Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
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1 Date / PetCO 2 (kpa) Interventions Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
2 END TIDAL CARBON DIOXIDE Transport No:... FIRST 10 END CARBON DIOXIDE MEASUREMENTS (taken at the same time as blood gases) PetC0 2 taken PetC0 2 taken Breath number Mean PetCO 2 Pretransfer PetCO 2 Post transfer END TIDAL CARBON DIOXIDE MEASUREMENTS IN TRANSIT (every 5 mins) Date / PetCO 2 (kpa) Interventions Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
3 Comments Signature Nursing Handover given to: Date / of Handover Baby Safely Transferred into Incubator by at Post-transfer checklist Copy of discharge summary Copy of transport document Personal belongings stored Milk supplies refrigerated Cot bureau contacted Parents Informed & Updated Incubator plugged in Equipment on charge Disposables replenished Incubator cleaned Audit form completed All transport equipment secured Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
4 Comments Signature Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
5 Ventilation Chart Inspiratory Pressure Expiratory Pressure Rate Inspiratory O 2 Flow O 2 % End Tidal CO 2 Circuit Checked Activity Tone Circulation Colour Air entry Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
6 HeartRate SaO Resps Skin temp Incubator Mean BP Syst/Dia Cuff/Art Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
7 Intravenous Fluids Fluid infusing Fluid infusing Fluid infusing Equipment No Equipment No Equipment No Site Site Site Rate Level Vol Total Press mmhg Rate Level Vol Total Press mmhg Rate Level Vol Total Press mmhg Fluid infusing Fluid infusing Fluid infusing Equipment No Equipment No Equipment No Site Site Site Rate Level Vol Total Press mmhg Rate Level Vol Total Press mmhg Rate Level Vol Total Press mmhg Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
8 Nursing Observation Record Transfer of baby into transport incubator Baby safely transferred into transport incubator at. by.. Monitoring Commenced: ECG O 2 Saturations Resp Rate NBP ABP Skin Temp IV fluids transferred and recommenced as prescribed (Please record levels on IV fluid chart) IVI 1 Sited in; IVI 2 Sited in; Long line Sited in; Arterial line Sited in; Limb Perfusion Oxygen (%) Blood Aspirates Glucose Bowels Opened Last Last Passed Urine Oral Feeds Last Fed Regime Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
9 Condition on arrival at accepting unit Baseline measurements and audit data Axillary Temp ( c) Art BP sys / dia (mean) ph Arterial PaO 2 (kpa) Saturation % Blood Glucose Value Latest blood gas Arterial / Capillary / Venous ph pco 2 po 2 Base Excess Bicarb Respiratory Current ventilation mode Supplemental Oxygen CPAP IPPV HFOV Ventilation Parameters Rate or amplitude PIP / EEP Insp. or Insp. Fraction FiO 2 ET tube Diameter Length Oral / Nasal CXR position Air entry Fixation / security Examination findings Cardiovascular Examination findings Other systems Examination findings: Medical Handover given to: Date / of Handover Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
10 Pre-transfer checklist Accepting Unit information given Contact details for parents Maps to accepting unit Maternal transfer requested Baptism (if appropriate) Photocopies of notes / charts X rays Name band check Contacted accepting unit EBM into Freezer Box Procedures and condition during transfer of departure Please record observations every 15 minutes on chart Names of Staff undertaking transfer: Signature.. Signature.. Signature.. Greater Manchester, High Peak and East Cheshire Neonatal Transport Service
11 Assessment prior to transfer from referring unit Baseline measurements and audit data Axillary Temp ( c) Art BP sys / dia (mean) ph Arterial PaO 2 (kpa) Saturation % Blood Glucose Value Latest blood gas Arterial / Capillary / Venous ph pco 2 po 2 Base Excess Bicarb Respiratory Current ventilation mode Supplemental Oxygen CPAP IPPV HFOV ET tube Diameter Length Oral / Nasal CXR position Air entry Fixation / security Ventilation Parameters Rate or amplitude PIP / EEP Insp. or Insp. Fraction FiO 2 Examination findings Cardiovascular Examination findings Other systems Examination findings: Issues Discussed with Family; Parents Contact Details; Greater Manchester, High Peak and East Cheshire Neonatal Transport Service - 9 -
12 Intravascular lines Arterial line/uac UVC Long line Cannula 1 Cannula 2 Cannula 3 Insertion site Tip position n/a n/a n/a Infusion fluids Security Infusion site/ limb perfusion Infusion Name Dose Rate (ml/hr) Date / begun Infusion site Drug Name Dose Route Frequency Date begun last given Changes to treatment Procedures undertaken and investigations Prescription Drug ml/kg Amount in 30ml Rate Greater Manchester, High Peak and East Cheshire Neonatal Transport Service - 8 -
13 Handover received from: Assessment and stabilisation on arrival Baseline measurements and audit data Heart Rate Resp Rate SPO 2 Axilla Temp BP sys/dia & Mean Blood Glucose Value Latest blood gas Arterial / Capillary / Venous ph pco 2 po 2 Base Excess Bicarb Current ventilation mode Supplemental Oxygen CPAP IPPV HFOV ET tube Diameter Length Oral / Nasal CXR position Air entry Fixation / security Ventilation Parameters Rate or amplitude PIP / EEP Insp. or Insp. Fraction FiO 2 Examination findings Cardiovascular Examination findings Other systems examination findings: Abdomen Neurological Skin Morphology Other Greater Manchester, High Peak and East Cheshire Neonatal Transport Service - 7 -
14 Advice Check list for referring unit: Please ensure the following are available for the transport team on arrival Item please tick when completed Photocopies of Maternal obstetric notes Photocopies of Neonatal medical notes Photocopies of Neonatal nursing notes and observation charts Photocopies of Blood gas and investigation charts Photocopies of Drug and fluid prescription charts Sample of maternal clotted blood for transfusion (Hope Hospital) Discharge summary or letter including transfer summary front sheet Name of doctor / ANNP giving pre-transfer advice (PRINT) Name of referring clinician (PRINT) Signature Date Greater Manchester, High Peak and East Cheshire Neonatal Transport Service - 6 -
15 Neurological Latest scan findings Conscious level Normal / lethargy /obtunded / stupor / coma Description of neurological problems, movements and treatment Sepsis Summary of symptoms and management of infection Antibiotics Genetics Congenital Malformations and Dysmorphic features. Significant family history. Social Summary of Family and Social Factors Current Drug and Fluid Therapy Name of Drug or Fluid Dose / Route / Frequency / of administration (can complete on arrival) Greater Manchester, High Peak and East Cheshire Neonatal Transport Service - 5 -
16 Recent changes to ventilation Respiratory diagnosis and summary of management Cardiovascular Assessment Cuff / Arterial BP sys / dia (mean) Perfusion Treatment Total Volume given (ml/kg) Dopamine (mcg/kg/min) Dobutamine (mcg/kg/min) Other (specify) Summary of Cardiovascular problems / management: Fluids and renal Maintenance IV Fluids (ml/kg/day) Enteral Feeds (ml/kg/day) Total Sodium intake (mmol/kg) Total Potassium intake (mmol/kg) Urine Output Phototherapy Gastrointestinal and Nutrition Feed type Feed volume / hour Abdominal appearance Gastric aspirate (size/colour) Frequency of bowel motions Appearance of bowel motions Problems with feeds and fluids: Greater Manchester, High Peak and East Cheshire Neonatal Transport Service - 4 -
17 Pre-transfer discussion and advice To be completed by transfer medical / ANNP staff and faxed to referring and receiving units before transport team departs Summary of Obstetric and Perinatal Details Please summarise as many details as possible including maternal complications, PROM, steroid therapy, mode of delivery etc Resuscitation and stabilisation None Oxygen / mask ventilation Intubation ECM Resuscitation Drugs Blood / Saline / Other Current Blood Glucose 1 Minute Apgar 5 Minute Apgar 10 Minute Apgar Cord ph Age at intubation (mins) Age at Surfactant (mins) Current axillary temperature Respiratory system Current ventilation mode Supplemental Oxygen CPAP IPPV HFOV Ventilation Parameters Rate or amplitude PIP / EEP Insp. or Insp. Fraction FiO 2 ET tube Diameter Length Oral / Nasal CXR position Air entry Latest blood gas Arterial / Capillary / Venous ph pco 2 po 2 Base Excess Bicarb Greater Manchester, High Peak and East Cheshire Neonatal Transport Service - 3 -
18 Equipment Checklist To be completed by transport nurse and doctor Incubator / Equipment checked by: Type of incubator Equipment on incubator Check squad fully charged Number of full Oxygen cylinders Flexible tube holder Ventilator working Oxygen tubing Suction functioning Monitor Spare battery Number of Infusion pumps Equipment inside incubator Bag and mask set ECG leads x3 Apnoea probe Saturation probe / posey wrap Sheets / blankets / towels Bubble wrap Hats / bootees / mittens Nappy Transwarmer Set of medical / surgical notes rigerated items Curosurf Other drugs Cassettes for I-stat gas analyser Maternal Milk available Red Transport Bag Nurse) Doctor) Hill Rom Notes Check incubator will heat up Must be 2 size E Check circuit connections and alarms Calibrate sensor Check tubing and catheters Check all leads attached, battery Remove from monitor in use Check battery, take 2 more than need Notes 2 of each size mask Appropriate size Admission pack, charts and notes Notes Keep cool e.g prostin, atracurium Keep cool, return to fridge if unused Cool bags and ice packs for transfer Ensure seal is unbroken Greater Manchester, High Peak and East Cheshire Neonatal Transport Service - 2 -
19 Acute Multidisciplinary Transfer Document To be completed by Cot bureau coordinator Date of erral Age at erral Gestation erring Clinician erring Hospital Contact Number of referral Sex Weight (g) Receiving Hospital Contact Number Your Name M / F Brief summary of reasons for referral Is maternal milk available for transfer? Please request photocopies of the infant and maternal notes, including blood gases, drug charts and investigation results. Also request transfer summary front sheet to be completed. Action Remarks / reasons for delay Cot located Location: GMAS notified Job N.o Ambulance arrives Team departs from SMH Team arrives at base unit Team departs base unit Team arrives at accepting unit Team departs accepting unit Team arrives at SMH. Greater Manchester, High Peak and East Cheshire Neonatal Transport Service - 1 -
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