The stakes in this seemingly bureaucratic exercise are extraordinarily high. When a newborn at a referring hospital develops a condition beyond that facility’s capabilities, the clock starts ticking immediately. Timely stabilization and transfer to a tertiary or quaternary neonatal intensive care unit is imperative for optimal outcomes, and specialized pediatric transport teams simply cannot respond to every request with the same urgency. Until now, the most commonly used criterion for an emergent transfer was a blunt one: infants transferred for escalation of care, or whose referring physician requested immediate transport, measured by a dispatch time of thirty minutes from the referral center request. That definition, the authors note, is broad and subjective, and it ignores crucial factors such as the resources available at the referring center, the clinical expertise on site, and the specific diagnosis driving the transfer.

The consequences of this definitional vacuum extend well beyond individual bedside decisions. Regulatory and ranking frameworks increasingly require neonatal centers to report transport-related metrics as part of quality assessment and benchmarking, but without a standardized definition of what constitutes an emergent transport, the reported data lack consistency and comparability across institutions. A transfer deemed emergent at one hospital might be classified as routine at another, rendering national comparisons of transport performance scientifically meaningless. The new consensus framework, the researchers argue, provides a foundation for standardized reporting, meaningful benchmarking, and robust quality improvement initiatives that have been impossible to conduct on a large scale until now.

To build the guidelines, the team turned to the Children’s Hospitals Neonatal Consortium, a collaborative network of forty-nine Level IV neonatal intensive care units across the United States and Canada, the highest tier of neonatal care. The consortium operates through twenty-nine clinically focused groups that connect subject-matter experts across institutions, and its Transport Focus Group includes neonatologists, transport medical directors, program administrators, and registered nurses specializing in neonatal critical care transport. A designated subgroup of nine neonatologists, all medical directors of their respective institutions with a collective 119 years of experience caring for newborns, directed the consensus process. Between January and October 2025, the subgroup convened ten videoconference meetings to manage the effort after receiving formal orientation in Delphi methodology and consensus procedures.

The Delphi method itself is a well-established technique for distilling expert judgment in clinical areas where rigorous evidence is scarce. It aggregates opinions through multiple rounds of questionnaires and structured feedback, allowing participants to revise their views as group results are revealed while maintaining anonymity to prevent dominant voices from swaying the outcome. The approach is particularly suited to neonatal transport triage, where the literature is thin. In their comprehensive narrative review of neonatal and pediatric transport classification systems, the researchers found only two prior publications addressing the classification of neonatal transports, a striking gap for a field that moves so many of the most fragile patients in medicine. That review was supplemented by institutional protocols voluntarily submitted by the nine participating centers.

From this synthesis, the subgroup generated an initial list of twenty-three candidate conditions, each assigned to one of three conceptual domains: primary diagnosis, critical clinical sign or physiologic instability, and requirement for specialized equipment or resources unavailable at the referring center. This tripartite structure deliberately mirrors the real-world reasoning of transport teams, who must weigh not only what is wrong with the infant but also what the sending hospital can actually provide. Two rounds of structured, asynchronous surveys were then administered to each participating CHNC site using the REDCap electronic data capture platform, with each institution providing a single physician-led response to ensure consistency. Respondents answered with a binary yes or no on whether each condition warranted emergent transport, with the option to add comments or propose additional conditions, and a four-week response window with reminders for non-respondents.

The consensus threshold was set a priori at eighty percent agreement, a standard benchmark for Delphi studies in health sciences. The results exceeded every expectation. In the first round, responses arrived from thirty-one of forty-nine sites, and every single proposed condition cleared the eighty percent bar. Feedback from that round prompted revisions to wording and categorization, including a deference to the clinical judgment of both referring and accepting institutions regarding available therapies, and the broadening of one criterion from bilious emesis with concern for malrotation to encompass other urgent imaging needs. A new condition was also introduced: cardiac arrhythmia with hemodynamic instability or need for intervention such as pacing or antiarrhythmic therapy. In the second round, participation climbed to forty of forty-nine sites, and again every condition achieved consensus, with high concordance between rounds despite respondents being free to change their answers.

Patterns in the voting revealed how experts think about transport urgency. Conditions requiring urgent subspecialty or multidisciplinary input, such as pediatric cardiology, genetics and metabolism, or pediatric surgery, drew the highest agreement. Conditions with somewhat lower, though still above-threshold, agreement tended to be those whose urgency depends on the comfort level and capabilities of the referring institution. The final framework includes physiologic instability criteria such as refractory shock, seizures, and respiratory failure, alongside resource-based criteria including the need for extracorporeal membrane oxygenation, renal replacement therapy, urgent imaging, or surgical intervention. Notably, the panel also endorsed the clinical judgment of the transport medical control physician as a consensus criterion, formally embedding expert assessment within the standardized structure rather than replacing it.

The authors are candid about the limitations of their work. Consensus rested on physician-led expert opinion rather than outcome-based validation or multidisciplinary response, and participation was limited to CHNC-affiliated sites, with a potential twenty percent non-response bias in the second round that may have introduced institutional clustering. The guidelines also do not account for variability in local resources, staffing, or transport logistics, and the inclusion of medical control judgment introduces an element of subjectivity that may limit reproducibility. The researchers emphasize that the framework is not intended to universally define emergent transport: an infant with esophageal atresia requiring mechanical ventilation at a Level III NICU staffed by experienced neonatologists may not need an emergent transfer, while the same infant at a Level I delivery hospital with no in-house advanced neonatal expertise would.

Looking ahead, the team calls for prospective validation of the criteria and implementation studies examining how they perform across varied transport systems, resource settings, and referral patterns. Integrating the consensus framework into transport triage tools, referral communication pathways, and quality improvement initiatives could standardize decision making and data collection, ultimately supporting evidence-based standards for neonatal transport prioritization while preserving the indispensable role of clinical judgment. For the smallest and sickest patients, whose survival often hinges on the minutes between a phone call and a team rolling out the door, a shared language of urgency may prove to be one of the most consequential advances neonatal medicine has delivered in years.

Subject of Research: Consensus criteria for classifying emergent neonatal interfacility transports

Article Title: Development of consensus guidelines for classification of emergent neonatal transports using a Delphi process

Article References: Viehl, L., Anson, E., Dariya, V., Dirnberger, D., Martinez-Hannon, R., Nesterenko, T., Trivedi, S., Wong, S., Lee, K.-S., & on behalf of the Children’s Hospitals Neonatal Consortium (CHNC) Transport Focus Group (2026). Development of consensus guidelines for classification of emergent neonatal transports using a Delphi process. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02900-w

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02900-w

Keywords: neonatal transport, Delphi method, neonatal intensive care, consensus guidelines, interfacility transfer, triage, Children's Hospitals Neonatal Consortium, transport medicine, benchmarking, quality improvement, Level IV NICU, clinical decision making