Making Paediatric and Neonatal Transport Safer

A five-dimensioned quality management plan has been developed to make the paediatric and neonatal transport safer in a family-centred care model. The goal is to move towards excellence in care.

Introduction

The Emergency Medical System (known in Spanish as the Sistema de Emergencias Médicas, SEM) is part of CatSalut, the Catalan Health Service. The Specialized Pediatric medicalised emergency transport began in Catalonia back in 1995. Ever since, the system has undergone a series of upgrades in order to optimise resource distribution leading to its present-day form, making it one of Europe’s most advanced paediatric specialised transport systems and the single one of its nature in the whole of Spain.

The advanced life support ground unit located at Saint John of God's Hospital (SJG Unit) is one of the specialised units that provide care for children in Catalonia in need of interhospital transfer and stabilisation. SJG unit encompasses a group of paediatricians, nurses and emergency medical technicians specialised in paediatric and neonatal critical care, working 24-hour shifts and granting medical care 24/7, 365 days a year.

On top of its clinical duties, the unit is also involved in teaching and academic tasks, research and innovation. Clinical protocols and guidelines are developed and revised periodically, with efforts currently being made to upload them onto the intranet of the institution for better accessibility. Lastly, an internal commission on patient safety and quality care exists, ensuring all procedures are carried out in accordance with national and international quality standards.

Quality Management Plan

The SJG Unit elaborates a five-dimensional quality management plan aligned with the principles of our institution, led by the internal commission on patient safety and quality involving the entire team. The plan brings together pre-existent working topics such as quality indicators, team training, clinical protocols, as well as the patient and family-centred care model implemented across the different paediatric SEM units in the last ten years.

Evidence-Based Medicine and Standardised Clinical Practice

All members of the unit follow updated protocols devised to ensure standardised, accurate clinical practice. These are reviewed periodically and uploaded to a cloud repository, making them accessible to all professionals remotely and while on duty, as most clinical practice is carried out outside of the hospital. All of them are also available through the intranet website of the hospital. The protocols are reviewed by professionals from specialised units when necessary to ensure the highest quality.

They encompass three main topics: general protocols, paediatric protocols and neonatal protocols discussing different subjects detailed in Table 1. The team monitors adherence to protocols through quality indicators designed for this purpose. It is relevant to minimise the variability of clinical practice and to ensure the best results.

Furthermore, the unit has actively participated in the creation of the SEM’s clinical guidelines published in 2024, a compendium of all the procedures and conditions managed by adult and paediatric teams. These can be accessed online via the following link https://guiescliniques.sem.gencat.cat/#/INT, or can be downloaded as an app on portable electronic devices.

Patient Safety

We perform notification of safety incidents through the application on the tablet that we use during transport. We also have an incident report system on our intranet on the SJG website. Our committee is responsible for analysing these incidents and discussing them with SEM and the rest of the team. At the same time, we promote safe practices, such as unequivocal patient identification, effective communication, the use of a checklist and the use of risk drug protocol, among others.

The safety incident reporting culture has been well implemented in our unit. We have recently published our experience analysing the incidents that occurred during interhospital transport and the changes after implementing safety measures and the creation of the quality and safety group (Corniero et al. 2025). The clinical incidents decreased from 20.3% to 5.1%; P < .001. Implementing measures to improve patient safety reduced the frequency of these incidents and optimised care quality.

Patient Experience

Patients can be accompanied by their families while in the ambulance, a milestone achieved after an amendment was made to the insurance of the ambulance, extending its policy to the relatives of the patient attended. This possibility has become the norm, and families are offered to either sit in the driver’s area or inside the patient compartment alongside their child.

This contributes greatly to family-centred care, diminishing the anxiety of parents and children alike and overall increasing global patient satisfaction as reflected on the quality indicators, which encouraged the team to maintain this practice even during the SARS-Cov2 pandemic. A collaborative study amongst both terrestrial SEM units is currently being conducted to better depict this domain. One picture is attached to this document to illustrate this, with consent from the family. In the image, the mother travels in the patient compartment alongside her child. Appropriate paediatric restraint systems are used to ensure safety during transport (Image 1).

In addition, our team has recently evaluated the incidence of adverse events during transport, finding that interhospital paediatric transport performed by teams trained in clinical safety leads to few incidents. The presence of parents during transport was not associated with an increase in incidents (Corniero et al. 2025).

Medical Education and Specialised Training

Education and research have always been one of the core principles of the team at SJG unit, actively promoting clinical workshops as course directors while also organising internal training sessions.

At the same time, the transport team welcomes paediatric residents (both medical and nursing), who usually spend one month rotating with the on-call healthcare team. As part of their rotation, they also conduct case reviews and present topics of interest related to transport in the team's general meetings and monthly assembly.

Furthermore, an internal training committee prepares and emails a monthly update on a topic of interest in paediatric or neonatal critical care medicine to all team members. This usually consists of a clinical case, a protocol review, and a set of questions open to discussion. It is an informal system but very effective within the team's dynamics of the team.

Every year, two sessions of complex clinical cases with high-fidelity simulation are held, along with one internal monographic course on a topic of interest to the team (e.g., portable ultrasound use, difficult airway approach in transport, non-technical skills, ...). Additionally, an external paediatric and neonatal transport course is conducted yearly, with the entire team participating as instructors, composed of an online theoretical module and two days of workshops and clinical case simulations (Image 2). In parallel, a simulation course is also held for all residents who have been rotating throughout the year.

Moreover, many members of the transport team participate as co-instructors in various courses, both in-hospital or in national and international courses across the country and abroad.

In a paediatric transport team, effective communication is just as crucial as technical skills. While technical proficiency ensures the safe and efficient transport of critically ill children, clear communication among team members ensures coordination, reduces errors, and fosters a collaborative environment. Miscommunication can lead to delays, misunderstandings, and potentially harmful situations, especially in high-pressure environments where decisions must be made quickly. Working on communication skills, such as active listening, clear instructions, and team briefing/debriefing, poses an important challenge. This not only improves patient outcomes but also supports the mental well-being of the team by reducing stress and promoting a supportive working atmosphere.

With this goal in mind, the SJG unit has implemented a two-step debriefing protocol in two phases using a validated methodology (TALK), the results of which are currently being analysed:

• Step 1. Each service performed is analysed with a hot debriefing (immediately after the service)

• Step 2. Particularly problematic or challenging cases are discussed in team meetings (cold debriefing)

Quality Indicators and Benchmarking

Regular assessment of healthcare quality is essential to identify opportunities for improvement, thus guaranteeing the best possible care is provided, with quality indicators being amongst the most effective tools to accomplish this task. Thus, an internal commission on patient safety comprised of one paediatrician, two nurses and one emergency health technician periodically reviews and integrates the information reaped by the quality indicators, identifying and suggesting areas for improvement when necessary. All data is shared and discussed with the rest of the team monthly in the general assembly held at the end of each month.

For this approach to be effective, healthcare teams must use widely accepted and well-defined indicators, enabling comparisons amongst different units to improve the quality of care given (internal audit and benchmarking).

With this aim in mind, a nationwide initiative in Spain promoted by the Pediatric and Neonatal Critical Transport group of the National Society for Pediatric Critical Care in 2018 reached a consensus agreement and defined a series of standardised quality indicators by means of a Delphi consensus (Garrido et al. 2021). Quality indicators were established, which all specialised units in Spain record after each transport in a RedCap database, with periodic meetings to review and comment on them being held since 2019. Additionally, the SJG unit registers other potentially clinically relevant information. The quality indicators registered are detailed in Table 2.

Conclusion

The implementation of a comprehensive, five-dimensional quality management plan by the SJG Pediatric and Neonatal Transport Unit is a huge leap towards increasing the safety, efficiency, and quality of care in interhospital paediatric transport. With the incorporation of evidence-based clinical guidelines, robust quality indicators, effective patient safety culture, and commitment to ongoing education and family-centred care, the unit has created a model that not only meets but also tries to exceed current standards.

Family integration during transport, review of adverse events in a systematic manner, and development of validated debriefing and training tools also demonstrate the commitment of the unit to excellence and continuous improvement. These activities support a safety culture, promote professional development, and ultimately result in enhanced experience and outcomes for critically ill children and their families.

Conflict of Interest

None.