W.M.Wisniewski MD, MHPE – Page 3

Caring for a sick newborn in a NICU is complicated; doing that in transport greatly surpasses that. The choice of a hospital, communication, preparation for transportation, and documentation may all lead to legal problems for a physician, referring hospital, and accepting hospital. Below, I will discuss various aspects of care before and during newborn transport that may increase legal risks. In another article I wrote, you will find information about errors and neonatal diagnoses frequently associated with malpractice in the NICU. First, let's examine why newborns are transferred from one hospital to another. The most common causes that I observed in my career as a neonatologist are listed below: The hospital lacks experienced staff (physicians, nurses, respiratory therapists) or equipment to care for the newborn's condition. There are two essential distinctions here to make. One situation is that a hospital is a small community organization that would not be expected to have such capabilities. On the other hand, when a university center or level 3 perinatal center does not have such capabilities due to their neglectful planning, that would be of more significant concern. In such cases, I would ask when they knew they did not have such capabilities and when they should have informed their clients (families coming to have a baby there). When a family comes to a highly specialized center to have a baby, they have a reasonable expectation that no matter what problems their child develops, the doctors can handle it. They do not want to be told after birth that the hospital has no available ventilators or that some other organizational problems impact their child's care (you can read more about hospitals' potential liabilities in my article here). Legal requirements. Some states put restrictions and define medical problems each hospital or nursery can treat. In addition, the American Academy of Pediatrics developed guidelines regarding this issue. In short, all nurseries or hospitals are assigned to one of the three (or 4) levels of care. Level 1 Nursery primarily cares for healthy babies or those with minor and transient problems. Level 3 or 4 NICUs will care for the sickest babies with subspecialty problems, including surgical diagnoses. The organization of the perinatal system in each state is a complex subject impacting institutional and personal liability in health care; therefore, I will write a whole article on it. Parents' request. Sometimes, parents lose trust in the hospital or team treating their baby. All interested parties should discuss the issues, and if parents insist on transport, physicians should arrange and facilitate it safely. Physician's request. Sometimes, despite the official designation of the hospital that would allow physicians to keep and treat the patient, they will elect to transfer them to another institution. There may be numerous reasons for that: a patient developed complications, a physician has doubts regarding diagnosis or response to the treatment or the physician does not trust other members of the team who may not have enough experience (for example, an agency nurse staffing the NICU or lack of respiratory therapist experienced with pediatric patients). A patient will be part of a research clinical trial. Only some hospitals and doctors conduct research trials. In the past, when "head cooling" or "nitric oxide" were studied, when I had a patient who could potentially benefit from those treatments, I had to transfer such a patient to the center participating in the trials. Who makes a decision and why? It would be easy to say that a neonatologist or pediatrician who cares for a baby in the nursery will decide on the need for transport. Unfortunately, it is not always that way. This decision will be influenced by stakeholders such as the charge nurse, hospital administrator, parents, insurance agents or caseworkers, and an accepting hospital physician with his designees. At times, charge nurses and hospital administrators apply soft pressure on physicians to keep patients "in-house" due to financial reasons. Insurance agents or case managers often warn doctors or parents that transport may not be covered by insurance or that a baby does not meet the conditions. Parents may prefer to keep the baby in the hospital of choice where the baby was born because it is the closest hospital to their house. It is an essential consideration for the mother and father, given that premature babies stay in the NICU even for several months. Finally, I talked multiple times in my life to doctors from higher levels of care who wanted to minimize the need to transfer my patient. In their view, my patient was "not sick enough," or they had only one or two more beds available. As we can see, despite the stress associated with treating a very sick newborn, a pediatrician or neonatologist has to talk to many different stakeholders who may inappropriately influence his final decision regarding the transfer of the baby. As a reviewer of neonatal charts, I want to ensure that the doctor in charge of care for the baby explains in his documentation why a patient needs a transfer, the communications with other people, and the ultimate decision. Destination Hospital and its NICU The accepting hospital should be chosen based on the availability and quality of care a patient will likely receive there. As mentioned above, other factors may play a role, but it is inappropriate for a doctor in charge to be swayed by those. Example. Based on the initial evaluation, the doctor suspects a congenital heart disease in the baby. There are two hospitals within 30 miles. One has only cardiology services and is affiliated with the referral hospital. The other is an unaffiliated university hospital capable of providing cardiology and cardiac surgery if needed. To avoid the potential need for another transport of the sick baby, we should transfer this patient to an institution that can provide both a final diagnosis and surgical treatment. Sadly, physicians are often pressured into sending their patients to affiliated institutions instead of the most appropriate ones for the patient. Transport team members and mode of transportation Neonatal transport can be conducted by air (fixed wing or helicopter) and ground ambulance. The latter is the cheapest and allows more space for people and equipment to care for the patient during transport. The other two are speediest but will also require additional modes of transportation between hospitals and landing places (helipad or airport). Hence, there is an additional need for equipment and personnel familiar with it. During the documentation analysis, a chart reviewer should find the justification for choosing any particular mode of transportation. All members of the neonatal transport team need specialized training and skills. Nurses and respiratory therapists conduct most NICU transports without a doctor. Therefore, it is the accepting hospital's responsibility to ensure that all team members possess enough experience to respond to emergencies and all patient's needs during transport. They must be able to insert central lines, intubate the patient, decompress a pneumothorax, and conduct a resuscitation. Many of these skills are mastered only by doctors or nurse practitioners. In some hospitals, only doctors have hospital privileges to perform those procedures. Without a doubt, a hospital will be responsible for the quality of training provided to the transport team and their work performance. Communication before and during the transport All communications about neonatal transport need to be adequately documented by referring and accepting hospitals. Calls to larger institutions' transport centers are often recorded and kept for future reference. People involved in transport communications and decision processes, especially if things go wrong, often want to blame the other party. Referral hospitals or doctors are blamed for not providing complete and truthful information. The accepting institution may need to respond faster or give more advice to referral physicians to help manage patients. If a referral physician expects the patient to need a specific treatment during the transport (for example, body/head cooling), he must communicate that need promptly. Interim management of the baby (Transfer of care) It is not always clear when the actual transfer of care from one team to another occurs. Does it start with the first phone call requesting a transfer? Does it begin at the time of arrival of the transport team in the referral hospital? Or the actual transfer of responsibilities occurs only when the patient physically crosses the hospital doors and is placed in the ambulance or helicopter. It is helpful if institutions sign a contract specifying the particular responsibilities and necessary communications that should take place between referral and accepting hospital. As a neonatologist, I always felt responsible for the patients until they left NICU tacked in in the transport bed, connected to the new monitors, and surrounded by transport team members, ideally with stable vital signs on the monitor (source article). Referring physicians must be available and, if needed, co-manage the patient with transport team members. Transport team nurses may have more experience caring for critical babies than pediatricians, but referring physicians may be able to help. Especially if a patient crashes or resuscitation is needed. Preparation for transport and management en route All necessary treatments needed to safely transport a patient from one hospital to another should be implemented before the transfer. Certain services, especially surgery, may be only available in accepting NICU (source article). However, referring physicians or transport teams should foresee specific problems such as deterioration of respiratory status en route (and the need for mechanical ventilation) or loss of IV access. Experienced teams will prefer to intubate a patient and place them on mechanical ventilation in a referral hospital whenever there is a slight chance that they will decompensate later in the ambulance. Similarly, the best practice guidelines require making sure that one has at least two solid IV accesses, with one preferably being a central line. Performing a procedure on a tiny baby in an ambulance or helicopter is much more complex than in the hospital on the ground. Documentation of neonatal transports Whenever a baby suffers a bad outcome, and people involved in neonatal transport are blamed, one needs to review all medical charting and any contracts about the transfer of patients between the referral hospital and the accepting institution. Contract Hospitals that send or receive newborn patients should use special contracts or agreements to specify each party's responsibilities and requirements for information sharing and documentation. The contract should delineate who makes decisions to accept the patient, how quickly those decisions will be communicated, who will be responsible for transporting the patient, by what means, and how to proceed if an institution does not have an available bed. Finally, who is responsible for the patient's medical management at each point should be clear. Medical documentation A referring doctor and his nurse must make detailed notes about why the patient is being transferred, all communications with parents, other doctors in the referring hospital, and the accepting hospital. Documentation of conversations between two institutions should include what was said and at what time. The institution receiving a patient frequently has unique forms for the transport team to fill out. These forms help with proper documentation but also guide care for the patient. Such documents will include an assessment of the patient's vital signs and respiratory, cardiovascular, and metabolic well-being. In addition, evaluation of each medication, IV infusion, and invasive procedures done before their arrival will occur. In my work as a reviewer of neonatal charts, it is extremely beneficial to compare two separate medical assessments, one by a referring physician and another from the transport team when they arrived to take the patient. Differences in evaluations or omissions are often very telling and require further analysis. In Summary: Neonatal transport is often necessary to give each baby the best chance to survive without long-term consequences. Due to the complex nature of neonatal physiology and the unique skills neonatal providers need to master, transferring a patient adds some risks. In addition to medical management provided by referring hospitals, numerous external factors (administrative, financial, insurance, training, availability of equipment and personnel) may impact medico-legal liability related to neonatal transfers.