Skill List > Interhospital Transfer of Children and Young People (Child)
Clinical Alert
Following on from the NHS review of paediatric intensive care provision in UK (Paediatric Intensive care: Framework for the Future 1997), paediatric intensive care in the UK was centralised, which has resulted in an increased number of children being referred and transported from networks of local hospitals. Current evidence supports that specialist transport services provide a safer service (Ramnarayan et al. 2010) with evidence of fewer critical incidents and improved outcomes after specialist transfer (Bellingan et al. 2000).

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Mosby Nursing Skills
Adapted by: Neil Bloxham RSCN RN
Updated by: Janet Kelsey BSc(Hons) MSc PGCEA AdvDipEd RSCN RN RNT
Last updated: April 2019
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of interhospital transfer of critically ill children.

Introduction

Following on from the NHS review of paediatric intensive care provision in UK (Department of Health 1997 Paediatric Intensive Care: 'A Framework for the Future'), paediatric intensive care in the UK was centralised to 29 paediatric intensive care services, which has resulted in an increased number of children being referred and transported from networks of local hospitals. Current evidence supports that specialist transport services provide a safer service (Ramnarayan et al. 2010) with evidence of fewer critical incidents and improved outcomes after specialist transfer (Bellingan et al. 2000). Hence specialist teams undertake the majority of these transfers, with only 7% conducted by a non-specialist team. In 2013, there were 10,726 unplanned admissions to PICU not after surgery, with 5382 admitted via another hospital and so necessitating a transfer (The Paediatric Intensive Care Audit Network 2014). In most cases, stabilisation before transport is recommended (Samuels & Wieteska 2011). 

The Paediatric Intensive Care Society (2010) defines the standards for specialist paediatric transport teams. These state that the service should have a consultant available 24 h a day, who is not providing cover for the PICU, to advise and join the transport team if necessary. Other healthcare professionals on the team are also required to be appropriately trained in transferring critically ill children. The purpose of interhospital transport is to ensure maintenance of the critical care environment and delivery of the child in a stable or improved condition from the referring to the receiving centre. Transport of critically ill children from one hospital to another is based on the receiving hospital’s ability to deliver a higher level of care (e.g. services that are not available at the referring facility) (Warren et al. 2004) thus enabling improved outcomes for the child. Informed consent may be required before the transfer of a child to another hospital except in the case of a true medical emergency (Insoft & Schwartz 2016, Warren et al. 2004).

Appropriately qualified and competent staff (Paediatric Intensive Care Society 2010) should undertake the transport of critically ill children. The knowledge, skills and attributes of staff should include the following as appropriate to the needs of the child:

  • Understands the principles of safe transfer of patients.
  • Understanding of ambulance/aircraft environment and associated health and safety issues and relevant legislation.
  • Knowledge and competency to carry out paediatric life support (PILS, APLS).
  • Familiarity with all transfer equipment bags and devices.
  • Ability to carry out appropriate nursing observations and nursing care in the transport environment.
  • Ability to plan potential needs of child and communicate within a team.
  • Use of oxygen, respiratory therapies and portable ventilator, basic monitoring (ECG, NIBP, pulse oximetry, invasive monitoring), ventilation. 
  • Ability to care for arterial lines, central lines and other indwelling catheters and to use/access appropriately. Fluid management including the preparation of infusions and the use of syringe pumps.
  • Knowledge of physiology of critical illness and pharmacology of drugs including sedatives, muscle relaxants, inotropes and vasopressors.
  • Ability to calculate the volume of oxygen and medical air cylinder supplies that are necessary based on the child’s requirements and the anticipated duration of transport.
  • Use of appropriate safety devices for the child (e.g. car seat) and crew (e.g. nonflammable uniforms, appropriate weather gear in the event of vehicular breakdown, rubber-soled shoes, helmets, ear protection) in the transport environment (CEN 2007, Hallworth & McIntyre 2003, Insoft & Schwartz 2016, Paediatric Intensive Care Society 2010).
  • Knowledge of the physiological effects of the transfer process and acceleration/deceleration forces in the critically ill.

Transport equipment must (Committee for European Standardization (CEN) 2007):

  • Be portable, sturdy, lightweight, and securable.
  • Be compatible with other equipment (e.g. regulators and hoses).
  • Have AC/DC compatible batteries able to last twice the estimated time of the transport.
  • Be able to withstand vibration, altitude, and temperature changes.
  • Be able to easily access the respective vehicle.
  • Be able to be lifted by two personnel.

The mode of transport choice is dependent on many factors, including: 

  • Urgency of the transfer
  • Condition of the patient
  • Geographical factors
  • Weather conditions 
  • Traffic 
  • Availability 
  • Suitable landing sites at destination, including secondary landing site to hospital and availability of vehicle (where required)
  • Distance.
The risks of inter-hospital transfer include (Insoft & Schwartz 2016, Warren et al. 2004):

  • Vehicle crash
  • Instability of the child’s condition resulting from the change in environment
  • Death resulting from inability to perform needed procedures or surgery because of space and resource limitations.

Patient and family education


  • Give appropriate information to the child and family that is specific for the child’s condition and transfer circumstances.
  • Review the benefits of the services of the accepting hospital with family.
  • Discuss the risks of transport with family.
  • Provide family with directions to and contact numbers for the accepting hospital if they are unable or not permitted to travel with the child. If possible enable a parent to travel with the child.
  • Obtain contact numbers for family.
  • In the event of an ambulance transport, if family members are proceeding in their own vehicle, tell them not to follow the ambulance.
  • Encourage questions and answer questions as they arise.

Preparation and safety

  • Introduce yourself to the child and parent/guardian and confirm the child’s identity.
  • Perform hand hygiene and utilise protective clothing if indicated by the child’s condition.
  • Assess the child’s developmental level and ability to interact.
  • Assess the parent’s or legal guardian’s language skills and preferred language.
  • Assess the child’s and family’s understanding of the reasons for and the risks and benefits of transfer to another hospital.
  • Assess the child’s airway status and risk of respiratory deterioration.
  • Assess the desire of family members to accompany the team during the transport.
  • Ensure the parents see the child before transfer.
  • Assess the child’s level of comfort and anxiety during the transport.

Procedure

  1. Ensure that demographic data, the child’s specific location, and an assessment of the child are communicated to the receiving hospital (Dixon & Crawford 2012, The Paediatric Intensive Care Society 2010).
    Rationale – The receiving hospital requires demographic information in order to admit the child before their arrival. The specific location of the child at the referring hospital is imperative for accurate directions and timely transfer. The child’s dependency and overall condition will dictate the mode of transport and staff required.
    Key required information for the receiving hospital may be accessible as a template through the internet.
  2. Ascertain whether a parent or legal guardian is present.
    Rationale – Consent for transport should be obtained before assuming care for the child unless the situation is a medical emergency and every effort has been made to contact a parent or legal guardian (Dixon & Crawford 2012, Hallworth & McIntyre 2003, Insoft & Schwartz 2016, Warren et al. 2004).
    Ask the parent to stay with the child. If the family needs to go home first, negotiate the time at which the family must be available at the referring facility or obtain verbal consent for the transport.
  3. Select an appropriate transport vehicle and route (Hallworth & McIntyre 2003, Holleran 2010, Insoft & Schwartz 2016).
    Rationale – Promotes the safety of the transport team and child. Appropriately qualified, competent, and experienced staff with equipment appropriate for the transport environment must perform patient transfers.
    When selecting an appropriate vehicle, consider distance, transport time, timely treatment, transport delays, critical care requirements, inaccessible areas, and local ground resources. In the event of an air transport, the pilot decides whether a family member can accompany the team and child. If a family member does not accompany the child, obtain consent and a mobile phone number (if available) before the family leaves to travel to the receiving hospital.
  4. Contact the accepting consultant paediatrician or paediatric intensivist and discuss the child’s status and mode of transport.
    Rationale – The accepting consultant will be able to advise and support the management of the child.
    The receiving nursing team or senior nurse as well as medical staff will be able to support and advise the appropriate management of the child.
  5. Evaluate oxygen and medical air levels in the transport vehicle’s tanks  (CEN 2007, Holleran 2010, Samuels & Wieteska 2011). 
    Rationale – Support of airway and breathing is an essential component of transport care; adequate gas supplies must be available.
    High-flow ventilators or nebuliser systems, distance, and the potential for vehicle breakdown must all be considered in the calculation of the required gas supply. Calculate twice the expected usage in anticipation of unforeseen delay.
  6. Ensure directions to the receiving hospital are obtained and any specific local arrangements (e.g., admission through the emergency department) prior to transfer to the receiving unit/ward. If a road vehicle is being used, satellite navigation may be used; ensure correct destination coordinates or postal code and check for the availability of maps covering the area.
    Rationale – The timeliness of transport depends on accurate directions.
    Ask a team member to sit in front if the driver is unfamiliar with the destination.
  7. Pack special equipment or medications required based on the assessment, management and provisional diagnosis  (Holleran 2010, Insoft & Schwartz 2016). 
    Rationale – Ensures that the transfer team is prepared to care for the child; anticipates the child’s individual care needs.
    The perception of competency in caring for a child may be in doubt if the team is unprepared.
  8. Ensure that the unit from which the transport team originate have details of the team members.
    Rationale – A motor vehicle crash or catastrophic event may occur while the team is en route; promotes team safety.
    The transport team parent unit should have emergency contact numbers for all staff participating in the transport.
  9. If an external transport team is being used, inform the referring unit/hospital of the team’s departure time and estimated time of arrival (ETA). Obtain an update as to the child’s current condition and ask whether the parents are still available.
    Rationale – Facilitates planning on the part of the referring unit/hospital. Parents will need information as to the transport process and destination, and parental consent may need to be obtained on the team’s arrival.
    Lack of or inaccurate ETA may delay a transport if the team arrives and the child is not ready to leave, for example, appropriate drug infusions made up (some teams may not carry drugs or ready-made infusions), waiting at the bedside for notes, charts, and X-rays to be copied.
  10. Turn off the inverter once the transport vehicle’s engine has been turned off and unload the necessary equipment.
    Rationale – Saves the ambulance battery. Maintains an adequate level of care and helps prevent unexpected emergencies; the team must maintain an adequate level of care, with the necessary equipment and medications, for unexpected emergencies between the equipped transport vehicle and the patient and on the way back to the equipped transport vehicle.
    Backup for all critical systems and policies for intervention should be in place in case of power failure and/or ambulance breakdown (Beckmann et al. 2004, Bérubé et al. 2013, Hallworth & McIntyre 2003, Moss et al. 2005, Neill & Hughes 2004). The child’s level of care should never decrease.
  11. Upon arrival at the referring hospital, ensure that the receiving unit/hospital is contacted and updated as to the overall condition of the child and interventions implemented or anticipated.
    Rationale – Facilitates planning at the receiving hospital. Permits all appropriate equipment to be set up at the bedside. Keeps the medical and nursing teams updated regarding the child’s condition.
    Depending on the child’s condition, the transport team may need to make a decision to continue to stabilise and resuscitate, or to proceed if the child is as stable as possible and interventions that are time critical are required that are not available at the referring centre. In most cases, stabilisation before transport is recommended including airway and intravenous access (Beckmann et al. 2004, Holleran 2010, Insoft & Schwartz 2016, Samuels & Wieteska 2011).
  12. Consent for transport and admission may be required from the parent or legal guardian (Holleran 2010, Insoft & Schwartz 2016). 
    Rationale – Ensures medical-legal compliance appropriate to country. Ensures parents are kept up to date.
    Ascertain whether the family member with the child is the actual legal guardian. In an emergency situation, the decision for transport may be taken in the best interests of the child.
  13. If required in the location or country in which the child is a patient, ensure that the referring unit has completed transport consent with the child’s legal guardian.
    Rationale – Ensures medical-legal compliance. Transport consent must be completed by a representative of the organisation that requests transport.
    The legal guardian must be informed of all risks to provide informed consent (e.g., vehicular crash, death, inability to perform surgery on transport).
  14. Offer family directions to and telephone numbers for the receiving unit/hospital.
    Rationale – Decreases family’s anxiety; even if a parent does accompany the child in the transport vehicle, other family members usually drive or are driven to the receiving facility.
    If the parents are upset, consider suggesting that, for their own safety, they find a relative or friend to drive them to the receiving facility. Advise them not to attempt to ‘chase’ the transport ambulance, particularly if it is travelling with ‘blue lights’ (Dixon & Crawford 2012).
  15. On arrival at the referring unit/hospital, complete a primary survey by assessing airway, breathing, and circulation (ABC).
    Rationale – Reassesses the child’s status; helps identify emerging problems and facilitates prompt intervention.
    At a minimum, the patient’s ABC or primary survey should be stabilised before departure from the referring unit/hospital.
  16. Complete a secondary survey (head to toe) and perform any necessary interventions for stabilisation (Hallworth & McIntyre 2003, Insoft & Schwartz 2016, Samuels & Wieteska 2011).
    Rationale – Facilitates identification of problems that necessitate management or stabilisation before transport.
    Any hospital environment is considered a higher level of care than a transport setting, and the initial stabilisation should be completed within the hospital setting. Radiology is not available in the transport setting.
    1. Review chest X-ray (CXR) and recent blood gas analysis, haematology, and chemistry results, if applicable, to determine the effectiveness of ventilation and endotracheal tube placement.
    2. Assess the sufficiency and patency of venous and arterial access.
    3. Secure all lines and tubes.
  17. Secure the child and the necessary equipment to the transport incubator or stretcher and transport the child and equipment to the vehicle (CEN 2007, Insoft & Schwartz 2016, Hallworth & McIntyre 2003).
    Rationale – Prevents the child and equipment from becoming projectiles in the event of a crash and helps ensure the safety of the child, family, and caregivers.
    Appropriately designed restraint systems should be used (CEN 2007, Insoft & Schwartz 2016, Hallworth & McIntyre 2003).
  18. Contact the receiving unit/hospital to inform medical and nursing staff of the team’s departure.
    Rationale – Allows the receiving unit/hospital to anticipate and plan for the child’s approximate ETA.
    Allows anticipation and preparation for arrival of the child and immediate care needs.
  19. Plug in any necessary equipment and turn on the inverter. 
    Rationale – Prevents equipment batteries from draining.
    Backup for all critical systems and policies for intervention should be in place in case of power failure or vehicle breakdown (Bérubé et al. 2013, Hallworth & McIntyre 2003).
  20. Continue to assess the child frequently throughout transport. Obtain vital signs throughout transport at a frequency dictated by the child’s condition.
    Rationale – Reassesses the child’s status. Helps identify emerging problems and facilitates prompt intervention. 
    Changes in assessment are communicated with the coordinating/receiving unit for ongoing information and advice.
  21. Perform any necessary treatments the child may need to ensure continued stabilisation during the transport process.
    Rationale – Maintains the level of care.
    Contact should be made with the coordinating/receiving unit with update and advice in the event of deterioration.
  22. On arrival at the receiving unit/hospital, the child is transferred to the bed with all necessary equipment to manage ABC and maintain the level of care (Hallworth & McIntyre 2003, Holleran 2010, Insoft & Schwartz 2016).
    Rationale – The team must maintain an adequate level of care, with the necessary equipment and medications for unexpected emergencies, between the equipped ambulance and the patient’s floor.
    The child’s level of care should never decrease.
  23. Provide the receiving team with a report, including updates and changes in the child’s status (Hallworth & McIntyre 2003, Holleran 2010, Samuels & Wieteska 2011).
    Rationale – Promotes a smooth transition of care.
    For the purposes of expediting the transport, a detailed history may not always be possible; ensure that telephone numbers of the referring unit or medical nursing team are available. Relevant information may be faxed or sent by secure email.
  24. Document the procedure in the child’s record.

Ongoing care, monitoring and support

  • Contact family if they did not accompany the child and inform them of the child’s safe arrival.
    Rationale – Decreases family anxiety and eases concerns.
    If family cannot be contacted after several attempts, ensure that this is communicated to the child’s nurse and consultant for appropriate action to be taken in accordance with local policy.
  • Complete all documentation and paperwork (Dixon & Crawford 2012, Hallworth & McIntyre 2003, Insoft & Schwartz 2016).
    Rationale – Ensures the receiving unit/medical and nursing team have documentation of care, interventions, and medications provided during transport.
    Documentation must be completed once transport is completed.
  • Restock equipment and medications (Dixon & Crawford 2012, Holleran 2010, Insoft & Schwartz 2016).
    Rationale – Packs and equipment must be complete and ready for the next transport.
    Equipment checks are part of the transport process. If unable to completely restock with equipment and medications, ensure that the responsible person is informed in order that further supplies are ordered, and ensure that documentation is completed to ensure that all transport staff are aware of deficits.

Documentation and reporting

  • Initial assessment of the child, location of the child, and names of the staff from the referring unit/hospital.
  • Informed consent for transport and the name of the individual who provided consent as appropriate and according to local policy.
  • Names of the members of the transport team.
  • Transport team’s assessment of the child at the referring unit/hospital on the arrival of the team.
  • Interventions necessary for stabilisation before departure from the referring unit.
  • Method used to secure the child for transport.
  • Clinical observations and ongoing assessment performed throughout transfer.
  • Time of departure from the referring unit/hospital and time of arrival at the receiving unit/hospital.
  • Names of the medical and nursing team who assumed care of the child on arrival at the receiving unit.
  • Information given to the child and family.
  • Contact numbers for family.
  • Unexpected outcomes and related treatment.

 

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