Working group

Contributors

Working group for first edition

Working group for second edition

Contributors for second edition

Transport medicine is recognised as a specialist area of clinical practice. It requires individuals to work safely and efficiently in small teams, often delivering very complex care in the mobile environment. For children there are only a small number of specialist centres able to deliver intensive care. This has led to the development of stand‐alone transport services with teams solely dedicated to this work. For adults there is also a significant requirement to move unwell patients but the more evenly distributed specialist critical care services has led to a different model. Adult transport teams tend to be assembled from hospital personnel with additional training to work in the transport environment.

In addition to the critical care transfers, patients of all ages are often moved either within a hospital, or between hospitals in order to access diagnostic or therapeutic modalities that are not available locally. Although these movements may require much less technology and intensive support they are still subject to many of the same risks as transports of much sicker patients. These transfers are also generally carried out by staff who have not received training in transport medicine. This considerably raises the risk to the patient (and the staff), especially when the patient is approaching an acuity that might require critical care support.

Two courses and their manuals were developed to provide an introduction to the basic knowledge and principles needed to undertake the transfer of sick patients: Paediatric and Neonatal Safe Transfer and Retrieval (PaNSTaR) and (Adult) Safe Transfer and Retrieval (STaR). They were aimed both at those embarking on training in transport medicine and those who might expect to undertake such transfers on an occasional basis. Over the last few years it has become clear that some clinicians, particularly those based in district general hospitals, find themselves transferring both children and adults. Given that the principles of transport medicine are common across all age ranges it was decided to merge these two resources into one manual and one course: Neonatal, Adult and Paediatric Safe Transfer and Retrieval (NAPSTaR). This manual is the product of that fusion.

The focus is on inter‐hospital transfers. However, the principles are also directly applicable every time a patient is moved between clinical areas. There are inevitably discussions of clinical situations throughout the text, however the focus is primarily on the logistics of the transfer process rather than the clinical detail. Those whose primary requirement is to enhance their knowledge of resuscitation should direct their reading to the Advanced Life Support (ALS), Advanced Paediatric Life Support (APLS), Advanced Resuscitation of the Newborn Infant (ARNI) and Newborn Life Support (NLS) manuals and courses as appropriate.

Neonatal, Adult and Paediatric Safe Transfer and Retrieval: A Practical Approach to Transfers has been developed by a multi‐professional group from across the UK. A systematic approach is employed throughout that has its roots in both the original PaNSTaR and STaR courses.

The book is divided into six parts. Part 1 provides an introduction. Part 2 introduces the ACCEPT approach (see next page) and examines the component parts in detail. The practical issues that are encountered during the transfer process from an equipment perspective, and from a clinical perspective, are discussed in Part 3. Part 4 focuses on clinical considerations beginning with a generic overview and then specifically focusing on neonatal, paediatric and adult practice. Part 5 discusses particular situations and provides additional background information that is required to plan for special circumstances. The appendices in Part 6 contain supporting information and provide sample checklists and examples of documentation for those undertaking transfers.

A great many people have worked hard to produce this book and the accompanying course. The editors would like to thank all the contributors for their efforts and all NAPSTaR (formerly PaNSTaR and STaR) providers and instructors who took the time to send their comments during the development of the text and the course.

The NAPSTaR working group would like to acknowledge that this book has been developed from the preceding manuals and that a number of chapters in this book are essentially updates of those found in Paediatric and Neonatal Safe Transfer and Retrieval: The Practical Approach and Safe Transfer and Retrieval: The Practical Approach (second edition).

We thank the Difficult Airway Society (DAS), Great Ormond Street Hospital, National Tracheostomy Safety Project (NTSP) and North West and North Wales Paediatric Transport Service (NWTS) for the shared use of some of their figures and algorithms. We also thank Kathryn Claydon‐Smith, Joanne Cooke, Brendan McGrath, Richard Neal, Matthew Davis, Paul Reavley and Mark Woolcock for sharing their photographs and illustrations.

Finally, we would like to thank, in advance, those of you who will attend the NAPSTaR course for your continued constructive comments regarding the future development of both the course and the manual.

ALSG: www.alsg.org
For details on ALSG courses visit the website or contact:
Advanced Life Support Group
ALSG Centre for Training and Development
29–31 Ellesmere Street
Swinton, Manchester
M27 0LA
Tel: +44 (0)161 794 1999
Fax: +44 (0)161 794 9111
Email: enquiries@alsg.org

Clinicians practising in tropical and under‐resourced healthcare systems are advised to read International Maternal and Child Health Care – A Practical Manual for Hospitals Worldwide (www.mcai.org.uk) which gives details of additional relevant illnesses not included in this text.

Updates

The material contained within this book is updated on a 5‐yearly cycle. However, practice may change in the interim period. We will post any changes on the ALSG website, so we advise that you visit the website regularly to check for updates (www.alsg.org).

References

All references are available on the NAPSTaR course pages on the ALSG website www.alsg.org.

On‐line feedback

It is important to ALSG that the contact with our providers continues after a course is completed. We now contact everyone 6 months after their course has taken place asking for on‐line feedback on the course. This information is then used whenever the course is updated to ensure that the course provides optimum training to its participants.

The anytime, anywhere textbook

1.1 Background

In children’s critical care alone there are in excess of 5000 paediatric intensive care unit (PICU) transfers between hospitals and 16 000 transfers of neonatal patients in the UK every year. In addition to this there are numerous high dependency unit (HDU) and non‐urgent transfers between centres and countless thousands of intra‐hospital transfers undertaken by healthcare professionals every year. Each one of these transfers represents an episode of care which is associated with a period of increased risk for both the child and the clinical staff. These risks can at best be eliminated and at the least be minimised through appropriate training.

The NAPSTaR manual together with its associated course is aimed at a multi‐disciplinary audience and has been developed to provide a comprehensive introduction and overview of the process of transferring unwell patients. Its conception followed from the success of the PaNSTaR and STaR manuals and courses. The underpinning concepts described herein, and in particular the ACCEPT principles, are essentially the same.

Throughout the text the use of the words ‘child’ or ‘children’ should be taken to refer to the entire age range (neonate up to 16 years of age). Where appropriate, more specific references to particular age groups will be made where practices vary according to age. Neonates will be used to refer to all preterm babies and also term babies of less than 28 days of age. Infants shall refer to all those under 1 year and adults for those over 18 years. Parent refers to any person with parental responsibility.

With regard to the transfer of children there has been a cultural change which has occurred in many centres where non‐paediatricians have distanced themselves from paediatric practice, triggered by the centralisation of paediatric services. Many district general hospital (DGH) practitioners, faced with a critically ill child, may now find themselves practicing at the edge of their comfort zone. This is perhaps particularly true if they have to undertake a transfer.

Most neonatal intensive care units (NICUs) and PICUs will have an associated retrieval team. However, the majority, if not all, of these teams are not sufficiently resourced to be able to provide a robust service 100% of the time.

In adult practice most centres do not have a dedicated transport team and transfer teams are drawn from in‐patient staff (often from critical care). There will be occasions, such as patients with surgically treatable lesions following a traumatic head injury, where current practice would dictate that the referring hospital should undertake the transfer in order to minimise the time to neurosurgery. These factors mean that referring centres may expect to carry out the transfer for up to 25% of the children that they refer for urgent tertiary care.

Reading this manual and attending a NAPSTaR course will provide you with the basic strategies and background that you need to join a transfer team. It is important to note that proficiency in this area only comes with the additional training and experience that may be gained from working with practitioners already experienced in this area.

1.2 The approach to transfer

Any transfer process may be broken down into three components:

• Organisational and management strategy
• Practical issues
• Training required to appropriately use the equipment needed during the transfer

The course focus is on the transportation of patients between hospitals. However, the same approach can, and should, be applied to the transportation of unwell patients within hospitals.

The usual purpose of an inter‐hospital transfer or retrieval is either to allow the patient to be treated more effectively or to obtain additional diagnostic information, in a geographically separate site. Transfer per se does not constitute therapy and represents a time of increased risk. It is therefore essential to always consider the risks versus the benefits before undertaking a potentially hazardous journey.

In the neonatal population, babies may be transferred acutely because they require intensive care unit (ICU) therapy that is not available at the referring hospital. There are also a significant number of neonates that may be moved for specialist examinations or opinions. Infants and older children are primarily transferred when they are acutely unwell to a central PICU or HDU. Some transfers will also occur for secondary or tertiary opinions, but the majority of these patients will not present a clinical risk and will be transported by their parents. In acute cases, children may sometimes have to be transferred significant distances, especially at busy times such as midwinter, as beds may not be available in their nearest tertiary centre.

The source of patients also varies widely:

• Delivery suite
• Emergency department
• NICU
• Adult ICU
• Paediatric wards
• Theatres
• HDU
• Coronary care unit

Emergency departments are probably the most frequent starting places for the movement of PICU patients. Sometimes children are moved to local critical care facilities prior to transfer. Either way, the adequacy of resuscitation and the degree of packaging that will have been undertaken before the arrival of the transfer team is highly variable. When dispatching a team to undertake a transfer it is always best to assume they will need to do everything and therefore must have the knowledge and skills to do this.

Transfers are not infrequently associated with adverse events, which may be recorded on transfer forms. Those seen most commonly are:

• Supply failure (electrical power, gases, fluids or drugs)
• Equipment failure
• Significant hypotension
• Significant hypoxia
• Inadequate resuscitation
• Significant tachycardia
• Mechanical ventilator not available
• No capnography available (when clinically indicated)
• Delay in getting ambulance
• Ambulance getting lost en route
• Cardiac arrest in ambulance

The number of inter‐hospital transfers continues to rise. This is perhaps driven by increasing expectations on the part of both the public and healthcare professionals.

This manual will provide those who may be involved with the transfer of unwell patients with a systematic approach to guide their work. It does not seek to teach or develop the clinical skills required to undertake such care but it does provide a structure that should help eliminate the majority of the non‐clinical pitfalls. There is no substitute for the practical training that may be gained by working with those experienced in this field.

2.1 Introduction

Moving patients from one clinical environment to another is a process that requires careful thought, preparation and attention to detail. This move could be from a home environment to hospital, from the scene of an accident to an emergency department, from a hospital ward to a computed tomography (CT) or magnetic resonance imaging (MRI) scanner or from one hospital to another. In any scenario, it is essential that the staff involved in moving the patient have given due consideration to the process of the move, considered what equipment and monitoring is required, who should accompany the patient and the best means of transport.

2.2 SCRUMP

This chapter aims to briefly outline some of the considerations that come to bear at the time any transport is initiated. These issues will be dealt with in more detail later in the manual, but can be usefully brought to mind using the acronym SCRUMP.

Shared assessment

Whenever a patient is to be moved from one environment to another, the teams must share key information about the patient’s clinical condition. The subsequent decision making is based on these shared assessments. For example, a neurosurgeon may advise that a patient is transferred as quickly as possible; a radiographer may suggest that a patient is brought to the scanner immediately; an intensive care unit may suggest that it is safe for a patient to remain locally for a number of hours before they are transferred: the team leader needs to assimilate all information and recommendations and agree a plan with the multi‐disciplinary teams This will ensure that each transport episode can be undertaken safely.

2.3 ACCEPT

The NAPSTaR structure for the practical delivery of safe patient transfer is captured through the ACCEPT principles.

These will be discussed in detail throughout this text with reference to the challenges of medicine on the move identified by SCRUMP.