NEONATAL TRANSPORT

VEHICLE INSPECTION SUPPLEMENT

Date:

Service: Permit No.:

Pass Fail

Inspector’sSignature:

EQUIPMENT

A U(A = Acceptable U = Unacceptable)

Transport Incubator

Thermometer

Blanket (insulating blanket or chemically activated warm pack approved for neonate use)

Above equipment maintained in neutral thermal environment.

PH-3941 (Rev 7-2017)Page 1 of 2RDA - 10137

OXYGEN DELIVERY & MONITORING

A U(A = Acceptable U = Unacceptable)

Oxygen Tanks

Air Tanks

Pressure Gauges

Flow-Meters

Oxygen Analyzer

Oxygen Blender

Oxygen Tubing and Adapters

Oxygen Hood orNasal Cannula

Neonatal Oxygen Mask

Neonatal Resuscitation BVM

(with Manometer)

Continuous Positive Airway

Pressure Apparatus

Mechanical Ventilator

Non-Invasive Oxygen Monitor

(i.e. Pulse Ox)

AIRWAY / GASTRIC DECOMPRESSION

A U(A = Acceptable U = Unacceptable)

Bulb Syringe

Regulated Suction w/Gauge

Suction Catheters (#6, 8, 10 Fr)

Feeding Tube (# 8 Fr.) w/20 ml Syringe

Replogle Tube (#8 Fr.)

MONITORING (VITAL SIGNS)

A U(A = Acceptable U = Unacceptable)

Continuous Heart-Rate Monitor

Neonatal Stethoscope

Body Temperature Monitor

Non-Invasive & Invasive BP Monitor

Glucometer or Equivalent

PUMPS

A U(A = Acceptable U = Unacceptable)

IV Pump

(portable, battery powered, failsafe & calibrated)

ENDOTRACHEAL INTUBATION

A U(A = Acceptable U = Unacceptable)

Laryngoscope Handle with Blades (00, 0, 1)

Spare Laryngoscope Bulbs

Spare Batteries

ET Tubes (# 2.5, 3.0, 3.5, 4.0 mm I.D.)

Disposable Stylette (# 6 Fr.)

Adhesive Tape

Scissors

INTRAVENOUS INFUSIONS

A U (A = Acceptable U = Unacceptable)

Intravenous Needles/Catheters

(22, 23, 24, 25, 26 gauge)

Syringes (1, 3, 6, 12, 20, 35 ml)

Intravenous Arm-Board

Intravenous Tubing

Infusion Device

Tape

Alcohol Preps

Betadine Preps

3-Way Stopcock

Umbilical Catheterization Equipment

MEDICATIONS / ADMIXTURES

Therapeutic Equivalents are Acceptable

A U(A = Acceptable U = Unacceptable)

Adenosine (antiarrythmic)

Ampicillin (antibiotic)

Atropine (antispasmotic)

Calcium Gluconate

Chloral Hydrate (sedative)

Dextrose Solution (D5W)

Dextrose Solution (D10W)

Digoxin (antiarrythmic)

Dobutamine (adrenergic)

Dopamine (Sympathomimetic)

Epinephrine (1:10,000)

Fentanyl (narcotic)

Furosemide (diuretic)

Gentamicin (antibiotic)

Heparin (anticoagulant)

Morphine Sulphate (narcotic)

Naloxone Hydrochloride

Normal Saline

Phenobarbitol (anticonvulsant)

Protaglandin E1 (require refrigeration)

Sodium Bicarbonate (4.2%)

Sterile Water

Surfactant (requires refrigeration)

EQUIPMENT FOR DIAGNOSIS & MANAGEMENT OF AIR-LEAK SYNDROME

A U (A = Acceptable U = Unacceptable)

Transilluminator

Chest Tubes (8, 10, 12)

Chest Tube Kit

25g Angiocath or Butterfly

Heimlich Valve

3-Way Stopcock

Luer Lock and Slip Tip Syringe (35/60ml)

EQUIPMENT FOR HANDWASHING

AND PERSONAL PROTECTION

A U(A = Acceptable U = Unacceptable)

Antiseptic Solution or Towelettes

Gloves

Full-face Protection or Goggles andMask

Fluid-Retardant and Fluid-Resistant Gowns

Infectious Waste Disposal Bags

Soiled Linen Disposal Bags

Sharps Box

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COMMENTS

LATEX FREE EQUIPMENT AND SUPPLIES SHOULD BE AVAILABLE

PH-3941 (Rev 7-2017)Page 1 of 2RDA - 10137