Statewide Incubator Care Guideline:

Clinical management of babies requiring an incubator for inter-

hospital transfer in Victoria (without a PIPER Neonatal escort)
1. Introduction
In 2014, sixteen portable transport incubators funded by the Victorian Department of Health and Human
Services (DHHS, then Department of Health) were deployed in selected ‘host’ health services throughout
Victoria (Appendix 1). The incubators were provided as resources for use within these health services as
well as within and between regions. For consistency, a single brand and model (V808) portable transport
incubator was deployed.

The Paediatric Infant Perinatal Emergency Retrieval (PIPER) service in collaboration with Ambulance
Victoria (AV) and DHHS, have developed these clinical and operational guidelines to ensure
standardisation and competency in the management and utilisation of the portable transport incubators.

2. Transport Options
The choice of platform for inter-hospital transport of babies who require an incubator depends on the
baby’s illness acuity, age, weight, and effective use of resources. The options for the inter-hospital
transfer of small babies (less than 5 months corrected age) are summarised in Table 1.

Table 1

Inter hospital transfer option Indications Examples

(Babies <5 months corrected age)
PIPER Neonatal team with their Clinically unwell baby or where risk Babies requiring respiratory support
infant transport system. of deterioration in transit is beyond low flow oxygen.
moderate – high.

Transport incubator secured to an Transfer of low acuity babies from a For example Ararat to Ballarat, or
ambulance stretcher. maternity service without a Portland to Warrnambool.
newborn service to a maternity
Note: The need for a health service hospital with a level 3 to level 5
nurse/midwife or doctor to newborn service#1.
accompany the baby should be a
rare event and only when agreed Stable babies who require rapid Bile stained vomiting in a “well”
by the PIPER Neonatal Consultant, transfer to a level 6b newborn baby.
referring staff and Ambulance service. This system will enable a
Victoria staff*. much faster response and transfer
time compared to using a PIPER
neonatal transfer.

Relatively well babies who require Ballarat to Ararat.

back transfer from a newborn
service or between services.

* This may include Non-Emergency Patient Transport services.

# All levels of newborn care referred to in this document align with Defining levels of newborn care for Victorian health services
(2015)1

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 1 of 12
3. Governance
Suitability to transfer a baby without a PIPER Neonatal team is determined after consultation between
referring hospital clinical staff, the PIPER Neonatal Consultant and Ambulance Victoria while taking into
account clinical, logistical and other factors.

Host services and paramedics within each region have been provided with training opportunities
including education on the use of incubators, in-service training and online tools. Parker Health will
provide ongoing education and training during their regular site visits to ‘host’ services.

It is the responsibility of the host service to ensure that clinical staff develop and maintain knowledge
with regard to using the incubator, using the harness to secure a baby to the incubator, and accessing
online tools2, 3. A checklist that details equipment items required when the incubator is dispatched and
returned has been developed to ensure the incubator remains in a “ready to use” condition4.

It is the responsibility of Ambulance Victoria to ensure that paramedics are aware of online educational
tools and are educated and supported to use the incubators to ensure they are comfortable with their
operation including the procedure for securing the incubator to a Stryker stretcher5.

Host services are responsible for the ongoing care and maintenance of the incubators and are expected
to develop local policies that govern their use including:

 How hospitals in the region will access and manage the use of the incubator.
 Procedures for the return of the incubator to the host service at the completion of the transfer.
Please note that this is the joint responsibility of the host and other health services involved in the
use of the incubator.
 Responsibility for costs incurred (e.g. taxi costs associated with relocation) when using the incubator
for inter-hospital transfer.

4. Appropriate use of Statewide incubators

The transport incubators are appropriate for use in transporting small babies (less than five months
corrected age) that are not ill enough to need a PIPER neonatal escort, but require transfer in an
incubator for clinical or restraint purposes. The transport incubators:

 May be used for transport by road or air.

 Are suitable for babies weighing <5kg.
 Have an infant restraint harness that meets the Ambulance Victoria standard for inter-hospital
transfer.
 Have an inbuilt pulse oximeter to enable appropriate monitoring of a baby’s oxygenation.
 Have an inbuilt oxygen analyser to enable titration of supplemental oxygen if required.
 Can be used for inter or intra hospital transfers.
In most instances, after the incubator has been secured to an ambulance stretcher, a paramedic will
accompany the baby to the receiving health service. The need to send a referring health service
nurse/midwife/doctor to escort the baby to the receiving service should be a rare event and should
reflect a consensus between the PIPER neonatal consultant, health service staff and Ambulance Victoria
staff.
The V808 transport incubators should not be used as the choice of transport platform when:

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 2 of 12
1. The baby requiring transport is clinically unwell or where there is a significant risk of deterioration in
transit. These babies must be transferred using a PIPER Neonatal team with their infant transport
system.
2. Using an infant car seat type restraint system secured to an ambulance stretcher. V808 incubators
are not appropriate for use using this type of restraint system.

Clinical criteria for inter-hospital transfer without a PIPER Neonatal escort

1. Baby is >34 weeks and 2000g.
2. Baby is haemodynamically stable and at low/no risk of deterioration during transport.
3. Baby requires less than 30% oxygen or 2 Lpm sub nasal oxygen to maintain oxygen saturations 91-
95%.
4. The baby is not anticipated to require respiratory support (including nasal CPAP or high flow sub
nasal blended oxygen) during transport.
5. IV fluids are not essential during the transfer.
6. The baby’s blood glucose is >2.5 (or if mild hypoglycaemia is present it is being effectively managed).
7. Baby is not at risk of requiring exchange transfusion or other neonatal ICU type interventions.

5. Organising a transfer using the V808 incubator

(See Flow Chart - Appendix 2 )
 Requests for inter-hospital transfer of babies should be directed to the PIPER emergency line (Phone:
1300 137 650). “Return” transfers of babies can be arranged between the referring and receiving
unit directly or via PIPER if preferred.
 For acute transfers the PIPER Neonatal Consultant triages the requests and the level of receiving
hospital is agreed with the referring clinician.
 If the baby is suitable to be cared for in a level 3 to level 5 newborn service then the Paediatrician for
the suggested receiving hospital will be invited to join the conference call to ensure the clinical
condition of the baby is appropriate for their special care nursery. Bed availability will be assessed at
this time.
 Suitability to transfer the baby without a PIPER Neonatal team is determined, taking into account
clinical, logistic and other factors.
 Transfer using an incubator is subject to the availability of appropriate resources (e.g. incubator,
referring hospital nurse or midwife, ambulance, or aircraft) to achieve safe transport to a health
service with an appropriate level of care. An alternative plan must be formulated if there are
insufficient resources available (e.g. PIPER Neonatal might do the retrieval).
 The default position is that once the baby is secured in the incubator by nursing/midwifery staff, the
basic functions of the incubator likely to be required during transfer (e.g. pulse oximeter and
temperature control) should be communicated to the paramedics. The transfer can then proceed in
most cases with a paramedic. This decision will be made after consultation between the PIPER
Neonatal consultant, referring hospital staff and ambulance.
 Public health services that have been allocated a transport incubator are responsible for developing
policies that govern the use of the incubator within their region. A list of questions detailing the
scope of material that should be addressed by health services when developing local policy and
procedures has been developed (Appendix 3).

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 3 of 12
6. Procedure for Caring for a baby in an Incubator

Definition of terms
Neutral thermal environment (NTE): an environment in which a baby with a normal body
temperature has a minimal metabolic rate and therefore minimal oxygen consumption.

6.1 Nursing management of the neonate in an incubator

6.1.1 Start and test the incubator as per V808 operation video2.

6.1.2 Incubator air control: Set the desired internal temperature as per V808 operation video.
 Determine at what air temperature to set the incubator by referring to the
temperature ranges for NTE6, 7(Appendix 4).
 If a baby has been nursed in a nursery incubator for some time prior to transfer, and
the baby’s temperature is within normal range, set the transport incubator at the
same temperature.
 In babies the normal temperature range is 36.5 – 37.5oC. Do not wean air
temperature any faster than 0.5oC per 30 minutes or 1oC per hour.
 Note the transport incubator should be plugged into a power source and turned on
at all times to provide a stable standby “admission” temperature. When preparing
to place a baby into the incubator wait until the air temperature reads the same as
the set temperature before placing the baby into the incubator.
 The incubator should be kept away from drafts, direct sunlight and cool or warm
windows that may affect the incubator temperature. If outside the hospital the
incubator will need a cover to reduce the effects of external weather influences.
 Both High and Low alarms for the set temperature will go to default values.
 Avoid keeping portholes open except for examination or care. Cluster care so the
opening of portholes is kept to a minimum.

NOTE: Do not turn the incubator off. The fan does not work with the incubator off so
there is no air movement within the canopy and carbon dioxide may accumulate.

6.1.3 Place the baby into the incubator.

 Place the baby supine into the incubator as per V808 operation video2. Position the
baby in the center of the mattress, the head to the left and feet to the right.
 Ensure the front admittance panel is closed and the knobs repositioned to lock the
panel.
 Secure the baby using the DHS 590 infant baby harness. See Fitting Instructions: Atom
V808 strapping of patient harness on the Stryker stretcher3.
 Apart from an environmental cover where required do not place anything on top of
the incubator or talk over the incubator as noise is amplified in the incubator6.

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 4 of 12
 6.1.4 Skin temperature monitoring.
 Clean the site of the probe with lukewarm water and dry. Attach yellow skin probe,
silver side down and cover with reflective temperature probe cover e.g. Neosmile.
 Attach the skin temperature probe to the baby and the other end to the left side
panel of the main body of the incubator.
 Position the skin temperature probe to the upper abdomen e.g. in the midline above
the umbilicus, avoid boney prominences. Do not position the temperature probe
under the axilla7.

6.1.5 Monitoring of incubator oxygen.

 Calibrate oxygen monitoring unit as per V808 operating video2.
 Set upper and lower alarm limits 5% above and below the required amount of oxygen
required by the baby. Adjust flow to increase or decrease the oxygen percentage to
that prescribed.
 Keep portholes closed at all times when not requiring direct access to the baby.
Opening the portholes affects the oxygen concentration being administered into the
incubator canopy.

6.1.6 Pulse oximetry.

 Position sensor on baby’s right hand or wrist8.
 Set High and Low alarm limits for saturations:
o
If the baby has an oxygen requirement: Low limit 89%, High limit 95%
o
If the baby does not have an oxygen requirement: Low limit 89%, high limit
100%.
 Set High and Low alarm limits for heart rate:
o Low limit 100bpm
o High limit 180bpm
 If the baby is otherwise well and has a sleeping heart rate less than 100bpm it may be
appropriate, following discussion with the PIPER Neonatal Consultant, to set the Low
limit to 90bpm.

6.1.7 Frequency of observations: Option to use observation charts from referring hospital.
Document hourly:
 Axillary temperature unless febrile or hypothermic whereby the temperature should
be recorded more frequently.
 If axillary temperature is below 36.5oC increase the incubator by 0.5oC, checking the
temperature half an hour later.
 If axillary temperature is greater than 37.5oC the incubator temperature is decreased
by 0.5oC checking the temperature half an hour later.
Document half hourly:
Skin temperature, heart rate, respiratory rate, SpO2, color, oxygen concentration or flow
rate of sub nasal oxygen and baby activity.

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 5 of 12
6.2 Other Considerations
6.2.1 Operation should align with accreditation requirements, particularly those relating to the
following National Safety and Quality Health Service (NSQHS) standards9:

 Standard 1. Governance for Safety and Quality in Health Service Organisations

 Standard 2. Partnering with Consumers
 Standard 5 Patient Identification and Procedure Matching
 Standard 6. Clinical Handover
 Standard 8. Preventing and Managing Pressure Injuries
 Standard 9 Recognising and Responding to Clinical Deterioration in Acute Health Care
 Standard 10. Preventing Falls and Harm from Falls.
6.2.2 Training:
It is important that all staff are given appropriate training and opportunity to familiarize
themselves with the harnesses and incubator settings.
6.2.3 Resuscitation:
Ensure self-inflating bag (240mL) and appropriate size mask accompanies the baby. AV
may have this in their vehicle.
6.2.4 Suction:
All AV vehicles have suction if required. Paramedics may need to source Fg 8-10 suction
catheters from the referring hospital.

6.2.5. Securing incubator to AV stretcher – Ambulance Victoria Work Instruction: Securing the
Atom V808 Transport Capsule Incubator to a Stryker Stretcher5.
6.3 Cleaning
 Clean incubator as per procedure10.
 Do not use an alcohol based solution or acetone on the incubator.
 Clean the DHS 590 baby harness and DHS 585 incubator harness as per procedure3.
 The responsibility for cleaning should be documented within locally developed policies and
procedures.

7. Caring for an Incubator Battery

It is recommended that host services check the working order of the incubator on a weekly basis.

7.1 Battery maintenance

To ensure the battery is fully charged and in correct working order for when a transfer is
required, it is important to ensure that the Atom V808 Transport Incubator is plugged into a
power source and turned on at all times so it is providing a moderately warm temperature inside
the incubator. No damage will occur to the incubator by having it plugged in and turned on at all
times.

Having the incubator plugged into a power source and turned on at all times to provide a stable
admission temperature ensures that, in the event of a transfer, the incubator is at a stable
temperature which will prolong the battery running time. Please note that the incubator cannot
run in battery mode if the unit has not been pre-heated.

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 6 of 12
 As part of your weekly check you should ensure that the Atom V808 Incubator is:
 Plugged into a power source and turned on with a stable admission temperature set.
 The Battery 1 power indicator located on the front of the V808 transport incubator is
illuminated indicating that the incubator is fully charged. If the Battery 1 power indicator is
not fully illuminated and the incubator has been plugged in for a minimum of 8 hours, please
contact the Parker Healthcare service department on 03 9872 0222 for further assistance.

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 7 of 12
 References
1. Defining levels of newborn care for Victorian health services (2015).
https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal-
reproductive/maternity-newborn-services/newborn-care-in-victoria

2. Parker Healthcare. 2014. Atom V808 Incubator Basic Use Video. Melbourne. Internal publication.
https://www.youtube.com/watch?v=_En_cNVrgB8&index=1&list=UU5uOmK-tlEtGWSNGfLuSNgw

3. Fitting Instructions: Atom V808 strapping of patient harness on the Stryker stretcher. PIPER 2017.

4. Checklist for Atom V808 Incubator. PIPER 2017

5. Ambulance Victoria Work Instruction: Securing the Atom V808 Transport Capsule Incubator to a
Stryker Stretcher. Version 2.0. 3 February 2017.

6. Royal Children’s Hospital. 2011. Isolette use in the paediatric wards. Policies and Procedures.
Melbourne: Internal publication.
http://www.rch.org.au/policy/policies/Isolette_Use_in_Paediatric_Wards/

7. Gardner SL., Carter BS, Enzman-Hines M. and Hernandez JA. 2011. Merenstein & Gardner’s
Handbook of Neonatal Intensive Care. 7th Ed. St Louis: Mosby.

8. Australian and New Zealand Resuscitation Committee on Resuscitation (ANZCOR). 2016. Guideline
13.1. Introduction to resuscitation of the newborn infant. P4. Melbourne: Internal publication.
http://resus.org.au/guidelines/

9. Australian Commission on Safety and Quality in Health Care. September 2012. National Safety and
Quality Health Service Standards.

10. Parker Healthcare. 2014. Atom V-808 Cleaning instructions. Melbourne: Internal publication.

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 8 of 12
 Appendix 1
State-wide V808 incubator:
“Host” Health Services

1. Echuca Regional Health

2. Portland District Health

3. Western District Health Service (Hamilton)

4. Barwon Health

5. Ballarat Health Service

6. Albury Wodonga Health

7. Northeast Health Wangaratta

8. Wimmera Health Care Group (Horsham)

9. Swan Hill District Health

10. Bendigo Health

11. Goulburn Valley Health (Shepparton)

12. Peninsula Health

13. Monash Health

14. Northern Health

15. Gippsland Southern Health Service (Leongatha)

16. Latrobe Regional Health (Traralgon)

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 9 of 12
 Appendix
Appendix 2 3

Referral – Interhospital transfer

without PIPER Neonatal Escort
See Clinical Criteria Guideline

Phone 1300 137 650 – PIPER coordination centre

Referring Clinician and PIPER
Neonatal Consultant discuss
possible transfer and decide if
transfer can proceed.
Clinical, logistic and other factors decide
suitability for transfer.

Transfer suitable for state-

NO
wide incubator

Referring hospital to organise

YES Ambulance Victoria as per Baby becomes a
local protocols PIPER Neonatal
transfer
Receiving hospital  Baby to be secured in OR
paediatrician to join V808 incubator by
conference call to referring hospital Baby stays at
nursing/midwifery staff. referring hospital
 Confirm suitability of (As per V808 protocol)
transfer to receiving  Controls of incubator set
hospital by nurse/midwife
 Confirm bed is  Handover to paramedic.
available

Incubator returned to Host hospital: This is the responsibility of the health services involved in the
transfer and is determined by locally agreed procedures developed by the health service that owns the
incubator.

The decision to transfer (with or without referring hospital escort) will be made after consultation
between
 Referring hospital staff,
 PIPER Neonatal staff and
 Ambulance Victoria staff.

Data collection tool being developed.

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 10 of 12
 Appendix 3
Local policy and procedure development: questions for consideration by health
services when ‘hosting’ a V808 statewide incubator
Public health services (host services) that have been allocated V808 transport incubators are responsible
for their ongoing care and maintenance. Host services are also expected to develop local policies that
govern the use of the incubators within their region including:

 How hospitals in the region will access and manage the use of the incubator.
 Procedures for the return of the incubator to the “host” service at the completion of the transfer.
 Responsibility for costs incurred (e.g. taxi costs associated with relocation) when using the incubator
for inter-hospital transfer.
The following questions are presented as a means of detailing the scope of material that should be
addressed by health services in developing local policy and procedures for the management and
operation of State-wide V808 incubators:
1. Which maternity hospitals in our area could conceivably use the incubator?
2. Who are the key contact people?
3. How are our own clinical staff and those of surrounding hospitals made aware of the incubator and
its potential use?
4. How do clinical staff develop and maintain knowledge with regard to using the incubator and using
the harness to secure the baby in the incubator?
5. Have the various educational resources (links to videos, power points, operational manuals,
guidelines for use etc.) been propagated to clinical staff?
6. How does the incubator get to a referring hospital in your area? Will the local ambulance take it
(sometimes, always, never)?
7. How has the ambulance service in the region been engaged so that they are aware of the
circumstances in which the incubator may be used in the region?
8. How will the empty incubator get back to the host hospital after (a) the baby has been transferred
from the host hospital to somewhere else or (b) after a baby has been moved between hospitals
other than the host hospital?
9. In relocating incubators can it be moved by taxi? What are the manual handling issues involved in
this? Does it require a wagon or maxi?
10. Who bears the cost incurred when relocating the incubator?
11. How do we manage the situation if we feel a staff member should travel with the baby?
12. How does the staff member get back to their hospital if the ambulance is not returning to that
hospital? Is there a mechanism to pay for a return taxi fare?
13. The trolley supplied to the host hospital does not go with the incubator during a transfer. How is this
managed at the non-hosting referring hospital and receiving hospital?
14. How is the location of the cot monitored so that its whereabouts is known?
15. Is a checklist required to ensure all components of the cot are present and in working order and are
dispatched and returned when the cot has been used for transfer? Suggested checklist can be found
here: Checklist for Atom V808 Incubator. PIPER 2017

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 11 of 12
 Appendix 4
Neutral Thermal Environment Temperatures
[Adapted from: Gardner SL., Carter BS., Enzman-Hines M. and Hernandez JA. 2011]

Age and weight Starting Temp (oC) Range of Temp (oC)

0-6 hr
1501-2500g 34.0 33.0-34.0
Over 2500g and >36 wk 33.5 32.0-34.0
>6-12 hr
1501-2500g 33.0 32.0-34.0
Over 2500g and >36 wk 33.0 31.5-34.0
>12-24 hr
1501-2500g 33.0 32.0-34.0
Over 2500g and >36 wk 32.5 31.0-33.5
>24-36 hr
1501-2500g 32.5 31.5-33.5
Over 2500g and >36 wk 32.0 30.5-33.5
>36-48 hr
1501-2500g 32.5 31.5-33.5
Over 2500g and >36 wk 32.0 30.5-33.5
>48-72 hr
1501-2500g 32.5 31.0-33.5
Over 2500g and >36 wk 31.5 30.0-33.0
>72-96 hr
1501-2500g 32.0 31.0-33.0
Over 2500g and >36 wk 31.5 30.0-33.0
>4-12 days
1501-2500g 32.0 31.0-33.0
Over 2500g and >36 wk
4-5 days 31.0 29.5-32.5
5-6 days 31.0 29.5-32.0
6-8 days 30.5 29.0-32.0
8-10 days 30.5 29.0-32.0
10-12 days 30 29.0-31.5
>12-14 days
1501-2500g 32.0 31.0-33.0
>2-3wk
1501-2500g 31.5 30.5-33.0
>3-4wk
1501-2500g 31.5 30.0-32.5
>4-5wk
1501-2500g 31.0 29.5-32.0
>5-6wk
1501-2500g 30.5 29.0-32.0

Note: for this table, Scopes and Ahmed had the wall of the incubator 1 to 2 o C warmer than the
ambient air temperatures. Generally, the smaller infants in each weight group require a
temperature in the higher portion of the temperature range. Within each time range, the
younger the infant, the higher the temperature required.

r:\management - piper leadership\state wide incubators\final documents for incubators\statewide-incubator-care-guideline - v9 04 04 2017_cf ms.docx Page 12 of 12