Section three - DETAILED GUIDANCE FOR THE TRANSPORT TEAM
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1 Section three - DETAILED GUIDANCE FOR THE TRANSPORT TEAM Plan of the day Ambulance moved from base to level three unit on duty for transfer. Ambulance connected to external power supply. Member of team checks answer phone for recorded messages which might include notification of transfer requests from the night. In such instances, ring unit, obtain information and give appropriate advice. Nurse or administrator to check occupied and vacant cots in all units and potential for creating vacant cots Team to check all equipment, drugs, and gas supplies. Fridge drugs checked and available Team to discuss prioritization of calls and plan of action for the day. Consultant has ultimate control. If no acute retrievals requested by 9 am team to undertake any planned back transfer, first by checking with requesting unit that this is still required and then with receiving unit to inform them that the transfer is about to take place and double check on cot availability. Any acute retrieval requests after 9 am to be fielded by consultant on for transport who would give advice and decide whether he/she would proceed directly to the unit requesting assistance or await the return of the ambulance and team from the back transfer Retrieval /transfer undertaken Ambulance parked and connected to charge point Incubator off loaded and plugged into mains Cleaning of incubator after each transfer 1
2 Between routine journeys (eg back transfers non infected baby) this will consist of cleaning the inside of the incubator and all the surfaces with which the baby has been in contact with tuffie wipes (alcohol). At the end or beginning of the day and after any transfers of an infected baby eg MRSA, Influenza, RSV, there should be a full deep clean. The whole incubator must be stripped down washed with soapy water and then cleaned with tuffie wipes and all pumps removed and washed down in a similar fashion. All transfer documentation and entry of data to database should be completed before the team leaves to complete the shift for the day. Team debrief after each transfer. This is to be done at the end of the day if the team is busy all day, or the start of the next shift if the team returns to base after 8 pm. Any learning points to be shared with other teams at a suitable time. Equipment used to be restocked At 7 pm if all tasks are complete, ambulance to return to base at Bryncethin. Checklists prior to transfer The dedicated ambulance will be stationed at an outside power point in order to ensure that the batteries are fully charged. Prior to setting out all transport equipment must be checked and fully functional, the oxygen and air cylinders must be full, both on the transport trolley and in the ambulance and the equipment must be fully charged. The following checklist to be made and signed off for each transfer Departing Base Air, oxygen, nitric oxide cylinders on trolley Gas on ambulance (For a baby ventilated on 100% oxygen oxygen gas required = 2 X flow rate of the ventilator in litres/ min X estimated journey time in minutes). Similar calculation for air cylinder if baby transferred in air. This is the amount required if the baby is transferred for the entire journey twice without using any ambulance supply and is regarded as capacity for optimum safety. HX cylinder = 2300 litres when full F cylinder =1360 litres when full 2
3 E cylinder = 680 litres when full Fridge drugs Equipment bags (see check list) Trolley equipment (see check list) Phones/bleeps Ventilator circuit / block Monitor and modules Paperwork Mattress and neo restraint I stat machine and cartridges Transwarmer mattress Neonatal cold light Money/ packed lunch Phone referring unit to advise depart time and estimated time of arrival Moving the trolley and equipment Team members are encouraged to wear protective shoes and to take extreme caution when moving the trolley. There is a risk of injury if the trolley runs over people s toes. The ambulance driver has the authority to direct the other members of the team regarding the method by which the trolley is manoeuvred and secured onto the vehicle. The other team members should assist, under his direction. In the ambulance whilst outward bound for a retrieval the equipment and gas must be switched off to conserve resources. The equipment should always be connected to the power supply of the ambulance on the way out to enable recharging. All equipment must be secured safely so it does not turn into a missile in the event of an accident. Arrival at referring unit - handover and stabilisation Connect ambulance to outside power supply Phone base to advise them of time of arrival The transport trolley will be moved to the neonatal unit 3
4 Transport equipment will be plugged in to the mains electrical supply to ensure that the batteries continue to charge whilst the baby is being stabilised on the unit. The transport ventilator and neopuff resuscitator will be piped into the hospital gas supply for oxygen and air in order to conserve cylinder supplies. Introduce team members. Speak to parents if available Take handover from referring staff. Ensure that patient identification procedure is followed. Use NHS number preferably to unit hospital number. Ensure baby has 2 armbands. Use the arm bands from the referring hospital during the transfer and until handover at the receiving hospital. Examine the baby to confirm clinical findings and agree to the appropriateness of the transfer at the time. This will constitute a complete handover. Sign when handover is complete and document the time. Do not accept the care of the baby until this entire process is undertaken. Infection control measures. Communication with the parents normally takes place on at least two separate occasions. a) Initially ambulance crew to explain to the parents principles of transport and care required, to where the baby is being transferred and arrangements for their travel etc. Also give written information including phone number, post code and map of unit. Ambulance crew have role to generally support the parents and explain what the team is doing and why b) Clinicians to explain to parents about the clinical condition of baby, steps needed to stabilize, reason for transfer and what is likely to happen on arrival etc. Also to give parents opportunity to ask questions Parents should have chance to see baby prior to setting out and given a photo of the baby if they do not already have one. Assess and stabilise the baby (see below). The transfer team will make a clinical assessment of the condition of the baby using the ABCDE approach. It will be a required standard that all clinical members of the team (nursing and medical) should be trained and be confident in using every piece of transport equipment. They 4
5 should help each other during stabilisation and transfer of the baby. This will substantially reduce stabilisation time and reduce risk should a staff member become unwell. For a ventilated baby the endotracheal tube must be of an appropriate size and positioned at the correct length. The ET tube must be very securely attached so that it cannot become dislodged during transfer. Also the patency of the tube must be assured. Ventilator settings must be optimised. For a ventilated baby it is usual practice to use analgesia with morphine. If paralysis is used it is likely that the ventilator settings will need to be increased as the baby s own respiratory drive will be removed. There must be at least one blood gas taken after the baby has been stabilised on vecuronium and morphine prior to transferring to the ambulance. For an intensive care baby there will need to be at least two intravenous access devices. Monitoring must include all the usual parameters including ECG, respiration, temperature, saturation and blood pressure. End tidal CO2 should be available soon. If blood pressure is borderline it is advisable to set up a syringe driver of a suitable inotrope prior to setting out, so that the infusion can easily be commenced during the journey if required. Any umbilical catheters, long lines, pneumothorax drains or other devices must be very securely attached to the baby to ensure that they cannot become dislodged during transfer. Pneumothorax drains should be connected to a flutter valve rather than an underwater seal for transport. Ventilator humidity should be used where power supplies are adequate.(this would be switched on in the dedicated ambulance as it consumes a very high amount of power). It cannot be used on the Fabian ventilator when transferring from neonatal unit to ambulance and vice versa Prior to leaving ensure that there has been a satisfactory blood gas and the blood sugar is normal with a glucose infusion in a steady state. Ensure transport document is filled in correctly. 5
6 Moving the infant to the incubator To be undertaken only after baby s condition has been optimised, ET tube, iv devices, catheters have been securely attached to the baby and a set of observations have been recorded All transport equipment will be placed as close as possible to the baby. All equipment will remain on mains electricity/gas supply Adjust and check the transport ventilator settings and oxygen concentration All monitoring except saturation to be removed from the baby If feasible, fluid syringes will be transferred to the transport pumps before the move If not feasible, essential fluid will be transferred first. It is important to organise every infusion circuit into individual neat piles during transfer of the baby to and from the incubator to avoid difficult untangling and wastage of valuable time. Final observations will be checked and within acceptable limits before the baby is disconnected from the saturation monitor and the ventilator and moved to the transport incubator Moving the infant involves at least two people. Do not attempt this alone Upon moving the baby connect the ventilator swiftly first priority Connect the monitoring equipment saturation probe first Assess the air entry and chest movement and saturation. When these are satisfactory transfer any remaining fluid syringes to the transport pumps Position the baby appropriately, allowing good visibility of ventilation, tubing, chest,iv sites and drains The baby must be securely attached to the incubator using the neo restraint. This reduces the amount of vibration to the baby. The use of the neo restraint will also reduce the risk of injury to the baby in the event of an accident. Commence the observations on the chart 6
7 Departing referring unit Consult departure checklist (x rays, maternal blood sample for cross match, summary as appropriate) Leave copy of transport documentation with referring unit Phone accepting unit when you leave Phone base Disconnect from mains power and gas and ensure working from batteries and cylinders on transport equipment The ambulance journey Attach equipment plugs to ambulance power supply Attach to ambulance air and oxygen supplies Turn off trolley gas supply Safety regulations state effective locking devices must be used to ensure that the transport trolley cannot move in the ambulance thus injuring staff or baby. Ferno locking devices should be used to secure the trolley to the floor of the ambulance. All equipment should be firmly bolted down onto the trolley, so no equipment is able to come loose in the event of a sudden acceleration or deceleration potentially causing injury. There must be adequate power and gases. For calculations on air and oxygen capacity requirement see above. Disconnect power cable from ambulance to external mains supply All members of the transport team to be seated with seat belts fastened prior to ambulance being mobilised and at all times when ambulance is in motion Carry out and record observations at least every 30 mins and more frequently if clinically indicated If the baby becomes unstable and needs reassessment then it is important that this is not done until the ambulance vehicle is stationary in a safe environment. If possible leave the motorway and find a safe lay-by to park. Do not park, if possible, on the hard shoulder of a motorway. All the usual neonatal procedures such as endotracheal tube suctioning and ventilation reassessment, taking of blood gases, administration of iv 7
8 fluids etc, drainage of pneumothorax etc can be done in the ambulance, but because space is limited these are likely to be time consuming and technically more difficult. These are best avoided by adequate stabilisation and preparation prior to setting out. Arrival at accepting unit The ambulance power will be connected to the outside power supply. Disconnect power and gases from ambulance and use trolley supplies Move incubator to unit Use unit power and gas supplies whilst handing over Phone base Speak to parents if available Hand over to accepting team. Document the time Make sure handover documents are signed by both parties with time recorded Add the number for the transfer to the transfer document. Make photocopy (or ask the unit to do this) Give copy of transfer document to accepting unit. Keep the original as your record and a copy of badgernet summary appended to this. Phone referring hospital that you have arrived A note about handovers Transport Handovers have to be clearly defined and timed and documented. The medicolegal lines of responsibility have to be clearly defined. For the transport team medicolegal responsibility is from handover and acceptance at referring unit until hand over and acceptance at the receiving unit. The times must be clearly documented. The transport team will receive a formal handover from the referring unit. We will not accept care of the baby until this has been completed. We could decline the transfer if this is not done. We must provide a formal hand over to the accepting team and our responsibility does not end until this has been completed. 8
9 If it is felt that the acceptance of a baby at handover is not appropriate, for whatever reason, we may decline to accept the baby. Such instances may include lethal condition, baby too unstable eg for nurse only transfer etc. The situation must be discussed with the transport consultant who will make the final decision whether or not accept the handover or proceed with the transfer. If the decision is made to leave the baby in the care of the referring unit, the transport consultant should discuss with the consultant covering that unit the reasons for the decision and make it clear that the baby is to remain in their care. Departing accepting unit Clean incubator (see above) Collect new sheets and blankets Restock items used if possible or make a list of them Phone base that you are leaving and check whether there are any further calls pending On return to base Ambulance connected to external power source Take equipment trolley to transport office/store. Connect all equipment to mains power supply to enable recharging, undertake cleaning of the incubator (if not already done), check and restock equipment and gases Ensure that all information is entered into a database for audit and benchmarking purposes. This must be done the same day by the team who undertook the transfer Team debrief Guidelines for working hours and rest of staff undertaking successive transfers will be in place to ensure safety. Arrangements for parents Arrangements for the parents to travel are the responsibility of the referring unit. In intensive care transports there are often genuine reasons why parents may not be able to travel in the ambulance with their baby such as 9
10 Clinicians and nurses need to concentrate on the care of the baby and cannot provide care for the parents There is no suitable stretcher on which to transfer the mother There is not always a seat physically in the ambulance and space is limited On occasions it may be possible for one or more parent to accompany the baby such as during a stable back transfer. The decision whether it is possible for a parent to travel in the ambulance is the responsibility of the most senior clinician on the transfer, or the consultant overseeing the transfer. Parents will be actively discouraged from following directly behind the ambulance vehicle Arrangements for parent accommodation in accepting unit. These are the responsibility of the referring unit to sort out with the receiving unit. Documentation All clinical data will be entered onto the transport form. There is a separate document in addition for cooled babies. Any drugs or fluids prescribed or administered by the transport team are to be written on a CHANTS specific prescription chart to be carried in the ambulance. All documentation will be photocopied at the accepting unit. The originals will go into the baby notes at the accepting unit and the copy is to be retained by the CHANTS team and taken back and stored at their unit. Shortly we hope to have a transport database. Each unit will be responsible for entering their transport data onto this. Documents to be stored in keeping with Caldicot guidance and kept for a minimum of 5 years Guidelines for observations during transport Place ECG pads one mid left axilla, one right mid axilla, one lower left axilla BP cuff to cover two thirds of limb. Cuff is to be placed on legs or upper arms. If possible measurements not to be carried out on limbs which have lines in situ If indwelling arterial line in situ transducer to be connected and zeroed after the baby has been settled into the transport incubator. Zero after any position change. 10
11 Thermometer to be placed in axillary region. Bulb to be placed in mid axillary line. To be held in place until indicted that measurement taken. Rectal probe to be used for babies being cooled SaO2 to be placed on the hand or foot of the baby taking care not to attach too tightly. Cover probe with posy wrap. Probe site to be changed at least 4 hourly. All alarm limits to be set appropriate to the age and gestation of the baby Transfer service Uniform Ambulance drivers to wear their own uniform. Other team members will be provided with protective steel capped shoes to reduce risk of injury. The neonatal trolley and its associated equipment are very heavy.it is a well recognized risk that injuries to toes and feet can occur when the trolley is moved as it can run over toes. All team members are to exercise great care when moving the trolley. The trolley should only be moved when handled by two people minimum. Nurses to wear their all Wales uniform. Doctors and other health personnel to wear suitable attire in keeping with their LHB policy. Each team member to be offered a warm fleece to protect against cold weather. Team members to wear personal identification badges at all times 11
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