ÃÛÌÒAPP

Paediatric commissioning

The paediatric division of NECTAR is commissioned by NHS England to provide Paediatric Critical Care advice and transport of critically unwell patients to the two Level 31 Paediatric Critical Care units (PICUs) at the Great North Children’s and Freeman Hospitals in ÃÛÌÒAPP. NECTAR would also transfer patients to the nearest supra-regional Level 3 bed during times of surge.

NECTAR is also commissioned to facilitate the transfer of patients from Level 3 paediatric critical care to a lower acuity of care within our region.

NECTAR have one Paediatric Team available 24/7 for Level 3 paediatric critical care transfers.

Un-commissioned work

NECTAR uses any spare capacity to enable the safe and timely transfer of paediatric patients between health care settings. This facilitates patient flow and helps manage the region’s paediatric bed capacity.

NECTAR have 1-2 practitioner led Paediatric teams every day 10am to 10pm primarily for Level 1 paediatric critical care transfers.

These types of transfers could be for the following reasons

a. Sub-speciality review at GNCH
b. General paediatric inpatient care from regional 24hr assessment units
c. Palliative care transfer
d. Sub-speciality clinic attendance from a hospital setting
e. Transfer out of region for quaternary services

Some of these transfers are infrequently occurring and require careful planning and requesting members of staff in addition to usual number of teams.

There are two broad categories of NECTAR transfers.

Paediatric Acute

This service is provided 24 hours a day, 7 days a week. All transfers are led by the NECTAR Consultant and in many instances delivered by the Consultant along with the NECTAR practitioner and the ambulance driver. However, an appropriately trained doctor or advanced critical care practitioner may carry out the transfer. These transfers are largely at Level 3 paediatric critical care but patients at other critical care levels may be transferred at the discretion of the NECTAR Consultant for the benefit of the individual patient.

NECTAR transport patients 0-16yrs of age

Pre-term neonates and transfers originating from a neonatal unit are by default the remit of the Northern Neonatal Transport Service (NNeTS)

Transfer of patients >16yrs of age fall under the remit of the adult division of the NECTAR Service.

Paediatric non-Acute

These are conducted by the NECTAR practitioners without an accompanying medic. NECTAR practitioners are highly skilled in critical care and transport but are not prescribers or Advanced Nurse Practitioners. Every paediatric non-acute transfer is objectively assessed using NECTAR’s non-acute tool to ensure that patients are safe to transfer without an accompanying medic.

Out of hours (after 2200) paediatric non-acute transfers can occur within a 30-minute radius of the NECTAR base. We aim to serve an unmet need for this type of transfer whilst not compromising commissioned transport of (Level 3) critically unwell paediatric patients. We are working with commissioners to expand our capacity overnight to ensure equitable service is provided throughout our region.

General Principles

• All hospitals in our region open to paediatric patients have the ability to manage patients at Level 1 paediatric critical care and escalate as necessary. The primary responsibility of assessing, resuscitating and stabilising a critically unwell child lies with the paediatric and critical care clinicians at the district general hospital.
  
• NECTAR is able to provide remote clinical advice (24/7) as requested in the resuscitation and stabilisation of the critically unwell child.
  
• NECTAR will always prioritise the timely transfer of the critically unwell child. Upon our arrival at the DGH we will share the responsibility of further stabilisation of the patient with the local team until our departure.
  
• Acutely unwell children will be only transferred after clinical stability is established following initial treatment
  
  • Eg. Severe DKA after commencement of insulin, infants in respiratory failure stable after 1-2hrs of HHFNC
• Acutely unwell children who are likely to require transfer and sub-speciality input for ongoing management should preferably be referred via NECTAR.

Level 2 PCC

• James Cook University Hospital is the only Level 2 commissioned unit in the North East. NECTAR is not currently commissioned to transfer patients for uplift of care from Level 1 to Level 2. A very small cohort of patients may be suitable for transfer for ongoing Level 2 PCC on a case-by-case basis Eg LTV patients to Level 2 units for ongoing care, children with Neurodisability in respiratory failure etc.
• However, the following conditions need to be satisfied
  • NECTAR have a backup option ensuring that our response for the transfer any other Level 3 paediatric patient is not affected.
  • The patient is suitable and likely to be clinically stable for the duration of the transfer.
• NECTAR always will ensure that there is robust discussion with an aim to achieve the best outcome for the patient whilst balancing the needs of the service as a whole.

Critical Care advice

There is a well-established process of referring critically unwell patient to NECTAR for decision support and advice prior to escalation to Level 3 paediatric critical care. NECTAR also receives a number of advice calls from clinicians in the DGH about acutely unwell children who may not necessarily require a transfer.

In those situations

• It would be helpful to specify the critical care advice sought at the beginning of the referral call
• These calls should be ideally Consultant to Consultant unless there is a clinical emergency or ongoing resuscitation.
• In patients requiring speciality advice without transfer, the conference call may not necessarily include the NECTAR Consultant.