A neonate is a term used in the international literature to refer to infants, specifically from birth through the first 28 days of life. Neonates can be further categorised into newborns (at the time of birth), early neonates (from birth to 7 days of life) and late neonates (from 7 to 28 days of life) (Smith et al. 2009). Critically ill neonates are those who have life-threatening illnesses associated with single or multiple organ system failure (Whyte & Jefferies 2015). The inter-facility transport of critically ill neonates is an integral component of emergency medical services in South Africa. The treatment of sick neonates in more specialised neonatal intensive care units (NICUs) has been linked to decreased morbidity and mortality (Pai et al. 2020). Transfers become crucial when neonates are born in hospitals that are ill-equipped or ill-prepared to deliver specialised neonatal intensive care (Wahab et al. 2019).

Research in South Africa has found that the likelihood of an adverse event occurring during the transportation of neonates is at least 75% (Pan 2017; Sabzehei et al. 2016). Apart from transportation, the change of environment from an ambulance to a specialised NICU adds additional stress to the neonate, commonly resulting in either minor or life-threatening events (Chakkarapani et al. 2020). Physiologically related adverse events are directly linked to the clinical deterioration of the neonate, with physiological changes being a real possibility during both ground and air transportation (Sethi & Subramanian 2014). The common physiological changes that result in the clinical deterioration of neonates include hypothermia, hypotension, hypoglycaemia, cardiac dysrhythmia, respiratory deterioration and decreased levels of consciousness (Pai et al. 2020). Goldsmit et al. (2012) documented that 49 (31%) of the 91 neonates who experienced physiological changes during transport, required immediate cardiorespiratory support. Thermal instability was the most common adverse reaction, with 73 (46%) of the neonates deteriorating as a result (Goldsmit et al. 2012). In South Africa, although there is limited literature on inter-healthcare facility transfers of critically ill neonates, evidence that exists reflects cause for much concern. Mgcini (2011) who conducted a cross-sectional, descriptive study of 104 transfers by both private and public ambulances in Gauteng province from October to December 2007 found that many neonates arrived in a poor clinical condition following transfer to a referral hospital. This resulted in a relatively high mortality rate (7%) occurring within 48 h after the transfer with the most significant predictors of mortality being bradycardia, hypoxia, hypotension and hypothermia. Mgcini (2011) listed the common adverse clinical events noted on arrival at the receiving hospital as hypotonia (32%), hypoxia (22%), hypothermia (21%) and acidosis (40%). Similar findings were made by Ashokcoomar and Naidoo (2016), whose study found that of the 29 (24.2%) critically ill neonates transferred, 10 (8.3%) had physiologically related adverse events during transfers, including one (0.8) death. The remaining nine incidents were all potentially life-threatening and included conditions such as respiratory and cardiac deterioration, desaturation, the development of hypothermia and cardiorespiratory arrest. The causes of the neonatal death included inappropriate pre-transport preparation, lack of pre-transfer stabilisation and a lack of available ALS paramedics (Ashokcoomar & Naidoo 2016). These findings are similar to the international findings from developing countries, such as India (Deepak, Adhisivam & Vishnu 2015) and Jamaica (Henry & Trotman 2017), where physiological changes, such as hypothermia and hypoglycaemia were commonly reported during transport. These studies concluded that the resulting issues could have been prevented had neonates been stabilised prior to departure.

Critical care and monitoring of a critically ill neonate during the transfer process is provided by an advanced life support (ALS) paramedic. These paramedics are registered as either Critical Care Assistants (CCA), National Diploma in Emergency Medical Care (NDEMC) or Emergency Care Practitioners (ECP). These ALS paramedics play a vital role in the emergency medical care (EMC) environment as they are the pre-hospital specialists and currently responsible for intensive care during the neonatal transfer (Health Professions Council of South Africa [HPCSA] 2014). Their scope of practice enables them to provide a wide range of intensive care interventions including, but not limited to, advanced airway management and ventilation, cannulation (intravenous, intraosseous and umbilical), pharmacological administration, emergency cardiovascular care and advanced cardiac arrest management.

The aim of this research was to analyse the current inter-healthcare facility transfer of critically ill neonates in KwaZulu-Natal and to investigate the state-of-the-art practice that guides the transfer of critically ill neonates. Moreover, this study explored the views of ALS paramedics on all aspects that need to be operationalised in a programme that will guide the inter-healthcare facility transfer of critically ill neonates in South Africa.

This study highlighted several findings that were of concern. Poor pre-transfer preparation of the neonate, equipment related challenges, lack of clinical support available during transfers and pressure to effect inappropriate transfers were some of the challenges they faced. These challenges coupled with insufficient education and the lack of sub-speciality programmes to capacitate, rendered them unprepared to deal with neonatal transfers effectively. The findings highlighted two broad themes, that is, challenges associated with the transfer process and specialised knowledge and skills.

Theme one presented the following sub-themes: pre-transfer challenges, preparation of the neonate, the transfer journey to the hospital, lack of clinical advice and pressure to effect inappropriate transfers. The first sub theme, pre-transfer challenges, reflected the lack of accurate information pertaining to the critically ill neonate and undertaking transfers without requisite equipment. Paramedics have a sense of helplessness because of these difficulties and the reality of the threat to the survival of the already fragile neonate. In this vein, Whyte and Jefferies (2015) asserted the importance of the Emergency Medical Care Centre receiving as much information as possible about the neonate and the transfer requirements, so that this information can be accurately relayed to the team leader. Similarly, Stroud, Trautman and Meyer (2013) argued that the staff managing the Emergency Medical Care Centre should be well trained in neonatal transfers, and to receive calls and provide accurate information regarding transfer requirements so that there is proper preparedness for the transfer. In addition, the dispatch details given by the communication centre to the transfer team leader should be audible, and clearly understood, to avoid misunderstandings. Communications should include information about the neonate’s condition, the treatment already undertaken, equipment required and any other information vital for the transfer (Boxwell 2010). This inevitably creates a level of stress and anxiety for those paramedics who have to quickly read in anticipation of difficulties that may arise during the transfer.

The findings with regard to the preparation of the neonate, under sub-theme two highlighted the doctor’s lack of knowledge and expertise with regard to such procedures, particularly related to critically ill neonates. More importantly, however, it exemplifies the need for ALS paramedics to have the requisite training and sound experience in being able to undertake intubation and ventilation. Foglia et al. (2019) described neonatal tracheal intubation as a potentially dangerous procedure and argued the need to identify factors to improve neonatal intubation. The issues in the data highlight the need for ALS paramedics who are confronted with the transfer of a fragile neonate and have to deal with the unpreparedness of the hospital and other medical personnel associated with the transfer.

Messner (2011) supported this finding saying that pre-transfer preparation was a critical aspect of identifying the factors that may potentially arise and compromise the survival of neonate, before they are transferred out of the referring facility. This stabilisation was crucial to their ability to tolerate the transfer and to ensure a successful outcome (Carreras-Gonzalez & Brió-Sanagustin 2014). Hence, pre-transfer preparation of the neonate, is a vital component of the transfer which is crucial to ensuring the survival of the neonate during the transfer (Kumar et al. 2010).

The third sub-theme, that is, the transfer journey to the hospital, highlighted the fact that managing a critically ill neonate is a complex process, as the paramedic has to monitor the baby’s condition during the journey, in particular ventilation and oxygenation, thermal, cardiovascular and metabolic support and provide lifesaving interventions if necessary (Chakkarapani et al. 2020). This suggests the need for greater respect and support for the views of paramedics, when decisions are made within the transfer process.

The data also reflected in sub-theme four, that paramedics are left powerless within what appears to be a hierarchical work environment, which then compels them to follow instructions, from those in authority even when they believe a transfer should not be performed. Moreover, a lack of knowledge amongst these health care professionals, who may not always have sufficient information and expertise related to neonates, may be potentially dangerous when they issue instructions to undertake risky transfers. As evidenced, paramedics often receive instructions to issue transfer, regardless of the fact that they have not physically assessed the neonate. What was particularly concerning is that these paramedics often felt they had to implement the transfer regardless of them indicating that the neonate was unstable.

The fifth sub-theme namely, pressure to effect inappropriate transfers, reflected the pressure that paramedics received from several stakeholders to effect transfers. The literature also reflects that a ‘swoop and scoop’ is no longer considered appropriate, with speed being viewed as detrimental, in comparison to investing time in resuscitating and stabilising the neonate before the journey. Gilpin and Hancock (2016) supported this notion saying that pre-transfer stabilisation and preparation was perhaps more beneficial than rapid delivery to a healthcare facility. The objective of the transfer team should therefore be to achieve physiologically acceptable haemodynamic and metabolic parameters before transportation. Hence, transfers should not be performed hastily and panic transfers may result in morbidity or mortality. As Messner (2011) said, it is the hospital or clinic that provides a less risky environment for stabilising a critically ill neonate, than the challenging ride in the back of an ambulance or in a restricted space of a noisy unstable aircraft. Hence, everyone involved in the transfer process from beginning to end, including doctors, nurses, emergency care providers and support services should have a thorough understanding of the risks and processes involved, so that an informed decision is made, with a positive outcome for the neonate (Ratnavel 2013).

Theme two presented the following sub-themes: inadequate educational preparedness and the lack of subspeciality programmes. The sub-theme related to inadequate educational preparedness highlighted concerns around the inadequate educational training for neonatal transfers. This lack of unpreparedness rendered paramedics the ‘weakest link’, in a transfer chain where other professionals have more specialised knowledge and skills relevant to NICU. Moreover, they expressed the need for paramedics to secure relevant specialised experience related to transfers. One participant further suggested the need for paramedics to express their preference to work specifically with neonatal transfers. They added that some paramedics prefer trauma patients or medical patients and argued that those with a personal preference for this specialised type of transfer, be considered for this type of work.

The final sub-theme highlighted that the lack of a subspeciality programme compromised their ability to gain knowledge and experience related to neonatal transfers. In more developed countries, this appears to be implemented as neonatal transfer team members are selected on the basis of interest in the field and are capacitated with specialised education and training to ensure that they can provide an acceptable level of care that is beneficial to the outcomes of the neonate (King et al. 2007). In the absence of subspeciality programmes in South Africa (Ashokcoomar & Naidoo 2016), paramedics remain unprepared for neonatal emergency care.

The data also reflected that paramedics involved in neonatal transfers should be able to have a choice in terms of undertaking such work. A lack of educational preparedness coupled with a lack of expertise, derived from rigorous experience gained from being part of a neonatal transfer team, compromises their ability to be competent within the context of neonatal transfers. This suggests the need for adequate educational preparedness prior to paramedics becoming involved in this specialised area of practice.

What also emerged as important was the need for sub-speciality programmes so that paramedics could be capacitated on an ongoing basis. The intensive care unit (ICU) is a technologically sophisticated environment, which provides complex and detailed health care for various acute life-threatening conditions (De Beer, Brysiewicz & Bhengu 2011). Specialised knowledge and experience to function within this milieu is important to capacitate paramedics. Sub-speciality programmes are also important in terms of enabling further and continuous clinical preparedness for neonatal transfers.

Once ALS paramedics qualify, they register with the HPCSA and can immediately enter the field of EMS, with no internship programme that enables a level of preparedness for emergency transfers of critically ill neonates. Hence, whilst they may enter the workplace with a broad theoretical base and skills acquired through supervised experiential learning, the data suggest that this is insufficient to deal with the complexities of critically ill neonates. This places them at disadvantage, to those doctors or nurses in the NICU’s, in terms of both clinical decision-making and competence with regard to both transfer decisions and the ability to work effectively should the neonate deteriorate.

Mothers, who accompany neonates may also present with clinical emergencies during the transfer as they are often still patients themselves. Training under the supervision of a competent paramedic who is conversant with all these issues is crucial before those without clinical expertise should be allowed to effect neonatal transfers.

The interviews were covered only with the paramedics from KwaZulu-Natal. Whilst this is offset by the fact that qualitative inquiries seek information richness from small samples, a national inquiry would have shed greater light on issues across South Africa. Moreover, the sample consisted of mainly participants from the public sector and urban areas. Hence, the results cannot be generalised to the private sector and rural areas.

The study revealed several challenges confronting paramedics faced with neonatal emergency transfers. These ranged from issues related to poor preparation and stabilisation of the neonate prior to the transfer and the lack of important information with regard to the neonate’s condition, which was crucial, so that paramedics could prepare themselves for dealing with the unique needs of the neonate. The study found out that the neonate was also not adequately stabilised prior to transfer and there were suggestions of a rushed transfer that could potentially become life threatening. The transfer journey itself appeared to have its own challenges.

Registration with the HPCSA demands a high level of professional competence to avoid negligence, as per statutory requirements. Given that the data suggest that EMC education may not be providing adequate preparedness for neonatal transfers, it is crucial that ongoing training in conjunction with a period of supervised practice with competent team members be initiated. Training should ideally cover stabilisation and resuscitation of the neonate, clinical skills that cover all emergency scenarios, use of specialised equipment, ambulance and aeromedical environment, safety guidelines and protocols, communication between relevant stakeholders, multi-disciplinary teamwork, debriefing, ethical issues and trauma support services for accompanying mothers. The latter should also enable paramedics to be well prepared for neonatal transfers.