Policy for emergency referral of an infant or child.

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Description Children's Hospitals have on call intensivists and other specialists available for discussion of critical and/or difficult acute clinical problems in infants and children. Other requests for acute admission or advice should be directed to the Emergency Department of a Children's Hospital. For newly born infants, Children's Hospitals and Perinatal Referral Centres have neonatal ICUs. Registrar and/or consultant advice is available from them for neonatal problems.

It is expected that referring hospitals would involve their specialists pædiatricians (where on staff) in transfer decisions about children. However, written policies should define how this operates locally, particularly in reference to the hospital's Emergency Department.

Referring medical officers in rural areas should contact their Base Hospital or regional centre for general pædiatric problems - according to regional policy guidelines. The appropriate names and/or telephone nbumbers can be entered in the box on the wall chart which all hospitals can obtain from NETS.

Ideally, referring staff should expect to make only one phone call. A tertiary service will provide a 'solution', including a bed.

Procedure For life threatening problems or an acute problem likely to require intensive care, the preferred Tertiary Perinatal Referral Centre (baby) or Children's Hospital (baby or child) can be contacted.  They will offer assistance, including acceptance of the patient for transfer or arranging an alternative suitable destination.  The referring doctor should not have to 'ring around' for a bed.

General pædiatric problems should be discussed with the pædiatrician on duty for that hospital. Hospitals without a pædiatrician (eg. in many country areas) may choose to contact the pædiatrician at the affiliated regional or Base hospital. Emergency Departments at Children's Hospitals offer advice and accept admission requests.

NETS should be called (1300 36 2500) when medical retrieval is contemplated. NETS can link multiple parties by telephone to discuss a clinical problem. The patient's immediate treatment requirements are the highest priority. Full discussion with appropriately senior medical staff should occur.

Based on that discussion, an appopriate clinical escort (retrieval team or other escort) will be selected, and a vehicle tasked.

If at any time clinical circumstances change after the initial call, another call should be made so that any changes in arrangements can be made without delay.

Lastly, a bed will be located and confirmed.  The last step should not delay the dispatch of a retrieval team and can often be arranged while the team is stabilising the patient.

If a 'one-way' transfer (with ambulance and/or referring hospital staff) is chosen, the referring hospital should make an ambulance booking through 13 1233 (road) or 1300 36 5333 (air). Referring hospitals may be contacted by the Ambulance Service for additional information about the patient. Teenage patients may be more suitable for admission to an 'adult' hospital. There are guidelines for the age cut-off for admission to a children's hospital.

Escorts The type of clinical escort required for the patient is determined by the patient's need for pre-transport assessment, stabilisation and in-transit care. Further advice is available, upon request, from NETS.

The need for a skilled paediatric assessment, a difficult airway or ventilatory problem or the management of multi-trauma may necessitate different or addional skills in the team.  NETS liaises with the Adult Medical Retrieval Unit (1800 65 0004) for older children and adolescents.

Transfer of a patient by local hospital staff should not be undertaken if there is a substantial risk of en route deterioration.  It is better to stay and wait for a retrieval team in the hospital setting with support by telephone (as required), than to attempt emergency patient care in a vehicle. Transfer of babies and children by air ambulance is assisted by the availability of a highly trained flight nurse.

If 'one way' transfer of a patient is judged appropriate, the time it takes to reach the destination is usually determined more by the interval between 'decision-time' & 'patient departure-time' than the time spent in transit.

Vehicles  Road ambulances, medical helicopter and fixed wing aircraft are available for medical retrieval. The selection of vehicle(s) for medical retrieval follows the NSW Department of Health's published guidelines.  These "Guidelines for Mode of Transport Selection" take clinical urgency, distance, patient condition, team and vehicle availability, access to referring and receiving hospitals and other factors into account.

Problem solving Tertiary hospitals may contact NETS if they have failed to obtain a bed in either their own hospital or a suitable alternative hospital for a patient referred to them. A state-wide NETS consultant is available through the NETS Line to assist this process.

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