Transitional IssuesDr Paul RolfeConsultant Paediatric Anaesthetist

Cambridge University Hospitals NHS Foundation Trust

Transition Process• Importance recognised for

some time by Health, Education and social care

• Fairly well developed by some medical disciplines

• Perioperative care lags behind• Transition is not a specialist

topic, it’s for everyone• We only see a “snapshot”• Health requirements of the

young person in the broader context of family, relationships , education, work and social care

Lam P-Y, Fitzgerald BB, Sawyer SM. Young adults in children’s hospitals: why are they there? Med J Aust 2005; 182: 381-384

Transition is…

“ a purposeful, planned process that addresses the medical, psychosocial and

educational/vocational needs of adolescents and young people with

chronic physical and medical conditions as they move from child-centred to adult

oriented health care systems.”

Based on Blum RW, Garell D, Hadgman CH et al. Transition from child-centred to adult health-care systems for adolescents with chronic conditions. A positionpaper of the Society for Adolescent Medicine. J Adol Health 1993: 14; 570-6.

Benefits of Well Managed Transition• Uninterrupted co-ordinated health care• Reduced psychological distress and anxiety• Significantly improved disease control• Prevention of medical catastrophe/premature death• Better follow up• Improved documentation of transitional issues

• Vanelli M, Caronna S, Adinolfi B et al. Effectiveness of an uninterrupted procedure to transfer adolescents with type 1 diabetes from the paediatric to adult clinic held in the same hospital: eight year experience with the Parma protocol. Diabetes Nutr Metab 2004; 17: 304-308

• Flume PA, Taylor LA, Anderson DL et al. Transition programs in cystic fibrosis centers: perceptions of team members. Paediatr Pulmonol 2004; 37: 4-7

• Reid GJ, Irvine MJ, McCrindle BW et al. Prevalence and correlates of successful transfer from pediatric to adult health care among a cohort of young adults with complex congenital heart defects. Pediatrics 2004; 113: 197-205

Adolescent Development

• Vulnerable period with rapid Biopsychosocial changes

• Development of abstract thinking, personal identity, “bullet proof” – increased health risk

– Decision making– Discussion of risk

• Relevance of timing of puberty

• Only period we don’t deal directly with adults

• ‘Resilience’

Transitional Care

Getting it right for children and young people (Sir Ian Kennedy 2010) Commissioning a good child health service (RCGP March 2013) Transition: getting it right for young people (DH 2006)

Kennedy Report 2010

Transition is a “phenomenon created by the system”

Care from an organisational perspective rather than the needs of the child being care for.

Young person’s needs evolve but services change abruptly at arbitrary points

“Transition” often amounts to “transfer”

Experience “disruptive discontinuity”

Important Aspects of Transitional Planning• Professional and

Managerial Attitudes• Differing perspectives

clinicians• Appropriate environment• Effective dialogue

between clinicians, managers, commissioners and other agencies

• User consultation• Agreed policies on timing

• Preparation period• Education programme

Communication

• Clear Co-ordinator• Administrative support• Information transfer

• Personal Health Record• Health Passports

• “Fail Safe” mechanisms• Monitoring• Transition checklists

• Ensure primary care involvement

Models of delivery

Dedicated Follow up service in adult

setting

“Seamless” clinic(joint approach)

Lifelong Follow up in Paediatric

Setting

Transition co-ordinators for large

geographical regions.

Generic Transition team

e.g. “On Trac”

On Trac – Taking Responsibility for Adolescent/Adult Care

Early Adolescence Ages 10-12 Introduced to process Begins to participate in own care

Mid-adolescence Ages 13-15 Gains understandingPractices skillsGathers informationSets Goals

Late Adolescence Ages 16-18Prepare to leave paediatric setting with confidenceUses independent health care behaviours and consumer skills

THEMES:Self-advocacy

Independent health care behavioursSexual Health

Social supportsEducational/Vocational/Financial planning

Health & Lifestyle

Relevance to Anaesthesia

• Wider context of anaesthesia– Intensive care medicine– Obstetrics– Pain medicine

• Operating theatre

Relevance to Anaesthesia

• Wider context of anaesthesia– Intensive care medicine– Obstetrics– Pain medicine

• Operating theatre

If transitional care relates to ensuring a young persons needs are met within an adult orientated health care system then

what are the challenges for us in the perioperative setting?

Case illustration

19 year old man (weight 33kg)Cerebral Palsy and global developmental delayFemoral osteotomy.Initial plan to care for in paediatric settingDOSA – admitted to adult orthopaedic ward as

children's ward had no capacityAdult trained orthopaedic surgeonAdult trained anaesthetistNo regional techniquesAdult recovery care – severe painPCA morphine regimen prescribed6 hours later found unresponsive with RR 6Mother had been activating PCAGiven naloxone and sent to PHDU

Case illustration

19 year old man (weight 33kg)Cerebral Palsy and global developmental delayFemoral osteotomy.Initial plan to care for in paediatric settingDOSA – admitted to adult orthopaedic ward as

childrens ward had no capacityAdult trained orthopaedic surgeonAdult trained anaesthetistNo regional techniquesAdult recovery care – severe painPCA morphine regimen prescribed6 hours later found unresponsive with RR 6Mother had been activating PCA on son’s behalfGiven naloxone and sent to PHDU

EnvironmentService constraints

Familiarity / ConfidenceTraining / SupportTechnical ability

Appropriate techniques

Parental involvementNurse/Carer expectations

Education / trainingPatient assessment

Clear communication

Themes that emerge

Familiarity with childhood disease

Technical and training issues

Paediatric vs adult care Transitional policies for

perioperative care

Brennan LJ, Rolfe PM. Transition from pediatric to adult health services: the perioperative care perspective. Pediatric Anesthesia 2011: 21: 630-635

Familiarity with childhood disease

• Congenital vs. Acquired• ↑ survival rates in conditions

once limited to childhood• Move from familiar paediatric

setting to a hospital with more adult orientated perioperative care

• Potential solutions include– Flexible working at paediatric

centres– Joint programmes at adult

hospitals– Collaborative working e.g.

neurosurgical centre

• Urgent surgery away from base hospital

• Disparity of transition arrangements of parent speciality and perioperative care

• Family and young person as ‘expert’ in their condition

Survey: Evidence of collaborative working in 79% centres

Technical and Training issues

• Differing approaches between adult and paediatric anaesthetist• Regional anaesthesia

– Under anaesthesia or awake?– Paediatric proportions

• Analgesic regimens– Opioids– Epidural

• Strategies for difficult airway management– Equipment– Training in appropriate technique

• Pain Assessment– Cognitive impairment

• Early warning scores– Recognition of the deteriorating patient

• Ensuring an appropriate environment

Paediatric vs. Adult care

• Aspects of perioperative care– Appropriate presence of parents and families– Equivalent support to that of play therapists– Inhalational induction – Topical local anaesthesia to facilitate

intravenous induction– Sedative premedication

• Appropriate environment

• Important to recognise the benefits of adult orientated care

Transitional policies

• Perioperative care lags behind other specialties• Transition plan in place by age 14• Vital that there is anaesthetic input into transition planning,

even if this is to advise on the degree of expertise required.• Flexible, safe and appropriate• Manage local and national service constraints• Outside of the UK, lack of affordable health care insurance

Survey: A specific policy covering perioperative care was present in only 5% of hospitals. However transitional arrangements were thought to be adequate in 64%

Final thoughts

• Transition is hugely important for all young people

• The challenge for perioperative care– Consider best use of local (regional) services– Reconcilling the disparity of the transition arrangements of a parent

specialty and anaesthesia– Collaborative working– Embrace flexibility – greater individualisation– Challenge rigid pathways and procedures

Email: paul.rolfe@addenbrookes.nhs.uk