The transport of critically ill children continues to be an area 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 Española de Cuidados Intensivos Pediátricos (Spanish Society of Paediatric Intensive Care, SECIP), Sociedad Española de Neonatología (Spanish Society of Neonatology, SENeo), Sociedad Española de Urgencias Pediátricas (Spanish Society of Paediatric Emergency Care, SEUP) and the Sociedad Española de Medicina de Urgencias y Emergencias (Spanish Society of Emergency and Urgent Care, SEMES) to start collaborating in pursuit of a shared goal: the optimization of paediatric and neonatal transport (PNT) in Spain in every age range. The first step in this collaboration took place a few months ago with the publication of a position statement regarding the need to create PNT units for interhospital transport (IHT).1

In Spain, paediatric primary transport (generally from transfer of patients from site of illness or injury to the nearest hospital) is usually carried out by the EMS system of each autonomous community in Spain and coordinated through a switchboard. The units that provide this initial care and transport are basic or advanced life support units (Table 1) that also transport critically ill adults. At present, there are no standardised requirements regarding equipment or the training in paediatrics of the staff in these units.

Secondary transport involves IHT, and in the specific case of critically ill children usually involves transport from the hospital where stabilization is initiated to another hospital with greater resources to manage the patient’s condition and, in some instances, transport back to the original hospital. It is during IHT that paediatric equipment should never be lacking, as this allows to initiate the care at the sending hospital (SH) that the children will be receiving in the receiving unit (most likely a paediatric intensive care unit [PICU] or neonatal intensive care unit [NICU]) with awareness and anticipation of the potential complications that could emerge during transport.2,3 The benefits of it are well documented in the literature,4–7 some short-term (decrease in morbidity, mortality and length of stay) and others long-term (cost-effectiveness in child health and reduction in health care costs).

Our aim was to review the advantages of using specialised PNT, provide an updated perspective on the situation of PNT in Spain and highlight the human and material resources required for this service.

At the international level, no particular model of transport team has been established in terms of its composition,8,9 and multiple options apply: respiratory therapist and nurse, nurse and adjunct physician or nurse and resident physician, among others, in addition to 1 or 2 technicians. Spain has opted for a model consisting of an emergency medical technician (EMT), nurse and/or physician.

The composition is the same in PNT teams, with the added requisite that every member of the team (paediatrician/neonatologist, nurse and EMT) should have specific training in paediatric/neonatal care and medical transport, although this is not always the case in real-world practice. A variety of models can be found throughout Spain (SENeo 2018 nationwide survey) that differ in how transport is managed and in the composition of the transport team (Fig. 1, Tables 2A, 2B and 2C). This heterogeneity is partly explained by the characteristics of each autonomous community (economic, sociodemographic and geographical). However, since children have the right to receive the best possible care during medical transport, as established by articles 3 and 24 of the Declaration of the Rights of Children10 and articles 20 and 30 of the Spanish Constitution of 1978,11 we believe that the following is warranted:

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  For all children of any age to be extended the right to this service.

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  For staff in these teams to have extensive knowledge and skills in paediatric and neonatal critical care and experience and knowledge of medical transport.

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  All medical devices and stabilization supplies should be available and ideally located in the vehicles of the specialised team.

Figure 1.

Paediatric and neonatal transport models in Spain.

EMS, emergency medical services.

(0.29MB).

The transport of a critically ill paediatric patient does not consist solely of moving a patient from one location to another, but is a more complex process that allows adequate stabilization and involves the SH, the transport team, the receiving hospital and the coordinating facility through their collaboration. Thus, PNT makes available the human and material resources of a PICU or NICU to patients wherever they happen to be. Thus, PNT teams:

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  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 through minimally invasive methods; setup and delivery of nitric oxide12; non-invasive ventilation13,14 (high-flow nasal prongs, continuous positive airway pressure [CPAP]), which reduces the proportion of patients intubated for transport; ventilation interfaces appropriate for the size of paediatric/neonatal patients that are intubated or require high-frequency oscillatory ventilation15 (a modality applied nearly exclusively in neonatology/paediatrics and which requires experience for correct implementation).

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  Allow transport of patients with paediatric illnesses that require specific management: late preterm infants16,17 (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 respiratory support, abrupt haemodynamic changes carrying a risk of cerebrovascular insult, etc); hypoxic-ischaemic encephalopathy18,19 (with a specific time window for initiation of therapeutic hypothermia to improve neurologic outcomes and requiring careful management of fluids, electrolytes and haemodynamic support); cardiac diseases, both congenital and acquired in the first years of life, etc.

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  Allows transport of patients that need care that requires highly specific training, such as extracorporeal membrane oxygenation (ECMO)20,21 with the added peculiarities of infants and children compared to adults, and always with participation of other teams (surgeons, perfusionists, security/police, civil guard or armed forces).

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  Allows transfer back to SH of patients that still require specialised care during transport. This type of transfer contributes to the optimization of health care resources and to improving the quality of life of patients and their families.

Other ways in which severely ill children would benefit from the availability of PNT include transport children with palliative care needs22 under the best possible conditions to their homes; support in primary transport23 (in some cases in person and in others remotely); phone or online consultation to guide the care of critically ill children when the staff managing the patient has questions regarding assessment or treatment; assisting in transfer coordination and the selection of the appropriate hospital, and training the rest of the staff of the EMS system on paediatric care.

Critically ill children of any age are entitled to high-quality medical transport. To ensure this right, PNTs should be established throughout the Spanish territory which, despite possible variations in its composition, must meet basic standards in human and material resources. The implantation and integration of PNTs in EMS systems will also contribute to optimising their performance.

The authors have no conflicts of interest to declare.