Severn and Penin sula Traum ma Networks Paediatric Secondary Transfer Policy May 2014, V5
REVIEW DISTRIBUTION APPROVAL/ADOPTED 6 months after formal approval and then annually Severn major trauma network committee Severn MTC Steering Committee Peninsula Network Advisory Group Peninsula Major Trauma Management Committee To be agreed by the Severn and Peninsula Trauma Networks, the MTC s at Plymouth Hospitals NHS Trust and North Bristol NHS Trust, the PMTC at University Hospitals Bristol NHS Trust and all Trauma Units in both Networks AMENDMENTS DATE V1 Feb 2014 V2 & 3 March 2014 V4 April 2014 V4 May 2014 RELATED POLICIES AUTHOR/FURTHER INFORMATION THIS DOCUMENT WAS CREATED May 2014 Peninsula Trauma Network Automatic Acceptance Policy Peninsula Trauma Network Safe Transfer of Critically Ill Patients Amber Young, Paediatric Lead STN & PTN Victoria Legrys Severn Trauma Network Julian Shafee Peninsula Trauma Network THIS DOCUMENT REPLACES New policy
Contents Introduction & Purpose 3 The Policy 3 Application 3 Identification of patients who require secondary transfer 4 Transfer Arrangements 5 Summary of the Policy 5 Policy Principles 6 Appendix A Secondary Transfer Flowchart 7 Appendix B Contact details 8
1. Introduction/purpose of the policy Following the national introduction of Regional Trauma Networks, Major Trauma Centres (MTC s) are required to automatically accept patients requiring treatment for major trauma injuries. The purpose of this policy is to provide direction and guidance for actions for key individuals and organisations within the Severn and Peninsula Trauma Networks to improve the paediatric patient pathway and subsequent quality of care. 2. The policy The aim of this policy is to prevent unnecessary delays or incidents during the transfer of patients from the Trauma Units and Major Trauma Centres within the Severn and Peninsula Trauma Networks to the Bristol Paediatric Major Trauma Centre (PMTC) based at the Bristol Royal Hospital for Children (University Hospitals Bristol Foundation Trust) from May 2014 and acceptance of said patients by that Trauma Centre. This will be done by ensuring that automatic acceptance of all appropriate patients occurs and that rapid consultation for secondary and tertiary patients requiring transfer occurs through a single call to the Paediatric Trauma Team Leader (PTTL) at the Paediatric Trauma Centre Tel 0117 3420906 The aim of the trauma networks is to deliver all appropriate paediatric major trauma patients to a specialist paediatric MTC which has all the services available to receive and manage these seriously injured children. Those children who present to a Trauma Unit (TU) or adult MTC with serious injury which exceeds the resources and capability of that service will be rapidly transferred to a Paediatric Major Trauma Centre as soon as they are clinically safe for transfer. The Severn and Peninsula Trauma Networks have agreed that, for the purposes of major Trauma, a child shall be defined as a person under their 16 th birthday. There may however be some cases whereby a patient between the ages of 16 and 18 may not be suitable for care at an adult MTC. In these situations a discussion should be held with the Paediatric Trauma Team Leader as to where the most appropriate place will be for that patient to receive their definitive trauma care. This discussion must be in the best interests of the child and must NOT delay transfer for definitive care. All ISS 15+ cases not transferred, must be audited. As a PMTC has all the facilities and specialties required to be able to treat all children with any type of injury and in any combination, all children who have a potential Injury Severity Score (ISS) of greater than 15 should be considered for transfer to a PMTC. It may also be appropriate, in certain circumstances, for children with a potential ISS of 9 15 to be considered for transfer to a PMTC as well. A TU or adult MTC should only look after those children with mild - moderate or non-life threatening injuries (Locally Treatable Pathology see Appendix 3). These will include patients with injuries including simple fractures of one limb, mild or moderate abdominal injuries and minor head injuries. ISS is assigned retrospectively and will not be known at the time of presentation to ED, therefore decisions about secondary transfer will have to be made on the basis of presumed severity of injury which in turn is based on the information known at that time.
3. Application: To Whom This Policy Applies This policy will relate to all children, from the Trauma Units and adult Major Trauma Centres, within the Severn and Peninsula Trauma Network areas, during the acute phase of their injury(ies). It does NOT apply to patients for whom specialist ADVICE from the tertiary services at the PMTC is required, but where admission is not being requested. It also does NOT apply to patients who are being transferred as tertiary referrals, direct to the speciality, outwith the initial 24 hour period. This policy will apply only to primary and secondary transfers from TU to MTC. This policy applies to referring Trauma Units, adult Major Trauma Centres and the Paediatric Major Trauma Centre. It is the responsibility of all MTC s and TU s within the Severn and Peninsula Trauma Networks to ensure that this policy is adhered to by all personnel. The policy will primarily be implemented by personnel in the Emergency Department (ED), Intensive Care/ High Dependency Units (ICU/HDU) and Specialist Wards. However all personnel within the referring Trust are also expected to adhere to it. The final responsibility for the implementation of this policy lies either with the Paediatric Trauma Team Leader for those patients who trigger a trauma team activation, the ED or admitting consultant for patients who are subsequently identified as having serious injuries. Departure from the policy will have to be justified to the appropriate Trauma Network governance group and be subject to possible external review. 4. Identification of Children Who Require Urgent Secondary Transfer Initial resuscitation for patients with catastrophic haemorrhage and/or unsecured airways will take place at the TU or adult MTC. If damage control surgery is required prior to arrival at the PMTC then this must be done in liaison with the Paediatric Trauma Team Leader at the PMTC. If a child requires damage control surgery prior to transfer to the PMTC than it is appropriate to request that the Bristol PICU Retrieval Team undertake the transfer following the damage control surgery as per national recommendations. All requests for the PICU Retrieval Team are to go via the Paediatric Trauma Team Leader Tel 0117 3420906 If there are serious injuries with a clear indication for transfer to the PMTC, especially, for example; a traumatic brain injury (TBI) meeting paediatric automatic TBI acceptance criteria, then an immediate transfer to the PMTC should be undertaken. Network transfer policies should be activated and the Paediatric Trauma Team Leader should be informed. If, within the Peninsula Trauma Network region, a child with Cardiothoracic or Neurological injuries is considered too unstable for transfer or unlikely to survive a transfer without prior treatment, the respective surgical teams have agreed that in those circumstances they will undertake life-saving surgery, in liaison with their respective colleagues at the PMTC, at the adult Major Trauma Centre at Derriford Hospital prior to transfer. When considering a Time-Critical Transfer from the Peninsula Trauma Network, it is imperative that the Paediatric Trauma Team Leader takes the transfer time from the particular hospital into account. This applies particularly to Derriford Hospital and the Royal
Cornwall Hospital (who can stop at Derriford for DCS Surgery not available locally). Please see Appendix 4 for travel times from the Severn and Peninsula Hospitals to BRCH. For all other isolated brain injuries, that do not meet automatic acceptance criteria, the referring hospital should contact the Paediatric Trauma Team Leader who will discuss the case with the on-call consultant neurosurgeon and decide whether there is an indication for transfer to the PMTC. Some of these patients will have a potential ISS 16, or ISS 9-15 but the decision to transfer to the PMTC rests with the Paediatric Trauma Team Leader at the PMTC. All paediatric patients with serious or major trauma (whether isolated or poly-trauma) should be considered for referral to the PMTC. The PMTC is able to care for patients that require: Neurosurgery Cardiothoracic Surgery Burns care Plastic Surgery Paediatric Surgery Vascular Surgery General Surgery Hepatobiliary Surgery Orthopaedic Surgery General Paediatric care Trauma / neurosurgical / burns HDU PICU. In all cases, where the management of a child with major trauma injuries is outside the capability of the MTC or TU, then the patient should be transferred to the PMTC. Automatic acceptance applies. Network transfer policies should be activated and the PMTC Paediatric Trauma Team Leader should be informed. Patients who have a moderate injury with an ISS suspected to be 9-15 or less with potentially locally treatable pathology might appropriately be treated at a TU or MTC +/- advice from the PMTC. If the injuries are complex, or will require multi-specialty input their care should be discussed with the MTC and transfer arranged where clinically indicated. A low threshold for transfer should be adopted where it maybe in the patient s best interests to be managed in a PMTC, even if the pathology is locally treatable. Patients who have been identified as needing palliative care only, may not need to be transferred to the PMTC if the care required is within the capability of the MTC or TU. However this must only be considered after in-depth discussions with the PMTC, PICU and family. 5. Transfer Arrangements 5.1 All calls regarding primary and secondary transfers will be to the Paediatric Trauma Team Leader at the PMTC: Duty Trauma Consultant 0800-2359 ED middle grade 2359-0800 The telephone number 24/7 is 0117 3420906
5.3 The transfer discussions and arrangements must be carried out at Trauma Team Leader to Paediatric Trauma Team Leader level. 5.4 The PMTC Paediatric Trauma Team Leader will inform the appropriate speciality, anaesthetic staff, theatre and PICU of an impending patient arrival. 5.5 Full patient details including name of referring Trauma Team Leader to be recorded in the trauma booklet which should accompany the patient to the receiving hospital. 5.6 All time-critical transfers must be transferred by the referring team. It is the responsibility of that transferring team to arrange both the transport and an appropriate escort for all transfers to the PMTC. It is imperative that both the transport and the escort be arranged as soon as the probable need for an acute or time critical transfer is identified. 5.7 All time-critical transfers must be transferred by the referring hospital who are responsible for notifying the Ambulance Service Coordination desk of the transfer and details of the patient. For patients who require a time critical secondary transfer to the PMTC the TU/MTC should phone 999 requesting an urgent/ emergency transfer and the call will be given the same priority as all 999 calls. (If ambulance control feel that a transfer from a TU or MTC to the PMTC does not fall within their contract, then they can be advised that this is a transfer to a higher level of care and as such does fall within their remit). 5.8 When transport is requested it is important that the trauma team leader assesses which method of transport is most suitable, bearing in mind such factors as travel time, location of the PMTC, loading and unloading time for air transfers, weather etc. 5.9 Once the patient has left the TU or MTC it is the responsibility of that TU/MTC to advise the PMTC that the patient has left and provide an ETA. 5.10 The transferring Paramedic crew will also give the PMTC an ATMIST approximately 15-20 minutes (or when they reach the city boundary) prior to their arrival at the MTC. 5.11 On arrival at the PMTC, the child must be taken directly to the ED resuscitation room and trauma call procedures initiated. 6. Principles This policy applies: 24 hours a day 7 days a week 52 weeks a year. All transfer discussions must be undertaken by trauma team leader (or equivalent) to Duty Paediatric Trauma Lead. All relevant clinical information must be given to the receiving Trust.
When the transfer of the child is organised by the referring hospital, it is essential that they provide the necessary escort(s) and equipment, together with all necessary documentation (incl the Network trauma booklet/copy of the ED records, Critical Care Transfer form, and a copy of the SWAST PCR). This policy should be read in conjunction with the relevant Network policies: Peninsula and Severn: The Paediatric Automatic Acceptance policy The Paediatric TBI policy (under development) The Paediatric Burns Policy (under development) The Paediatric Critical Care Transfer Policy (under development)
Candidate Major Trauma V5 Rapid Assessment by Referring Hospital Undertake Critical Interventions ONLY i.e. Intubation, Chest Drain, Procedures required for Transfer etc. Undertake Critical Investigations/Interventions ONLY Consider the need for blood or blood products prior to or during transfer. Please Note All Burns All other Major Trauma SWUK Children s Burn Centre (0117) 923 0000 Bleep 6780 Paediatric MTC Paediatric Trauma Team Leader 0117 3420906 Children are defined as patients before their 16 th birthday Non Emergency Secondary Transfers Stable patients who require treatment at the PMTC and have not been transferred as an emergency, should be referred to the relevant speciality at Bristol Children s Hospital (PMTC) and transferred within 48 hours. PIC Retrieval Service Patient s injuries are Time-Critical* and requires immediate Damage Control Surgery (DCS) prior to transfer Patient has Time-Critical* injuries and requires Immediate Cardiothoracic surgery or Neurosurgery Patient has non Time-Critical Injuries Can this be provided with 30 minutes at the TU/MTC? No Admit to TU or Peninsula MTC for definitive management Button if transfer to BRCH not required Yes Consider transfer to Paediatric MTC Peninsula ONLY Both available at MTC if Time Critical* Injury and not able to reach PMTC within 4 hrs of injury TU/MTC Theatre Retrieval Service can be requested, if appropriate, for patients post DCS MTC or TU to arrange and UNDERTAKE all time-critical* transfers (incl Neuro & Burns) Call Ambulance Control and request Immediate or 999 Transfer to Paediatric MTC PIC to undertake all non-timecritical retrievals MTC/TU to call Paediatric TTL and request Retrieval The Paediatric Trauma Team Leader will make arrangements with the PICU Retrieval Service for non-time critical transfers and the PIC will notify the sending MTC/TU of the arrangements All non-time critical transfers are to be retrieved by the PIC Retrieval team unless otherwise clinically indicated. Please remember to consider whether Air Transfer will be the most appropriate method? Transfer to Paediatric Button MTC Amber Young / Julian Shafee_ April 2014
Appendix 2 Contact details Hospital Major Trauma Centres Bristol Royal Children s Hospital (Paediatric) Town Switchboard number Bristol 0117 923 0000 Derriford Hospital (Adult) Plymouth 01752 202082 Frenchay Hospital (Adult) Bristol 0117 970 1212 Trauma Units Bristol Royal Infirmary Bristol 0117 923 0000 Gloucestershire Royal Hospital Gloucester 0300 422 2222 Great Western Hospital Swindon 01793 604020 Musgrove Park Hospital Taunton 01823 333444 North Devon District Hospital Barnstaple 01271 322577 Royal Cornwall Hospital Truro 01872 250000 Royal Devon & Exeter Hospital Exeter 01392 411611 Royal United Hospital Bath 01225 428331 Torbay Hospital Torquay 01803 614567 Yeovil District Hospital Yeovil 01935 475122 Local Emergency Hospitals Weston General Hospital Weston-Super- Mare 01934 636363
Appendix 3 Definitions The following are a list of definitions for the two subheadings. These lists are not exhaustive and are meant as examples only. The final decision as to whether an injury is time-critical or not, will always remain with the Referring Trauma Team Leader and the Paediatric Duty Trauma Lead at the Paediatric MTC. Time-Critical Injuries* Extra-dural or sub-dural haemorrhage requiring evacuation Inta-thoracic or intra-abdominal injuries with signs of uncontrolled haemorrhage (not that DCS locally maybe required if transfer times maybe long) Suspected vascular injuries to limbs Locally Treatable Pathology** This will vary from TU to TU but may include: Multiple long bone fractures where paediatric orthopaedic surgeons and anaesthetist are available Spinal column injuries where paediatric spinal surgeons are available Maxillo-facial injuries in units used to dealing with children Isolated orthopaedic injuries It is expected that all significantly injured children will be discussed with the paediatric MTC and that decisions to treat locally will be agreed.
Appendix 4 Travel Times Peninsula By Air By Road (Average) (Average) Derriford Hospital to BRCH 45 mins 2 hrs 15 mins North Devon District Hospital to BRCH Royal Devon and Exeter Hospital to BRCH Royal Cornwall Hospital to BRCH TBC mins 2 hrs 30 mins 1 hr 30 mins 60 mins 3 hrs 15 mins Torbay Hospital to BRCH 45 mins 1 hr 50 mins Loading, unloading & handover time Loading time 10 mins Unloading time 10 mins Briefing time 5 10 mins Handover time 5 10 mins Severn Gloucestershire Royal Hospital to BRCH 14 mins 45 mins Great Western Hospital to 16.5 mins 50 mins BRCH Musgrove Park Hospital to 16.5 mins 1hr BRCH Royal United Hospital to BRCH 4.5 mins 25 mins Yeovil District Hospital to BRCH 16 mins 1hr 15 mins Loading time Unloading time Briefing time Handover time 10 mins 10 mins 5 10 mins 5 10 mins Weston General Hospital to BRCH 8.5 mins 40 mins Timings courtesy of N Hare, (DAAT). P Cowburn, (GWAA) & AA Route planner (2014)