Specialized pediatric and neonatal interhospital transport (PNIHT) is crucial for ensuring the safety of critically ill patients, especially for hospitals without pediatric or neonatal intensive care units or pediatric surgery departments.1

Specialized teams significantly reduce mortality and complications during interhospital transport.2 However, Spain lacks universal coverage, with significant regional differences.1 In this context, several Spanish medical societies (SECIP, SENeo, SEUP, and SEMES) have issued recommendations for its development.

We conducted a retrospective observational and analytical study (2018–2023) with consecutive sampling to analyze the characteristics, interventions, and complications of all patients transported from a secondary hospital without a PNIHT.

The sample included all patients aged less than 15 years, without exclusion criteria, and the objective was to identify vulnerability profiles and areas of improvement. We reviewed health care records and transport reports and analyzed the data with R Studio 4.2.0 (significance: P < .05). The study was approved by the Ethics Committee (No. 24317).

There were a total of 363 transports: 60.3% involved male patients, and the median patient age was 4.8 years. Of all transports, 93.1% (n = 338) were urgent, one-third (33.8%) required a mobile ICU, and 84.6% (n = 307) were performed within 24 h of admission.

The distribution by diagnosis showed a predominance of surgical cases (54.3%), primarily on account of appendicitis, which partly explains the low overall complexity of the cohort. Neonatal (10.2%) and respiratory (8.8%) conditions were associated with the highest clinical vulnerability, with a higher proportion of these patients requiring respiratory support (59.5% and 78.1%, respectively, compared to 0% for surgical patients; P < .001), neurologic support (43.2% and 9.4% comparted to 0%; P < 0.001), and admission to intensive care (78.4% and 87.5% compared to 4.6%; P < .001) (Table 1). We found no significant seasonal differences (P = .186) (Tables 1 and 2).

The incidence of complications was 5.7%, higher compared to specialized transport systems (1.6%–2.1%).2–5 However, direct comparison is limited by methodological and population differences. Newborns (13.5%) and respiratory patients (21.9%) were the groups at highest risk (P < .05), consistent with other studies.3 The observational design and the lack of risk-adjusted analyses precluded inferences of causality. However, the consistent clustering of complications in newborns and respiratory patients supports the biological plausibility of these findings. There were no deaths during transport or in the 24 h after.

Stabilization at the sending hospital is key to ensuring safe transport. In our hospital, initial stabilization and escalation of respiratory support were performed either before the arrival of the medical emergency team or upon arrival at the receiving hospital, which could contribute to higher rates of complications in neonatal and respiratory patients, although studies with control groups would be required to make a direct comparison. These findings are consistent with other studies, which identify them as the most vulnerable3 and likely to benefit from specialized transport.

Established systems such as CATS (United Kingdom) and NETS (Australia) have been found to improve safety and standardization of NPIHT following their implementation.2,4,5 In Spain, the Catalan model, among others, has made progress in this area, and positive clinical results have been reported.1,3

Based on this evidence, we propose three potential priorities for local improvement:

• 1

  Strengthen protocolization and team training at sending hospitals in patient stabilization and communication with receiving hospitals.

• 2

  Improve regional coordination through health care networks that optimize time and resources.

• 3

  Establish registers and shared indicators to enable ongoing evaluation and interregional comparisons.

Although our study was conducted in a single center, it provides recent data that is representative of the situation in many secondary hospitals in Spain.

Three decades after Rubio Quiñones et al. described these structural deficiencies in transport,6 the inequalities persist and the standardization of PNIHT is still pending. Our findings indicate the need to improve early identification and initial stabilization of high-risk patients, as well as to establish standardized registries that would allow for the evaluation of the safety of PNIHT in different clinical scenarios.

In Spain, the differences between autonomous communities call for organizational models tailored to each region, achieved through coordination among emergency services, tertiary hospitals, and health authorities. Ensuring safe and equitable critical care transport should be a priority for the National Health System. These findings underscore the need to reduce regional variability in pediatric transport. This is supported by the scientific evidence1–5: The outstanding debt owed to critically ill pediatric patients in Spain should be settled without further delay; today may be the time to move from diagnosis to action.

In conclusion, this study highlights the vulnerability of certain patients and supports the need to improve initial stabilization and coordination of sending teams. The creation of PNIHT networks would provide an opportunity to improve critical pediatric care in Spain.