key: cord-1036058-zcwiri61
authors: Stroud, Michael H; Miquel-Verges, Franscesca F; Rozenfeld, Ranna A; Holcomb, Robert G; Brown, Clare C; Myer, Keith
title: The State of Neonatal and Pediatric Interfacility Transport during the COVID-19 Pandemic
date: 2021-05-09
journal: Air Med J
DOI: 10.1016/j.amj.2021.05.003
sha: 375b8ae1c4b1d522bbe0f4a731e9df9909360749
doc_id: 1036058
cord_uid: zcwiri61

Background and Objectives The COVID-19 pandemic has altered the provision of healthcare, including interfacility transport of critically ill neonatal and pediatrics patients. Transport medicine faces unique challenges in the care of persons infected with the SARS-CoV-2 virus. In particular, the multitude of providers, confined spaces for prolonged time periods, varying modes (ground, rotor wing, fixed wing) of transport, and need for frequent aerosol-generating procedures place transport personnel at high risk. This study describes the clinical practices, personal protective equipment, and potential exposure risks of a large cohort of neonatal and pediatric interfacility transport teams. Methods Data for this study came from a survey distributed to members of the American Academy of Pediatrics Section on Transport Medicine. Results Fifty-four teams responded and 47 reported transporting COVID-19 positive patients. Among the 47 teams, 25% indicated having at least one team member convert to COVID-19 positive. A small percentage of teams (40% ground, 40% fixed wing, 18% rotor wing) reported allowing parental accompaniment during transport. There was no difference in teams with a positive team member among those that do (26%) and do not (25%) allow parents. There was a higher percentage of teams with a positive team member among teams that intubate (32% vs 0%) and place LMAs (34% vs 0%) during transport. Conclusions Our study shows that exceptional care during interfacility transport, including a family-centered approach, can continue during the COVID-19 pandemic. Teams must take steps to protect themselves, as well as the patients and families they serve, in order to mitigate transmission of the SARS-CoV-2 virus.

The COVID-19 pandemic has affected every aspect of healthcare. As of mid-January 2021 there have been more than 23 million cases and 400,000 deaths in the United States. In the past year we have learned that SARS-CoV-2, the virus responsible for COVID-19, is highly transmissible (primarily by respiratory droplets), affects all ages of the population, and has strained healthcare systems across the globe (1) . Transport medicine faces unique challenges in the care of persons infected or persons under investigation (PUI) for COVID- 19 . In particular, the multitude of providers, confined spaces for prolonged time periods, varying modes (ground, rotor wing, fixed wing) of transport, and need for frequent aerosol-generating procedures place transport personnel at high risk of exposure. Several groups and societies have published recommendations on caring for COVID-19 patients or PUI, including recommendations specific to transport (2) . However, there have been few publications describing experiences transporting PUI or COVID-19 patients, and none that describe the collective neonatal and pediatric interfacility transport experience. Recommendations include the use of standardized intake forms (3) , airway stabilization prior to transfer to avoid aerosol generating procedures during transport, (4) using appropriate personal protective equipment (PPE), (5, 6, 7) and rigorous decontamination procedures (8) . Risks to personnel must also be considered when deciding on need for patient transport (9) . The risk for transport team members includes personal safety as well as consequences of short staffing (10) .

The American Academy of Pediatrics Section on Transport Medicine (AAP-SOTM) FAQs and the European consensus recommendations are the only documents that refer specifically to pediatric and neonatal transport (2, 4) . The European consensus recommendations suggest transporting pediatric patients without a parent or caregiver, in order to protect the crew and minimize exposure to potentially infectious parents (4) . However, the AAP-SOTM FAQs recommend considering parental accompaniment under certain circumstances (2) .

Understanding the current practices among neonatal and pediatric transport programs is critical to assess potential opportunities for continued education on safe practices and standards.

This study used a survey developed to assess current practices among a large cohort of pediatric and neonatal transport programs who are actively transporting patients with known or suspected SARS-CoV-2.

Data for this study came from a survey distributed to members of the American Academy of Pediatrics, Section on Transport Medicine (AAP-SOTM). The survey was distributed to members via the section's email Listserv and social media page. The survey was open from August 3, 2020 through August 21, 2020 and included questions about PPE use, ventilation practices and filter use, and other transport-related and patient care questions. The survey was completed by 54 individuals, representing 54 unique transport teams. Among the 54 teams, 47 indicated they currently transport COVID-19 patients and are included in this study.

Given the small sample size, multivariate analyses were not feasible. Descriptive statistics include information about overall team characteristics as well as Fisher exact tests to assess differences in team characteristics by transport mode (ground, rotor wing, fixed wing).

Additionally, bivariate calculations using Fisher exact tests were conducted to assess whether there were differences in the percentages of teams with and without a COVID-19 positive team member based on different team-level characteristics and safety practices, stratified by team method. Regressions and demographic tests were analyzed using Stata, version 16. All tests were 2-sided assuming a p value of 0.05 as statistically significant; however, indicators of tests with p<0.10 are additionally provided. This study was determined to be non-human subjects research by the University of Arkansas for Medical Sciences Institutional Review Board (#261931). Table 1 provides characteristics of the 47 teams. Transport teams were located in all regions of the United States, with the highest percentage of teams located in the Midwest (34%), followed by the Southwest (19%), Northeast (19%), West (17%), and Southeast (9%). One team indicated a location outside the United States. The majority of teams (72%) transport pediatric and neonatal patients; 15% reported transporting only pediatric patients, and 13% reported transporting only neonatal patients. The most common team composition was a team of a registered nurse and a respiratory therapist (66%), followed by teams composed of a registered nurse and an emergency medical technician (15%). Among the 47 teams, 25.5% indicated having at least one team member convert to COVID-19 positive, of which 83.3% indicated that having a team member convert to positive resulted in staffing shortages. Table 2 provides the percent of ground, rotor wing, and fixed wing teams that answered "Yes" or "No" to each of the outlined questions regarding PPE use and patient care activities.

Fisher exact tests to test for differences in safety practices and patient care did not indicate any statistically significant differences in activities among different methods of transport ( Table 2) .

When asked whether the team allowed parents during transport, 40% of ground teams and 40% of fixed wing teams allow parents, compared to 18% of rotor wing teams (p<0.10).

Over 80% of teams indicated using disposable N95 masks for their own protection when treating COVID-19 patients, of which 53% indicated reusing disposable masks for more than one patient (Table 1) . Of note, among the teams that use KN95, PAPR, or equivalent, no team indicated having a positive team member. All teams with positive team members indicated using disposable N95 masks (results not shown). Around 30% of teams (ground: 36%, rotor wing: 31%, fixed wing: 26%) use N95 masks or equivalent when transporting all patients, regardless of COVID-19 status, compared to over 95% use of N95 masks (or equivalent) when transporting COVID positive or suspected positive patients. Nearly all teams reported using eye protection (ground: 96%, rotor wing: 94%, fixed wing: 91%), with fewer reporting use of Level 3 gowns (ground: 83%, rotor wing: 74%, fixed wing: 86%).

A majority of teams of all 3 transport modes indicated that COVID-19 positive or suspected positive patients did not use an N95 or equivalent with low flow oxygen use (ground: 59%, rotor wing: 64%, fixed wing: 67%) or high flow oxygen use (ground: 61%, rotor wing: 64%, fixed wing: 68%) ( Table 2) . (Table 2) . Around 80% to 90% of teams (ground: 83%, rotor wing: 88%, fixed wing: 87%) indicated they intubate and/or place a laryngeal mask airway (LMA) during transport (ground: 76%, rotor wing: 82%, fixed wing: 83%). Approximately 5% of teams indicated they do not provide cardiopulmonary resuscitation (CPR) during transport (ground: 7%, rotor wing: 6%, fixed wing: 4%). Table 3 provides the percent of teams that indicated having at least one team member convert to COVID-19 positive. Percentages add up to 100% within each transport team and within each "Yes" or "No" response. For example, among teams that allow parents during transport, 26% had at least one positive team member, compared to 25% among transport teams that indicated they do not allow parents during transport. Assessments using Fisher exact test suggest there was a higher percentage of teams with at least one positive member among ground teams who intubate during transport (32% vs 0%; p<0.10), ground teams who place an LMA during transport (34% vs 0%; p<0.05), and rotor wing teams who place an LMA during transport (41% vs 0%; p<0.10).

Our study is the first to describe the clinical practices, PPE use, and potential risk factors associated with interfacility transport of neonatal and pediatric patients via ground, rotor wing, and fixed wing vehicles during the COVID-19 pandemic. We collected data regarding the practices of 47 pediatric, neonatal, and mixed pediatric/neonatal transport programs across the United States and abroad in order to obtain a better understanding of the current practices among pediatric and neonatal transport teams. The interfacility transport of critically ill neonatal and pediatric patients is a complex task that specialized transport teams conduct safely and efficiently (11) . Transport of critically ill neonatal and pediatric patients allows for state-of-the-art care only available at tertiary care centers. The rampant global spread of the SARS-CoV-2 virus has further complicated the safe delivery of critically ill patients in an already austere environment.

The known increased asymptomatic and pre-symptomatic carriage rate of the SARS-CoV-2 virus in young children and the frequent need to provide aerosolizing procedures for respiratory distress and respiratory failure provides further risk to transport team members (12) . Given the limited number of pediatric and neonatal transport teams, infection during interfacility transport puts not only transport team personnel at potential risk, but limits on staffing can have impacts on transport of pediatric patients with COVID-19 as well as other critically ill children and neonates.

Family-centered care has been shown to improve patient and family outcomes, improve both family and professional satisfaction, decrease health care costs, and lead to more efficient use of health care resources (13) . A family-centered care approach has become standard practice at children's hospitals. The benefits of such an approach to care in the neonatal and pediatric intensive care units have been demonstrated in previous studies (14) . Neonatal and pediatric interfacility transport teams are the link between referring hospitals and tertiary care centers.

Children's hospital based family-centered care starts with the interfacility transport team, and benefits of family-centered care have been shown in neonatal (15) and pediatric transport (16) .

The majority of interfacility transport programs allow parental presence during ground and fixed wing transport. Parental presence during rotor wing transport is not as common, though many programs with large rotor wing aircraft also allow parental accompaniment.

The COVID-19 pandemic has changed many aspects of care provision for neonatal and pediatric patients, including limitations to the family-centered care approach. Although some limitations are necessary to prevent the spread of the SARS-CoV-2 virus, the benefits of familycentered care are none-the-less important. Our study shows that the COVID-19 pandemic has impacted the family-centered care approach to neonatal and pediatric interfacility transport with 40% of ground teams, 39% of fixed wing teams, and 18% of rotor wing teams indicating parental presence during neonatal and pediatric transport. Of the teams that allow parents during transport, we found no increased risk of team members converting to COVID-19 positive; 26% of teams that do allow parents had a positive team member, versus 25% of teams that do not allow parents. Though precautions such as screening parents for symptoms, parental masking, and physical distancing in vehicles when possible must be considered, teams should consider the known benefits of a family-centered care approach to interfacility transport during the COVID-19 pandemic. The present study suggests that a family-centered care approach may not place team members at increased risk of contracting the SARS-CoV-2 virus, providing evidence for the previously published family-centered care recommendation from the AAP-SOTM (2).

Between 50-75% of teams require parents who accompany the transport to wear an N95 or equivalent mask during transport.

Healthcare Physical distancing is often not possible during interfacility transport, and PPE use is vitally important. Our study shows high adherence with CDC guidance for COVID-19 positive or suspected patients with >95% use of N95/equivalent, >75% use of gowns, and >91% use of eye protection. Of note, there were no cases of SARS-CoV-2 positivity among teams who use higher level respirators. Around 30% of teams reported use of N95/equivalent for all transports, and around 50% of teams reported reusing disposable N95 masks at some point. PPE is vitally important to limit the spread of the SARS-CoV-2 virus, and adherence to the CDC (18) and AAP-SOTM (2) guidelines is strongly recommended during neonatal and pediatric interfacility transport by all modes. We did not identify significant deviations from the current guidelines, with the exception of reusing N95 masks. Additional efforts to supply transport teams with adequate supplies of N95 masks is critical for ensuring the safe transport of pediatric and neonatal patients with COVID-19 as well as other critical illnesses.

Respiratory symptoms are common in adults (18) Our study demonstrates a high rate of COVID-19 positive team members among teams who intubate (ground: 32%, p<0.10) and place LMAs (ground: 34%, p<0.05; rotor wing: 41%, p<0.10) during transport. Precautions including proper use of PPE and intubation by the most experienced personnel should be followed for neonates and pediatric patients requiring intubation for interfacility transport. Securing an airway for patients with a marginal respiratory status should be considered prior to transport, in order to prevent exposure to aerosol generating procedures in the confined spaces of transport vehicles. Planning, preparing equipment and medications, proper PPE, and safe distancing are better accomplished at referring facilities than in transport vehicles, regardless of mode. Additional consideration should be given to use of HEPA filters where possible during interfacility transport by all modes.

While novel in its data and critical for ensuring safety of pediatric and neonatal transport teams, our study has some limitations. First, the approach used to capture the data (via email and social medial posts) limits the ability to calculate a participation rate. Though 54 individual teams responded to the survey, we know at least 110 teams are members of the AAP-SOTM. A repository for data collection specifically for movement of COVID-19 positive or patients under investigation, may offer additional insight over time. Second, there are data points that were not collected in this study that could be beneficial for understanding transport team practices.

Questions were created based on use of currently available guidelines (CDC, AAP-SOTM FAQ); however, the survey was limited in questions in order to obtain complete survey responses. For example, questions regarding whether parents are tested prior to transport could have biased downward our findings regarding infection among teams that allow parents during transport.

Relatedly, the sample size was relatively small, which prevents the ability to have adjusted models of any kind. While causality of our findings cannot be assumed, this study is the first to capture and evaluate primary data regarding interfacility transport during the COVID-19 pandemic among a large cohort of neonatal and pediatric transport teams. Third, a given transport team member responded for information about ground, rotor wing, and fixed wing teams for their facility. This could limit findings if the representative respondent was misinformed about their facility's patient care and safety activities for all three transport modes.

Finally, this data was collected over a short time period and may not reflect the safety and patient care activities among transport teams during other times of the pandemic.

The COVID-19 pandemic has altered the provision of healthcare, including the safe delivery of neonates and children to tertiary care centers by interfacility transport teams.

Precautions must be taken to limit the spread of the SARS-CoV-2 virus in order for specialized transport teams to continue to provide the care needed for critically ill neonates and children during interfacility transport. Our study shows that exceptional care during interfacility transport, including a family centered approach, can continue during the COVID-19 pandemic.

Teams must take steps to protect themselves, as well as the patients and families they serve, in order to mitigate transmission of the SARS-CoV-2 virus. Hospitals should consider whether the benefits of family-centered care outweigh the cost of higher-level respirators and/or a steady supply of reusable N95s. Lessons learned during the current pandemic may also aid in future, unexpected widespread infectious diseases. 

Frequently asked questions: interfacility transport of the critically ill neonatal or pediatric patient with suspected or confirmed COVID-19

Interhospital transport of patients with COVID-19: Cleveland Clinic approach

European consensus recommendations for neonatal and paediatric retrievals of positive or suspected COVID-19 patients

Safe patient transport for COVID-19

Air Medical Physician Association Position Statement on COVID-19

Pre-hospital care & interfacility transport of 385 COVID-19 emergency patients: an air ambulance perspective

The transport medicine society consensus guidelines for the transport of suspected or confirmed COVID-19 patients

Fixed wing patient air transport during the COVID-19 pandemic

Decision support tool and suggestions for the development of guidelines for the helicopter transport of patients with COVID-19

Pediatric specialized transport teams are associated with improved outcomes

ARS-CoV-2 (COVID-19): what do we know about children? A systematic review

Committee on Hospital Care. Family-centered care and the pediatrician's role

Guidelines for family-centered care in the neonatal, pediatric, and adult ICU

Family-centered care during acute neonatal transport

Family-centered care in pediatric critical care transport

Clinical characteristics of coronavirus disease 2019 in China

A pediatric infectious disease perspective of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and novel coronavirus disease 2019 (COVID-19) in children

Pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): clinical presentation, ionfectivity, and immune responses

We thank the members of the neonatal and pediatric transport community for their tireless work to care for neonates, infants, and children during the current pandemic.Your passion, dedication, and selfless service are truly inspiring.