CHHS14/038 Canberra Hospital and Health Services Clinical Procedure Inter-Hospital Transfer – Patients Requiring Intensive Care (Adults, Paediatrics and Neonates) Contents Contents..................................................... 1 Purpose...................................................... 2 Scope........................................................ 3 Section 1 – Roles............................................4 Section 2 – Adult Patients Requiring Intensive Care..........9 Section 3 – Paediatric Patients Requiring Intensive Care....18 Section 4 – Neonatal Patients Requiring Intensive Care......22 Implementation.............................................. 24 Evaluation.................................................. 24 Related Policies, Procedures, Guidelines and Legislation....24 References.................................................. 24 Definition of Terms.........................................25 Search Terms................................................ 26 Doc Number Version Issued Review Date Area Responsible Page CHHS14/038 1 October 2014 April 2016 Critical Care 1 of 42 Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
Transcript
CHHS14/038
Canberra Hospital and Health ServicesClinical ProcedureInter-Hospital Transfer – Patients Requiring Intensive Care (Adults, Paediatrics and Neonates)
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Purpose
To provide clear guidance for Canberra Hospital and Health Services staff to follow when arranging and accepting patients requiring intensive care admission at Canberra Hospital.
Referral PrinciplesAll referrals for intensive care management must be made directly to the Intensive Care Consultant on call or delegate at the proposed receiving hospital.1. Patients in ACT hospitals requiring intensive care should be referred initially to the ICU
in their current hospital by their attending doctor. If they are unable to be accommodated within their hospital, referral should be made by the attending doctor to the ICU Consultant on call or delegate in the alternative ACT ICU.
2. For non time critical patients, NSW hospitals will utilise the Critical Care Resource System (CCRS) to locate an ICU bed within NSW. If one is not available then contact an ACT ICU directly prior to contacting Aeromedical Control Centre (ACC) (formerly known as Aeromedical Retrieval Service - AMRS) or Capital Region Retrieval Service (CRRS).
3. NSW hospitals will contact ACC or CRRS for referral of all intensive care patients and activation of retrieval team.
4. In specific cases, the referring Consultant may modify the sequence of the referral process based on clinical assessment and local knowledge.
5. The referring Consultant and Medical Retrieval Consultant/CRRS consultant may decide to refer a patient to a different hospital which is considered more clinically appropriate for definitive care.
6. All time critical patients (i.e. those requiring urgent life or limb saving procedures) will be referred directly to ACC or CRRS without contacting an ICU to negotiate bed availability.
Referral Categories and TypesThe document sets out the processes for the following categories of critically ill patients:1. Time critical tertiary referral to TCH2. Non-time critical tertiary referral to TCH3. Non-tertiary referral to an ICU4. Paediatric referrals (up to age 16), excluding neonatal intensive care referrals5. Super-specialities:
a. Severe burn injuryb. Acute spinal cord injuryc. Extracorporeal membrane oxygenation (ECMO)
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Scope
For the purpose of this procedure paediatric patients are defined as patients under the age of 16 years.
This document sets out the processes relating to patients requiring referral to higher or intensive care within the ACT, and should be used by all clinicians.
Hospitals covered by this document are: The Canberra Hospital (TCH) Calvary Health Care Bruce (CHCB) Calvary John James Hospital (CJJH) National Capital Private Hospital (NCPH) Southern NSW and Murrumbidgee Local Health District Hospitals
For Southern NSW and Murrumbidgee Local Health Districts (SNSWLHD / MLHD) this document should be used in conjunction with: ACT Inter-hospital Intensive Care Patient Transfer Standard Operating Procedure CED
10-011 (see ACT Health policy registry) NSW Health Critical Care Tertiary Referral Networks and Transfer of Care (Adult) Policy
Directive PD2010_021, 30 March 2010 (see appendix 7) NSW Health Critical Care Tertiary Referral Networks (Paediatrics) Policy Directive
PD2010_030, 02 June 2010 NSW Health policy directive Emergency Paediatric Referrals- Policy PD2005_157
Processes by Referral Category and TypeProcesses vary depending on the initial patient location, the level of critical care required and the urgency of transfer; these are listed under the Roles Section and each variation captured in charts 1 through 3 see Adults Requiring Intensive Care Section.
The following are key points relating to the referral categories and types.
For Inter-hospital Transfers 1. The appropriate destination must be agreed in advance.2. For CRRS missions, it is the responsibility of the CRRS consultant to confirm:
a) Acceptance in the destination unit by the relevant consultant (almost always ICU or ED)
b) Bed availabilityc) Accepting inpatient consultantThe CRRS consultant is then responsible for liaising with the ACT Ambulance Service (ACTAS) regarding organising an appropriate vehicle for transfer.
3. For non-CRRS missions:
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If Canberra Hospital is contacted regarding a patient that is either a) intubated, or b) on Inotropes (or likely to be before arrival), it is mandatory that:d) Both the Canberra Hospital ICU consultant & the ED consultant are contacted in
advancee) That the ICU consultant & the ED consultant directly contact each other, before the
patient departs the referring hospital, in order to agree on the appropriate destination
f) The consultant for the agreed destination unit (ICU or ED), is responsible for ensuring all relevant parties are communicated with e.g. accepting inpatient team, interventional radiologist, surgeon etc.
In the event that agreement cannot be reached, the Directors of the two units should be contacted to facilitate a resolution.
It is highly recommended that in complex cases, teleconference involving all the relevant senior staff is used, e.g. via ACC facilities.
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Section 1 – Roles
Referring HospitalInitial stabilisation of patientFor adults If NSW and non time critical utilise CCRS to locate an ICU bed and contact ICU
Consultant on call, if no bed in SNSWLHD available contact ACT ICU or ACC and provide the relevant patient information
If NSW and time critical contact ACC or CRRS to arrange transport to TCH If ACT and time critical, contact CRRS to arrange transport to TCH If ACT, and non-time critical, contact the relevant ICU at TCH or Calvary Health Care
Bruce (CHCB), depending on the referral category, then contact CRRS to arrange transport
For children (< 16 years) If NSW, contact NETS for conference call, advice and coordination of transfer If Calvary Health Care Bruce (CHCB) or Calvary John James Hospital (CJJH), contact NETS
for conference call, advice and coordination of transfer Provide all patient information necessary for triage
Aeromedical Control Centre (ACC)Contact number 1800 650 004
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Contact for all Southern NSW and Murrumbidgee LHD hospitals for critically ill adult patients (> 15 years) if unable to locate an ICU bed utilising Critical Care Resource System (CCRS)
Assistance with ICU bed availability when usual tertiary referral hospital ICU beds are unavailable
Contact point in NSW for ACT, if no bed available in ACT Mobilisation of an appropriate retrieval or transport service for the critically ill patient Facilitate all adult severe burn injury, adult acute spinal cord injury and extracorporeal
membrane oxygenation (ECMO) referrals ACC is not responsible for finding beds of non-critically ill patients who require referral
for a higher level of specialist care 1
Capital Region Retrieval Service (CRRS) Contact number 1300 873 711 Point of contact in ACT for ACC retrievals Liaise with referring hospital and relevant ACT ICU about transfer arrangements Triage the patient Arrange appropriate transport of the critically ill patient Liaise with ACC, if no bed available in ACT
The Canberra Hospital (TCH), Intensive Care Unit Contact number for Outreach Consultant 0401691574 Tertiary referral centre, Level 6 ICU (adults) for ACT and Southern NSW and
Murrumbidgee LHDs Care of critically ill adult patients requiring immediate emergency treatment:
o Trauma (Canberra Hospital is the major tertiary trauma service for Southern NSW and may receive patients from Murrumbidgee, see NSW State Trauma Plan 2,5 )
o Neurosurgeryo Cardiac surgeryo Vascular surgery
Initial stabilisation of patient with severe burn injury, prior to transfer to NSW Severe Burn Injury Service
Initial stabilisation of patient with acute spinal cord injury, prior to transfer to NSW State Spinal Cord Injury Service
Interim care of paediatric patients older than 2 years prior to transfer to the NSW Newborn and Paediatric Emergency Transport Services (NETS)
Invoke ICU escalation plan if required
Calvary Health Care Bruce (CHCB) Intensive Care Unit Contact number 6201 6097 Non-tertiary, general intensive care Level 4, with the exception of:
1 NSW Critical Care Tertiary Referral Networks and Transfer of Care (Adults) PD2010_0212 NSW Critical Care Tertiary Referral Networks and Transfer of Care (Adults) PD2010_021Doc Number Version Issued Review Date Area Responsible PageCHHS14/038 1 October 2014 April 2016 Critical Care 5 of 28
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Trauma Neurosurgery Cardiac surgery Vascular surgery Invoke ICU escalation plan if required
NSW Statewide Burn Injury Service3
Contact through ACC on 1800 650 004 ACT utilises the Statewide Burn Injury Service Referral Network located at Concord
Repatriation General Hospital and Royal North Shore Hospital for adults and The Children’s Hospital at Westmead for children
Adult patients from the ACT and SNSWLHD and MLHD are referred to Concord Repatriation General Hospital. For contact details see table on page 12 for advice and to arrange retrieval contact ACC
Children requiring attention for severe burn injury will be cared for at The Children’s Hospital at Westmead (CHW), contact CHW for advice and contact NETS for retrieval on 1300 362 500
NSW State Spinal Cord Injury Service (SSCIS)4
Contact through ACC on 1800 650 004 Responsible for management of adults who have sustained a spinal cord injury*, with
evidence of damage to the neural tissues as a result of trauma from a non- progressive disease (e.g. transverse myelitis, vascular occlusion,
compression by infective process or haemorrhage)
NOTE: Patients with vertebral fractures are to be referred to a spinal orthopaedic surgeon or neurosurgeon via the existing referral process for each health service. Progressive conditions such as demyelinating and degenerative conditions of the spinal cord, metastatic lesions or congenital disorders are not the province of the SSCIS
NSW Extra Corporeal Membrane Oxygenation (ECMO) Medical Retrieval Service5
Contact through ACC on 1800 650 004 Indications for ECMO support: patients with potentially reversible, life-threatening
respiratory and/ or cardiac failure that are not responding to maximal conventional therapy
NSW Newborn and Paediatric Emergency Transport Services (NETS) – for patients under 16 years of age Contact on 1300 362 500
3 NSW Critical Care Tertiary Referral Networks and Transfer of Care (Adults) PD2010_0214 See 55 See 5Doc Number Version Issued Review Date Area Responsible PageCHHS14/038 1 October 2014 April 2016 Critical Care 6 of 28
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State-wide emergency service for medical retrieval of critically ill newborns, infants and children (under 16 years of age) in NSW and ACT
Tertiary Default ICU Matrix, ACT and SNSWLHD/ MLHDA default tertiary referral hospital is the hospital responsible for a group of referring hospitals. The default hospital provides critical care irrespective of bed status, if no other appropriate ICU bed can be located. Information in this appendix is based on NSW Health Critical Care Tertiary Referral Networks (Adult) Policy Directive 2010 (PD2010_021)
The Canberra Hospital is default tertiary referral hospital for:
ACT Hospitals SNSWLHD/ MLHDCalvary Health Care BruceNational Capital PrivateJohn James Calvary Private
Bateman’s BayBatlowBegaBombalaBraidwoodCooma
DelegateMoruyaPambulaQueanbeyanTumutYass
Prince of Wales Hospital is default tertiary referral hospital for:
South Eastern Sydney Local Health District
SNSWLHD/MLHD
Prince of Wales (Private) BoorowaCrookwellGoulburn
Murrumburrah- HardenYoung
St Vincent’s Hospital is the default tertiary referral hospital for:
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St George Hospital is the default tertiary referral hospital for:
South Eastern Sydney Local Health District
MLHD
Kareena (Private)SutherlandSt George (Private)Wollongong
Albury*BarhamBerriganCorowaCulcainDeniliquin
FinleyHentyHolbrookJerilderieTocumwalUrana
*Albury is networked with clinical services in Victoria however referral to a NSW facility may be required due to clinical need
Southern NSW Local Health District Map Murrumbidgee Local Health District
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Section 2 – Adult Patients Requiring Intensive Care
Time Critical Referral to TCH
Chart 1: Time Critical Tertiary Adult ICU Referral - ACT and SNSWLHD/MLHD
Where a patient is critically ill and requires immediate emergency treatment, that patient must be transferred immediately to the nearest designated appropriate facility, irrespective of bed status.
Arrangements for transfer to the tertiary ICU can be addressed following or during the initiation of emergency care.
Patients should be transferred to the safest location in the receiving hospital, whilst minimising bed transfers and handovers, unless a more appropriate destination has been agreed upon with the ED, ICU and retrieval consultants. For example:a) Emergency department to emergency department b) (Neonatal or Adult) Intensive care unit to intensive care unitc) Cardiac Catheter lab, etc
Destination unit for Inter-hospital transfers:The following principles & examples are not exhaustive, but give guidance as to the appropriate destination unit:1. A patient on invasive ventilation, or on Inotropes should go directly to the ICU (e.g.
pneumonia/septic shock on Inotropes), unless they fit the categories below, or there is a clear benefit for initial management in the ED.
2. A patient, whose diagnosis and management plan is genuinely not clear, is best assessed in the ED initially (e.g. unconscious unclear cause, from a peripheral hospital without CT scanner).
3. All multitrauma patients within 48 hours of injury must go to the ED initially.
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4. The ICU & ED consultants should liaise and consider other issues such as extreme occupancy or activity in either area, bed availability, and overall what is in the best interests of the patient.
5. A patient who is ventilated with a confirmed non-multitrauma intracranial neurosurgical diagnosis (e.g. SAH), should go directly to ICU on arrival, unless there are exceptional circumstances.
Critically ill patients with any of the following diagnoses could be considered for immediate transfer to TCH Multi-trauma Neurotrauma Intracranial haemorrhage Unstable acute coronary syndrome Emergency cardiac surgery Acute vascular condition
The initial stabilisation of severe burns and acute spinal cord injury prior to transfer to the NSW Clinical Super-Specialty Service (see section 5 below)
Non-time Critical Tertiary Referral to an ICUCritically ill patients who require intensive care treatment at designated tertiary facility due to the need for speciality or sub-speciality services such as neurosurgery.
This category includes patients requiring investigations that are available only at the tertiary facility i.e.: Magnetic Resonance Imaging.
Refer to charts 2 and 3 below.
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Chart 2: ACT – Non-time critical ICU Bed required (no ICU bed available in referring hospital)
Chart 2A: ACT - Where tertiary bed required but not available at TCH on initial contact
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Tertiary ICU required
Non-tertiary ICU required
No bedavailable
Patient stays atreferring hospital
Referring Hospital Contact CRRS to arrange
transport
Patient transported to Calvary ICU
Bed available
Referring HospitalContact CRRS to arrange
transfer
Patient transported to TCH ICU
Referring Hospital Contact Calvary Speciality
for acceptance of care
CRRSNotify receiving hospital and
arrange transport
CRRSNotify referring hospital and arrange transport
2B2A
ACT Referring HospitalContact TCH Speciality for
acceptance of care
ACT Referring Hospital Contact Calvary ICU for
bed
No bed available
Care accepted
Referring Hospital Contact TCH ICU for bed
Bed available
Care accepted
Referral not appropriate
Referral not appropriate
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Chart 2B: ACT - Where non-tertiary bed required but not available at Calvary
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Chart 3: SNSWLHD/MLHD- Adult ICU Bed required (no ICU bed available in referring hospital) non time critical
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Non-tertiary Referral to an ICUCritically ill patients who require intensive care treatment which do not require tertiary level speciality services.
See charts 2 and 3, above.
Super-Speciality Referral Networks: Severe Burn Injuries, Acute Spinal Cord Injuries and Extracorporeal Membrane OxygenationACT Health services work in conjunction with the NSW Health Super-Speciality Referral Networks.
ACC is to be contacted on 1800 650 004 to facilitate all referrals and transfers for:Adult severe burn injury Adult acute spinal cord injury Adult extracorporeal membrane oxygenation (ECMO)
NOTE: If a patient has multiple injuries patients may be referred to another facility to accommodate the complexity of their injuries.
a. Severe Burn InjuriesSevere burn injuries may be stabilised initially at TCH, and referred to the NSW Statewide Burn Injury Service (Adult) in accordance with the NSW Critical Care Tertiary Referral Networks (Adult) Policy Directive 2010.
Process1. Ensure initial stabilisation*, and then follow the process for time-critical tertiary
referral (see chart 1).2. Contact the Burns Registrar/Consultant at Concord Repatriation General Hospital on
9767 5000, then page3. Contact ACC to arrange transfer to receiving hospital in accordance with the
guidelines listed below.
NOTE: Complete steps 2 and 3 as early as possible, preferably while the patient is being stabilised.
NSW GuidelinesInitial care and referral should be provided according to the “NSW Severe Burn Injury Service – Burn Transfer Guidelines available at Burn Transfer Guidelines - NSW Severe Burn Injury Service - 2nd Edition - NSW Department of Health
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The Children’s Hospital at Westmead ICU (02) 9845 1171 or via NETS
b. Acute Spinal Cord Injury Acute spinal cord injury patients may be stabilised initially at TCH ICU and referred to the NSW State Spinal Cord Injury Service (SSCIS) for ongoing care and rehabilitation in accordance with the NSW Critical Care Tertiary Referral Networks (Adult) Policy Directive 2010.
Process1. Ensure initial stabilisation, following the process for time-critical tertiary referral
(see chart 1)
2. Liaise with TCH Surgeon re timing of referral to SSCIS
3. Contact the SSCIS at Prince of Wales Hospital on 9382 2222
4. Contact ACC to arrange transfer to receiving hospital
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Referring Health Service Receiving Spinal Cord Injury Hospital
ACTSNSW LHD/ MLHD
Prince of Wales Hospital Director
Ph: (02) 9382 2222Secondary Receiving HospitalRoyal North Shore Hospital Head of Department
Ph: (02) 9926 7111Paediatric Referrals Facilitation of Care
Call NETS 1300 362 500
c. Extra Corporeal Membrane Oxygenation (ECMO) St Vincent’s Hospital and Royal Prince Alfred Hospital, in collaboration with ACC, provide the ECMO referral and transfer service and ECMO retrieval team on alternate weeks. ACC is notified of the active ECMO referral service. To organise the referral and transfer of a patient requiring rescue ECMO the following steps and conditions must be adhered to:1. Early notification of a patient potentially requiring referral for ECMO is essential and
should be undertaken in accordance with the following Indications for ECMO referral
6
6 NSW Critical Care Tertiary Referral Networks & Transfer of Care (Adults) PD2010_021Doc Number Version Issued Review Date Area Responsible PageCHHS14/038 1 October 2014 April 2016 HCID 16 of 28
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Absolute contraindications to all forms of ECMO Significant pre-existing co-morbidity, such as irreversible neurological condition,
cirrhosis with ascites, encephalopathy, history of variceal bleeding, active malignancy with predicted limited survival, HIV.
Relative contraindications to all forms of ECMO Age > 65 Multiple trauma with uncontrolled haemorrhage Multiple organ failureAbsolute contraindications to veno-venous ECMO (for respiratory failure) Pulmonary hypertension (mPAP>50mmHg) Severe right or left heart failure (EF<25%) Cardiac arrestRelative contraindications to veno-venous ECMO High pressure, high FiO2 IPPV for >1 weekRelative contraindications to veno-arterial ECMO (for cardiac failure) Severe aortic valve regurgitation Aortic dissectionRelative contraindications to veno-arterial ECMO Severe peripheral vascular disease
2. Initial contact is with ACC who will then contact the active ECMO service (either the on-call General Intensive Care consultant at RPAH or the Cardiac Intensive Care consultant at SVH). The receiving hospital’s ICU consultant would then discuss the case with the referring clinician, on-call cardiac surgeon and medical perfusionist.
3. The destination hospital (either SVH or RPAH) will be determined according to the patients underlying condition, required clinical/surgical intervention and access to an available ICU bed.
d. Contact NumbersCRRS: 1300 873 711ACC, NSW: 1800 650 004NETS, NSW and ACT: 1300 362 500TCH ICU: (02) 6244 3300Calvary Health Care ICU: (02) 6201 6097
e. GovernanceThe ACT Intensive Care Network is responsible for the development of these guidelines, their implementation and reporting structure. Changes to the document are reported by the ACT Intensive Care Network to the ACT Critical Care Taskforce. Incidents are reported to ACT Health through the incident management reporting system RiskMan.
f. Reporting Intensive Care Activity in the ACTEach month, ICU directors will report intensive care activity to the ACT Intensive Care Network.
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Reports will contain data on activity, referrals, refusals and transfers and will be collected through the reporting systems of both Intensive Care Units and the Capital Region Retrieval Service database. The Intensive Care Network will discuss details of all appropriate refusals and any findings referred from the Health Inter-agency Clinical Review Committee (HICRC) on reported incidents relating to inter-hospital transfers of ICU patients. Areas of concern raised by the Network will be investigated by the relevant hospital reporting back to the network with possible solutions.
g. Review of GuidelinesThe ACT ICU Network Coordinator will review these guidelines every 12 months after promulgation, to ensure currency and alignment with practices and policies in the ACT and SNSWLHD and MLHD.
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Section 3 – Paediatric Patients Requiring Intensive Care
Paediatric (under 16 years of age) Referrals to an ICUNOTE: NETS are to be contacted for any paediatric transfer/retrieval. To contact NETS call: 1300 362 500 Also see: http://www.nets.org.au/
ACT Hospitals: Calvary Health Care Bruce and Calvary John James Hospital1. Contact NETS for advice and coordination of retrieval and transfer to appropriate paediatric
intensive care facility.
2. If TCH ICU is not able to accept the patient transfer to Sydney Children’s Hospital or The Children’s Hospital at Westmead may occur.
Canberra Hospital1. Paediatric patients at TCH who require intensive care should be referred to the ICU if older than
2 years and to the Neonatal Intensive Care Unit (NICU) if under 2 years.
2. If ICU or NICU are unable to accommodate the patient referral to a Paediatric ICU will be required through NETS.
Southern NSW and Murrumbidgee LHD Hospitals1. Contact NETS for advice and coordination of retrieval and transfer
2. Transport may be provided by:
a. NETS (NSW) team for newborns or children
b. NETS (Victoria) for newborns and small infants (Riverina Hospitals in MLHD) contact on 1300 137 650 .
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For further information regarding NSW Referral Networks for Paediatrics see “NSW Health Critical Care Tertiary Referral Networks (Paediatrics)” PD2010_030 at www.health.nsw.gov.au or Critical Care Tertiary Referral Networks (Paediatrics) - NSW Department of Health
Paediatric Patients within CHHS requiring Intensive CareThis section pertains to paediatric patients within CHHS. Paediatric patients requiring intensive from outside CHHS should not be accepted but referred through NETS to the closest Paediatric Hospital with a Paediatric Intensive Care unit.
Contact NETS for advice and coordination of retrieval and transfer Transport may be provided by:a. NETS (NSW) team for newborns or children on 1300 352 500b. NETS (Victoria) for newborns and small infants (Riverina Hospitals in MLHD) contact on
1300 137 650 .
For further information regarding NSW Referral Networks for Paediatrics see “NSW Health Critical Care Tertiary Referral Networks (Paediatrics)” PD2010_030 at Critical Care Tertiary Referral Networks (Paediatrics) - NSW Department of Health
All paediatric patients requiring intensive care will be considered on a case-by-case basis depending on age, complexity and urgency of treatment.
All children requiring intensive care services should be referred to the relevant intensive care service and NSW Newborn and Paediatric Emergency Transport Services (NETS) if appropriate, to identify the most appropriate location for ongoing care.
Key decisions about patient movement, disposition and care should be made between all Consultants involved in the care of the patient as early as possible.
The discussion should be on a consultant level and should include: Paediatrics Intensive Care Neonatal Intensive Care Anaesthetics
Canberra Hospital1. All children requiring intensive care services at Canberra Hospital should be referred to
the relevant intensive care unit, dependent on age and complexity to identify the most appropriate location for ongoing care see below for contact details and process for
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referral. If the referral cannot be accommodated within the ACT, referral and transfer to a tertiary paediatric facility should be arranged via NETS.
Contacts for Paediatric Patients requiring Intensive Care at Canberra HospitalAny referral of a Paediatric Patient to Intensive Care must involve the Paediatrician caring for the infant or child
Age group Expected ICU stay
Referral ICU Type of Referral
Contact number
Comment
010months
Undefined Neonatal ICU TCH All For retrievalsNETS1300362500TCH NICU:61747322
Depending on complexity, infant may require transfer via NETS, but may be stabilised in NICU
10months-2years
Undefined Initial consultation NICU TCH then Paediatric ICU transfer via NETS
EmergencyTime Critical
For retrievalsNETS130036250NICU TCH61747322
May stay in ED or require temporary admission to NICU prior to retrieval
2 years - 12 years
Undefined Initial consultation General ICU TCH then Paediatric ICU transfer via NETS
EmergencyTime Critical
For retrievalsNETS1300362500TCH ICU62443300or62442222 ask for ICU Consultant on call
May stay in ED or require temporary admission to General ICU or prior to retrievalElective procedures not referred via NETS
2 years -12 years
24 hours General ICU TCH All For retrievalsNETS1300362500TCH ICU6244330062442222 ask for ICU Consultant on call
Dependent on complexity of patient and resources available
12 years Undefined General ICU TCH All TCH ICU6244330062442222 ask for ICU Consultant on call
Dependent on complexity of patient
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Referral of Paediatric Patients requiring Intensive Care at the Canberra Hospital
Paediatric patient requiring Intensive Care
How old is the child?
YesNo
Patient transferred
Call MET for stabilisation and resuscitation (if child <10 kg call neonatal MET
If child >10 kg call MET)Contact Paediatrician on call
Management of critically ill paediatric patient at TCH
Consider Paediatric Anaesthetic support
contact on call registrar
Contact NETS for retrieval to tertiary
paediatric ICU1300 362 500
Does the Child require long term ICU
or tertiary PICU?
Patient remains in current location
If the patient is greater than 2 years
Contact ICU Consultant on call
If the patient is 2 years or less
Contact Neonatologist see below
Admit to ICU Admit to NICU
Intensive Care Unit6244 3300
Consultant on call via TCH switch
Centre for Newborn CareContact Neonatologist on call
via TCH switch 6244 2222
Emergency Department Admitting Officer
&Paediatrician on call
via TCH switch6244 2222
Consideration to resources includesPaediatric Anaesthetic support
medical staff nursing staff
ICU bedPaediatric education
Bed managementPaediatric
support
Retrieval Services
NETS call 1300 362 500
Capital Region Retrieval Service (CRRS) call via TCH
switch 6244 2222
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2. Any referrals for intensive care management at Canberra Hospital must be made directly to the relevant Intensive Care Consultant or Senior Registrar on call.
3. TCH paediatric patients requiring planned post operative intensive care should be identified by the paediatric surgical team and discussed with the relevant teams, prior to placement on the surgical waiting list.
Calvary Health Care ACT 1. Children who present to the Calvary Hospital Emergency Department and require
intensive care will be referred to NETS. Assistance will be sought from the relevant internal resources such as Intensive Care Unit, Anaesthetics, and Paediatrician on call.a. Where possible the child will be stabilised in the Emergency Department until
transfer to either the Canberra Hospital or a Tertiary Paediatric Hospital occurs. b. In some circumstances such as adolescent patients (greater than 12 years)
presenting at Calvary Hospital, patients may be cared for in the Intensive Care Unit for short term treatment or until transfer can occur. This will be following consultation with NETS and the Paediatrician and Intensive Care Consultant at Canberra Hospital.
2. For any child not at Canberra Hospital the decision to transfer a child to Canberra Hospital prior to retrieval to a tertiary paediatric intensive care unit will not occur until discussion and agreement with NETS.
Southern NSW Local Health District 1. NSW hospitals will contact NETS for referral of all paediatric patients requiring intensive
care.
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Section 4 – Neonatal Patients Requiring Intensive Care
The following neonates are eligible for admission to NICU at CHW&C: Requirement for assisted ventilation (intermittent positive pressure ventilation or
continuous positive airway pressure) Preterm <34 weeks corrected gestation until they meet the criteria for transfer to SCN
or peripheral level 2 nursery/paediatrics Cardiorespiratory monitoring for recurrent apnoea or seizures Monitoring with bedside aEEG Exchange transfusion Extreme systemic illness TPN via central or peripheral line Oxygen requirement >25% crib oxygen Complex multi-system life support Unwell infants up to 2 years of age requiring short term ventilation or stabilization.
Infants requiring longer term intensive care treatment are retrieved via NETS
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The following neonates are eligible for admission to Special Care Nursery at CHW&C: Preterm neonates >34 weeks, >1500gm, not requiring level 3 care who meet the
following criteriao Transient problems requiring cardiorespiratory monitoring / frequent laboratory
investigationso Infants requiring crib oxygen, up to 25% not requiring level 3 care o Infants requiring low flow or micro-low flow oxygeno Infants requiring peripheral IV fluids/antibioticso Convalescing infants recovering from acute problemso Assessment for poor feedingo Jaundiced infants requiring peripheral IV fluid therapy and closer monitoringo Assessment and treatment of NAS, if applicable, until stable o Infants requiring post-operative care following minor surgery
Convalescing infants <34 weeks corrected gestation or < 1500gms may be admitted to the SCN if they meet the following criteria:
Have less than 6 apnoeas/bradycardias per dayo Infants requiring crib oxygen, up to 25% not requiring level 3 care o Infants requiring low flow or micro-low flow oxygeno Infants requiring peripheral IV fluids/antibioticso These infants should be considered for transfer to a peripheral level 2 nursery or
paediatrics if appropriateALERT: Neonates requiring CPAP, high flow and/or TPN must be nursed in the NICU The decision to transfer infants from NICU to SCN will be A collaborative decision between the nursing team leader and the consultant
neonatologist If an infant deteriorates whilst in the SCN they are to be reviewed by the SCN registrar
during the day or NICU registrar after hours. If transfer to NICU is required notify the NICU registrar and CNC/team leader
Department of Neonatology Neonatal Retrieval Team: Neonates requiring care at a Level 3 tertiary facility are transferred to the Centenary
Hospital for Women and Children (CHWC) NICU by ACT NETS or NETS NSW retrieval services.
The decision for NETS ACT to retrieve a neonate is made jointly between the referring medical officer, NETS NSW and the receiving neonatologist from CHWC - NICU
The retrieval process is initiated and coordinated by NETS NSW and the designated CNC/team leader
All retrievals attended by ACT NETS that are outside the 30km radius of the ACT must be approved by the Director of Neonatology
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Implementation
Describe how this guideline or procedure will be implemented and communicated to the affected staff. Examples include incorporated into existing training programs, orientation plans or specific communication strategies eg placed in tea rooms etc.
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Evaluation
Outcome MeasuresAll patients requiring intensive care are transferred and managed in the most appropriate unit.
MethodIncidents reported through Riskman or to the Intensive Care Network. Evaluation will occur on an annual basis by the Intensive Care Network in conjunction with Canberra Hospital, Calvary Health Care ACT, Greater Southern Area Health Service and NETS NSW. The evaluation will be presented to the ACT Critical Care Taskforce annually.
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Related Policies, Procedures, Guidelines and Legislation
PoliciesACT Health Guidelines for Inter-hospital Referral and transfer of Intensive Care Patients ACT Inter-hospital Transfer Protocol CED08-027NSW Health Critical Care Tertiary Referral Networks (Adult) Policy Directive 2006
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References
College of Intensive Care Medicine, Minimum Standards for Intensive Care Units, 2003 www.cicm.org.au
NSW Health Intensive Care Service Plan- Adult Services 2001
NSW Health Critical Care Tertiary Referral Networks (Adult) Policy Directive PD2010_021, 30 March 2010
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NSW Health Critical Care Tertiary Referral Networks (Paediatrics) Policy Directive PD2010_030, 02 June 2010
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Definition of Terms
Critical Care Resource System (CCRS): NSW state wide web based information system
Time critical tertiary referral: those patients who have injuries or conditions require immediate emergency treatment or operation due to the risk of loss of life organ or limb e.g.: multi-trauma, neurological instability, haemodynamic instability.
Non-time critical tertiary referral: those patients requiring tertiary level care, but not at immediate risk of loss of life organ or limb.
Non-tertiary referral: patients requiring intensive care treatment at a level accommodated by level 4 or 5 ICU.7
Emergency: Patient is critically ill requiring high level care as soon as possible and at risk of deterioration.
Elective: Patient is scheduled for planned procedure.
Short Term: 24 hours or less.
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Search Terms
Patient transferInter hospitalAdultsChildrenNeonatesHospital, GeneralIntensive CareCritical CareRetrievalNeonatal Intensive CareNewborn Emergency Transport Service (NETS)
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Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
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Appendix 2: Escalation Plan/s (not referred to in the document)
This diagram sets out the fundamental principles for ACT Intensive Care Units to manage capacity and escalate patients to the appropriate level of care.ICU escalation plans must, at a minimum, address these principles. For information about facility-specific plans, contact the relevant ICU Director or Clinical Nurse Consultant/ Manager.
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Appendix 4: Role Delineation: ACT Intensive Care Services (not referred to in the document)
The Canberra HospitalIntensive Care Unit Level 6
Calvary HospitalIntensive Care Unit Level 4
Tertiary level service Neurosurgery Cardiac surgery Trauma Interventional cardiology Vascular surgeryPlus Regional level services
General intensive care with the exception of: Neurosurgery Cardiac surgery Trauma Interventional cardiology Vascular surgery
Intensive Care levels of care are based on the NSW Health Role Delineation of Services8. Level 6 ICU represents a unit able to provide mechanical ventilation, extra corporeal renal support services and invasive cardiovascular monitoring for an indefinite period. It approximately equates to Level III CICM minimum standards for Intensive Care Units9.
Level 4 ICU represents a unit able to provide mechanical ventilation and simple invasive cardiovascular monitoring for several hours. It approximately equates to Level I CICM minimum standards for Intensive Care Units.
8 NSW Health Intensive Care Service Plan- Adult Services 20019 College of Intensive Care Medicine. Minimum Standards for Intensive Care Units, 2003
www.cicm.org.au
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