Inter-Hospital Transfer – Patients Requiring Intensive ...



Canberra Hospital and Health ServicesClinical ProcedureInter-Hospital Transfer – Patients Requiring Intensive Care (Adults, Paediatrics and Neonates)Contents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc426617593 \h 1Purpose PAGEREF _Toc426617594 \h 2Scope PAGEREF _Toc426617595 \h 3Section 1 – Roles PAGEREF _Toc426617596 \h 4Section 2 – Adult Patients Requiring Intensive Care PAGEREF _Toc426617597 \h 9Section 3 – Paediatric Patients Requiring Intensive Care PAGEREF _Toc426617598 \h 18Section 4 – Neonatal Patients Requiring Intensive Care PAGEREF _Toc426617599 \h 22Implementation PAGEREF _Toc426617600 \h 24Evaluation PAGEREF _Toc426617601 \h 24Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc426617602 \h 24References PAGEREF _Toc426617603 \h 24Definition of Terms PAGEREF _Toc426617604 \h 25Search Terms PAGEREF _Toc426617605 \h 26PurposeTo 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.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.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).NSW hospitals will contact ACC or CRRS for referral of all intensive care patients and activation of retrieval team.In specific cases, the referring Consultant may modify the sequence of the referral process based on clinical assessment and local knowledge. 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.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:Time critical tertiary referral to TCHNon-time critical tertiary referral to TCHNon-tertiary referral to an ICUPaediatric referrals (up to age 16), excluding neonatal intensive care referralsSuper-specialities:Severe burn injuryAcute spinal cord injuryExtracorporeal membrane oxygenation (ECMO)ScopeFor 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 HospitalsFor 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 2010NSW Health policy directive Emergency Paediatric Referrals- Policy PD2005_157Processes 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 The appropriate destination must be agreed in advance.For CRRS missions, it is the responsibility of the CRRS consultant to confirm:Acceptance in the destination unit by the relevant consultant (almost always ICU or ED)Bed availabilityAccepting inpatient consultantThe CRRS consultant is then responsible for liaising with the ACT Ambulance Service (ACTAS) regarding organising an appropriate vehicle for transfer.For non-CRRS missions: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:Both the Canberra Hospital ICU consultant & the ED consultant are contacted in advanceThat 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 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.Back to Table of Contents Section 1 – RolesReferring HospitalInitial stabilisation of patientFor adultsIf 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 informationIf NSW and time critical contact ACC or CRRS to arrange transport to TCHIf ACT and time critical, contact CRRS to arrange transport to TCHIf 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 transportFor children (< 16 years)If NSW, contact NETS for conference call, advice and coordination of transferIf Calvary Health Care Bruce (CHCB) or Calvary John James Hospital (CJJH), contact NETS for conference call, advice and coordination of transferProvide all patient information necessary for triageAeromedical Control Centre (ACC)Contact number 1800 650 004Contact 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 unavailableContact point in NSW for ACT, if no bed available in ACTMobilisation of an appropriate retrieval or transport service for the critically ill patientFacilitate all adult severe burn injury, adult acute spinal cord injury and extracorporeal membrane oxygenation (ECMO) referralsACC is not responsible for finding beds of non-critically ill patients who require referral for a higher level of specialist care Capital Region Retrieval Service (CRRS) Contact number 1300 873 711 Point of contact in ACT for ACC retrievalsLiaise with referring hospital and relevant ACT ICU about transfer arrangementsTriage the patientArrange appropriate transport of the critically ill patientLiaise with ACC, if no bed available in ACTThe Canberra Hospital (TCH), Intensive Care Unit Contact number for Outreach Consultant 0401691574Tertiary referral centre, Level 6 ICU (adults) for ACT and Southern NSW and Murrumbidgee LHDsCare of critically ill adult patients requiring immediate emergency treatment: Trauma (Canberra Hospital is the major tertiary trauma service for Southern NSW and may receive patients from Murrumbidgee, see NSW State Trauma Plan ,5 )NeurosurgeryCardiac surgeryVascular surgeryInitial stabilisation of patient with severe burn injury, prior to transfer to NSW Severe Burn Injury ServiceInitial stabilisation of patient with acute spinal cord injury, prior to transfer to NSW State Spinal Cord Injury ServiceInterim 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 requiredCalvary Health Care Bruce (CHCB) Intensive Care Unit Contact number 6201 6097Non-tertiary, general intensive care Level 4, with the exception of:Trauma NeurosurgeryCardiac surgeryVascular surgeryInvoke ICU escalation plan if requiredNSW Statewide Burn Injury ServiceContact through ACC on 1800 650 004ACT 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 childrenAdult 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 500NSW State Spinal Cord Injury Service (SSCIS)Contact through ACC on 1800 650 004Responsible for management of adults who have sustained a spinal cord injury*, with evidence of damage to the neural tissuesas 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 SSCISNSW Extra Corporeal Membrane Oxygenation (ECMO) Medical Retrieval ServiceContact through ACC on 1800 650 004Indications for ECMO support: patients with potentially reversible, life-threatening respiratory and/ or cardiac failure that are not responding to maximal conventional therapyNSW Newborn and Paediatric Emergency Transport Services (NETS) – for patients under 16 years of age Contact on 1300 362 500State-wide emergency service for medical retrieval of critically ill newborns, infants and children (under 16 years of age) in NSW and ACTTertiary 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 HospitalsSNSWLHD/ MLHDCalvary Health Care BruceNational Capital PrivateJohn James Calvary Private Bateman’s Bay BatlowBegaBombalaBraidwoodCoomaDelegateMoruyaPambulaQueanbeyanTumutYassPrince of Wales Hospital is default tertiary referral hospital for:South Eastern Sydney Local Health District SNSWLHD/MLHDPrince of Wales (Private)BoorowaCrookwellGoulburnMurrumburrah- HardenYoungSt Vincent’s Hospital is the default tertiary referral hospital for:South Eastern Sydney Local Health District MLHDSt Vincent’s (Private)Sydney/ Sydney EyeCoolamonCootamundra GriffithGundagaiHayHillstonJuneeLeetonLockhartNarranderaTemoraTumbarumbaWagga WaggaWest WyalongSt George Hospital is the default tertiary referral hospital for:South Eastern Sydney Local Health DistrictMLHDKareena (Private)SutherlandSt George (Private)WollongongAlbury*BarhamBerriganCorowaCulcainDeniliquinFinleyHentyHolbrookJerilderieTocumwalUrana*Albury is networked with clinical services in Victoria however referral to a NSW facility may be required due to clinical needSouthern NSW Local Health District MapMurrumbidgee Local Health DistrictBack to Table of Contents Section 2 – Adult Patients Requiring Intensive CareTime Critical Referral to TCHChart 1: Time Critical Tertiary Adult ICU Referral - ACT and SNSWLHD/MLHDWhere 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:Emergency department to emergency department (Neonatal or Adult) Intensive care unit to intensive care unitCardiac Catheter lab, etcDestination unit for Inter-hospital transfers:The following principles & examples are not exhaustive, but give guidance as to the appropriate destination unit: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.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).All multitrauma patients within 48 hours of injury must go to the ED initially.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.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 TCHMulti-traumaNeurotraumaIntracranial haemorrhageUnstable acute coronary syndromeEmergency cardiac surgeryAcute vascular conditionThe 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.Chart 2: ACT – Non-time critical ICU Bed required (no ICU bed available in referring hospital)lefttopChart 2A: ACT - Where tertiary bed required but not available at TCH on initial contactChart 2B: ACT - Where non-tertiary bed required but not available at Calvary Chart 3: SNSWLHD/MLHD- Adult ICU Bed required (no ICU bed available in referring hospital) non time criticalNon-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. 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.ProcessEnsure initial stabilisation*, and then follow the process for time-critical tertiary referral (see chart 1).Contact the Burns Registrar/Consultant at Concord Repatriation General Hospital on 9767 5000, then pageContact 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 HealthReferring Health ServicePrimary Receiving Severe Burn HospitalACT SNSW LHD/ MLHDConcord Repatriation General HospitalBurns Registrar/ Consultant on callPh: (02) 9767 5000 then page. Intensive Care UnitPh: (02) 9767 6404Burn Unit/ Ambulatory Care Ph: (02) 9767 7775 (b/h)(02) 9767 7776 (a/h)Fax: (02) 9767 5835Burns CNCPh: (02) 9767 5000 then page 60271Secondary Receiving Hospital Royal North Shore Hospital Burns Registrar/ Consultant on call Ph: (02) 9926 7111 then pageIntensive Care UnitPh: (02) 9926 8640Paediatric ReferralsReceiving Hospital The Children’s Hospital at WestmeadICU (02) 9845 1171 or via NETSAcute 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.ProcessEnsure initial stabilisation, following the process for time-critical tertiary referral (see chart 1)Liaise with TCH Surgeon re timing of referral to SSCISContact the SSCIS at Prince of Wales Hospital on 9382 2222Contact ACC to arrange transfer to receiving hospitalReferring Health Service Receiving Spinal Cord Injury HospitalACTSNSW LHD/ MLHD Prince of Wales HospitalDirectorPh: (02) 9382 2222Secondary Receiving HospitalRoyal North Shore HospitalHead of DepartmentPh: (02) 9926 7111Paediatric ReferralsFacilitation of CareCall NETS 1300 362 500Extra 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: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 Absolute contraindications to all forms of ECMOSignificant 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 ECMOAge > 65Multiple trauma with uncontrolled haemorrhageMultiple 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 ECMOHigh pressure, high FiO2 IPPV for >1 weekRelative contraindications to veno-arterial ECMO (for cardiac failure)Severe aortic valve regurgitationAortic dissectionRelative contraindications to veno-arterial ECMOSevere peripheral vascular diseaseInitial 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.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.Contact NumbersCRRS:1300 873 711ACC, NSW:1800 650 004NETS, NSW and ACT:1300 362 500TCH ICU:(02) 6244 3300Calvary Health Care ICU:(02) 6201 6097GovernanceThe 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.Reporting Intensive Care Activity in the ACTEach month, ICU directors will report intensive care activity to the ACT Intensive Care Network.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.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.Back to Table of ContentsSection 3 – Paediatric Patients Requiring Intensive CarePaediatric (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: Hospitals: Calvary Health Care Bruce and Calvary John James HospitalContact NETS for advice and coordination of retrieval and transfer to appropriate paediatric intensive care facility.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 HospitalPaediatric 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. 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 HospitalsContact NETS for advice and coordination of retrieval and transfer Transport may be provided by:NETS (NSW) team for newborns or childrenNETS (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 health..au or Critical Care Tertiary Referral Networks (Paediatrics) - NSW Department of HealthPaediatric 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:NETS (NSW) team for newborns or children on 1300 352 500NETS (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 HealthAll 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:PaediatricsIntensive CareNeonatal Intensive Care AnaestheticsCanberra HospitalAll 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 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 childAge groupExpected ICU stayReferral ICU Type of ReferralContact numberComment010monthsUndefinedNeonatal ICU TCHAllFor retrievalsNETS1300362500TCH NICU:61747322Depending on complexity, infant may require transfer via NETS, but may be stabilised in NICU10months-2yearsUndefinedInitial consultation NICU TCH then Paediatric ICU transfer via NETS Emergency Time CriticalFor retrievalsNETS130036250NICU TCH61747322May stay in ED or require temporary admission to NICU prior to retrieval2 years - 12 yearsUndefinedInitial consultation General ICU TCH then Paediatric ICU transfer via NETS EmergencyTime Critical For retrievals NETS1300362500TCH ICU 62443300or62442222 ask for ICU Consultant on callMay stay in ED or require temporary admission to General ICU or prior to retrievalElective procedures not referred via NETS2 years -12 years24 hoursGeneral ICU TCHAllFor retrievalsNETS1300362500TCH ICU6244330062442222 ask for ICU Consultant on callDependent on complexity of patient and resources available 12 yearsUndefinedGeneral ICU TCHAllTCH ICU 6244330062442222 ask for ICU Consultant on callDependent on complexity of patientReferral of Paediatric Patients requiring Intensive Care at the Canberra HospitalAny referrals for intensive care management at Canberra Hospital must be made directly to the relevant Intensive Care Consultant or Senior Registrar on call. 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 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.Where possible the child will be stabilised in the Emergency Department until transfer to either the Canberra Hospital or a Tertiary Paediatric Hospital occurs. 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.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 NSW hospitals will contact NETS for referral of all paediatric patients requiring intensive care.Back to Table of Contents Section 4 – Neonatal Patients Requiring Intensive CareThe 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/paediatricsCardiorespiratory monitoring for recurrent apnoea or seizures Monitoring with bedside aEEGExchange transfusion Extreme systemic illness TPN via central or peripheral lineOxygen 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 NETSThe 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 criteriaTransient problems requiring cardiorespiratory monitoring / frequent laboratory investigationsInfants requiring crib oxygen, up to 25% not requiring level 3 care Infants requiring low flow or micro-low flow oxygenInfants requiring peripheral IV fluids/antibioticsConvalescing infants recovering from acute problemsAssessment for poor feedingJaundiced infants requiring peripheral IV fluid therapy and closer monitoringAssessment and treatment of NAS, if applicable, until stable Infants requiring post-operative care following minor surgeryConvalescing 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 dayInfants requiring crib oxygen, up to 25% not requiring level 3 care Infants requiring low flow or micro-low flow oxygenInfants requiring peripheral IV fluids/antibioticsThese 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 neonatologistIf 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 leaderDepartment 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 - NICUThe retrieval process is initiated and coordinated by NETS NSW and the designated CNC/team leaderAll retrievals attended by ACT NETS that are outside the 30km radius of the ACT must be approved by the Director of NeonatologyBack to Table of ContentsImplementation 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. Back to Table of ContentsEvaluationOutcome 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.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesACT 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 2006Back to Table of ContentsReferencesCollege of Intensive Care Medicine, Minimum Standards for Intensive Care Units, 2003 .auNSW Health Intensive Care Service Plan- Adult Services 2001NSW Health Critical Care Tertiary Referral Networks (Adult) Policy Directive PD2010_021, 30 March 2010NSW Health Critical Care Tertiary Referral Networks (Paediatrics) Policy Directive PD2010_030, 02 June 2010Back to Table of ContentsDefinition 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.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.Back to Table of ContentsSearch Terms Patient transferInter hospitalAdultsChildrenNeonatesHospital, GeneralIntensive CareCritical CareRetrievalNeonatal Intensive CareNewborn Emergency Transport Service (NETS)Back to Table of ContentsDisclaimer: 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.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.Appendix 4: Role Delineation: ACT Intensive Care Services (not referred to in the document)The Canberra HospitalIntensive Care Unit Level 6Calvary Hospital Intensive Care Unit Level 4Tertiary level serviceNeurosurgeryCardiac surgeryTrauma Interventional cardiologyVascular surgeryPlusRegional level servicesGeneral intensive care with the exception of:NeurosurgeryCardiac surgeryTrauma Interventional cardiologyVascular surgeryIntensive Care levels of care are based on the NSW Health Role Delineation of Services. 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 Units.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. ................
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