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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