetransportchildrenwith palliativecareneeds²²underthebestpossibleconditionsto theirhomes;supportinprimarytransport²³ (insomecases inpersonandinothersremotely);phoneoronlineconsulta- tiontoguidethecareofcriticallyillchildrenwhenthestaff managingthepatienthasquestionsregardingassessmentor treatment;assistingintransfercoordinationandtheselec- tionoftheappropriatehospital,andtrainingtherestofthe staffoftheEMSsystemonpaediatriccare.

Quality in PNT: human and material resources

Humanresources

GiventhecompetenciesrequiredfortheIHTofcriticallyill children,theidealPNTteamwouldincludeapaediatrician orneonatologistandapaediatricnursespecificallytrained intransport,inadditiontoanEMTtrainedinpaediatriccare.

Another appropriatemodel would be a prehospital emergency care physicianand nurse witha strong background in paediatric and neonatal care, which would probably

requirethedevelopmentofan officialtrainingcurriculum toensure thenecessary skillsandcompetencies. ThePNT teamshouldbeintegratedintheEMSsystemofthecorre- spondingautonomouscommunityandbebasedoffatertiary carehospitaltomaintaintheskillsofitsmembersandensure adequatecontinuingeducation.

Toguaranteethehigh-qualitycarerequiredbycritically ill children, resources in addition to the knowledge and skills foundin a PICUor NICU arerequired, morespecific tomedicaltransport,thatarenot usuallyatplay inhigh- levelintensivecaresettings,suchasteamworkintypically adverseenvironmentswithlimitedresourcesandaddeddif- ficultiesindiagnosisandtreatment.Transportteamsusually consistof2---3members(limitedhumanresources)andfre- quentlyhavetointeractwithotherinstitutionswithwhich sharedcareprotocolshavenotbeenestablished.Thephys- ical space is limited. There are physiological processes relatedtotransportthatmayhaveanegativeimpactonthe patient,andduetopotentialinterferencewithmonitoring devicesan adequate clinical assessment and stabilization need to be performed at the SH, where the care staff willhave torelyonthe few available diagnosticmethods (bedside blood gas analysis and ultrasound). Communica- tion skills are very important both for teamwork and to interact with families or with patients that, either due toage or illness, have difficulty understanding the situation.Leadershipskills arealsoimportantinthe individual in charge of the team, as is the delegation of tasks and theabilitytoenvisionpatienttransferasawholetoiden- tifyopportunities forimprovement andincreasetrustand rapport.

In this regard, some societies are already working on developingcompetencyprofiles,withtheroleofthephysi- cianbeingthemostdefinedthusfar,^24,25althoughdefining theroleoftheremainingteammembersisequallyimpor-

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Table2A SpecialisedPNTmodelsinSpain.

Region Type Indications Staff Material

resources Madrid Neonatal Anyneonatalpatientrequiring

higher-levelinpatientcare.

Returntransport.Transport within/betweenautonomous communities

Neonatologist,levelIIIB-C hospitaloncall

Nondedicated ambulance

Nonspecialisednursing staff/techniciansoftheEMS

EMSincubators EMShelicopter Valencian

community:

Valencia- Alicante

Neonatal Anyneonatalpatientrequiring higher-levelinpatientcare.

Neonatologist,levelIIIhospital oncall

Nonspecialisednursing staff/techniciansoftheEMS

TTincubators EMShelicopter Cantabria Neonatal Anyneonatalpatientrequiring

higher-levelinpatientcare.

Neonatologist/specialised nursingstaff,levelIIIhospital oncall.

DedicatedNT ambulance

Nonspecialisedtechniciansof theEMS

TTincubators Catalonia Neonatal/

Paediatric

Paediatric/neonatalpatientof anyagerequiringhigher-level inpatientcare.Activation criteriaapply

Physician

(paediatrician/neonatologist)/

DedicatedPNT ambulance

Specialisednursing

staff/specialisedtechnicians

TTincubator

Physicallypresentonsiteat headquarters

EMShelicopter Balearicislands Neonatal/

Paediatric

Physician(paediatri-

cian/neonatologist)/Specialised nursingstaff

DedicatedPNT ambulance

Onsiteduringtheday/oncall atnight

TTincubator

EMS

helicopter/plane Valencian

community:Castellon

Neonatal/

Paediatric

Physician(paediatri-

cian/neonatologist)/Specialised nursingstaff

Onsite TTincubators

EMShelicopter EMS,emergencymedicalservices;NT,neonataltransport;PNT,paediatricandneonataltransport;TT,transportteam.

tant.AccordingtotheSECIPandtheSENeo,thephysician, ideallyapaediatricianorneonatologist,shouldhavethethe- oreticalknowledgeandclinicalskillstodelivercareatthe samelevelaswouldbeofferedataPICUorNICU:abilityto intubatepatientsrangingfromextremelypretermneonates

toadolescentswithabodyweightof70kg,thoroughknowl- edgeofthehaemodynamicsupportrequiredinthecaseof sepsisinapreterminfantormeningococcalsepsisinachild, differentialdiagnosisskillstocorrectlyselectthereceiving hospital,andthenecessarycommunicationskillstoconvey

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Table2B NonspecialisedPNTmodelsinSpainthatincludepaediatricians.

Region Type Indicationsnonspecialised modelswithpaediatrician involvement

Staff Materialresources

ACoru˜na/

Pontevedra

Neonatal Anypatientrequiring higher-levelinpatientcare.

Withinautonomouscommunity

P/Nnottrainedintransport.

Onsite

Nondedicated ambulance IncubatorsinSH Asturias Neonatal/

Paediatric

Paediatric/neonatalpatient requiringhigher-levelinpatient care.Withinautonomous community

Differentmodelsdependingon healthdistrict

Nondedicated ambulance.

IncubatorsinSH ---

--- ---

EMShelicopter

Exception:Outside autonomouscommunity

OncallP/N+EMS Basquecountry Neonatal/

Paediatric

Paediatric/neonatalpatient requiringhigher-levelinpatient care.Within/outside

autonomouscommunity

EMSnonspecialisedteam Nondedicated ambulance.EMS incubators Selectcases:EMS+P/N EMShelicopter Leon/Burgos/

Salamanca

Neonatal/

Paediatric

autonomouscommunity

EMSnonspecialisedteam Nondedicated ambulance.

IncubatorsinSH Specialcases:EMS+P/N EMShelicopter Cuenca,

Toledo, Albacete

Neonatal/

Paediatric

autonomouscommunity

EMSnonspecialisedteam Nondedicated ambulance.EMS incubators Specialcases:EMS+P/N EMShelicopter Andalusia

Malaga

Neonatal/

Paediatric

autonomouscommunity

EMSD/NutrainedinNT Nondedicated ambulance.

RH/EMSincubators Transportbetweenprivate

facilities,CeutaandMelillato H.Málaga

Nonspecialisedtechnicians EMShelicopter

Physician/nursingstafftrained inNT

Murcia Neonatal/

Paediatric

Paediatric/neonatalpatient requiringhigher-levelinpatient care.Withinautonomous community

D/Nutrainedinneonatalcare Nondedicated ambulance.

IncubatorsinRH EMSnonspecialised EMShelicopter Outsideautonomous

community

Specialcases:EMS+P/N

D/Nu:doctor/nurse;EMS,emergencymedicalservices;NT,neonataltransport;PNT,paediatricandneonataltransport;P/N,paediatrician/neonatologist;RH,receivinghospital;SH,sendinghospital.

toparentsthattransportmaybelife-threatening.Nursing staffmusthaveexperiencecaringforcriticallyillpatients andbeabletoworkinsmallteamsandwithoutthesupport ofothernurseswithcomparableskillsandtraining,among otherrequirements. Bothphysiciansandnursesmusthave theskillsrequiredformedicaltransport.Emergencymedical techniciansarelargelyresponsibletoensurethesafetyof theteam,mustbeabletooperateabroadrangeofmedical

devicesandknowallthepaediatricsuppliesandequipment usedinstabilization tobeabletohelp withadvancedlife support(whichisparticularlyrelevantinpatientsrequiring respiratoryorhaemodynamicstabilizationduringtransport incasecomplicationsdevelop,suchastheneedofintuba- tionor themanagementofshock orcardiacarrest).Every memberoftheteammustbeaself-learnerseekingtocon- tinuouslyimprove.

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Table2C NonspecialisedPNTmodelsinSpainimplementedbyEMSsystems.

Type Indicationsnonspecialised modelsimplementedbyems system

Staff Materialresources

Lugo/Ourense Neonatal/

Paediatric

Paediatric/neonatalpatientof anyagerequiringhigher-level inpatientcare.

EMSnonspecialised D/Nu/T

Withinautonomouscommunity IncubatorsinSH

Neonatal/

Paediatric

Nondedicated ambulance Within/outsideautonomous

community

IncubatorsinSH/HR EMShelicopter Zamora,

Valladolid, Palencia, Soria, Segovia, Avila

Neonatal/

Paediatric

Within/outsideautonomous community

IncubatorsinSH EMShelicopter Extremadura Neonatal/

Paediatric

community

EMSincubators EMShelicopter Ciudadreal,

Guadalajara

Neonatal/

Paediatric

community

EMSincubators EMShelicopter

Canarias Neonatal/

Paediatric

community

EMSincubators Helicopter/Planedel SE

D/Nu/T:doctor/nurse/technician;EMS,emergencymedicalservices;RH,receivinghospital;SH,sendinghospital.

Atpresentthereisnosubspecialityorformaleducational pathwaythatcoversalloftherequirementsforPNT.How- ever,itisclearthatthedeliveryofqualitycaretocritically illchildrenshouldnotbelefttochanceandthepossibilities foundinavailableresourcestocovergapsincompetencies, but that thereshould bespecific structures, suchas spe- cialisedPNT,toguaranteeitonaregularbasisandwithinthe appropriateframework. Paediatricandneonataltransport units,aswehavebeendiscussing,aretrue‘‘teams’’.

Continuingeducationisalsoanecessitytomaintainexist- ing skills and add new ones through different methods, includingsimulationteamtraining.²⁶ This approachisstill notwidelyappliedtoPNT.

Paediatricneonataltransportmustbeintegratedinthe EMSsystemsothatthemostappropriatetransportresources are allocated to each child. Forexample, in the case of anaccident leadingtotraumaticinjury andpossiblyneed ofsurgery,thepatientmaymostbenefitfromallocationof theclosest medicaltransport,evenifitisnotspecialised, ora combinationof both. Inother cases,ifthepatientis notcritically ill,it maybe preferable toreserve thePNT unitduetothescarcity ofthisresource.The characteris- ticsofthe lifesupportunits thatarenotspecificfor PNT, the competencies of their staff and the desirable frame- worktoprovideaccesstothemarebeyondthescopeofthis article.

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Table3 Durableanddisposableequipmentandsuppliesthatarefrequentlyunavailableinadvancedlifesupportunits.

Vitalsignsmonitor Paediatricpatches

Bloodpressurecuffinseveralsizesstartingfrom1 Paediatricpulseoximeter

Rectaltemperatureprobe CapabilityforIBPM Incubatorandpreterminfant

supplies

Neonatalearprotectors Cutaneousthermometer Polyethylenebags Safetyrestraintsystems

Airway Laryngoscopebladessize00andup CuffedanduncuffedETTsineverysize DoublelumenETT

Laryngealmaskairwayssizes1through5 Guedelpatternairwayfromsize00 Resuscitationbagvalvemasksineverysize Transportventilator Paediatric/neonatalbreathingtubes

Paediatric/neonatalairwayfilters(lessdeadspace) CO2sensor(lessdeadspace)

AppropriateIMVforpreterminfants(e.g.preterminfantsweighing400gwillreceiveMVwith 0.08L/min)

NIVdevicewithoptionofpresetflowtrigger<1L/min

AppropriateinterfacesforNIV,includingfacemasksindifferentsizes.

Humidifiers

Gases Medicinalgases

Nitricoxide

HFOTnasalprongs Interfacesindifferentsizes Humidifiers

Centralvascularaccess Centralandarteriallines(3.5−7F) Umbilicalcatheters(3.5and5F)

Medication Surfactant

Caffeine Milrinone Prostaglandins Clonidine Phenobarbital Hypertonicsaline3%

ETT,endotrachealtube;F,French;HFOT,high-flowoxygentherapy;IBPM,invasivebloodpressuremonitoring;IMV,invasivemechanical ventilation,NIV,non-invasiveventilation.

Materialresources

Equipmentandvehiclesinthetransportunit

Regulationsonthetechnicalcharacteristics,medicalequip- mentandstaffingofgroundambulances²⁷establishageneral legal framework without specific details on the require- mentsforPNT.Therefore,wewrotethissectionbasedonthe current literatureandtheexperiencein PNTdomestically andabroad.

Paediatric and neonatal transport units should ideally havededicatedambulancesstockedwithalltheequipment and supplies that could be required for stabilization and transport.Sincetheirpatientsspantheentirepaediatricage range,thisentailsabroadvarietyofequipment(Table3).As analternative,equipmentcouldbepackedinbagsorcases andloadedinthe ambulanceallocated toeach transport, whichwouldadd totheresponsetime.Insomecases,for

instancetransportinfixed-wingorrotor-wingaircraft,thisis theonlyoption,asairambulancesarealsousedtotransport adultpatients.

Insomeinstances,paediatricambulancesneedtohave a greater capacity than regular ambulances (box body ambulances)²⁸duetotheamountofmaterialthattheyneed totransportonaccountofthewiderangeofpatientsizes andofresourcesthatmayberequired.

Helicopters are used to transport patients with time- dependent disease, when the distance to the receiving facilityislongoriftherearegeographicalortemporalbar- rierstotransport.Fixed-wing ambulancesareless flexible thanrotor-wingambulances,cancoverlongdistancesina shorttimeandusuallyhavepressurizedcabins.Teamsthat carryoutpatienttransportsinairambulancesmustreceive specifictraining.Allthemedicalequipmentmustbecerti- fiedforuseinairambulances.

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Documentationduringtransport

In addition to the usual patient transport reports and a patient identification system, PNT requires informed consent.^29,30

Anythingthattakesplaceduringstabilizationandtrans- port must be documented in the health record of the patient.Tothisend,aspecificformatcouldbeestablished for patienttransportreportstoallowplanning andantici- pateinterventionsintheeventofpotentialcomplications, facilitate the transfer of information to the staff of the receivingfacilityandcollectdataforqualitymetrics.^4,31

As is the case in any medical intervention, informed consentshouldbeobtainedpriortotransport,although in high-risk situationsverbalauthorizationcouldbeobtained fromparents or legalguardianstoavoid delays.Informed consent includes explainingany techniques or treatments thatmaybeusedduringstabilizationortransportandthe intrinsicrisksofmedicaltransport(thosedirectlyassociated withit,suchastherisk ofa motorvehiclecollision, risks associated withthe physiological changesthat take place duringtransportandrisksrelatedtotheparticularcondition ofthepatient).^30,32

Humanisationofcare

Family-centred care hasemerged asa standard in paedi- atriccriticalcare.Althoughthepresenceofparentsduring resuscitationandwhilethechildstaysinhospitalisendorsed bynumerousscientificsocietiesworldwide,thereisnofirm recommendation presence in PNT. In fact, parental presence in paediatric IHT is just starting to gain traction, and not only in Spain.^33,34 This can be explained by the potentialdisadvantagesthathealthprofessionalsattribute toparentalaccompaniment,includingorganizationalprob- lems (lack of space, legislation and insurance), potential increaseinparentalanxiety,fearthatthepresenceofpar- entsmayaffectcaredeliveryandmedicalandlegalconcerns of transport team members.³⁵ Despite these drawbacks, accompanyingthechildlessensparentalanxiety,improves collaborationintheawakechild,fostersanenhancedsense ofparentalinvolvementinthechild’scareandmakesitpos- sible for parents tostay informedof thecondition of the childinrealtime.Inmostinstances,transportteamshave a neutralor positiveperception of parentalpresence.^34,36 Thedataontheperceptionofchildrenatthetimeoftrans- port areveryscarce. Eighty-fourpercentof childrenaged 5---17 years consider being accompanied by their parents important,andthereforetheiropinionshouldbetakeninto accountindecision-making.³⁵

AllowingthepresenceofparentsinPNTisthefirststepto promotefamily-centredcareintransportteams,especially in groundtransport.Outsidethe specifictransportsetting ofhelicopters,forwhichstrongrecommendationshaveyet tobeestablished,studiestodateshowminimalimpacton healthcareworkerstresslevels,andthebenefitstopatients andparentsoutweightherisks.³⁷

Qualityindicators

As is the case in any other fieldof health care, a strate- gic and action plan is necessary to improvecare delivery in PNT based on quality indicators. At the international

level,thereareseveralsystems^38,39 withestablishedqual- itymetricsthatalsoallowcomparisonofdifferenttransport systems.InSpain,in2018,anationwidemulticentrestudy wasperformedand resultedin theselection of 15indica- tors to represent the needs of PNT in the country⁴⁰ that havesincebeenappliedbydifferenttransportteams.This allowsthecomparisonofPNTsystemsbothinSpainandat theinternationallevelandcontributestotheimprovement ofeachtransport.

Conclusion

Criticallyillchildrenofanyageareentitledtohigh-quality medical transport. To ensure this right, PNTs should be establishedthroughouttheSpanishterritorywhich,despite possiblevariationsinitscomposition,mustmeetbasicstan- dardsin human and materialresources. The implantation andintegrationofPNTsinEMSsystemswillalsocontribute tooptimisingtheirperformance.

Conflicts of interest

Theauthorshavenoconflictsofinteresttodeclare.

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