European Journal of Cardiovascular Medicine

India contributes significantly to global neonatal mortality, with approximately 66% of neonatal deaths occurring within the neonatal period.¹ Neonatal transport remains a critical component of perinatal care, particularly in resource-limited settings where tertiary-level neonatal intensive care units (NICUs) are geographically distant from birth centres. Timely, safe, and effective inter-facility transfer of critically ill neonates can significantly influence short-term survival and long-term neuro-developmental outcomes. The Transport Risk Index of Physiologic Stability (TRIPS) score, developed to quantify physiological derangements in four dimensions-temperature, blood pressure, respiratory status, and response to noxious stimuli-has emerged as a rapid, practicable tool for assessing the severity of illness in transported infants and guiding clinical decision-making.² Recent prospective cohorts in low- and middle-income countries have demonstrated that elevated TRIPS scores on admission correlate strongly with increased mortality and morbidity, underscoring the score’s predictive validity and its utility in triaging high-risk transfers.^3,4 Despite improvements in ambulance availability and training of transport teams, many out-born neonates continue to experience adverse events such as hypothermia, hypoglycaemia, and hemodynamic instability during transit, which exacerbate pre-existing vulnerabilities.⁵ Variations in pre-transport stabilization protocols, equipment availability, and communication between referring and receiving centres contribute to heterogeneity in transport outcomes. Additionally, the expanding evidence base from recent multicenter studies highlights the need for standardized transport protocols that integrate TRIPS scoring to optimize resource allocation and anticipate critical care requirements upon arrival.⁶ This study aims to evaluate the quality of neonatal transport by applying the TRIPS score in a prospective facility based observational study , with the objectives To determine the physiological stability of out-born neonates on admission—quantified by the Transport Risk Index of Physiologic Stability (TRIPS) score, to evaluate its association with survival and clinical status at 48 hours post‐transfer and To identify transport‐related variables and neonatal risk factors that predicts short‐term complications and adverse outcomes following inter-facility transfer.

A prospective observational study was conducted in the Neonatal Intensive Care Unit of a tertiary care center at Indore, Madhya Pradesh, India from November 2023 to October 2024. Institutional Ethics Committee approval was obtained prior to study initiation, ensuring adherence to ethical research standards. The study population comprised all out-born neonates (≤28 days of life) referred for tertiary‐level care. Using consecutively sampling methodology, 200 out-born neonates (≤28 days of life) meeting the eligibility criteria were recruited. Written and informed consent was obtained from the parents/guardian of the enrolled neonates. TRIPS score as a predictor of early neonatal mortality (i.e. mortality within the first seven days of admission).Transported neonates ≤28 days admitted to the NICU were included and Neonates discharged against medical advice within 48 hours, incomplete records, or guardian refusal were excluded from the study. On admission demographic characteristics (including age and gender), cause of referral, chief complains, transport characteristics (distance, mode of transport, person accompanying), maternal history, birth history were noted. General examination and systemic examination were performed to assess vital parameters (heart rate, respiratory rate, temperature, blood pressure, SpO₂, blood glucose). Assessment of severity of illness of these transported neonates at admissions important as it helps in predicting Outcome and thus in counselling the parents of these sick babies. Various illnesses Severity scoring system available for predicting neonatal outcome like Score for Neonatal Acute Physiology (SNAP), Clinical Risk Index for Babies (CRIB) but most of them take into account an exhaustive number of parameters including laboratory investigations and are expensive and time consuming.^7,8 There is a need of simple, rapid, practical, validated score which does not require sophisticated equipment. One such score is TRIPS SCORE, which was developed and validated by Lee SK et al in 2001.⁹ It is a practical, empirically weighted and physiology-based system for assessment of neonatal transport ‐ related factors (vehicle type, skilled personnel, oxygen support) and short‐term complications like hypothermia, hypoglycaemia, hypotension, need for mechanical ventilation. The TRIPS score was calculated using standardized criteria for temperature, respiratory status, systolic blood pressure, and response to noxious stimuli. Then sum of all four parameters of table1 was done to calculate TRIPS score.¹⁰ Admitted neonates were monitored for the outcome for 7days after admission. Outcome noted as mortality or survival during this post transport 7days period. All these findings were recorded on a predesigned and pre-tested proforma.

Table 1: TRIPS Score Parameters.¹⁰

Statistical Analysis: The categorical data was expressed in terms of rates, ratios, percentages and the continuous data was expressed in terms of mean ± SD. The association between outcome and TRIPS score and its components was tested using chi-square test. To find out the best cut off TRIPS score to predict mortality, ROC curve analysis was done. For all statistical analysis SPSS version22.0 was used and P value less than 0.05 was taken as significant.

The final results were tabulated and interpreted as below. 

Table 2: Baseline Socio-demographic and Clinical Characteristics of Study Participants (N=200)

Table 2 demonstrates the demographic profile of transported neonates, revealing a predominance of early neonatal referrals (69% within first week of life) with male preponderance (1.4:1 ratio). The majority of neonates were underweight (65.5% below normal birth weight), with respiratory distress being the leading indication for transport, reflecting the vulnerability of this population requiring specialized neonatal care.

Table 3: Physiological Parameters on Arrival and TRIPS Score Distribution

The physiological assessment (table 3) revealed that while most neonates maintained stable vital parameters upon arrival, a significant proportion exhibited respiratory compromise (52% with tachypnea) and nearly one-third demonstrated high-risk TRIPS scores. Temperature instability was observed in 20% of cases, and hypoglycemia affected 6% of transported neonates, indicating varying degrees of physiological derangement during transport.

Table 4: Association of Birth Weight with Mortality and TRIPS Score

Birth weight in table 4 demonstrated a significant inverse relationship with mortality (p=0.001), with extremely low birth weight neonates experiencing a 37.5% mortality rate compared to 1.5% in appropriate-for-gestational-age infants. This emphasizes birth weight as a critical determinant of transport outcomes and the heightened vulnerability of preterm, growth-restricted neonates during inter-facility transfer.

Table 5: Association of Key Physiological Parameters with Mortality

Critical physiological parameters in table 5 exhibited strong associations with mortality outcomes, with bradycardia, severe hypotension, hypoglycemia, and hypoxemia representing the most lethal derangements. The TRIPS score demonstrated exceptional discriminatory power, with neonates scoring >20 experiencing 21.4% mortality compared to zero deaths in those with scores ≤20, validating its utility as a prognostic tool.

Table 6: Predictive Performance of TRIPS Score for Mortality Prediction

Figure 1: Receiver Operating Characteristic (ROC) Curve for TRIPS Score Predicting Neonatal Mortality

The receiver operating characteristic curve in table 6 and figure 1 demonstrates the exceptional diagnostic capability of the Transport Risk Index of Physiological Stability scoring system in predicting mortality outcomes among critically ill transported neonates. The area under the curve of 0.987 positioned in the upper left corner represents outstanding discriminatory performance, substantially surpassing conventional clinical assessment thresholds and establishing the TRIPS score as a highly reliable prognostic instrument. At the optimal threshold of >35, the scoring system achieves perfect sensitivity (100.0%) while maintaining excellent specificity (94.7%), indicating that all neonates who experienced mortality were correctly identified while minimizing false positive classifications among survivors. This exceptional performance profile validates the clinical utility of the TRIPS score for early risk stratification, therapeutic decision-making, and parental counseling in the neonatal transport setting. The near-perfect curve trajectory reflects the robust physiological foundation underlying the TRIPS scoring methodology, incorporating critical parameters including temperature regulation, cardiovascular stability, respiratory function, and neurological responsiveness that collectively determine neonatal survival probability during interfacility transport.

The predominance of male neonates (58.5%) in this cohort aligns with observations by Reddy et al. (2024), who reported a similar male preponderance in out-born transfers.¹¹ In our study, male infants demonstrated significantly higher survival (97.4% vs. 89.2%, p=0.015) and more favourable TRIPS scores (≤20 in 82.1% vs. 57.8%, p=0.001), suggesting potential sex-related resilience or differential referral patterns. Low birth weight emerged as a critical determinant of outcome. Extremely low birth weight (ELBW) neonates experienced a 37.5% mortality rate (p=0.001). This finding concurs with Grass et al. (2020), who documented 30% mortality among ELBW infants and significant neuro-developmental impairments in survivors.¹² Similarly; Carballo Flores (2021) reported that lower birth weight was strongly associated with transport-related deterioration.⁶

Physiological derangements on arrival—namely hypotension, hypoglycaemia, bradycardia, and hypoxia—were potent predictors of mortality. Infants with systolic blood pressure <20 mmHg had 66.7% mortality (p=0.001), mirroring the high mortality observed in hypotensive neonates by Mukhmetshin et al. (AUC 0.831 for mortality prediction).⁵ Likewise, hypoglycaemia (<50 mg/dL) conferred 33.3% mortality (p=0.001), consistent with the 40% mortality reported by Shah et al. for hypoglycaemic neonates.¹⁰ Mehta et al. found 20% of 160 neonates with heart rate abnormalities, with 30% mortality, reinforcing the prognostic significance and noted 35% of 160 neonates with tachypnea, with 25% complication rates, supporting the illness severity. ¹³

The 100% mortality in bradycardic infants (<100 bpm) underscores the critical nature of cardiac monitoring, a risk highlighted by Olukemi et al., who found that bradycardia was associated with 22% mortality in Nigerian tertiary referrals.¹⁴ Respiratory compromise was also a significant risk factor: tachypnoea (>60 breaths/min) correlated with higher TRIPS scores (p=0.030), though not directly with mortality, reflecting findings by Karmegaraj et al., who observed that respiratory distress intensified post-transfer morbidity but did not independently predict death when managed promptly.¹⁵ Nevertheless, 36% of our cohort required mechanical ventilation, underscoring the importance of respiratory stabilization during transit.

The TRIPS score demonstrated exceptional prognostic utility, with an AUC of 0.987 (p<0.0001) and an optimal cut-off >35 yielding 100% sensitivity and 94.7% specificity. This performance surpasses earlier reports by Lucas da Silva et al.  (AUC 0.80) and aligns with the high accuracy reported by Reddy et al., validating TRIPS as a robust triage tool for early risk stratification.^2,11 Transport logistics—vehicle type and duration—did not significantly impact outcomes in our study, diverging from Arora et al., who linked longer transfers to increased deterioration in VLBW infants.¹⁶ This discrepancy may reflect regional differences in pre-transport stabilization protocols or ambulance equipment standards. However, only 61% of transports utilized public ambulances, and 45% lacked referral letters, indicating persistent system gaps that mirror the 55% documentation deficit noted by Dalal et al.¹⁷ The presence of skilled personnel and oxygen support in 74% of transports correlated with higher TRIPS scores (p=0.013 and p=0.024, respectively), suggesting that critical cases were appropriately allocated enhanced resources. Shah et al. similarly emphasized the role of trained teams and oxygen therapy in mitigating transport-related risk.¹⁰

Limitations: Include the single-centre design and convenience sampling, which may constrain generalizability. The absence of pre-transport TRIPS scores prevented analysis of deterioration during transit. Short follow-up restricted outcome assessment to 48 hours, without long-term neuro-developmental data. Missing referral letters in 45% of cases introduced potential information bias.

This study confirms that physiological instability on admission—particularly hypotension, hypoglycaemia, bradycardia, and hypoxia—pretend higher mortality in transported neonates. The TRIPS score exhibits outstanding predictive accuracy and should be integrated into referral and transport protocols. Addressing documentation gaps, ensuring skilled personnel and oxygen availability, and standardizing pre-transfer stabilization are critical steps to enhance neonatal transport safety and improve survival outcomes.

Recommendations

1. Implement standardized pre-transport stabilization protocols (e.g., STABLE, SAFER) across referring centres to optimize physiological parameters before departure.
2. Mandate comprehensive referral documentation, including TRIPS score and clinical summary, to facilitate continuity of care.
3. Equip all neonatal ambulances with essential monitoring and life-support devices—particularly ventilators—and ensure 24/7 availability.
4. Train dedicated neonatal transport teams, comprising neonatal nurses and physicians, with regular simulation-based competency assessments.
5. Integrate real-time telemedicine support between transport crews and receiving NICUs to guide in-transit interventions.

Relevance of the Study: By validating the TRIPS score’s high predictive accuracy (AUC=0.987) in an Indian tertiary-care setting, this research underscores its utility for risk stratification during neonatal transfers. The identification of modifiable risk factors—such as hypothermia, hypoglycaemia, and hypotension—provides actionable targets for transport protocol enhancement, ultimately aiming to reduce neonatal morbidity and mortality in resource-limited contexts.

Authors’ Contributions

All authors contributed substantially to study conception, data collection, analysis, and manuscript preparation. The corresponding author takes responsibility for the integrity of the work and accuracy of data analysis.

Ethical Consideration: The study received approval from the Institutional Ethics Committee of M.G.M. Medical College, Indore. Written informed consent was obtained from all parents or legal guardians. Participants confidentiality was maintained throughout the research process.

Financial Support and Sponsorship: This research was conducted as part of academic requirements without external funding support.

Conflicts of Interest: The authors declare no conflicts of interest related to this research.

1. Srivastava S, Upadhyay SK, Chauhan S, Kumar P, Yadav R, Mishra P, et al. Preceding child survival status and its effect on infant and child mortality in India: An evidence from National Family Health Survey 2015–16. BMC Public Health. 2021; 21:1577.
2. Lucas da Silva PS, Euzébio de Aguiar V, Reis ME. Assessing outcome in interhospital infant transport: the transport risk index of physiologic stability score at admission. Am J Perinatol. 2012;29(7):509–14.
3. Steenhoff AP, Coffin SE, Kc A, Nakstad B. Editorial: Neonatal health in low- and middle-income countries. Now is the time. Front Pediatr. 2023; 11:1168915.
4. Akhter M, Pervez M, Sultana SN, Haque M, Abdul Kadir M, Bhuiyan MFH, et al. Factors affecting the outcome of neonatal transport in a tertiary care hospital in Bangladesh. Int J Contemp Pediatr. 2025;12(3):356–61.
5. Mukhametshin RF, Davydova NS, Kinzhalova SV. Assessing the predictive value of TRIPS in newborns. Messenger Anesthesiol Resusc. 2021;18(4):73–9.
6. Flores RC. Aplicación del score TRIPS en los neonatos que requieren traslado interhospitalario. Interdiscip Rehabil. 2021; 1:5.
7. Richardson DK, Gray JE, McCormick MC, Workman K, Goldman DA. Score for neonatal acute physiology: a physiologic severity index for neonatal intensive care. Pediatrics. 1993;91(3):617–23.
8. Parry G, Tucker J, Tarnow-Mordi W. CRIB II: an update of the clinical risk index for babies score. Lancet. 2003;361(9371):1789–91.
9. Lee SK, Zupancic JA, Pendray M, Thiessen P, Schmidt B, Whyte R, et al. Transport risk index of physiologic stability: a practical system for assessing infant transport care. J Pediatr. 2001;139(2):220–6.
10. Shah DM, Bhuvaneswari GR. Utility of transport risk index of physiological stability score for predicting likely outcome of extramural neonates transferred to NICU. Int J Contemp Pediatr. 2020;7(5):1081.
11. Reddy NM, Athreya R. Assessing clinical profile and short-term outcomes of neonates retrieved by neonatal transport service and their co-relation with neonatal severity illness scores: an observational study. J Neonatol. 2024;38(4):548–54.
12. Grass B, Ye XY, Kelly E, Synnes A, Lee S. Association between Transport Risk Index of Physiologic Stability in extremely premature infants and mortality or neurodevelopmental impairment at 18 to 24 months. J Pediatr. 2020; 224:51–6. e5.
13. Mehta N, Sharma MK. Correlation of acute physiological parameters with immediate outcome among neonates transported to special care newborn unit: A prospective study. Indian J Child Health (Bhopal). 2018 Jan 25;05(04):280–3.
14. Olukemi T. Immediate outcomes of neonatal transport in a tertiary hospital in southwest of Nigeria. Glob J Pediatr Neonatal Care. 2020;2(1).
15. Karmegaraj B, Kappanayil M, Sudhakar A, Kumar RK. Impact of transport on arrival status and outcomes in newborns with heart disease: a low-middle-income country perspective. Cardiol Young. 2020;30(7):1001–8.
16. Arora P, Bajaj M, Natarajan G, Arora NP, Kalra VK, Zidan M, et al. Impact of interhospital transport on the physiologic status of very low-birth-weight infants. Am J Perinatol. 2014;31(3):237–44.
17. Dalal E, Vishal G, Solanki D. Study on neonatal transport at tertiary care centre. Int J Sci Res. 2013;2(12):288–92.