Reference No: Patient Name:

SONeT Acute Medical Transfer Form Date:

Version 2: March 2016 Page 1

SONeT ACUTE MEDICAL TRANSFER FORM

ADMINISTRATIVE DETAILS

REFERENCE NUMBER

DATE OF CALL CALLERS NAME

TIME OF CALL CALLERS JOB TITLE

Details Taken By: CALLERS CONTACT NUMBER

PATIENT DETAILS

PATIENT NAME DOB

PATIENT NHS NO. TIME OF BIRTH

BIRTH WEIGHT GESTATION AT BIRTH

CURRENT WEIGHT CURRENT GESTATION

PARENT NAMES PARENT CONTACT NO’S

Hospital/ Location Ward Contact Number Consultant

Referring Unit

Receiving Unit

CLINICAL INFORMATION

Clinical Reason for Transfer

Respiratory Support None □ Low flow O2 □ HFT □ CPAP □ Ventilation □

REFERRAL REQUESTS

Destination Hospital

Requested?

No

Yes

Requested Receiving Hospital Name

Requested Receiving Ward

Requested Receiving Consultant

Requesting Transport Consultant Advice?

Yes No Other Clinicians Requested for Conference Call

Yes No

TRANSFER CATEGORISATION ( Clinical team to fill in)

CATEGORY OF CARE

ITU HDU SCBU

CLINICAL General Medical

General Surgical

Specialist Medical

Cardiac Specialist Surgical

Neurosurgery

Neurology ENT

Respiratory Cardiothoracic

Endocrine

OPERATIONAL Uplift Capacity Repatriation OPD

TIME category Time-critical Immediate Urgent Non-urgent Further Discussion

Timescale <1 hour <6 hours <24 hours ≥24 hours

Reference No: Patient Name:

SONeT Acute Medical Transfer Form Date:

Version 2: March 2016 Page 2

TRANSFER TIMES (Clinical team to fill in)

Team Assigned Oxford Southampton

Decision to transfer Yes No Reason if not transferred

Date of Decision Time of Decision

Mode of Transfer Road Helicopter Fixed Wing

Location of team at time of call Base Other hospital On route

Time Ambulance Requested

Time Ambulance Arrived

Time of Departure Base/ other hospital

Time team arrive at baby

Time team depart with baby

Time of arrival at receiving hospital

Time of departure from receiving hospital

Time back at base or ready for next job?

Any delays? Yes No Reason for delay

Blue lights used Yes No Reason for blue lights

TRANSPORT TEAM

Transport Doctor

Transport ANNP

Transport Nurse

Driver

Transport Consultant

Specialist team advice (Cardiology/Surgical/Neurology/PICU/other)

GOVERNANCE (Clinical team to fill in)

Significant issues encountered : No Yes

Issue Categories Administrative Clinical Vehicle Equipment Training Communication

Delays Other

Details

INCIDENCE FORM /DATIXCOMPLETED No Yes

Reference No: Patient Name:

SONeT Acute Medical Transfer Form Date:

Version 2: March 2016 Page 3

CLINICAL HISTORY AT REFERRAL

Any significant Maternal /Antenatal History

RESUSCITATION AT BIRTH MEDICATION

Vit K □ Antenatal Steroids □

ALLERGIES Antenatal MgSO4 □

Inflation breaths

Venous Cord pH

Arterial Cord pH

Ventilation Details:

Cardiac Massage

Drugs

Apgars 1 min 5 min 10 min

AIRWAY AND BREATHING

Respiratory Support None □ Low flow O2 □ HFT □ CPAP □ Ventilation □

ETT Size Cm lips

Ventilation Settings Mode PIP/PEEP MAP/ ΔP Rate/Flow FiO2 IT

Blood Gases

pH

pC

O2

pO

2

BE

HC

O3

Lac

BSL

Date Time

Nitric Oxide Therapy Oxygen Saturations Surfactant Administration

Commenced:……:…… on .…/…./….. Pre-Duct Post-Duct Dose 1:……….…mg @ …...:…... Receiving……………ppm Dose 2:……….…mg @ …...:…...

Reference No: Patient Name:

SONeT Acute Medical Transfer Form Date:

Version 2: March 2016 Page 4

CARDIOVASCULAR/VITALS

VITAL SIGNS

HR

BP

Temp. Drug Commenced Infusing at

Prostin

Fluid Bolus

Dopamine

Dobutamine

Noradrenaline

Adrenaline

ECHO/ECG

Notes:

NEUROLOGY PAIN/SEDATION/PARALYSIS

HIE: Mild/Moderate/Severe Cooling: Passive / Active

Anticonvulsants:

Drug Commenced Infusing at

Morphine

Midazolam

Vecuronium

Notes:

GASTROENTEROLOGY/ SURGICAL INFECTION

FLUIDS FEEDS

Working Weight (kg) Blood Sugar (mmols)

Total Fluids (ml/kg/day) Last Fed (time)

Urine Output (ml/kg/hr) Gastric Aspirate (mls)

ADDITIONAL CLINICAL DETAILS PARENTS

Safeguarding issues Y □ N □ Aware of transfer Y □ N □ Maternal Transfer Required Y □ N □ Parent wishes to travel Y □ N □ NA □

Barrier Nursing Y □ N □

Reference No: Patient Name:

SONeT Acute Medical Transfer Form Date:

Version 2: March 2016 Page 5

LAB RESULTS & IMAGING

LINES & TUBES

Lines/ Tube Type/Size Insertion length Site/ Tip location

CLINICAL ADVICE GIVEN

Date/ Time

Reference No: Patient Name:

SONeT Acute Medical Transfer Form Date:

Version 2: March 2016 Page 6

CLINICAL CHANGES FROM ARRIVAL TO DEPARTURE AIRWAY AND BREATHING Interventions (Referring Hospital/ SONeT)

On Arrival at Referring Hospital At Departure Intubation RH □ SONeT □

Surfactant RH □ SONeT □

ETT reposition RH □ SONeT □

ETT securing RH □ SONeT □

Ventilation RH □ SONeT □

HFOV RH □ SONeT □

iNO RH □ SONeT □

Chest drain RH □ SONeT □

CXR RH □ SONeT □

CARDIOVASCULAR/ VITALS On Arrival at Referring Hospital At Departure CPR RH □ SONeT □

ECHO RH □ SONeT □

Inotropes RH □ SONeT □

Defib RH □ SONeT □

Prostin RH □ SONeT □

NEURO/PAIN/SEDATION On Arrival at Referring Hospital At Departure CrUss RH □ SONeT □

Cooling (passive) RH □ SONeT □

Cooling (active) RH □ SONeT □

CFM RH □ SONeT □

RH □ SONeT □

GASTRO/SURGICAL/INFECTION On Arrival at Referring Hospital At Departure NGT/OGT RH □ SONeT □

Urine Catheter RH □ SONeT □

Replogle Tube RH □ SONeT □

AXR RH □ SONeT □

RH □ SONeT □

LINES/FLUIDS/FEEDS On Arrival at Referring Hospital At Departure IV periph access RH □ SONeT □

UVC RH □ SONeT □

UAC RH □ SONeT □

Periph Art Line RH □ SONeT □

Long line RH □ SONeT □

Blood products RH □ SONeT □

MEDICATION On Arrival at Referring Hospital At Departure Sedation RH □ SONeT □

Paralysis RH □ SONeT □

RH □ SONeT □

LABS/IMAGING PARENTS Updated □ DETAILS

Travelling with Baby Y / N

Maternal Transfer Required Y/ N

Reference No: Patient Name:

SONeT Acute Medical Transfer Form Date:

Version 2: March 2016 Page 7

TRANSFER SIGNOFF

Handover at Referring hospital

Date Name of person giving handover Signature

Time Name of person receiving handover Signature

Present at Handover (please circle or tick)

Referring Team Referring Consultant Transport Team Parents

Day / Night Referring Specialist Day / Night

Handover at Receiving hospital

Date Name of person giving handover Signature

Time Name of person receiving handover Signature

Present at Handover (please circle or tick)

Receiving Team Receiving Consultant Transport Team Parents

Day / Night Receiving Specialist Day / Night

Transfer Checklist

Copies of patient notes/charts Name Bands x 2

SEND Discharge Summary Pre transfusion blood spot (if applicable)

Nursing Letter Maternal blood samples(if applicable)

Copy of Drug chart Lines/ tubes secured

Xray/ imaging/head scan PACS linked or copy Babies EBM

Copies of this transport record Parents given Transport PIL

Toys/ clothing/cards Parents given Feedback survey

Parent- held record/patient label Blood sugar/Blood gas checked pre-departure

Gas supply checked Temperature pre-departure (?transwarmer)

TRANSFER NOTES

Reference Number: SONeT Acute Medical Transfer Form

Page 8

Patient Name: OBSERVATION CHART Date: ETT size: ETT @ lips: cm A= arrival at referring unit S= stabilisation

T = transport R = accepting hospital

Time (24 hr) A S T R

200 HEART RATE 180

160 140

BLOOD PRESSURE 120

100 80

RESPS 60 40

Art Perfusion

MEAN BP

SpO2

Core CRT Temp (Axillary/Rectal) Circle as appropriate or use key

38 37•5

37 36•5

36 35•5

35 34

33•5 33

Cooling (Active)/(Passive)

Inc set Inc temp

Respiratory Support

MODE

PIP

PEEP

RATE

I Time

E Time

O2 NO/N

O2

Blood Gas

ETCO2/ TCM

SITE

pH

PC02

PO2

HCO3

BE

Lactate

BM

Suction (Oral /ETT)

Pain/Sedation Score

Page 9

Reference Number: Patient Name:

SONeT Acute Medical Transfer Form Date:

INFUSIONS

TOTAL FLUIDS (mls/kg/day

TOTAL FLUIDS (ml/hr)

Weight ( kg)

Infusion Infusion

Route Pump No. Route Pump No.

Time Rate Amount/hr TVI Pressure

Site

Time Rate Amount/hr TVI Pressure

Site

Infusion Infusion

Route Pump No. Route Pump No.

Time Rate Amount/hr TVI Pressure

Site

Time Rate Amount/hr TVI Pressure

Site

Reference Number: Patient Name:

SONeT Acute Medical Transfer Form Date:

Page 10

INFUSIONS

TOTAL FLUIDS (mls/kg/day

TOTAL FLUIDS (ml/hr)

Weight ( kg)

Infusion Infusion

Route Pump No. Route Pump No.

Time Rate Amount/hr TVI Pressure

Site

Time Rate Amount/hr TVI Pressure

Site

Reference Number: Patient Name:

SONeT Acute Medical Transfer Form Date:

Page 11

DRUG CHART

ALLERGIES WORKING WEIGHT (kgs)

STAT DRUGS

Time Drug Dose/Kg Dose Route Prescriber (PRINT NAME & SIGN)

Given by

Checked by

Fluid Prescription Route Fluid Total

Vol. Additives Rate

Ml/hr Signature & Print

Batch No

Added by

Check By

Date/ Time Started

Glucose 10%

50ml

Continuous Drug Infusions Route Drug Total

amount of drug

Dilutent Total Vol

Rate Ml/hr

Signature & Print

Batch No

Added By

Check By

Date/ Time started

Reference Number: Patient Name:

SONeT Acute Medical Transfer Form Date:

Page 12

ADDITIONAL INFORMATION/NOTES