The transport starts with initial triage of the patient, with active involvement from both the referring and accepting medical teams. As detailed above, a dedicated transport communication center is crucially important. All calls from outside hospital providers should be on recorded lines for quality assurance and improvement purposes, as well as for medical–legal considerations. It is most helpful for a member of the communications center staff to be actively listening to conversations between the referring and accepting physicians. This allows for “real-time” decision-making between the two clinicians and the transport team. It also allows for optimal coordination with groups not otherwise privy to these discussions, such as inpatient nursing leadership, bed management, and security. It also has the benefits of keeping the medical record up to date in a timely fashion. Finally, the transport team staff will often ask additional questions which may not be obvious to the medical command physician, but essential for transport. Some examples include questions about patient weight, the security of current intravenous access, the presence of copied radiographic studies and completion of consents, and parental availability at the referring hospital.

The medical command physician must, of course, ascertain the current adequacy of the airway and determine if recommendations are warranted for alternative airway procurement. A focused, pertinent history must be obtained to assess for prior difficulties with intubation or anatomic anomalies that might increase the likelihood of a critical airway. The respiratory status must be evaluated, along with the current mode of ventilation. Hemodynamic stability and support should be reviewed, as well as the current state of intravenous access. Teams must consider if there is specific time sensitivity for potential treatment protocol (i.e., therapeutic hypothermia) or surgical procedures (i.e., volvulus reduction.)

After the decision has been made to transport a patient, preparations must be made to dispatch the team. Once the team composition and mode are determined (see above) the medical command physician and transport team clinicians must determine the equipment necessary for safe transport. This might include, for example, assuring that the isolette is compatible with the chosen mode of transport, and if inhaled nitric oxide is being used, ensuring its requisite set-up is appropriate (Fig. 3). Transport-ready “go-bags” (Fig. 4) stocked with a consistent set of common medications and standard equipment (Tables 2) are a must. In some cases, additional medications or equipment might need to be obtained prior to departure.

The transport team must ensure that an adequate supply of oxygen is available for the duration of transport. This must factor in unexpected acute decompensations. The oxygen supply of each tank can be determined by the following formula:

Minutes of O2 flow = cylinder pressure x cylinder factor / flow of oxygen (in L/min).

Standard size tanks each have a coordinating cylinder factor: D (0.16), E (0.28), and H (3.14).

A pre-transport “Safety Checklist” is an invaluable tool for every transport team. This should be a comprehensive review of necessary equipment, medications, oxygen supply, essential demographic information, and other important reminders. All team members should participate in the completion of the safety checklist. This should be done for all modes of transport. A checklist should also be completed prior to departing for and from the referring institution. Fig. 5 depicts a sample checklist from The Children’s Hospital of Philadelphia.

The arriving transport team should quickly perform an assessment to confirm clinical status. It is possible that the patient’s condition may have changed and be significantly different than anticipated. The transport team should establish continuous monitoring and confirm placement of all support tubes and lines. Care should be taken to minimize tangling of lines, which can increase risk of dislodgement. It is extremely important to have unobstructed intravenous access and to have all lines carefully labeled for fluid boluses, re-administration of sedation, or in case resuscitation medications become necessary.

Special attention should be made to the pre-transport stabilization of any advanced airway and widely used noninvasive airways such as nasal CPAP. Importantly, the use of nasal CPAP has risen substantially over the last ten years, with many more infants now being transported on these devices (Fig. 6).

Before departing, recent radiographs should be reviewed to confirm endotracheal tube location and vascular access placement. A single-center study found that post-intubation chest radiographs resulted in endotracheal tube position change in nearly half of neonates awaiting transport. Not surprisingly, this was also associated with an increased time at referring hospital [15].

While all team members ideally should function in predetermined roles to streamline the process, it is also useful to have a team approach to ensure all duties at the outside hospital are completed in a timely fashion. Constant communication is paramount, and frequent reevaluations are necessary.

As above, the responsibility for obtaining consent for transport is primarily the role of the transferring institution. However, it is always good practice for the transport team to review the risks and benefits of the transport with the family. When practical, one team member may leave the immediate bedside to have this discussion with the parents. The needs for transport and additional resources available at accepting institution should have been reviewed with the family by the transferring physician, but these topics may be reinforced. Parents should have the opportunities to ask questions. Many institutions hand out a “Welcome Pamphlet” with important information about the receiving institution. When practical, support, such as clergy, should be present if requested.

The physical transfer of the patient to the isolette may be the point of greatest vulnerability to the patient. The team member executing the transfer is responsible for assuring lines and equipment do not tether patient. Astute attention must be paid to vital signs and patient response to transfer, with a team member free to respond quickly if intervention is required. The transfer process should be performed while attached to the referring hospital’s oxygen and medical air supply, thus reserving transport isolette resources for time out of hospital. Once the patient is in the transport isolette, a quick but thorough repeat assessment is performed of all support apparatuses before securing the patient into a neonate restraint system. After it is determined all necessary emergency equipment is accessible and belongings have been gathered, the last step is to disengage from referring hospital oxygen source, medical air, and electrical sources.