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Early Human Development 85 (2009) 477–481

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Early Human Development

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Best Practice Guideline article

Setting up a neonatal transport service: Air transport

Lesley Jackson ⁎, Charles H. Skeoch 1

West of Scotland Neonatal Transport Service, Ground Floor, Cuthbertson Building, Glasgow Royal Infirmary, Glasgow, G31 2HT, Scotland, United Kingdom

⁎ Corresponding author. Tel.: +44 01412115400.E-mail addresses: lesley.jackson@ggc.scot.nhs.uk (L.

charles.skeoch@ggc.scot.nhs.uk (C.H. Skeoch).1 Tel.: +44 01412115400.

0378-3782/$ – see front matter © 2009 Elsevier Irelandoi:10.1016/j.earlhumdev.2009.05.007

a b s t r a c t

a r t i c l e i n f o

Keywords:

NewbornAir transportDedicated transport teams

Air transport is an integral part of any system that provides neonatal care in the developed world. To ensurethat this is developed in an efficient and appropriate manner a prospective analysis is required to allow amultidisciplinary team to progress a project aimed at providing appropriate staff with adequate trainingusing equipment that has satisfied all regulatory bodies.This article highlights the difficulties in achieving this, reflecting on the way in which established airtransport teams have overcome many of the difficulties.The commonalities with land based transport are emphasised along with those issues which are specific toteams providing such a service who aspire to become “air capable”.

© 2009 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4772. Assessing the need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4783. Multi-professional approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4784. Equipping a service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4785. Staffing a service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4796. Communication and organizational issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4797. Specific clinical issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480

7.1. Altitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4807.2. Acceleration / deceleration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4807.3. Thermal issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4807.4. Noise and vibration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4807.5. Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480

8. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481Key guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481Research directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481

1. Introduction

Most parts of the developed world services in neonatology arestructured in order that increased levels of dependency are providedbymore regionalised or centralised institutions. Such a structure leadsto the necessity to have in place a method of ensuring that infants canbe transferred between these institutions in a safe and timely fashion.Regional neonatal transport services have existed in many areasworldwide for some time and many of these services have

Jackson),

d Ltd. All rights reserved.

incorporated the ability to provide air transport [1], utilizing eitheraircraft dedicated to the service, leased on an ad-hoc basis orrequesting the support of the military when necessary.

It is recognised by all who participate in transport that the air modepresents some difficult challenges. When setting up a service it isimportant to tease out those issues which require to be managed in adifferent fashion from isolated road transportation. Such issues aremainly in the domains of organisation, equipment, communication andstaff training. Clinically, stabilisationhas to take into account the fact thatthe aircraft cannot simply stop when the infant requires intervention.

It is also important to recognise that air transport does not exist inisolation, the infant will require a road transfer during the event,except in those circumstances where helicopter landing sites areavailable at both receiving and referring institutions. Any transport

478 L. Jackson, C.H. Skeoch / Early Human Development 85 (2009) 477–481

service regularly or even intermittently using air mode has to sourceand maintain equipment that can be used in both environments.It also has to ensure compatibility in all modes of vehicle with acommon organisational base.

In countries such as the United States of America and Australia airtransport for the newborn is well established. That is unfortunatelynot the situation in all developed countries. In the United Kingdom,Scotland alone has a fully developed national service, with England,Wales and Northern Ireland still highly dependant on the use ofmilitary assets for emergencies. The aims of this article are to highlightthose issues which should be of prime concern to any region orcountry that is considering air transport and to discuss some of theways of dealing with those issues. Although many of the regulatorybodies and rules mentioned relate to the United Kingdom, neonataltransport service commissioners in other countries should easily beable to identify their equivalent bodies.

2. Assessing the need

There are several reasons why air transport is considered. Mostoften it is when there is an emergency such as an infant requiringextracorporeal life support which can only be accessed at a distantinstitution. Such a transfer, if not executed by an organised andexperienced team can be fraught with difficulties. It highlights theneed for specialists in neonatal transport to be involved at the veryearly stages of development of any new regionalised service for thenewborn. It should be an accepted principle that any transport teamshould be capable of providing intra-transport care aimed atimproving the clinical condition of the infant. It therefore followsthat each area or country has a responsibility to prospectively assessthe need for air transport, analysing the numbers, the validity of theperceived indication and the level of dependency and skill require-ments for those transfers. Based on these data amodel can then evolvewhich will take into account those land based services already inexistence which have the potential to expand to become air capable.

During such an assessment other factors have to be taken intoaccount such as numbers of infants that may need to be moved fromremote and rural areas for relatively low dependency reasons.Regionalisation of neonatal intensive care also leads to the necessityto move infants back promptly to their base hospital thus freeing upintensive care spaces. This may on occasions involve air transport.Commissioning an air transport service is a very expensive project andit is vital that its progress is based on the highest quality information.

3. Multi-professional approach

Developing a model for air transport does not just depend on theneonatal services. When an individual air transport event is analysedthere are many professions involved in ensuring the safe passage ofthe infant and staff.

Air transport should not be viewed in isolation from roadtransport. At the start of a project aimed at creating an air transportservice an individual should be identified who has the requiredbackground knowledge and inter-professional links needed tointegrate clinicians, aviation operators, ambulance managers, engi-neers, and other disciplines.

Such a group should then look at the assessment of needs and decidehow it is best possible to provide a service for a defined population andgeographical area. Such a group has to also consider the sustainability ofany solution, and factors that may over time alter patterns of clinicalneed. Such factorsmaybenewhospitals or clinical services bothofwhichmay substantially affect any neonatal transport service. It thereforefollows that commissioning bodies for neonatal services should beapproached prior to committing any specific model for air transport.

The success of any air transport service depends to a great extenton the integration with road services. Local or national ambulance

services are central to this therefore early and extensive linkage mustbe forged. An understanding of expected response times and clinicalpriority ratings should be established, particularly if the aircraftdestined to be utilized have responsibilities in other commercial areas.

4. Equipping a service

The level of equipment to be carried by an air transport team willdepend on the planned clinical use of the service. It is highly likely thatwith the expensive investment involved most neonatal transportteams offering air capabilitywill wish to provide for all possible clinicalsituations. To this end a transport incubator system (TIS) including aventilator, syringe pumps, a multiparameter monitor, inhaled nitricoxide (iNO), alarms and oxygen analyzer will be required as aminimum. Factors involved in deciding the type of equipment will bethe suitability for the transport environment, in particular theresponse to movement, repeated harsh knocks and vibration. Visualalarm systems are preferable to audible ones. Any project leader andclinicians should also take into account potential incompatibilityissues with equipment used in referring and receiving institutions.

All component parts of the TIS should be placed to allow clinicianaccess in the confined space of the aircraft to be used and be securedto the TIS assembly satisfying the appropriate regulatory body rules(In Europe the European Aviation Safety Agency; http://www.easa.eu.int/home/index.html). It should be noted that not all commerciallyavailable TISs can be utilized in an aircraft due toweight, configurationand equipment issues.

Detailed stress reports of the TIS assembly are required to be madeavailable prior to EASA certification as do electrical installationreports. The stress testing for the TIS takes into account the differentG force stability requirements for fixed and rotary wing aircraft andland based vehicles.

Some commercially produced TISs are available on the marketwhich has already gone through these procedures. In the nationalservice in Scotland we use the TIS produced by Paraid UK Ltd.

Even using systems such as these however, compatibility testshave then to be undertaken which are aircraft specific. These aredesigned to ensure that the electromagnetic signature of the TIS doesnot interfere in any way with the avionics, computer or navigationsystems utilized by the specific aircraft liable to carry the TIS. Electricalintegrity testing also includes ensuring that any power surge duringflight will not lead to danger to the aircraft.

It is important to realise that medical equipment that receivescertification is specific for that exact model and a specific aircraft. Anychange, no matter how minor, invalidates the certification.

Maintenance of EASA certification requires a documented servi-cing agreement to be in place.

Medical oxygen and air delivery requires careful planning.Dedicated aircraft such as the Beech King Air 200 and the Eurocopter135which are used by the Scottish Ambulance Service AirWing have afully integrated gas delivery system. Military assets used in the UKsuch as the Seaking helicopter do not and consideration must be givenwell in advance about howmedical gas delivery is to be achieved. In asimilar fashion full compatibility with aircraft electrical supply shouldlead to an uninterrupted power source for the TIS and associatedequipment during long journeys.

The use of iNO should be a standard practice now for all air capabletransport teams. The requirements to allow carriage and use of iNO inthe air are governed by the Dangerous Goods Convention (Class 2Division 2,3). Issues that have to be taken into account are the volumeof space in the aircraft, the likely concentration of nitric oxide in thecase of total and sudden dispersement of the cylinder and thefrequency of recirculation of cabin air. Based on these parameters theaviation operators and the transport service must develop protocolsfor events following an unexpected total release of cylinder contents.When a situation such as this happens it is mandatory to follow the

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deployment and use of oxygen masks the aircrew should land at thenearest airport with medical facilities and undergo an examinationprior to continuing the flight. This highlights the need for forwardplanning by all teams who use iNO in the air. In the absence of suchcertification for use, iNO can only be used in military assets with theirpermission. In the Scottish Service we have had one completedispersal of an iNO cylinder during air transport, that beingencountered during a Seaking helicopter journey in darkness in adisorientating environment. It is much preferable to prospectivelyplan a certified and safe system.

Loading and unloading the TIS is an event which must beaccomplished in a safe and controlled manner with the minimum ofmanual handling. Automated systems are available for loading into aspecific aircraft, however clear responsibility and training for this partof the transfer has to be decided and implemented prior to thecommencement of a service.

It is clear from the above that a dedicated medical physicstechnician is essential to the development of an air transport service.This also ensures that in the event of equipment malfunction there isno conflict of duties with a hospital based neonatal service leading todelay in assessment and repair.

5. Staffing a service

There is great diversity worldwide in terms of who actuallyundertakes the transport of infants by air. The traditional doctor andnurse team has seen many variations over the past few years. Mostteams are led by a medical director, who has the overall responsibilityfor issues such as maintaining service delivery, training and clinicalgovernance.

Actual service delivery however can be accomplished by manydifferent professional groups provided appropriate training has beengiven.

In Vancouver Canada, for example, the neonatal transport serviceutilizes paramedics for all transfers, including complex air transfers.This system has the benefit of retention of highly trained paramedicstaff for long periods, many in excess of twenty years (personalcommunication, Kieran Twohig).

New South Wales and Victoria in Australia utilizes a combinationof medically qualified transport fellows and nurses to cover bothneonatal and paediatric transfers. In Scotlandwe utilize a combinationof transport fellows and Advanced Neonatal Nurse Practitioners(ANNPs) alongside transport nurses.

The most important factor is that whoever undertakes an airtransfer has sufficient knowledge of the organizational, logistical,equipment and clinical issues involved to allow them to participate.This requires that there is a formal training followed by a “buddyingup” until confident. All staff who are involved in air transport shouldbe proficient in landmoves before theymove on to training to become“air capable”.

The authors feel that it is important that a senior clinician (i.e.,consultant in transport or regional coordinator in the Scottish service)assesses the need for an air transport and tasks the appropriate staff.The question of whether the consultant staff should be available fortransfer is one which provokes much debate. Our feeling is that it isnot just the physical transfer by air, but the assessment, stabilisationand communication issues which are important. The hardest decisionis often the one to not transfer a baby due to the clinical state. Airtransport is extremely expensive and demanding on other profes-sional groups and this scarce resource should be policed at a seniorlevel.

All staff participating in an air transfer should be aware of eachothers responsibilities. This requires the medical director to ensurethat staff such as pilots, ambulance air crew, etc. have the opportunityto meet to discuss these issues.

Some aspects of air transport require specific safety training suchas helicopter immersion training. Although not mandatory, this isoffered to all personnel participating in air transport in Scotland.

Incorporating both paediatric and neonatal cases in a transportteam is in itself a major challenge. This requires a specific organiza-tional structure that allows senior input from all paediatric sub-specialties to support the transport team when they are out on a call.This system has been successful in New South Wales, Australia andmany centres in the U.S.A. In our own service in the West of Scotland,it is intended that we share accommodation, communication servicesand medical physics support with our paediatric intensive carecolleagues. For the present time however we will provide separateclinical personnel for neonatal air transfers.

It should be realized that although the transport team areresponsible for the actual move, the referring institutions should bethought of as part of that “team”. This is particularly applicable inremote and rural areas. Links should be built up with such areas andoutreach training be offered both in resuscitation and stabilizationprior to transport.

It is important not to underestimate the need for non clinicalsupport. Medical physics technicians are vital, and secretarial supportis as important for this aspect of neonatal transport as for land basedmoves.

Staff safety is an essential consideration. Issues surrounding flightsafety, protection against the elements, and suitable high visibilityclothing must be addressed. Flame resistant clothing along with headprotection to the same standard as pilots should always be provided.

A study undertaken in the West of Scotland demonstrated that onthe majority of shifts legal limits for Peak Noise levels during roadtransport were exceeded, leading to all our regular staff receivingannual hearing tests and sophisticated hearing protection whichpermits continued reception of alarms and vocal communication.

It would seem important that this aspect of staff safety is notoverlooked.

The staff must also be adequately insured in the event of injury ordeath. Personal insurance policies are unlikely to cover this activitytherefore it is the responsibility of the medical director to ensureappropriate cover is in place for all. The possibility ofmedical students,trainees in neonates and, for example, medical physics personneltraveling, should be taken into account. The Scottish service havesecured insurance for transport , including air, based on a maximumindividual payout on death or severe injury, not related to salary. Thecost for this is approximately £40,000 per annum based on a total of1400 transfers per year with around 7% of transfers by air.

6. Communication and organizational issues

Central to any transport team are communication and anorganizational structure. Air transport is extremely expensive andmay put staff and patients in vulnerable situations. It is vital thatdecisions about air transport are made by experienced staff and thosedecisions have a clear pathway which will lead to the efficientexecution of the transfer.

For this reason many services such as those in Vancouver andToronto in Canada, Sydney andMelbourne in Australia and in Scotlandhave a one phone number system including conference callingfacilities. During this phone call continuing advice regarding stabiliza-tion is offered by staff other than the transport team as they are oftenout of range during the outward bound leg of an air transfer. Clear andpredetermined routes of organization for all component parts of thetransfer are essential. If there are logistical issues such as weatherproblems or aviation operational issues those decisions require to beconveyed to the transport team quickly.

Communication during flight between the members of thetransport team should be optimised by using appropriate headsetswith noise reduction systems.

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Equally important are methods to ensure that critical incidentsspecifically pertaining to air transport can be dealt with quickly andeffectively. This requires good working relationships with the aviationcarriers and the ability to contact and discuss situations such as thesewith senior risk management personnel in all disciplines.

Links between geographically adjacent air transport teams shouldbe established to allow rapid discussion about a possibility of crosscover. Sufficient flexibility should reside in any system leading to onlyoperational issues limiting distances, and not strict pre-judgedcriteria.

Once again, in practical terms, this means a central coordinating“desk” for all transfers, with an up to date database of all appropriatecontacts.

7. Specific clinical issues

During the period immediately prior to staff training in expecta-tion of starting an air transport service, all protocols and guidelinespertaining to road transport should be reviewed and adapted toinclude those issues pertinent to travel by air. Mostly these will be todo with the effects of altitude, acceleration / deceleration, thermalissues and lack of the usual space. The degree of stability and theinterventions necessary to achieve that will require to be revised.

7.1. Altitude

Barometric pressure decreases with altitude. At sea level, baro-metric pressure is 760mmHg comparedwith 565mmHg in a standardcommercial airline leading to an equivalent percentage reduction inpartial pressure of oxygen. In normal operating situations a pressur-ized aircraft will sustain the cabin altitude around 2500 m. Duringtransport this will lead to a decrease in the infant's oxygen saturationwhich under some circumstances may be detrimental [2,3]. All effortsshould be made to maximise oxygen delivery in these circumstancesby optimizing both haemoglobin concentration and cardiac output [4].

As altitude increases gas expands in any enclosed area. This maylead to clinical problems in the setting of pneumothoraces, pneumo-peritoneum or intramural gas. Small insignificant air leaks can becomeclinically dangerouswith this alteration in barometric pressure. Henceit is important to ensure that air leaks are drained if possible and thatthe aircrew are aware of the need to maintain cabin altitude at thelowest possible setting.

Helicopters are unpressurised but with adequate pretransferstabilisation offer a few disadvantages in terms of altitude associatedproblems as they tend to fly at lower altitudes. The decision aboutwhether to use rotary or fixedwing aircraft is rathermade on the basisof distance, weather, and available landing sites.

7.2. Acceleration / deceleration

There are theoretical advantages and disadvantages in terms of theposition of the infant during take off and landing when extremes ofacceleration and deceleration are experienced. At take off with thehead forward there may be relative, but brief ischaemia of the brain. Onlanding the infant may experience a surge of excessive brain blood flow.There is some evidence that pre-term infants undergoing transportmay have a higher incidence of intraventricular bleeding [5,6].

Take off and landing speeds however are dictated by aviationoperational issues and once again this underlines the importance ofpre-transport cardiovascular stabilization.

7.3. Thermal issues

The importance of good thermal management has been welldocumented [7,8]. In a pressurized aircraft there is usually littledifficulty in maintaining an appropriate ambient temperature. The

difficulty arises when using helicopters, particularly military assetswhich often have no or suboptimal heating. Significant cooling of theenvironment is experienced for example during the landing proce-dure in the Seaking helicopter as the winchman has to visualize thelanding site and progress hence for a considerable time the large cargodoor is open. It is usually under these circumstances that AC oralternative battery power is not available for the TIS, henceconservation of internal battery power is essential. This may beachieved by the use of incubator covers (Isocovers, Eden Medical,Loanhead, Midlothian Scotland) and chemical gel heat generatingmattresses (Transwarmers {Draeger Medical, Lubeck, Germany}). DCpower cables should accompany the incubator on every flight, aprospective analysis of their safe use having been undertaken by theaviation carriers or the military. In some environments incubatoroverheating in direct sunlight may be a problem which can be easilyovercome with tailored incubator covers with reflective exteriors.

7.4. Noise and vibration

Vibration is not usually detrimental to the infant, but can dislodgelines and tubes and adversely affect monitoring equipment [9].Consideration should be given to equipment specifically designed tominimise the effect of movement artefact such as pulse oximetryusing Masimo technology.

Noise levels up to 125 dB can be experienced during the cruise inthe Beech King Air 200 which is the aircraft used for infant transfers inthe Scottish Ambulance Service. Levels in excess of this areexperienced in the Hercules aircraft (personal communication MsAnn Marie Wilson, neonatal transport coordinator Scottish NationalNeonatal Transport Service.) This makes communication issuesdifficult and it is important to ensure that staff headsets are equippedwith the correct impedance microphone for a specific aircraft.

Although there is good evidence that excess noise can affect haircells in the developing cochlea there are no long term studies ofpossible hearing impairment in infants who have undergone airtransport [10,11]. Given themultiple risk factors in these infants it maybe an impossible task to study this. More importantly however excessnoise and vibration may cause distress and discomfort to the infantleading to a deteriorating physiological profile and clinical state. Itseems logical therefore to minimize both noise and vibration. This canbe achieved by methods such as the Squishon gel filled mattresses(Eden Medical) and the use of Minimuffs (Natus Medical, San Carlos,California, USA). The latter however only reduce noise by 7 dB. This isan area requiring further investigation.

7.5. Ventilation

In any transport event the decision as to whether to providemechanical ventilatory support should beundertakenprior to departurefrom the referring unit. For an air transfer it is even more important toassess the potential for deterioration without such support. Althoughguidelines are helpful the authors believe that where there is doubt adiscussion should take place with a consultant neonatologists experi-enced in air transport who can take all factors into consideration. Thesewill include the clinical state, the reason for the transfer (and likelihoodof being ventilated at the receiving hospital) and the potential adverseeffects of initiating mechanical ventilation (MV).

There are some areas that deserve special consideration. The use ofprostaglandin E2 tomaintain arterial duct patency is one such area. Thisdrug has the potential at high dose to cause apnoea. A clinical situationcommonly encountered requiring this therapy during air transport ishypoplastic left heart syndrome (HLHS) [12]. Most clinicians wouldagree that if possible these infants should be left to breathespontaneously. Initiating MV brings with it the difficulties of balancingpulmonary and systemic circulations, failure to do so efficiently leadingto deterioration.

481L. Jackson, C.H. Skeoch / Early Human Development 85 (2009) 477–481

The New South Wales Team in Australia, one of the mostexperienced in this area, ventilate all infants requiring more than20 ng/kg/min prostaglandin (Personal Communication, Dr AndrewBerry). This protocol however varies greatly between teams. Personalpractice of the authors is to ensure that a senior transport clinicianassesses and accompanies these infants, trying if possible to avoidintubation unless indicated for other reasons. We have adopted thispolicy recently, and it has implications for availability of senior staff asdescribed above.

The use of continuous positive pressure ventilation (CPAP) inaircraft is one which also presents clinical challenges. Our group haspreviously reported that we electively institute MV on all infants onCPAP for air transfer [13]. The group from Melbourne has recentlyindicated that it is feasible to transfer infants on CPAP by air, butsuggests that further work is undertaken to validate this approach[14]. There is no doubt that this and the use of high frequencyoscillatory ventilation (HFOV) will present future challenges intransfer of the newborn by air.

8. Conclusion

Air transport cannot be viewed independently from land basedsystems. It is essential that the infrastructure and component issues asdescribed above are coordinated and finally brought together in a waywhich satisfies not only the transport team but the many differentprofessional disciplines and regulatory bodies involved. Air transportis a constantly changing specialty requiring both rigid attention todetail in the acute events and an enquiring mind with a view tokeeping upwith the advances in hospital based neonatal care allowingthese to be applied where appropriate in flight.

Key guidelines

The following are the critical steps in establishing a neonatal airtransport service:

• Prospective assessment of numbers, demographics and validity ofindications for transport by air.

• Appointment of project leader with authority and experience of amultidisciplinary approach.

• Assessment of expansion of land based transport services to provideadequate air cover for geographical area.

• Adherence to all regulatory bodies involved.

• Extensive training, protective clothing and insurance for staff.• Senior screening and approval of air transport.• Continuing multiprofessional interaction for training and eventanalysis.

Research directions

• Validation of the appropriateness of combined paediatric andneonatal transport teams.

• The use of CPAP in air transport.• The use of HFOV in air transport.• Effects of excess noise on staff and physiological parameters in infants.• Comparison of differing professional groups providing care duringair transport of infants.

References

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