Big Ideas For Moving Small Patients

This series of steps on paediatric transfers has been developed by the Children’s Acute Transport Service (CATS), London, including contributions from Cathy Roberts, Dr Linda Chigaru, Dr Gerard Manning and Dr Emily Krennerich.

What Is ‘Paediatric’?

• The criteria for defining paediatric vs neonatal population differs based on country and/or institution.
• United Kingdom: Age 0-16 years.
• USA: Age 0 – 22 years (up to 26 years for special populations – congenital cardiac, cystic fibrosis, rare genetic diseases, etc).

Neonatal Considerations

• UK/USA: Premature and term infants up to 1 month of age with typical “neonatal” diagnoses.
• There is significant overlap in the paediatric and neonatal transfer patient groups, particularly in the late pre-term (34 weeks gestational age to 36 6/7 weeks gestational age) and neonatal patients < 1 month old.
• Neonates (< 1 month corrected age) are naturally separated from paediatric patients due to their differing physiology and common disease processes.
• Neonatology and Paediatric Intensive Care are different sub-specialties within paediatric medicine and thus the transfer of each patient population has evolved differently.
• Special Considerations for NICU transports: secure isolette, temperature instability, surfactant, access (UVC/UAC), twins/multiples, mother remaining inpatient and cannot travel, partner distress (stay with mother or go with child).

This section will focus primarily on paediatric transfer. For more information on neonatal transport please see the following resources:

• Neonatal Transfer Service London
• Guidelines for Air and Ground Transport of Pediatric and Neonatal Patients

Paediatric Considerations

• Paediatric transfer teams must carry equipment to support ICU patients of highly variable size from < 2kg to > 150kg.
• Medication dosing has to be thought about in two ways, depending on the size of the patient. For patients under 40-50kg, medication dosing is usually weight-based (ie: mg/kg) while for larger “adult-size” patients weight-based dosing would result in overdose for several common medications. Teams must be competent and flexible with using these.

Children often require different emotional support to adults. Many children have never been sick or on an ambulance, may feel scared or anxious and are often not able to be calmed with reason or logic. Babies may need music or swaddling, while adolescents may need distraction and a safe space to ask questions.

• Parents and family are a unique aspect of paediatric transfers. Most children will have a parent or caregiver travel with them and the team must attend to the needs of the patient as well as provide reassurance to the caregiver.

Paediatric Transfer Teams

• Paediatric transfer is undertaken by both specialist and non-specialist teams. Non-specialist teams include local ambulance and emergency services, which may be the only service available.
• Specialist teams may move children and adolescents at any stage of acuity, or they may be further specialised into paediatric critical care transport teams capable of providing ICU level transport.

Specialist Team Structures

• These exist in a variety of formats based on what is most appropriate for the hospital system and region.
• Ad Hoc: Created on an as-needed basis by pulling staff from any available area at the time a transfer is required. Staff are trained in paediatric transfer, but relatively few are performed per year.
• Unit Based: Staff are active in their home unit and are pulled from their assigned shift onto transfers as needed. Often, staff are designated first-on for transport, but may also take a bedside or clinical role that would need to be covered if a transfer occurs, for example STRS at Evelina Children’s Hospital in London.
• Hospital Based: A dedicated team not assigned to other clinical roles while on a transfer shift. They work in a particular hospital and are available to assist in busy units such as PICU or the emergency department when skilled staff are needed for short periods or tasks. They can devote time to service audit, quality improvement, or education activities while not on active transfers. An example is the Kangaroo Crew at Texas Children’s Hospital in Houston, Texas.
• Non-Hospital Based: Similar to hospital based but team members are dedicated to transfer only and are physically separated from clinical care buildings, for example CATS, based in London.

Team Composition

There is no consensus on the best team composition and a variety of models exist using what works best for their staffing and availability.

• Special consideration also needs to be made for trainee inclusion. There is generally not enough space in the back of an ambulance, helicopter, or plane for everyone that may be interested in learning. The highest priorities remain staff and patient safety but when space allows, a rotating schedule of trainee nurses, physicians, and paramedics can be encouraged to participate.
• Experienced team members will also need training shifts to upskill as teams expand to provide services such as flight or ECMO transport.

Learn more about the monitoring and governance of paediatric transfer teams