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Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network

Principal Investigator: Rachel Umoren, M.B.B.Ch., M.S., University of Washington, Seattle, WA 
AHRQ Grant No.: HS027259 
Project Period: 09/03/19-08/31/23 
Description: The lab’s overarching goal was to optimize clinical workflow and transport communication systems to enhance the value and safety of neonatal transport in a multistate regional network.

The specific aims were to:

  1. Codesign clinical workflow processes to optimize regional neonatal consultation, triage, and transport.
  2. Engineer a novel transport monitoring and communication system to improve information flow within the transport environment.
  3. Develop a system for timely and accurate online tracking of patient safety data during neonatal transport.

The lab comprised pediatric physicians and nurses, systems engineers, simulation experts, and hospital transport staff. It undertook a five-stage innovation cycle (i.e., problem analysis, design, development, implementation, and evaluation) to identify and model the current and ideal state for neonatal interfacility transfers among hospitals in the regional network. 

Although its work was limited due to COVID-19 pandemic restrictions, the lab successfully analyzed1-5:

  • Transport team factors (e.g., team and mode of transport, transport time and arrival on scene, departure, arrival at receiving facility) and procedures performed. 
  • Call patterns and duration of referral calls (using transport call logs) and transportation routes and task time distributions (using neonatal transport data).
  • Patient factors: 
  • Age, weight, gestation, 
  • Vital signs (temperature, heart rate, respiratory rate), 
  • Primary diagnosis (known at transport), 
  • Severity of illness, 
  • Hypotension (blood pressure, use of vasopressors, volume administration, establishment of arterial access), 
  • Acidosis (pH, base deficit, volume resuscitation, bicarbonate or acetate administration), and 
  • Respiratory failure (oxygen saturation, partial pressures of oxygen and carbon dioxide, mode of respiratory support, type of artificial airway). 
  • Patient outcomes: length of stay (total hospital days, intensive care unit days, ventilator days) and mortality (transport, 12 hours, 7 days, overall). 
  • Transport team procedures and guidelines, including decision support tools and pre-/post-procedural communication with medical control physicians.

The lab developed the Neonatal Transport Discrete Event Simulation (DES) model, encompassing communication and transportation submodels and several referring and receiving facilities to represent hospital capacity. Researchers conducted simulation experiments to investigate the effects of patient attributes, bed capacity, communication process, and ambulance resource allocation on bedside wait times and total transportation time.1,6 

A simulated Transport Communication and Monitoring application was also developed and tested in simulations to evaluate its impact on critical factors influencing communication, decision making, and workflow on transports. Such factors included staffing, bed availability at receiving and referring hospitals in a regional network, regional weather, and prevailing traffic patterns to support medical control physicians (MCPs) and transport teams. 

Three in situ healthcare simulations featured neonatal patients being transported from UW Medical Center to Seattle Children’s Hospital. The results of these simulations demonstrated better situational awareness of patients’ vital signs and trends, and of the baby’s location during transport, when teams used a transport monitoring and communication tool.1

Findings from this work revealed that adverse events occur in up to 70 percent of pediatric critical care ambulance transports, even if performed by a highly trained team. Ground and air transport environments need to contain many of the same things as an intensive care unit room, but in a considerably smaller space.2 Transport personnel must be able to reach necessary equipment, see monitors, and access their patients in the incubator, while keeping themselves safely restrained. 

Human factors are the root cause of 67 percent of avoidable adverse events in transport due to communication errors and equipment problems. MCPs are remotely located and respond by phone to referral calls, updates, and questions from the transport team.1 The MCP is responsible for triaging, identifying a receiving facility, and providing care recommendations to transport teams. Inaccurate or incomplete information shared between the sending facility, the transport team, the MCP, and the receiving facility was associated with one-third of all identified adverse events.

To date, this PSLL’s work has resulted in at least eight peer-reviewed journal publications, with 20 citations in other publications, as well as presentations at conferences in the United States and Canada.

Publications

2024

2023

2022

  • Greene ND, et al. Neonatal vital sign trajectories and risk factors during transport within a regional care network. Air Med J 2022 Nov-Dec;41(6):542-548.
  • McKissic D, et al. Intra-Transport Medication Use by a Regional Neonatal Transport Service. Paper presented at American Academy of Pediatrics National Conference and Exhibition, Anaheim, CA, 2022.
  • McKissic D, et al. Perspectives on the Neonatal Interfacility Transport Experience and the Use of Technology During Transport. American Academy of Pediatrics National Conference and Exhibition, Anaheim, CA, 2022.
  • McKissic D, et al. Rates of Peri-Transport Abnormal Vital Signs and Laboratory Values for Infants With Hypoxic Ischemic Encephalopathy. Paper presented at American Academy of Pediatrics National Conference and Exhibition, Anaheim, CA, 2022.
  • Patel S CM, et al. Health Professional Perspectives on Communication and Monitoring During Interfacility Neonatal Transport. Presented at Agency for Healthcare Research and Quality PSLL Abstract Session (virtual), 2022.

2021

References

  1. Umoren, RA. Final Report: Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network. 2023, University of Washington: Seattle, Washington. p. 1-10.
  2. Gray MM, et al. Neonatal transport safety metrics and adverse event reporting: a systematic review. Air Med J 2023 Jul-Aug;42(4):283-295.
  3. Umoren, RA. Progress Report: Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network. Madison, WI: University of Wisconsin; 2022, pp. 1-31.
  4. Cook M, et al. Health professional perspectives on communication and monitoring during interfacility neonatal transport. Proc Hum Factors Ergon Soc Annu Meet 2023;67(1):79-85.
  5. Greene ND, et al. Neonatal vital sign trajectories and risk factors during transport within a regional care network. Air Med J 2022 Nov-Dec;41(6):542-548.
  6. Li L, et al. A simulation-based approach to analysing delays in the transport of critically ill neonates. Health Syst 2024 Aug 23:1-16.
Page last reviewed January 2025
Page originally created January 2025

Internet Citation: Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network. Content last reviewed January 2025. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/resources/learning-lab/neonatal-interfacility-transfers-long-desc.html

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