The inter-hospital transfer of pediatric surgical patients represents a critical juncture in the continuum of care for children with complex or life-threatening conditions. Unlike routine medical transfers, surgical transfers often involve neonates and infants with congenital anomalies, traumatic injuries, or emergent surgical pathologies that require timely access to specialized operative and postoperative resources not available in all healthcare settings [1]. The efficiency and safety of these transfers are not merely logistical challenges but are directly linked to clinical outcomes, including reduced morbidity, mortality, and long-term disability [2].

In recent years, the trend toward regionalization of pediatric surgical care has intensified, with high-acuity cases increasingly centralized at designated children’s hospitals or specialized pediatric surgical centers [3]. This model, while improving outcomes for complex cases, inherently increases the volume and distance of patient transfers. Consequently, the transfer system itself becomes a vital component of the regional healthcare infrastructure, requiring coordination among emergency medical services, referring hospitals, and receiving specialty units.

Despite its importance, there is a relative paucity of detailed analyses focusing specifically on the surgical pediatric transfer population. Most existing literature either amalgamates medical and surgical transfers or focuses exclusively on neonatal transfers without stratifying by surgical need [4]. Understanding the unique demographics, clinical profiles, and resource utilization patterns of surgical transfers is essential for several reasons: it informs the training and composition of transport teams, guides the allocation of specialized equipment (e.g., transport ventilators, surgical resuscitation kits), and helps design predictive models for bed management in receiving hospitals.

This study aims to fill this gap by providing a detailed retrospective analysis of all pediatric surgical transfers to a major tertiary children’s medical center over a nine-month period. We will systematically examine the origins of these transfers, the clinical characteristics of the patients, the intensity of care required during transit, and their final destinations within the hospital. By doing so, we seek to achieve three primary objectives: first, to delineate the epidemiological and clinical landscape of pediatric surgical transfers; second, to assess the alignment between patient needs and existing transfer system capabilities; and third, to generate actionable insights for optimizing transfer protocols, enhancing inter-hospital communication, and ultimately improving the quality and safety of care for this vulnerable patient population during a critical phase of their treatment journey.

During the nine-month study period, a total of 1552 inter-hospital transfers were recorded by our center. After applying the inclusion and exclusion criteria, 408 pediatric surgical transfer cases were identified and constituted the final analytic cohort for this study.

This study provides a detailed epidemiological and clinical snapshot of pediatric surgical transfers to a major tertiary referral center. Our findings illuminate several key characteristics of this patient flow and have important implications for the organization of regional pediatric surgical care, transport system design, and hospital resource planning.

The Central Role of Tertiary Hospitals and Regional Networks

The observation that over 70% of transfers originated from other tertiary hospitals is particularly noteworthy [5]. This finding challenges a simplistic model where transfers flow primarily from lower-level hospitals to higher-level centers. Instead, it suggests a complex referral network among tertiary institutions, likely driven by sub-specialization. For instance, a tertiary general hospital may transfer a neonate with complex congenital heart disease to a pediatric cardiac surgery center. This underscores the concept of “centers of excellence” within pediatric surgery and highlights the need for seamless coordination and established referral pathways between tertiary institutions themselves, not just from primary/secondary to tertiary levels. The significant inter-provincial transfer volume (14.2%) further solidifies our center’s role as a national-level referral hub, necessitating robust systems for long-distance transport coordination and family support.

The Dominance of the Neonatal and Infant Population

The overwhelming predominance of neonates and infants (80.4% under 1 year) in surgical transfers aligns with the epidemiology of major surgical conditions in childhood, which are often congenital or present early in life [6]. This concentration has profound implications for transport teams, which must be exceptionally proficient in neonatal physiology, thermoregulation, vascular access, and the management of conditions like pulmonary hypertension and patent ductus arteriosus. The transport vehicle and equipment must be specifically configured for this age group. Furthermore, this demographic trend reinforces the argument for integrating neonatal and pediatric critical care transport teams or ensuring deep cross-training.

Spectrum of Disease and Implications for Preparedness

The diagnostic profile reveals a heavy burden of congenital anomalies (cardiac, gastrointestinal) and surgically correctable conditions of prematurity (e.g., NEC, ROP). The high prevalence of congenital heart disease and intracranial hemorrhage, both conditions prone to acute decompensation, partly explains the substantial need for advanced respiratory support during transfer. The finding that nearly one-quarter of patients required invasive ventilation is a critical metric for system planning. It mandates that transport teams are not merely “scoop and run” services but are mobile intensive care units, staffed by personnel skilled in advanced airway management, ventilator management in motion, and the use of inotropes and sedatives [7]. The concurrent need to be prepared for a wide variety of surgical pathologies—from trauma to oncology—requires transport teams to have broad knowledge and adaptable protocols.

Resource Allocation and Receiving Unit Coordination

The distribution of patients directly into intensive care units (NICU, SNICU, PICU, CICU, SICU) for the majority (80.2%) of arrivals places significant pressure on these high-acuity resources. It necessitates very close communication between the transport team, the transfer center, and the receiving ICU bed managers to ensure a bed is available upon arrival. Delays at this interface can negate the benefits of a timely transfer. The data argue for predictive modeling that incorporates surgical transfer patterns into daily ICU capacity planning. Furthermore, the fact that 16.4% went directly to a surgical ward suggests a subset of transfers are for elective or semi-elective complex operations. Optimizing scheduling and pre-transfer workup for these patients could improve efficiency and reduce last-minute strains on the system [8].

Limitations and Future Directions

This study has several limitations. Its single-center, retrospective design limits generalizability. We did not collect data on transfer times, distances, en-route complications, or ultimate clinical outcomes (e.g., mortality, postoperative complications), which are crucial for a full assessment of system effectiveness. The “Other” diagnostic category remains heterogeneous and merits further sub-analysis.

Future research should focus on multi-center collaborations to validate these patterns across different healthcare systems. Prospective studies linking transfer characteristics (e.g., team composition, pre-transfer stabilization) to patient outcomes are essential [9]. Additionally, qualitative studies exploring the decision-making process of referring surgeons and the challenges faced by transport teams could provide rich insights for process improvement. Investigating the cost-effectiveness of different transport modalities (ground vs. air) for specific surgical diagnoses would also be valuable for resource stewardship.

This analysis delineates the pediatric surgical transfer population as predominantly neonatal, critically ill, and originating from within a complex network of tertiary hospitals across a wide geographic region. The high acuity is evidenced by the frequent need for invasive respiratory support and direct ICU admission. These findings underscore that pediatric surgical transfer is a specialized discipline distinct from general pediatric or adult transfer. To meet the needs of this vulnerable population effectively, healthcare systems must invest in: 1) SpecializedTransport Teams with expertise in neonatal/pediatric critical care and surgery; 2) Enhanced Telemedicine Infrastructure to facilitate pre-transfer consultation and stabilization, particularly for long-distance referrals; 3) Standardized Regional Protocols for triage, communication, and handover between referring and receiving centers, especially given the high volume of transfers originating from other tertiary hospitals; and 4) Integrated Bed Management Systems that anticipate the high ICU utilization from surgical transfers. By addressing these areas, we can strengthen the vital link that inter-hospital transfer represents in the chain of survival and recovery for children requiring surgical care.

Qiang Wang contributed to the conception of the study, literature review, and drafting of the manuscript. YonglingSong and Yan Hong provided clinical expertise, participated in data interpretation. YanhuanMao and YongxianLiang participated in data collection, validation, and database management. Zihao Tan and Rong Chen was responsible for the data curation, and performed the statistical analysis. GuangmingLiu contributed to revising the manuscript.

The authors extend their sincere gratitude to the physicians, nurses, and healthcare professionals of the specialized transport team at the Guangzhou Women and Children’s Medical Center, whose exceptional skills and compassionate care have made these complex transfers possible. We also express our heartfelt appreciation to our colleagues from the Departments of Pediatric Surgery, Neonatology, Pediatric Intensive Care, Anesthesiology, and the Emergency Transfer Center for their collaborative support. Their seamless cooperation serves as the cornerstone of an efficient transfer system.

All data generated or analyzed during this study are included in this published article.

The study was supported by the Guangzhou Municipal Science and Technology Bureau Project (Grant No. 2025A03J4385)—Establishment of a Regional Critical Care Pediatric Transport System and Its Application in Pertussis Case Transfers.