Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_37_библиотеки_им_акад_М_И_Перельмана
.pdf
TABLE
https://t.me/medicina_free
3.1
LEVELS OF PERINATAL AND NEONATAL CARE AND THEIR EXPECTED CAPABILITIES*—cont’d
Level II: Special care nursery
Level III: NICU
Level IV: Regional NICU
CHAPTER 3 Perinatal Transport and Levels Of Care
PERINATAL CARE PERSONNEL
• LevelIcapabilitiesplus
• Providecareforinfantsbornat32weeksof
gestation or later and weigh 1500 g or more
whohavephysiologicimmaturityorwhoare
Level I health care providers plus
• Neonatologists
• Pediatrichospitalists
• Neonatalnursepractitioners
moderatelyillwithproblemsthatareexpected
toresolverapidlyandarenotanticipatedtoneed
subspecialtyservicesonanurgentbasis
• Providecareforinfantsconvalescingafter
intensive care
• Providemechanicalventilationforbriefduration
(lessthan24hours)orcontinuouspositive
pressureairwaypressure,orboth
• Stabilizeinfantsbornbefore32weeksofgesta-
tion and weigh less than 1500 g until transfer to
anNICUfacility
• LevelIIcapabilitiesplus
• Providesustainedlifesupport
• Providecomprehensivecareforinfantsbornbe-
fore32weeksofgestationandweighlessthan
1500 grams and infants born at all gestational
Level II health care providers plus
• Pediatricmedicalsubspecialists
• Pediatricanesthesiologists
• Pediatricsurgeons
• Pediatricophthalmologists
ages and birth weights with critical illness
• Providepromptandreadilyavailableaccessto
a full range of pediatric medical and surgical
subspecialists, pediatric anesthesiologists, and
ophthalmologists
• Provideafullrangeofrespiratorysupportthat
mayincludeCMVand/orHFV,andiNO.
• Providesadvancedimaging,withinterpretation
onanurgentbasis,includingCT,MRI,and
echocardiography
Level III capabilities plus
• Locatedwithinaninstitutionwiththecapability
Level III health care providers plus
• Pediatricsurgicalsubspecialists
to provide surgical repair of complex congenital
oracquiredconditions
• Maintainafullrangeofpediatricmedicaland
surgical subspecialists, and pediatric anesthesiologists on-site
• Facilitatetransportandprovideoutreach
education
49
†
†
†
†
*Includes all health care providers with relevant experience, training, and demonstrated competence
†
Atthesiteoratacloselyrelatedinstitutionbyprearrangedconsultativeagreement.
ARDS,Adultrespiratorydistresssyndrome;CM,certiedmidwife;CNM,certiednursemidwife;CPM,certiedprofessionalmidwife;CT,computedtomography; FNP,familynursepracti-
tioner; FP,familypractice; ICU, intensive care unit; MD, medical doctor; MFM, maternal-fetal medicine; MRI, magnetic resonance imaging; NICU, neonatal intensive care unit; NNP, neonatal
nurse practitioner; NRP,NeonatalResuscitationProgram;Ob-Gyn,obstetrician-gynecologist;PNP, pediatric nurse practitioner; RN, registered nurse; S.T.A.B.L.E.,S.T.A.B.L.E.Program;US,
ultrasonography.
ModiedfromAmericanAcademyof Pediatrics,AmericanCollegeofObstetriciansandGynecologists:Organizationofperinatalhealthcare.InGuidelines for Perinatal Care. 8th ed. Elk
GroveVillage,IL:TheAcademy;2017.
50 UNIT TWO Support of the Neonate
https://t.me/medicina_free
Medical
Director
Clinical
Oversight
Essential Components of a Perinatal
Administrative
Director
Programmatic
Implementation
FIGURE3.1 Organizationalstructureofneonatal/perinataltransportsystem.
Transport System
Leadership
Quality
Assurance
REGIONAL PERINATAL
REFERRAL AND TRANSPORT
SYSTEM
Independent of the health care system with which
one identifies (universal versus market driven), the
referral system must identify a subspecialty care
regional perinatal center, for which the responsibility of coordinating interfacility perinatal
transfer lies. Although many different models pro-
vide clinical care in transport, the transport system
should include the minimal components of (1)
leadership (both medical and administrative), (2)
communication, and (3) quality assurance (Fig. 3.1).
Quality
Director
Accreditation
Medical Director
Clinical Oversight
Standardization
of Treatment
Guidelines for
Transport Practice
FIGURE3.2 Role of medical director of transport services.
Continuous
Quality
Improvement
Clinical
Enterprise
Implementation
of New Therapies
for Transport
Transport
Medical
Control
Leadership
One proposed model is the implementation of a
leadership team that comprises a medical director,
administrative director, and quality director. This team
approach enables collaborative and timely oversight
of the transport system with potential for growth and
quality improvement. The medical director should
be a physician with expertise in transport medicine
and evidence-based care. The medical director’s role
includes overseeing the following54 (Fig. 3.2):
• Development, implementation, and monitoring
of patient care and transport standards
• Scopeofpracticeofteammembers
• Teamselection
• Trainingandcontinuingeducation
• Supportofperinatalpartnershipsandadvocacy
The administrative director working in con-
junction with the medical director oversees the
budget and day-to-day management of the transport process, including maintenance of equipment.
The administrative director should possess clinical
transport knowledge paired with strong administrative qualities, because this role includes oversight of finance, human resources, and communication operations (Fig. 3.3).54 The quality director
should be a health care provider with a professional
background in continuous quality improvement,
process analysis, and management. In association
with the medical director and administrator, the
quality director is responsible for the development
and maintenance of a transport database for operational management, quality assurance, and analysis.
This administrator should also be able to apply the
basic concepts of quality improvement and lean
management to implement novel interventions
aimed at improving the perinatal transport system
(Fig. 3.4).
78
CHAPTER 3 Perinatal Transport and Levels Of Care
https://t.me/medicina_free
Administrative Director
Programmatic Implementation
51
Finance
Asset
Management
Ambulance Equipment and
Instrumentation
Education
Internal External
Budget Allocation of
FIGURE3.3 Role of administrative director of transport services.
Quality
Assurance
Community Liaison Chart Review
FIGURE3.4 Roleofqualitydirectoroftransportservices.
Resources
Quality Director
Accreditation
Communication
As indicated in Table 3.1, a regional subspecialty
perinatal care center should be responsible for
coordination of perinatal transport. Integral to
the regional transport system is the creation
of a centralized communication center with a
perinatal regional hotline.27 The communication
center is responsible for coordinating maternal and
neonatal transports within the different levels of
care. Roles within this center include referring physician, dispatcher, bed locator, and transport medical
control officer (obstetrician and neonatologist).
The inclusion of specialized personnel in the initial
communication process may support rendering
institutions appropriate treatment strategies while
decreasing diagnostic discordance.
For purposes of basic communication, a cen-
tral dedicated telephone line is recommended
68
Human Resources
Clinical Staff
Transport
Continuous Quality
Improvement
Debrief
Collection Maintenance
Database
Communication
Direct
Phone Line
Dispatch
to provide direct, easy, and immediate access to
the regional system. This access should be staffed
24 hours per day, 7 days per week and should be
unencumbered. This model also includes the transfer of the referral call to the transport medical control officer, thereby greatly simplifying the process
for the referral-consultation. The ability to support
communication among the referring physician, the
dispatcher, and the medical control officer simultaneously can speed up decision making and the
initiation of transport. Once the transport is initiated, communication among the transport team,
the referring physician, and the medical control
officer becomes integral to the care provided (Fig.
3.5). Changes in weather, patient status, equipment
needs, and bed status need to be communicated in
a timely manner. This information may demand a
review of the transport plan and is best facilitated
through a central communication center.
27,54
The
52 UNIT TWO Support of the Neonate
https://t.me/medicina_free
Communication Process
Referring MD
call to
communication
center (CC)
Call to medical
control officer (MCO)
and standby page
to transport team
CC provides
transport, weather,
and distance
information
FIGURE3.5 WorkingmodelofVanderbiltTransportCommunicationTool(unpublished),versionSeptember2008.(ContributedbyS.
Brodtrick,D.Quinn,andM.Cortez.)
CC connects
referring MD
with MCO
(3-way
recorded call)
Consult
Completed?
Done
MCO and CC
stay on line
to decide
treatment team
and mode
“Respond” page
sent to
transport team
organization of a perinatal regional hotline
has been shown to significantly increase both
in utero and neonatal transports, allowing for
safe, 24-hour, on-call management of perinatal
transports and the collection of epidemiologic
indicators relative to perinatal transfers.
27
The rapidly advancing field of telecommunications offers a wide variety of opportunities
for transmitting medical information, subject to
proper consideration of privacy and confidentiality requirements. This medium permits the use
of satellite technology and video-conferencing
equipment to conduct a real-time consultation
between medical specialists in two geographically
different areas. Store-and-forward telemedicine
involves acquiring medical data (e.g., medical
images, bio-signals) and then transmitting these
data to a medical specialist for assessment offline.
It does not require the presence of both parties at
the same time. These technologies may facilitate
appropriate referral of patients according to complexity and may decrease incidence of inappropriate transfer or diagnostic discordance, allowing
for optimal use of resources.
67,85
Furthermore,
these innovative strategies have the potential
to overcome de-regionalization of services by
creating virtual regional networks for perinatal
transport.
Telemedicine consults by neonatologists have
been found to improve the quality of high-risk
newborn resuscitations.28 Fang et al. conducted
MCO and transport
team leader
clinical discussion
CC dispatch page
Launch site
information
provided
Prepare for transport
TRANSPORT
Ground, fixed wing,
or rotor wing
MCO call to referring
MD with ETA of
transport and patient
status update
a retrospective cohort study comparing newborns
who received a telemedicine consult during resuscitation at a community hospital to those who did
not receive a consult.28 They found that for those
who received a consult, not only was the care of the
newborn enhanced, but that the remote neonatologist had a positive impact on team behaviors in the
form of additional leadership and management. The
newborns in the telemedicine consult group
were more likely to have had their temperature, glucose, and blood gas monitored.28 Fang
et al. concluded that telemedicine programs had the
potential to reduce disparities in access to care and
increase the quality of care.
28
Quality
The regional subspecialty perinatal care center,
as noted in Table 3.1, is responsible for regional
outreach support, education, and continuous
quality oversight. Traditionally, quality improve-
ment was assigned to the medical director. However,
in light of current health care complexities and regulatory specifications surrounding the quality and
safety of patient care, it is recommended that this
role be assigned to an individual with the expertise
to effectively evaluate programmatic performance
at all levels of the organizational structure. This
continuous evaluation of the process will facilitate
modification of the transport system when potential
problems are identified.
78
CHAPTER 3 Perinatal Transport and Levels Of Care
https://t.me/medicina_free
53
The leadership team should oversee overall
transport performance. The systematic collection
and analysis of carefully selected performance
indicators such as patient demographics, management and outcome data, safety standards, logistics, equipment malfunction, and cost will drive
quality initiatives. A quality review of individ-
ual transports, incidence reports, and occurrence debriefs will enhance this process.
54,89
Using a validated transport physiologic score (e.g.,
the transport risk index of physiologic stability
[TRIPS]) to evaluate patient status before, during,
and after transport can assist team and transport
performance.
48,51,54
The Academy of Pediatrics Section on Transport
Medicine has developed a database for neonatal/
pediatric critical care transport quality metrics.
The GAMUT database (Ground and Air Medical
qUality Transport database) borrows its name from
the expression “run the gamut.” Quality metrics
include those listed in Box 3.1. GAMUT wel-
comes all types of transport programs big or small,
academic or corporate, adult or pediatric—all programs that wish to collaborate with others and use
benchmarking to drive the quality of the care they
provide. Tracking of data related to these quality
metrics is just beginning. Teams’ data contributions
(kept anonymous from other teams) will help determine the performance benchmarking goals necessary to begin the quality improvement phase of this
work.30 Preliminary data have been published,72
and the process is ongoing.
7
In addition, quality assurance may be implemented through continuing education both internally and externally. Transport programs must
create individualized internal training programs
that effectively provide current and continuous
education to ensure maintenance of appropriate skills for high-quality perinatal transport.
A similar program must be adapted to provide
educational resources to the referring hospital
where training in pre-transport resuscitation and
stabilization is imperative. Ensuring competence
in these areas has the potential to improve shortterm and long-term morbidity of sick infants, offsetting the negative effects of de-regionalization and
distance between interhospital transfer facilities.54
Building strong relationships of trust within
network delivery hospitals will facilitate this
process. Independent of the level of care, these hos-
pitals will deliver emergency sick preterm and term
BOX
3.1
• Ventilatoruseinneonateswithadvancedairways
• Average(mean)bedsidetimeandaveragescenetimeattransport
• Unintendedneonatalhypothermia
• Bloodglucosecheck
• Waveformcapnographyforventilatedpatients
• Firstattempttrachealtubesuccess
• First-attempt establishment of airway without neonatal hypoxia/
• Vericationoftrachealtubeplacement
• Numberofpatientstransportedwithouthospitaladmission
• Medicationerrorsontransport
• Percentofneonatesundergoingrapidsequenceintubationwhereall
• Appropriatemanagementofbloodpressureforaorticemergencies
• Unplanneddislodgementoftherapeuticdevices
• Rateofseriousreportableevents
• Incidenceofhypoxiaduringtransport
• Managementofhypertensioninhemorrhagicstroke
• Percentoftransported patientswithaccuratelyinterpreted12-lead
• Appropriatemanagementofhemorrhagicshock
• Medicalequipmentfailure
• Adversedrugeventduringtransport
• Patientnear-missorprecursoradverseevents
• Reliablepainassessments
• Averagemobilizationtimeofthetransportteam
• Rateoftransport-relatedpatientinjuries
• RateofCPRperformedduringtransport
• Rateoftransport-relatedcrewinjury
• Useofastandardizedpatientcarehand-off
CPR,Cardiopulmonaryresuscitation;ECG, electrocardiogram.
ModiedfromGAMUTQualityImprovementCollaborativeConsensusQualityMetrics,version 5/16/2016. Available at: http://gamutqi.org?GAMUT%20Metrics_version%20
5.16.2016.pdf.AccessedFebruary5,2019.
GAMUT QUALITY IMPROVEMENT
COLLABORATIVE CONSENSUS METRICS
hypotension
elements of the protocol are used
ECGs
infants; it is therefore imperative that local health
care teams develop the expertise to resuscitate and
stabilize these infants before transport if necessary.
The regional subspecialty perinatal care center is
responsible for working with these hospitals to
ensure they develop adequate 24/7 resuscitation
and stabilization teams; the use of scheduled team
skills training with simulation and the implementation of real-time communication through advanced
technologies like telemedicine will support achieving this goal.
54 UNIT TWO Support of the Neonate
https://t.me/medicina_free
High-Risk Maternal Referral
The most effective method to decrease mortality and morbidity during the perinatal and
neonatal period is the timely and appropriate
referral of mothers with high-risk pregnancies to
medical centers in which both the human and
technical resources are available to address complications.
low-birth-weight (VLBW) infants (birth weight
<1500 g) have been associated with birth and early
care at level III centers,17 early identification of
maternaltransportcandidatesisneeded.Deliveryof
a VLBW infant at a level I or II center often leads
to the need for neonatal transport. Robles et al.
conducted a retrospective cohort study to assess
the frequency of VLBW infants born at non-level
III hospitals.73 Using discharge data from 2008
to 2010 for VLBW infants, the study showed that
mothers with an antepartum stay of greater than
1 day between admission and delivery occurred in
14.0% and 26.9% of VLBW births in level I and
level II hospitals, respectively. Clearly opportunities
for maternal transport still remain.
In situations in which the risk to the mother
outweighs the benefit of her transfer during
active labor, the timely dispatch of the neonatal transport team from the regional perinatal
center for resuscitation and stabilization of the
high-risk neonate may be considered the optimal approach to delivery of care when it occurs
in a timely manner.
Adequate referral of high-risk perinatal
patients begins with high-quality antepartum
surveillance.74 Indications for referral to a
regional center are shown in Box 3.2. Early iden-
tification of factors that can affect pregnancy outcome is important in developing appropriate diagnostic and treatment plans. Optimal perinatal care
implies having well-trained and up-to-date obstetricians at all levels of care during both the antepartum
and intrapartum period. These physicians should
be experts in identifying maternal-fetal risk factors
and complications through their knowledge, clinical skills, and expertise in prenatal ultrasonography
and fetal monitoring.
this level of expertise is not available, medical and
nursing personnel should be specifically trained
to identify high-risk pregnancies with the objective of pursuing early referral. Consultation and
referral decisions for the high-risk mother should
20,27
As better clinical outcomes for very
73
1,22,39,66
In situations in which
BOX
3.2
A. Prenatal Diagnosis
1. Complexfetalgeneticorcongenitalanomalies
2. Severeintrauterinegrowthrestriction
3. Hydropsfetalis
4. Severeoligohydramniosandpolyhydramnios
5. Fetalairwayanomalies
B. Maternal Medical Complications
1. Advancedoruncontrolleddiabetesmellitus
2. Severeorganicheartorlungdisease
3. Severerenaldisease
4. Maternalinfectionthatcanaffectthefetus
5. Thyrotoxicosis
C. Maternal Surgical Complications
1. Acuteabdominalemergency
2. Traumarequiringintensivecare
3. Thoracicemergencyrequiringintensivecare
D. Obstetric Complications
1. Premature onset of labor
2. Prematureruptureofmembranes
3. Third trimester bleeding
4. Severepreeclampsiaorhypertension
5. Multiplegestations
6. Rh isoimmunization
INDICATIONS FOR REFERRAL TO A
REGIONAL PERINATAL CENTER
57
be based on the results of a thorough evaluation of
each patient and specific guidelines. The ACOG has
established a classification system for levels of maternal care. These guidelines help women receive care
at centers that are prepared to provide the level of
specialized care each requires.
57,73
Communication
between the referral center and the regional perinatal center may be facilitated through the use of
video-medicine technology.
28
Neonatal Referral
Despite efforts to identify high-risk perinatal
patients during the antepartum period, as many as
30% to 50% of infants who ultimately require additional neonatal care may not be recognized until
the late intrapartum or early neonatal period.47 For
this reason, all hospitals that provide obstetric
services must be prepared for the birth, resuscitation, stabilization, and treatment of premature
or term sick infants. The Neonatal Resuscitation
Program (NRP)
66,87
sponsored by the American
CHAPTER 3 Perinatal Transport and Levels Of Care
https://t.me/medicina_free
55
BOX
3.3
Sugar and safe care
Temperature
Airway
Blood pressure
Lab work
Emotionalsupportforthefamily
ModiedfromKarlsenK.The S.T.A.B.L.E Program: Post-resuscitation/Pre-Transport Stabilization Care of Sick Infants—Guidelines for Neonatal Healthcare Providers. 6th ed. Park
City,Utah:S.T.A.B.L.E;2013.
S.T.A.B.L.E. PRETRANSPORT
STABILIZATION OF THE NEWBORN©
Heart Association and the American Academy of
Pediatrics is an excellent resource for training individuals and maintaining resuscitation skills in both a
regional program and an individual hospital setting.
Certification (and renewal) of NRP training
should be a universal standard for all delivery
room and nursery staff. The frequency of renewal
will depend on the average number of resuscitations that occur on a yearly basis in each institution.
Institutions with a low average number of deliveries
should renew their skills training more frequently to
maintain their individual and team resuscitation and
stabilization skills. Beyond the immediate delivery
room setting, supportive care should be offered and
maintained until the transport team has arrived and
assumed care (Box 3.3). The S.T.A.B.L.E. program
is the only neonatal continuing education program
to focus exclusively on the post-resuscitation and/
or pre-transport stabilization care of neonates.
37,40
NEONATAL TRANSPORT
Stabilization of patients and preparation for
transport should begin immediately on identification of a need for transport and before the
transport team arrives. The S.T.A.B.L.E. curric-
ulum provides a comprehensive set of generalized
guidelines for the assessment and stabilization of
sick infants in the postresuscitation/pretransport
stabilization period. The “S.T.A.B.L.E.” mnemonic
was created to assist with information recall and to
standardize and organize care in the pretransport/
postresuscitation stabilization period. Prevention of
adverse events and delivery of safe patient care are
stressed throughout the program.37 In consultation,
the referring center (physician) and transport medical control officer (MCO) may address additional
areas of attention based on specific patient clinical
assessment and presumptive diagnosis. Although the
reasons for neonatal referral may be quite diverse
and based on needs of infants relative to the capabilities of the referring center, the most common
indication is respiratory distress of the neonate.37
Other common indications include prematurity,
congenital anomalies (surgical and nonsurgical),
and suspected congenital heart disease. Stabilization
and support of these infants may require frequent
interhospital communication (referring physician
and transport MCO) to identify specific medical interventions. The importance of this form of
continuing dialogue with respect to accuracy in
diagnosis, management, and changes in patient
status cannot be stressed enough. Again, the use of
video-telemedicine may facilitate the accuracy of
these interactions.
28
Assumption of care of the neonate is a complex
issue without a straightforward answer. However,
transition of care should be seamless. Many health
care professionals can have medical responsibility for a single patient at one time. The fact that
one person has acquired medical responsibility
does not automatically release someone else.
On arrival of the transport team, collaborative
management is of utmost importance. While the
patient remains in the referring facility, the referring
physician cannot hand off the patient and proceed as
if the patient has left the facility and his or her care.
The referring facility allows the specialty team to
provide care under the supervision and authority of
the referring physician. The specialty team leads
the effort to prepare the patient for transport.
However, leading does not command or infer
sole medical responsibility. The referring physi-
cian retains involvement and ultimate responsibility
and signs the transfer certificate at the time of actual
transfer. If at any time the referring physician deems
it is in the best interest of the patient to intervene
or cancel the transfer, it is the physician’s right and
responsibility to do so. Simultaneously the trans-
port team has a medical responsibility to the
patient. A team approach is in the best interest
of the patient and should involve all participants
in the process. Communication between the refer-
ring physician, the transport team, and the accepting
physician is of great importance.58 As long as the
transport team is in the referring hospital, the
56 UNIT TWO Support of the Neonate
https://t.me/medicina_free
ultimate responsibility lies with the referring
physician. On leaving the referring facility, the
transport team and receiving facility assume
responsibility and control for medical decision
making.80 In the event that a community emergen-
cy medical service (EMS) is used for transport, the
referring physician retains medical control until the
patient reaches the regional referral center.
Pediatric and neonatal interfacility transport
teams are unique entities. Provision of intensive
care in the transport environment incorporates the
philosophies of neonatal and pediatric critical care,
but in a mobile environment with physical and
environmental constraints of staff, space, mobility,
and equipment. It is important to recognize that
the physical requirements of team members
are different from those who work solely in a
hospital or clinic environment. Team members
will be required to lift patients or carry equipment
often with little or no help. The ability to function
within the confines of a moving vehicle is important. Personnel should not be unusually prone to
motion sickness or have mastered the techniques
to mitigate the effects of motion sickness. Weight
restrictions are a consideration in regard to aircraft.
Personnel with chronic illness or disability may not
be able to perform all expected duties. Pregnancy
may pose a temporary limitation, and medical clearance should be provided by the member’s obstetrician at a minimum. In the event a team member is
unable to function, patient and crew safety may be
compromised because there are few options should
a team member be incapacitated while on duty. For
this reason, team members with certain medical
conditions may be at least temporarily precluded
from participation on a transport. Policies developed
with human resources and legal counsel should be
put into place and address the physical requirements
for team members.
58
Interfacility transport teams are a part of the
continuum of care provided by the system of
emergency medical services for neonates and
children. Transition of care should be seamless
without compromise of level of care or monitoring.
Neonatal-pediatric interfacility transport teams do
not “scoop and run” or “swoop and scoop” (limited
evaluation at the scene with rapid stabilization and
transport to an advanced care environment as the
primary goal) as may be appropriate for the prehospital transport from an accident scene. Patients
transported by neonatal-pediatric interfacility
teams benefit from organized, coordinated, controlled transport that does not prioritize speed
over thorough stabilization described as a “stay
and play” philosophy. The exception to this prin-
ciple is the patient whose outcome will be compromised without access to care not available at the
referring hospital or in the transport environment.
60
Team Composition and
Configuration
Transport teams may be composed of a variety of
medical personnel, including physicians, neonatal
nurse practitioners, physician assistants, registered
nurses (RNs), respiratory therapists (RTs), paramedics, and emergency medical technicians.
Karlsen et al. conducted a Web-based national
survey of 335 neonatal transport teams to describe
the United States Neonatal Transport Team workforce.38 Published in 2011, variations in aspects of
neonatal transport teams were described including
team composition. There were a total of 26 compositions reported.38 The most common composi-
tion among unit-based and dedicated teams was
the RN-RT composition; the same finding as a
more recent survey where 30% were RN-RT.82
Another recent survey of transport teams listed
by the AAP found that most transport teams are
nurse-led and consist of an RN and one other team
member (i.e., another RN, medic, RT). Many teams
adjust composition based on the neonate’s acuity.64
Interfacility transport should be accomplished in
the most efficient and safe manner by qualified personnel. The composition of a neonatal-pediatric
transport team should be tailored to meet the
specific needs and resources of its patients and
referral region.58 Factors that can influence team
composition include program resources, program
design, unit-based versus dedicated teams, transport
volume, and transport mode, as well as local, state,
and regional regulation agencies.80 As a general
guideline, a transported infant or child should
receive the same level of care en route as will
be provided in the unit to which he or she will
be admitted.
58
There is considerable debate regarding the
presence of physicians on transport. Traditionally
pediatric teams have included a resident or attending physician, but in a recent survey, less than 5%
of pediatric teams used a physician for transport.82
There is little evidence to support that such a
38,48,49
CHAPTER 3 Perinatal Transport and Levels Of Care
https://t.me/medicina_free
57
composition results in more favorable outcomes.
Many neonatal teams have been led by nurse
practitioners or advanced practice nurses, as
described by Karlsen et al.38 Nurse-led teams
have been shown (1) to provide better continuity of care, improved documentation, better
maintenance of transport equipment, improved
team availability, and stronger liaisons with referring hospitals and (2) to reduce overall operating costs.54 Leslie and Stephenson evaluated
physiologic parameters of infants stabilized and
transported by neonatal nurse practitioners versus
physicians.50 Though stabilization of the infants by
the nurse practitioners took longer, physiologic
conditions were improved for pH and Pao2 in the
pretransport period, and temperature and oxygen
saturations were improved in the post-transport
period when transported by nurse practitioners.
King et al. reported on the effects on patient outcomes when team composition was changed from
RN-physician team to nurse only.42 There was
no difference found in mortality rates between
groups, and team response times were significantly
shorter for the RN team.42 Limited research has
demonstrated that providers such as RNs and RTs
can function safely and effectively in the transport
environment without the direct supervision of a
physician.
58
Team configuration has been categorized as ded-
icated and unit based. Dedicated teams are those
whose members perform neonatal transport on
a full-time basis. They generally are not assigned
to any other major clinical responsibilities. However,
between transports, team members may assist with
procedures, attend deliveries, or have other respon-
sibilitiesthatdonotinvolvepatientcare.Dedicated
teams can be based in a receiving facility or in a
freestanding transport service not affiliated with a
hospital.38 Unit-based teams are composed of
members who, although available for transport,
are primarily involved with other clinical duties.
Institutional factors should drive the decision about
which type of team to use. These factors often
include the acuity of care level managed in the unit,
annual volume of transports, financial support, and
national, state, or local laws regulating the expanded
role of nurses and respiratory therapists in health
care.58 Regardless of the team composition, the
team must have the cumulative expertise to
resuscitate, stabilize, and provide critical care
throughout the transport.
Dedicated transport teams originated in the
1970s to 1980s, when regionalized perinatal care
was established38 and large metropolitan hospitals
began to experience an increase in the demand
for neonatal transport. These teams often are
composed of a nurse designated as team leader
and a respiratory therapist as a partner, with
a physician or nurse practitioner added to
the team when a neonate is critically ill and
more advanced procedures may be anticipat-
42,49
ed.
The principal advantage for dedicated
teams includes their immediate around-the-clock
availability and their advanced training in neonatal resuscitation and stabilization procedures.
However, the additional personnel necessary for
dedicated teams may make them expensive to
maintain. Dedicated neonatal teams were found
to transport greater distances, to have larger transport volumes, were more likely to use all modes
of transport, and were more rigorous with regard
to orientation, annual skills maintenance, use of
protocols, and quality assurance activities.
38
Unit-based teams usually are made up of staff
nurses and respiratory therapists within the
neonatal intensive care unit (NICU).49 The
advantage to having a unit-based, nondedicated
transport team is the large pool of trained personnel
available around the clock. Qualifications of team
members can be based on their daily bedside critical
care experience and supplemental education, such
as certification as a neonatal resuscitation provider.
The primary disadvantage to this team design
is that the transport nurse’s patient assignments
must be absorbed by the unit nursing staff until
he or she returns. However, unit-based teams are
usually very cost-effective because critical care skills
are maintained during regular patient care, advanced
skill training may be more focused, and administrative oversight duties are diminished.
49
The American Academy of Pediatrics’ Section of
Transport Medicine article “Pediatric and Neonatal
Interfacility Transport: Results from a National
Consensus Conference”80 describes an additional method of categorizing transport teams. Four
types of transport systems are described: hospital based, community based, EMS based, and
a hybrid (mix of the previous three systems).
Hospital-based teams are owned and operated by
sponsoring institutions and serve the needs of these
institutions. These systems often operate at a net
loss. Indirect revenue is generated providing an
58 UNIT TWO Support of the Neonate
https://t.me/medicina_free
overall profit. Community-based teams are most
often owned and operated by private companies
and are dependent on a mix of adult transports,
high volumes, and low expenses. EMS-based teams
are typically subsidized by local, regional, and
state government funding, including taxpayer revenue. Hybrid teams are gaining popularity with an
increased awareness of cost and resource sharing and
increased collaboration.
80
Transport Education and Training
The goal for training of transport teams should
be the development of a program that ensures
that members will have the combined expertise to effectively assess and manage actual and
potential problems in the transport environment.
The training program should enable team members
to demonstrate their abilities to plan, implement,
and evaluate ongoing stabilization efforts and interventions during transport. The scope of this training program should reflect the team member’s
job description, transport responsibilities, patient
population, and modalities of travel.
often begun during an orientation period but must
continue throughout the career of the transport
team member. Orientation is accomplished through
participation on transport under the supervision of
an experienced team member, as well as with the
use of didactic and process curricula.
knowledge should be demonstrated in transport and
medical content areas.58 Team members should
be able to recognize and manage life-threatening conditions as appropriate for their transport
population. New team members will need train-
ing designed to enhance their current knowledge
base and will need to learn and interpret certain
assessments, techniques, studies, and procedures
not usually expected in their standard or previous
positions.
58
Procedural skills required by transport teams
will be defined by patient population, program
guidelines, and legal scope of practice. Suggested
skills and procedures are described by the AAP.58
Resourcefulness is required for the development of
opportunities to attain and maintain the necessary
skills. Laboratory simulations are available for certain skills. Electronic computer-linked simulators
are additional resources but are limited by their
availability and expense to purchase and maintain.
Resources exist within the hospital for attainment
60,83
Training is
58,80
Cognitive
and maintenance of procedures and skills and
include the operating room, NICU, delivery room,
pediatric intensive care unit, and emergency department. Each area provides unique opportunities for
skill and knowledge development.
58
Continual education for transport team mem-
bers is vitally important because as technology
changes, therapies will change. Procedural skills
must be maintained because some skills are only
performed occasionally if ever in actual practice.
Continual learning of rare conditions allows team
members to be prepared to initiate appropriate management of these conditions.58 Multiple
modalities are used for continuing education and
can include quality improvement initiatives, case
conferences, didactics, skills laboratory sessions, case
simulation, literature review, computer-based activities, and peer performance.
64,80
Research related to simulation in health care
is supporting the idea that didactic and experiential learning alone is not enough to fully prepare
teams to transport patients.15 Transport teams must
maintain competency of many skills and procedures of which some may not be used frequently
or at all. Simulation training can be used as an
adjunct to transport team education to reinforce
knowledge and skills.
15,23
The most recent survey
of transport teams found that 80% use simulation
as part of their education programs.64 Procedures
can be performed in a safe, controlled environment. Patient care environments (transport vehicle
workspace) can be simulated. Simulation training
should include interprofessional team members,
providing the opportunity to learn collaboration
skills and prepare teams to achieve high reliability.15
Scenarios can be created to assess not only resusci-
tationskillsbutalsoteamdynamics.Debriefingisa
vital component to simulation. Through facilitated
discussions, participants review and critique their
experiences.
80
The use of specialty-specific models has been
shown to improve outcomes, collaboration, and
care delivery.
34,83
The Circle of Caring Model for
Neonatal Transport focuses on collaboration and
evaluation, noting that teamwork is a critical component throughout the transport process. Although
the model is linear for clarity, the process is very
fluid and dynamic.83 Based on experience, knowledge base, and intuition, the team must collaborate
and work through complex thought processes using
critical thinking skills to make patient care decisions.
Соседние файлы в папке Библиотека им академика М.И. Перельмана