Keywords

Introduction

Successful outcome of a medical treatment or an operation in pediatric surgery depends not only on the skills of the pediatric surgeon but also on that of a large interdisciplinary team consisting of pediatrician/neonatologist, anesthetist, radiologist, pathologist, biochemist, nurses, and other disciplines necessary dealing with the patient (Puri and Doodnath 2011). Injured or severely ill children may present in hospitals which may not be equipped to manage complex pediatric medical requirements, and thus, an emergency transport to a pediatric tertiary care facility must be organized (Quinn et al. 2015). The objective is to transport the critically ill or severely injured child to a tertiary hospital in the right condition and in the right time by an appropriately trained and skilled team of health professionals. Prompt access to high quality care offers the best and only chance of a successful outcome.

Transport team and transport vehicle should be a natural physical extension of the intensive care unit, able to supply advanced critical care management for children of all ages at remote sites and during transport to a tertiary hospital (Ajizian and Nakagawa 2007). Effective and efficient treatment can only be available by optimizing resources, medical and technical equipment, and skilled staff in a few specialist pediatric centers which have responsibilities to a particular region (Messner 2011). There has been a dramatic development in the last three decades regarding to the knowledge, capabilities, and delivery of neonatal and pediatric transport (Moss et al. 2005; Ratnavel 2009). There is strong evidence that the use of specialist transport teams results in improved survival for critically ill children (Calhoun et al. 2017; Edge et al. 1994; Orr et al. 2009; Ramnarayan et al. 2010).

Transport Management

Transport teams and clinics should follow benchmarks of transport consensus groups for best practices and quality improvement in transport procedure and clinical care (Schwartz et al. 2015).

The transport staff must cautiously monitor the patient’s condition during the travel as well as ventilation and oxygenation, cardiovascular, metabolic, and thermal support (Messner 2011).

Previously, a swift transfer management (“scoop and run”) has been postulated to rush the patient to the hospital as quick as possible (Stroud et al. 2008). This idea of the “golden hour,” the time between harm and arrival at specialized center for definitive care, originated in 1973 (Cowley et al. 1973; Stroud et al. 2008). Because of this management, early implementation of goal-directed therapy was often delayed until arrival at the intensive care unit (ICU), but early goal-driven treatment, e.g., for septic shock and head trauma has been shown to improve outcome in adults and children likewise (Stroud et al. 2008).

Factors associated with time to arrival at a pediatric trauma center are field triage and decision-making, which correlate with the injury’s severity and rapid transport of the most severely injured children to definitive trauma care (Odetola et al. 2016).

To improve transport quality, everyone involved in pediatric transport should be aware of physiologic deterioration, laboratory values, interventions, equipment failure, process error, and safety issues (Gunz et al. 2014). Jones et al. identified that these so-called UNSEMs (unintended injury, near miss, suboptimal action, error, management complication) are especially more likely when transport originates from a scene compared to hospital (Jones et al. 2016).

Despite the urge of ensuring specialized pediatric trauma treatment, a significant number of pediatric trauma transfers are preventable (Fenton et al. 2016). Fenton et al. recently showed that in their trauma transportation cohort, 87% of the children were discharged within 24 h, demonstrating that beside high transportation costs, often little medical treatment is required for a considerable amount of patients, and the current triage system needs to be optimized. Tools such as image-sharing networks and telemedicine programs may help to limit unnecessary transfers by providing contact to pediatric trauma specialists at hospitals which are not otherwise equipped to care for injured children (Fenton et al. 2016).

Telemedicine delivers information and health-care advice across distances (Patel et al. 2015). Real-time video and phone conferences can be equally good in quality, connectivity, and duration. Especially videos seem to improve the patients’ assessment and disposition as they not only support communication with the referring hospital staff but also help to see and interact with patient and parents likewise (e.g., see certain body aspects in advance; see and correct ventilator settings, etc.) (Patel et al. 2015).

Airway Management

After arrival in the primary care area, one should ensure that the airway is clear, the child is well oxygenated, and ventilation can be maintained during transport if required. If there is any risk for deterioration of spontaneous respiration during transport, the patient needs to be intubated before departure, because emergency intubation while travelling may be hazardous or difficult (Lloyd 1996). Airway suction of intubated patients should be performed regularly.

Endotracheal intubation is considered the gold standard for airway management (Freeman et al. 2016). Because regular training is necessary to maintain this skill, there is now often focus on providing sufficient sustained bag mask ventilation in pediatric patients instead (Freeman et al. 2016). Mask ventilation, however, can be difficult over long periods of time, especially in a moving vehicle (Bosch et al. 2014; Freeman et al. 2016). Laryngeal airways are also frequently chosen alternatives because they require minimal training, can be quickly placed, do not require direct visualization, and may be easier to sustain than mask ventilation (Freeman et al. 2016).

Circulation and Homeostasis

Secure routes of intravenous (i.v.) access should be in place as severely injured children or neonates with congenital malformations may experience abnormal loss of water, electrolytes, proteins, or blood, which must be replaced to prevent hypovolemia and shock (Puri and Doodnath 2011). Intravenous fluids (IVF) should be started immediately and, if necessary, inotropic catecholamines to maintain organ perfusion (Lloyd 1996; McHugh and Stringer 1998).

Trauma-induced hemorrhage is considered the main cause of preventable death in the first 24 h after admission (Garwe et al. 2016; Holcomb et al. 2011). Its management usually includes early rapid intravenous fluid replacement at the site of the accident and during transport to the trauma center (Garwe et al. 2016). However, a propensity-adjusted survival analysis by Garwe et al. showed neither a beneficial nor an adverse effect from prehospital IVF, and the authors concluded that time-consuming venous access and IVF maintenance should not be the reason for delay as their IVF patients had significant prolonged scene, transport, and total prehospital times (Garwe et al. 2016).

Besides IVF, goal-directed resuscitative interventions such as early peripheral administration of inotropic agents and correction of electrolyte abnormalities (including abnormal glucose and calcium levels) influence the outcome of critically ill children (Stroud et al. 2015). Additionally, maintenance of pulse oximetry >95%, continuous measurement of vital signs, oscillometric blood pressure readings every 3–5 min, and threshold age-adjusted heart rates maintenance are recommended (Stroud et al. 2015).

In case of excessive fluid losses or IVF, a urinary catheter helps to closely monitor the urinary output. Depending on the trauma in the pediatric patient, but crucial for almost every neonate, an adequately sized and securely taped nasogastric tube should be placed to prevent vomiting and aspiration. It should be kept on open drainage, attached to a low-pressure suction pump aspirated or suctioned frequently to prevent occlusion (Lloyd 1996). Glucose blood levels need to be monitored on a regular base and corrected if necessary (Puri and Doodnath 2011). Prophylactic broad-spectrum antibiotics should be started if there is a risk of infection.

Documentation

Following essential documents should be transferred with the pediatric or neonatal patient: a copy of the children’s chart including the complete medical data and notes, all X-rays/ultrasound/MRI/CT scans, laboratory reports, and nursing documentation (urine output, passage of stools, vaccination status, blood type, other medication administration) (Puri and Doodnath 2011).

In case that operative treatment is already foreseeable, the parental consent for operation (signed by the mother if the parents are not married) should be sent in case the parents cannot accompany their child. Also, contactable phone number of parents and hospital/ward should be exchanged in case of urgent consultations.

A meticulous documentation of vital parameters during transport is important as in certain conditions (e.g., shock and traumatic head injury) unrecognized hypotension and/or hypoxia are associated with increased morbidity and mortality (Hewes et al. 2016; Larsen et al. 2011; Zebrack et al. 2009). Heart rate; blood pressure; pulse oximetry and, if required, Glasgow Coma Scale; respiratory rate; and blood glucose should be assessed and documented in pediatric transport. However, vital signs are far too often documented infrequently (Drayna et al. 2015; Hewes et al. 2016). Likewise, any kind of intervention during the transport procedure needs to be documented (cardiopulmonary resuscitation, medication, ventilation, i.v. placement, intravenous fluids, etc.).

Transport Team

Although it is widely accepted that specific transport training is required for staff transferring neonatal and pediatric patients (Fenton and Leslie 2009; Orr et al. 2009; Stroud et al. 2013), the benefit of specialist transport teams remains controversial (Meyer et al. 2016b).

Several studies found that transport morbidity during high-risk transfers is reduced by having pediatric transport teams (PTT) on board due to fewer adverse events (e.g., improper endotracheal intubation or loss of vascular access) (Calhoun et al. 2017; Edge et al. 1994; Orr et al. 2009; Ramnarayan et al. 2010). In contrast, Meyer et al. found no significant difference in adjusted 48-h pediatric ICU mortality for children transported by pediatric transport teams (Meyer et al. 2016b). Furthermore, a recent Cochrane analysis has shown that there is no credible evidence from literature-based randomized trials to support or confute the benefits of specialist neonatal transport staff for neonatal outcome on morbidity and mortality as there are currently no eligible trials to compare (Chang et al. 2015). However, general emergency medical services (EMS) often feel uncomfortable treating children due to lack of skills/ knowledge/training which leads to stress and anxiety and, as a consequence, errors in medical treatment (Cushman et al. 2010). Moreover, it has been stated that frequently adverse events and near misses in the pediatric EMS environment, mostly due to omission, are not reported (Cushman et al. 2010). Specific problems are related to pediatrics, medication/calculation errors, procedural skill performance, unsuitable equipment size, parental interference, and omission of treatment related to providers’ discomfort with the patient’s age (Cushman et al. 2010).

Children transported by pediatric transport teams are usually younger and sicker (Calhoun et al. 2017). Despite longer transport times, children transported by PTT do not have an increased hospital length of stay or more adverse events during transport (Calhoun et al. 2017).

Individual and local factors will determine whether the referring or receiving center sends the transport team. The composition of the team members may also vary institutionally. Preferably, the transport team consists of a neonatologist/pediatrician/physician with pediatric experience and a trained neonatal/pediatric nurse familiar with and able to anticipate potential problems associated with specific lesions (Puri and Doodnath 2011). The staff should be familiar with equipment on board and should be experienced in stabilizing an infant or child in suboptimal conditions.

Vehicles and Equipment

Transport Vehicles

The transport staff is constantly facing complex decisions from the time of the initial referral call as well as throughout transport and clinical care for the child, with one of these decisions being the choice of the optimal transportation mode for each patient (Quinn et al. 2015).

The mode of transport dependents on travel distance, geography, weather conditions, ground traffic, vehicle availability, size of the transport team, the nature of the children’s problem, and the need for speed (Messner 2011). One should be aware that deterioration of the patient’s medical condition may be influenced by transport-related factors such as response and stabilization time or the transport vehicle (Borrows et al. 2010; Puri and Doodnath 2011; Ramnarayan et al. 2010).

Ground ambulances, rotary-wing aircraft (helicopters), and fixed-wing aircraft are currently popular conveyances. The level of clinical concern in coherence with the perceived travel distance and potential respiratory or neurovascular problems have been found to significantly influence the decision to mobilize a helicopter (Quinn et al. 2015). Interestingly, other clinical concerns such as heart rate, blood pressure, or perfusion have not been found to be statistically significant factors in choosing a helicopter for interfacility transfer (Quinn et al. 2015). If the concern is lower, ground transport ambulances are chosen more frequent, even if that means that the out of hospital time is prolonged. This circumstance is not necessarily a disadvantage as critical care transport teams are highly trained to deliver a wide range of life support measures and aggressive medical management on transport, even on the road (Quinn et al. 2015).

Advances in aircraft design and technical equipment allow now even mobile extracorporeal membrane oxygenation (ECMO) for critically ill children on board of modern rotator and fixed-wing aircrafts (Broman et al. 2015; Bryner et al. 2014; Holt et al. 2016). However, a major disadvantage of air transport is that additionally separate ground transport is necessary at both receiving and referring institution to move the child between airport and hospital. Exceptions are those in which helicopter landing sites are available at both centers. Vibration is not usually detrimental to the patient but can dislodge lines and tubes and adversely affect monitoring equipment (Gajendragadkar et al. 2000). Noise and vibration may cause distress and discomfort to the patient, resulting in deterioration of the clinical condition and may also complicate the monitoring of vital signs (Gajendragadkar et al. 2000; Puri and Doodnath 2011). Transport stretcher and child should be securely strapped in case of turbulence of the plane. Altitude effects on the children’s body can be detrimental (Jackson and Skeoch 2009). With increasing altitude, the partial pressure of oxygen decreases; therefore, diffusion of oxygen across the alveolar membranes becomes more difficult, arising in decreasing oxygen saturation in the infant. To maintain the same level of oxygenation, a higher percentage of oxygen may be required. Moreover, the barometric pressure will also decrease with increasing altitude, the volume of gas will increase, and any air trapped in a body cavity will expand, which could have a dramatic effect on pulmonary function, and small insignificant air leaks can become dangerous (Puri and Doodnath 2011). This is particularly vital in the setting of pneumothoraces, pneumoperitoneum, or intramural gas (Gajendragadkar et al. 2000). It is therefore important to ensure that all air leaks are drained, if possible (Puri and Doodnath 2011).

Medial staff operating in air travel should receive special training regarding the aircraft environment and also specific problems that they may encounter in safety, logistics (landing sites), or airborne environment (Fenton and Leslie 2009). Personnel serving air transport need to consider the influence of altitude on cuff pressure. Two recent studies found that the cuffed endotracheal tube cuff pressure (ETTCP) regularly exceeds recommended pressure limits even at relatively low altitudes (but no additional pressure increase related to cuffed endotracheal tubes size, Long et al. 2016; Orsborn et al. 2016), which potentially has the risk of decreasing mucosal blood flow and cause tracheal stenosis or rupture (Orsborn et al. 2016). The ETTCP should be kept below 30 cm H2O as there is evidence that tracheal mucosal perfusion is endangered when ETTCP exceeds 30 cm H2O and that the blood flow over the tracheal rings and posterior tracheal walls is absent when ETTCP exceeds 50 cm H2O (Orsborn et al. 2016; Seegobin and van Hasselt 1984). Regular ETTCP checks before and during transport are advisable as well as the use of saline instead of air for cuff blockage (Orsborn et al. 2016).

The benefit of air transport is controversial. Brown et al. postulated that helicopter EMS is associated to improved survival compared to ground transport in pediatric trauma population (Brown et al. 2016). Other authors, however, state that helicopter/air service is often overused (Meyer et al. 2016a; Michailidou et al. 2014). Stewart et al. found that ground versus helicopter transport type is not significantly associated with survival, length of stay in the ICU, or discharge management (Stewart et al. 2015). In their study, helicopter EMS did not result independently in better outcomes for pediatric trauma patients, and moreover, they found that 22.3% of their children transported by helicopter EMS were not even significantly injured (Stewart et al. 2015).

Monitoring and Equipment

Due to impaired lighting, noise, vibration, and space limitation, clinical evaluation of the patient can be limited, and proper functioning monitor equipment is essential. Pulse oximetry, hemodynameter (for invasive and noninvasive measures of arterial pressure), electrocardiograph (ECG), thermometer, and pressure transducers for central venous and intracranial pressure must be on board. There is often no electrical connection available while travelling, and monitors and syringe pumps must be able to run on battery (McHugh and Stringer 1998). An appropriate stock of airway and ventilatory equipment (self-inflating resuscitation bags, masks, airways, laryngoscopes, cuffed and uncuffed endotracheal tubes of various size, humidifiers, portable suction apparatus, oxygen supplies, etc.) as well as i.v. supplies, intraosseous needles, chest tubes, umbilical catheter kits, and emergency drugs should be present at any time (Puri and Doodnath 2011).

Table 1 lists necessary transfer equipment for neonatal and pediatric transports. Figure 1 shows an emergency kit containing drugs and medical aids for pediatric and neonatal transport.

Table 1 Transfer equipment for neonatal and pediatric transports
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Fig. 1
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Emergency kit containing emergency drugs, intravenous fluids, tubes, needles, cannulas, and catheters. The shown equipment is property of the National Neonatal Transport Programme Ireland (NNTP) (Picture taken with permission of NNTP)

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Transport Procedure

A good transfer requires early and effective communication between the referring and specialist center, stabilization of the patient before the transfer, and preparation of special needs and care during transport (Lloyd 1996) to avoid preventable adverse events such as vomiting with aspiration, airway obstruction, hypovolemia, or hypothermia (Puri and Doodnath 2011). Preferably, transfer is arranged at a senior level.

An increasing importance has the so-called family-centered care during the transport procedure (Joyce et al. 2015; Mullaney et al. 2014). Parental accompaniment has been found to be emotionally beneficial to the child, reduce separation anxiety and parental anxiety, and improve parental satisfaction and child cooperation during procedures (Joyce et al. 2015; Macdonald et al. 2012; Piira et al. 2005). Physicians involved in transport of sick children should be educated in family-centered care.

Schwartz et al. recently evaluated quality metrics for pediatric and neonatal critical care transport (Schwartz et al. 2015). Identified as very important were “unplanned dislodgement of therapeutic devices, verification of tracheal tube placement, average mobilization time of the transport team, first-attempt tracheal tube placement success, rate of transport-related patient injuries, rate of medication administration errors, rate of patient medical equipment failure during transport, rate of cardiopulmonary resuscitation performed during transport, rate of serious reportable events, unintended neonatal hypothermia upon arrival to destination, rate of transport-related crew injury, and the use of a standardized patient care hand-off” (Schwartz et al. 2015). Everyone involved in the transport procedure should bear these cachets in mind whenever transferring patients to assure good transfer management.

Any incident during transfer must be reported and critically reviewed as this can reduce the number of adverse events during transport of sick children by providing staff training and implementation of guidelines for maintenance readiness of equipment (Moss et al. 2005).

Receiving Center

On arrival at the receiving center, a brief report for the reason of transport (accident, operation, congenital malformation, clinical deterioration of preexistent disease, etc.), transport problems, or adverse events while travelling as well as the current status of vital sign parameters should be given by the transport team to the receiving care unit staff. For neonatal transport, also data of prenatal reports, labor, delivery, and details of the newborn’s resuscitation need to be added (Puri and Doodnath 2011). The accompanying transport physician should evaluate the patient and all documents together with the accepting surgeon and neonatologist/pediatrician or anesthetist, if necessary. Foronda et al. reviewed the importance of an accurate handover after transport of severely ill children as communication failure and human factors (professional hierarchies, lack of teamwork, role ambiguity, differences in values) are serious factors for detrimental health outcomes. The authors highlighted that during handover and also during transfer, specialized teams using standardized communication (including handover tools and mnemonics) can improve the patients’ outcomes, transport costs, and provider satisfaction likewise (Foronda et al. 2016).

The parents should be introduced to all staff who will be involved in the care of their child. Every procedure should be explained in a clear and comprehensive language to avoid confusion and parental fear. If necessary, the consent form should be updated. Further examinations (blood tests, imaging procedures) can be ordered subsequently.

Special Considerations for Neonates

Prenatal Transfer

The best and safest way to care for both mother and the newborn is the transfer of the pregnant woman to a high-risk perinatal center before delivery (Messner 2011). This involves especially high-risk fetus such extremely preterm and very low birth weight fetuses and those with life-threatening neonatal surgical problems (Puri and Doodnath 2011). Another special problem of these high-risk babies is hypothermia as it adversely affects the neonatal outcome and seems to be an independent predictor of mortality (Goldsmit et al. 2012; McCall et al. 2008; Puri and Doodnath 2011).

Neonatal Transfer

Transport of a surgical newborn to a tertiary center for specialized pediatric surgical care may become necessary if a prenatal transfer is not feasible, the child’s surgical condition is prenatally unknown, or the neonate develops the surgical emergency postnatally. Table 2 lists neonatal conditions requiring transport to a tertiary center for surgical care. Figure 2 shows gastroschisis in conjoined twins.

Table 2 Neonatal surgical conditions requiring transport to a tertiary center for operative care
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Fig. 2
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Conjoined twins with gastroschisis

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Transferring a newborn without proper stabilization is associated with increased morbidity and mortality, and therefore no neonate should be transported without sufficient resuscitation to survive the journey (Puri and Doodnath 2011). Nevertheless, a high percentage of referred neonates suffer deterioration during transport regardless their clinical status, resulting in a higher risk of early neonatal mortality (Goldsmit et al. 2012). Therefore, precaution and careful attention to pre-transfer management will provide a higher safety margin during the transport, especially as the vehicle environment is usually noisy, and the access to the patient is restricted, leading to potential difficulties in providing adequate treatment should problems arise (Lloyd 1996). For neonates, the usage of inhaled nitric oxide on the road as well as high-frequency oscillation ventilation has been shown to be feasible and safe (Chassery et al. 2015; Lowe and Trautwein 2007; Mainali et al. 2007). To assure an optimal neonatal transport by guiding accompanying doctors and operating the equipment, some institutions use advanced neonatal nurse practitioners (ANNPs) or have formed a special nursing transport team (Fenton and Leslie 2009; Leslie and Stephenson 1997).

For good documentation and referral practice in newborns, it should be clearly stated whether and how much vitamin K was administered. A sample of maternal blood should be sent along for cross-matching as well as a cord blood specimen and a copy of maternal records (including complete maternal history, labor, and delivery records) (Puri and Doodnath 2011).

Temperature Regulation

Neonatal thermoregulation requires critical attention. Hypothermia causes an increase in the neonate’s metabolic rate with a subsequent increase in glucose and oxygen use ensuing acidosis, and if not reversed, persistent pulmonary hypertension of the neonate develops (Puri and Doodnath 2011). Unlike older children and adults, neonates are unable to maintain thermogenesis through shivering. Their heat-producing mechanism is limited to metabolism of brown fat and peripheral vasoconstriction (Gillick and Puri 2009; McCall et al. 2008). Hypothermia with a core body temperature below 36.4 °C (97.5 °F) is associated to increased neonatal mortality, which can be avoided by warming the baby to a core temperature of at least 36.5 °C and using a pre-warmed transport incubator in a pre-warmed ambulance (McCall et al. 2008). Hypothermia may also occur as a sign of infection and must implicate diagnostic evaluation and antibiotic treatment if required (Gillick and Puri 2009). On the other hand, one should also avoid hyperthermia above 37 °C (98.6 °F) as it correlates with perinatal depression and hypoxic brain injury (Gillick and Puri 2009).

Transport Incubators

Standard requirements for transport incubators are established in an international standard (International Electrotechnical Commission 2009; Koch 1999). An incubator is a central piece of equipment that has to provide warmth, visibility, and access. Every incubator must be able to maintain a specific temperature under a variety of different ambient conditions (e.g., −15 °C/5 °F to 28 °C/82 °F) (Koch 1999). The patient compartment of the transport incubator is usually equipped with a front flap for loading for good access to the neonate in the event of an emergency (Koch 1999). Incubators should be able to run on batteries and must be equipped with a recharger. Guidelines state that the energy of the battery should be sufficient for a minimum of 90 min in an ambient temperature of 15 °C/59 °F (Koch 1999). Cardiorespiratory monitor, pulse oximeter, oxygen analyzer, oxygen and air cylinders, infusion pump, double plexiglass walls, and shock-absorbing wheels must be commercially provided (Puri and Doodnath 2011). In the case of transporting very sick neonates and preterm babies, ventilation may be required. In these cases, the incubator should be equipped with a mechanical ventilator which is time-cycled, pressure-limited, and capable of delivering conventional ventilations and constant positive airway pressure (Koch 1999). When securing the neonate in the incubator, one must keep in mind the infant’s size, the extreme sensitivity of preterm skin, the reduced muscle tone, low body profile, and body weight distribution.

Figure 3 shows a modern transport incubator system including equipment for ventilation, delivery of nitric oxide, cooling, suction, and infusion. Special ambulances have space for one or two of these transport systems, providing optimal transport for sick neonates (Fig. 4),

Fig. 3
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Transportable incubator system with monitor, ventilator, nitric oxide delivery system, humidification, suction, cooling, and infusion pumps. The shown equipment is property of the National Neonatal Transport Programme Ireland (NNTP) (Picture taken with permission of NNTP)

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Fig. 4
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View into an ambulance equipped to transport incubator systems. This special neonatal ambulance has the facility to transport two transport incubators systems at the same time, e.g., for transport of twins (Picture courtesy of National Neonatal Transport Programme Ireland (NNTP))

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Conclusion and Future Directions

The main challenge for health-care providers dealing with the pediatric population is its unique subset consisting of neonates, infants, toddler, school-aged children, and adolescents, and therefore “age-appropriate” skills and equipment is mandatory. The care management of injured children and high-risk newborn has changed considerably in the last decades. Improvements in therapeutic interventions and transport vehicles as well as equipment and education have contributed to the opportunity to deliver critical care in the field (Stroud et al. 2015). Every child with a serious condition requiring transport to a specialized hospital must be assessed and stabilized by experienced staff prior to and during transport as adequate stabilization before transport is associated with reduced morbidity and mortality. Bringing the facilities of the intensive care unit management to the patient’s bedside during transport should be the overall aim of every transport. Ongoing assessment and improvement in transport protocols and procedure will help to optimize pediatric transport and, subsequently, patients’ health outcome.

Cross-References