The “travelling NICU”

Transport of high-risk neonates in Portugal

A guest article by Professor Hercília Guimarães NICU, Centro Hospitalar São João, Faculty of Medicine, University of Porto, Porto, Portugal Alameda Professor Hernâni Monteiro, Porto, Portugal

What was the idea behind your project and what was the starting point?

The transport system of high-risk newborns in Portugal was established in 1987 in the context of regionalisation of perinatal health care in the country. In Portugal, the network of perinatal healthcare works as follows: 
1) Level II hospitals transfer mothers or newborns to level III hospitals in their area; 
2) the very low birth weight infants are born in level III hospitals; 
3) all transfers of pregnant women and newborns are carried out taking the geographical area, the pathology and the availability of places into consideration. 

Hence the exchange between the level II and III hospitals is well-coordinated. This allows for organising transport of newborns back to a level II hospital as soon as intensive care in a level III neonatal intensive care unit (NICU) is no longer necessary. In order to transport critically ill newborns between NICUs within the country, a subsidiary service of the National Institute for Medical Emergence called INEM, was provided exclusively whenever in uterus transport was impossible. This ambulance is so well equipped that it seems like a “travelling NICU”. However, for long distances, air transport is used. The transfer of pregnant women is always better because we know that outborn (i.e. delivered) infants have a worse prognosis compared to inborn infants. However, neonatal transport is essential and a valid alternative to the best transport for the newborn, the mother’s womb.

image: Ambulance in Portugal (c) INEM

How was the idea put into practice?

In September 1988, hospitals and INEM signed an agreement, and the first guidelines for the transport of high-risk newborns were written down. The doctors and nurses who collaborated in neonatal transport were doctors and nurses of the NICUs in the country. The standards for the transport of newborns were prepared, namely the schedule for all hospitals involved, the transport instructions, such as the indications, contraindications to the transport and the coordination.   

Which challenges did you face?

Until 1993, some incidents were reported; some of them related to the poor access to hospitals and qualified medical services. The lack of paediatricians or physicians with experience in paediatrics, was still a frequent reason for the transfer of newborns at risk. Another challenge we faced was the insufficient number of doctors collaborating in neonatal transport, due to the disproportion between the admission and the exit of the doctors of the central hospitals, discontinuing the medical scales. 

Which changes where achieved?

After 1994, a new agreement among the INEM central hospitals was signed in order to improve the transport of high-risk infants. The standards for the neonatal transport were reviewed. All neonatal transports are up to date done by a paediatrician and a nurse, trained in neonatal intensive care, while this extra work is often performed on a voluntary basis. During this period, the transport team had an important mission to train professionals in hospitals and great improvements in healthcare for newborns allowed for an improved stabilisation and a decrease in complications during transport. 

Before the transfer, the team showed the newborn to the mother, took a picture of the baby and gave the mother the photograph. The father and other family members could follow the ambulance in their own car. These aspects, at that time (in the 1980s) corresponded to family-centred care (FCC), an approach that is so widely spread today. 

Being a standard nowadays, FCC during acute neonatal transport should be optimised in a way that parents become active participants in the care of their infants, even during the transport process. In a recent study, approximately 40% of parents felt they had received adequate information about their infants’ care during the transport, but 40% cited separation. Applying FCC core concepts during the neonatal transport has been shown to be increasingly important to parents and may facilitate communication and help them become active participants in their child’s’ care. These simple attitudes have a very positive effect on perinatal healthcare and should be reinforced.