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Expert Group on Acute Maternity Services: Reference Report
ANNEX F SUMMARY OF REPORT ON NEONATAL TRANSPORT
Introduction
The Neonatal Transport Working Group remit was:
Criteria for transport of neonates.
Guidance on outreach resuscitation and stabilisation pre-transfer.
Recommendations for a Scotland-wide co-ordinated neonatal transport system in conjunction with the Scottish Ambulance Service, which would identify issues relating to appropriately trained manpower, equipment, modalities of transport, access, training and education, and regional and national audit.
Neonatal transport services have developed in an ad-hoc and inconsistent fashion throughout Scotland, outwith a defined organisational structure and with no dedicated transport staff. The cost of this service is currently unknown, but the majority of cost and responsibility for the service is presently borne mainly by the tertiary centres in Glasgow, Edinburgh, Aberdeen and Dundee. However, units in Inverness, Paisley and Ayrshire presently carry out a number of transports utilising resource capacity from within their own units. Transport incubator/ventilator systems are complex and costly, currently most funded through charitable sources. However, a significant amount of equipment is facing obsolescence and new regulations with Health and Safety Executive and Civil Aviation Authority approval will require a development and revision of equipment. With a reduction in the manpower availability (see earlier), possible rationalisation of peri-natal services in Scotland and equipment constraints, many professionals now believe the neonatal transport service to be unsustainable and in crisis. Recently the units in Glasgow, Edinburgh, Aberdeen and Dundee have intimated that they can no longer guarantee a neonatal retrieval service to other neonatal and maternity units in Scotland.
The Study
There were 25 neonatal units in Scotland providing Level 2 support and 13 neonatal intensive care units with Level 3 support. Due to the paucity of transport data, the Working Group undertook a 3 month prospective audit between 1 May 2000 and 31 July 2000 which captured data on 100% of neonatal transfers in Scotland:
209 transfers in total.
153 (73%) originated Monday to Friday within normal working hours of 09.00-17.00.
56 (27%) were outwith normal working hours and weekends, with higher rates in Highland and Aberdeen reflecting remoteness and rurality.
50 transports required mechanical ventilator support: 24% overall, but 39% in out-of-hours cases reflecting their emergency nature.
55% of transfers were in west, 35% in the south-east and 9% in the north.
The rate of neonatal transport of this study was 15 per 1,000 live births compared to a previous study in 1995 of 5.6 per 1,000 live births (Scottish Neonatal Consultants Study 1995). Extrapolation of these figures, albeit on a small sample size and time, would suggest 836 neonatal transfers per annum in Scotland. With the possible rationalisation of feto-maternal care and the possibility of midwifery managed units, the Group suggested that a projection of between 900 and 1,000 neonatal transports per annum in Scotland was a working hypothesis. Neonatal transfers are a relatively common occurrence in Scotland and the level of intensity of care required during transport is variable depending on the case mix: it is usually for step-up to a higher level of neonatal intensive care, access to specialist neonatal services, such as cardiology, cardiac surgery or neonatal surgery and the more elective "back transfers". Location of the referring hospital, weather conditions and terrain are factors in the determination of whether land or air transport is the most appropriate option.
The Option Appraisal
An Option Appraisal was carried out using 6 agreed and weighted criteria, which were developed from an initial 16, and they are as follows:
Staffing
Co-ordination
Equipment
Patient benefit
Training and service pressures
Response time and accessibility
The options, with final weighting scores attached are identified as follows:
1. Status quo with no modification | - 55 |
2. Status quo with modification | + 45 |
3. 13 NNIC Units with individual transport systems | - 30 |
4. 3 Regional Transport Groups | + 210 |
5. 1 National Transport System | + 145 |
A 3 Regional Group co-ordinated service was the preferred option and is supported by the Scottish Neonatal Consultants Group and the Royal College of Paediatrics and Child Health Scottish Committee. While different from the conventional regional groupings in Scotland, they are identified as follows:
North | Covering Grampian, Tayside, Highland, Orkney and Shetland with 3 transport teams operating as locally as possible from Ninewells, Raigmore and Aberdeen Maternity, but with regional back-up depending on case mix |
South | Covering Fife, Lothian and Borders with one transport team located within Simpson Centre for Reproductive Biology |
West | Covering Greater Glasgow, Argyll and Clyde, Ayrshire and Arran, Forth Valley, Lanarkshire, Dumfries and Galloway, with 2 complementary teams operating from PRMH and QMH |
Summary of Working Group Recommendations
Establish a 24 hour safe and reliable national service based in 3 Regional Transport Groups with all stakeholders involved in the development and implementation.
Appoint a National Neonatal Transport Co-ordinator, 3 Regional Transport Co-ordinators, identify unit lead clinicians (already within the FMS) and a National Audit Co-ordinator.
Guidelines should be developed for an integrated neonatal transport network and include resuscitation and stabilisation, criteria for transfer, transfer and aftercare, and entry into the network.
Referral and retrieval should be arranged by senior staff with advice for pre-care transfer and transport modality with a single telephone call referral entry into the network.
A lead Scottish Ambulance Service should be appointed to co-ordinate both air and land transport and develop a central SAS co-ordinating centre with a one telephone call system entry and to review an innovative approach to back transfers.
A critically ill newborn infant should only undergo one episode of transport.
Information: develop standardised transfer documents, agree a minimum dataset for pre, intra and post transfer, the application of a unique identifying transport number, national audit and feedback and the development of parent/carer information packs.
Supply of appropriate equipment for land and air transport and work towards standardisation consistent with CAA, SAS and HSE requirements - from central funding.
Adequate staffing levels for 24 hour retrieval team capability with adequate experience and qualifications.
Training and education - development and funding of a multiprofessional programme of generic and specialist training for transport staff depending on competency level and outreach education for referring unit staff. Essential to acquire and maintain skills.
Adequate insurance cover for all members of the transport team.
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