Frequently Asked Questions: Interfacility Transport of the Critically Ill Neonatal or Pediatric Patient with Suspected or Confirmed COVID-19

The screening process begins with the initial intake of the patient transport by the access center, dispatch, or transport team and includes questions concerning common symptoms (fever, cough, shortness of breath, rhinorrhea, sore throat, headache, diarrhea, loss of sense of taste or smell) and recent exposures (within last 2 weeks) to those who have received a diagnosis of or tested positive, or have a test pending for COVID-19. These questions pertain not only to the infant or child but also to the mother, father, and other close contacts. This information, along with the clinical state and results of any COVID-19 screening tests performed on the child or family, must be shared with the transport team during the pretransport huddle. At the time of arrival at the referring center, a secondary screen by the transport team should be performed prior to entering the clinical patient area.

Efforts should be made to avoid the emergency department and other high-traffic areas if at all possible, for arrivals and departures. However, communication with the referring facility can help determine the best possible entry for the transport team. Security escorts for the arriving transport team can help with this process. Transport teams should be wearing surgical masks, eye protection (eg, goggles, face shield), and gloves, at a minimum, prior to entering the referring facility.

For the duration of this pandemic, members of the transport team, including ambulance, rotary, and fixed-wing personnel, should wear at least a surgical mask, eye protection (eg, goggles, face shield), and gloves. If patient is confirmed COVID-19 positive or is treated as a PUI, see FAQs covering those circumstances in the sections below.

If a child being transported is a PUI or confirmed as being COVID-19 positive, transport team members, including ambulance, rotary, and fixed-wing personnel, should wear PPE consisting of an N95 mask or powered air-purifying respirator (PAPR), eye protection, an impermeable gown, and gloves. This additional PPE should be donned prior to entry into the patient care area. An N95 respirator mask with eye protection (eg goggles, face shield) or PAPR is required for any team member who is performing an aerosolizing procedure (bag-mask ventilation, intubation, suctioning, oxygen at a flow >2 LPM/kg, continuous positive airway pressure and/or positive pressure ventilation, cough assist or cough-inducing procedures, or medication administration via nebulization).

If a patient requires the use of a bag-valve-mask or bag-valve-endotracheal tube (ETT), an approved bacterial/viral HME/HEPA filter (>99.97% filtration, specifications similar to an N95 mask) should be placed in line with the bag and mask or ETT. Of note, teams have reported a need for use of higher inspiratory pressures to ventilate through the filters with a bag. If a patient requires a ventilator, the filter should be placed at the expiratory side to limit exposure to the team. As an added measure of caution, attempts should be made to keep supply bags outside the immediate clinical patient care area, with a “clean area” team member. In general, aerosol-generating procedures should be avoided during transport unless absolutely necessary for patient care. When intubating patients suspected or known to have COVID, the most skilled person should perform the intubation to prevent or limit failed attempts, The team should collaborate with the referring facility on environmental protections that are available to support airway management in this patient population.

Appropriate PPE should be worn to include gown and gloves, with either an N95 respirator mask and eye protection goggles or face shield or PAPR that provides eye protection. The mother should wear a surgical mask, and if possible, the resuscitation table should be placed greater than 6 feet from the mother. If intubation of the mother is necessary for general anesthesia, the transport members should leave the operating room during the intubation procedure, if possible. These protections are needed, given both the increased likelihood of maternal virus aerosols and the potential need to perform newborn resuscitation that can generate aerosols (bag-mask ventilation, intubation, suctioning, oxygen at a flow >2 LPM/kg, continuous positive airway pressure, and/or positive pressure ventilation). Again, use of an approved bacterial/viral HEPA filter in line with the bag is recommended. Once the neonate is placed in the transport isolette, every effort should be made to keep the portals closed and access limited to emergencies.

All neonates delivered to women with suspected or confirmed COVID-19 or infants who have had contact with someone who is symptomatic should be treated as presumptively positive for COVID-19 for the duration of the transport. Appropriate PPE should be worn, and alerts should be made to the receiving facility prior to the arrival of the transport team.

Prior to departure from the building onto the helipad or flight line, teams should consider removal of the PPE gown. This would also apply prior to off-loading the patient. A balance of infection control with flight line safety must be met to preserve the safety of the transport team members and the patients they transport. This will be especially important for any rotary or fixed-wing “hot” load. Teams that normally “hot” load may consider shutting down when transporting at-risk patients. At a minimum, an approved surgical level 3 mask or N95 mask must be worn by all nonclinical team members (eg, pilot, copilot, safety officer if no clinical duties) in the cabin for all PUIs and patients with confirmed COVID-19 during the flight.

A plan must be in place to address the unique psychological stress and challenges a symptomatic child and his or her family members experience during transport prior to departure. When transporting a child with an impairment in communication, the transport team should be aware of how the child expresses pain or what he or she needs. In the case of a child with disabilities, a caregiver who knows the child might be required for the transport. The risks and benefits of allowing a caregiver who does not have COVID-19 or is not a PUI on pediatric transports should be considered. If the caregiver has tested positive for COVID-19 or is a PUI, they should not be transported with the patient. In addition, the caregiver should be screened by the transport team for COVID-19 symptoms and cannot travel with the patient if they screen positive. A caregiver should be discouraged from traveling with a neonatal patient. Masks should not be used for patients under the age of 2 years. For patients over the age of 2, use of a mask on a PUI or patient with confirmed COVID-19 can seem intimidating but is still encouraged. If a parent or guardian does accompany the child, he or she must wear a surgical mask for the duration of the transport. Finally, before departing the referring hospital, advising the family of any restricted visitor policies at the receiving institution prevents any misunderstanding during this very stressful period.

Each transport team must work in partnership with air and ground vendors to ensure the safety and well-being of all team members. In addition, each vendor should have specific cleaning procedures that must be performed after each transport of a PUI or patient with confirmed COVID-19. It is recommended that full PPE be worn during each cleaning procedure, and any surface that potentially becomes contaminated during transport should be wiped clean using an EPA-approved disinfectant.

Per manufacture guidelines:

Voyager Transport Incubator - Cleaning Guide Addendum

This cleaning guide details the appropriate steps to fully disassemble the Voyager Transport Incubator for cleaning purposes and should be considered as a supplement to the Operator’s Manual.