There are no hard and fast rules about when to refer child to the CATS team and we are always happy to discuss a case. We decide about mobilising the transport team on a case-by-case basis, based on patient acuity, potential for deterioration, and the resources available at the referring hospital. Our primary role is, however, to perform transports of children requiring admission to a PICU. For a child to require PICU they do not need to be invasively ventilated. For example, children on intravenous infusions of vasoactive drugs, or children with severe diabetic ketoacidosis (DKA), may warrant admission to a PICU.
Many hospitals ring CATS as soon as they are first concerned that a sick child is deteriorating and may need intensive care. A significant proportion of the CATS workload is offering telephone advice, and early discussion may help optimise treatment and potentially avert a PICU admission. However, if the local hospital feels competent managing a sick child and instituting high dependency or intensive care, it is not necessary to routinely let the CATS team know. It is acceptable to make the referral once the child is ready for transport (for example, once the child has been intubated).
Our primary role is to transport children requiring PICU, and this includes finding an appropriate PICU bed. If resources allow and it is considered clinically appropriate, then CATS will undertake transports of children to an HDU. This may include, for example, children normally on home ventilation with an intercurrent illness requiring an increase in their ventilation settings. On these occasions CATS may ask the referring team to locate the HDU bed.
We know that managing a critically ill child can be stressful and that every minute counts. However, without enough clinical information, we cannot make an informed decision about the urgency of retrieval, nor can we provide good quality advice. We aim to take a succinct referral and reach a decision quickly.
In all cases, you can expect from us:
- A prompt and courteous response
We have a team of transport administrators available 24/7 to attend the Referral Hotline. The administrators will record some basic patient details before passing the referral to the clinical team. - A patient ear and immediate advice
The clinical team, consisting of experienced critical care doctors and nurses will collect all relevant information that is needed to make a decision. They will also offer some immediate advice that might be helpful to manage the critically ill child. - A prompt decision about PICU admission and transport
All referrals are discussed with the CATS Consultant before any decision is reached. The CATS Consultant decides whether the CATS team should be mobilised and prioritises the referral according to clinical urgency. For children requiring admission to a PICU, CATS will locate the bed. - Rapid team mobilisation
If a team is available, they will aim to leave CATS base within 20 minutes of accepting an urgent referral. We have maintained this target for team mobilisation time for the past 10 years. - A patient-centred approach to transport
We always ask the referrer if the patient is already known to a tertiary centre, so that we can transfer critically ill children to the most suitable available PICU bed. If a child needs urgent admission to PICU, we will transfer them to any available PICU bed, even if it is outside London.
Once we accept a referral for transport, we aim to mobilise a transport team within 20 minutes. The median (average) CATS team mobilisation time is 20 minutes. The time we take to reach the patient’s bedside after accepting the referral (team response time) depends on how far we must travel, but our median response time is around 75 minutes. This means that in most cases the CATS team will be at the referring hospital within an hour and a half. To ensure we reach the bedside as quickly as possible we always travel on ‘blue lights’.
If we must travel over 150-180 minutes by road to reach the patient, and the child’s condition warrants it, we will aim to use a helicopter or a fixed-wing aircraft.
We audit our triage process continuously to check that it is robust and that it does not delay us reaching a sick child. Our mobilisation data is reported annually to PICAnet to allow benchmarking against other paediatric critical care transport services.
The CATS team will provide ongoing advice on acute management and stabilisation while en route to the patient. Advice will always be tailored to the clinical scenario and will vary from case to case, but the basic principles of stabilisation at the referring hospital are covered below:
Experienced team
Senior and experienced clinicians need to be closely involved in the acute management of a sick child. In addition to the paediatric team CATS recommends that the anaesthetic team is involved in most cases. Other specialists such as ENT surgeons may need to be involved in cases where a difficult airway is anticipated.
The right equipment
A well-stocked paediatric resuscitation trolley with airway, breathing and circulation equipment is a pre-requisite for acute stabilisation. Multi-parameter patient monitoring (including end-tidal CO2 measurement), a mechanical ventilator, and IV infusion pumps are required in most cases.
Patient management
This should follow the established principles of ABCDE. View our CATS Guideline on Management of the critically ill child at the local DGH for more details.
Good communication
Please ensure that copies of relevant patient notes are ready for the CATS team. Radiology should be transferred in most cases via IEP (Image Exchange Portal) to the destination hospital.
CATS have two transport teams available 24/7 (occasionally increasing to three teams during times of peak activity in winter), and transfer 1200 critically ill children to intensive care or high dependency units each year (on average: 3-4 retrievals per day). During times of peak demand for PICU beds all transport teams may be busy at the same time.
If CATS are unable to provide a transport team we will triage the patient based on their clinical condition and manage the referral accordingly.
If the referral is triaged as being urgent:
CATS will immediately refer the patient to other transport services such as the South Thames Retrieval Service (STRS: http://evelinalondon.nhs.uk/strs) or the London Neonatal Transport Service (NTS: http://www.neonatal.org.uk) and ask for their assistance.
If London teams are busy, we will contact other neighbouring transport teams such as Southampton & Oxford Retrieval Service (SORT) or Birmingham Kids Intensive Care & Decision Support (KIDS) for assistance.
If the child is relatively stable:
CATS will establish if the child can be safely managed at the local hospital while waiting for the CATS team. We will maintain regular telephone contact with the referring hospital and provide ongoing advice as necessary, until a CATS team (or other transport team) becomes available.
We closely monitor delays in sending a transport team due to capacity constraints and report any stays >8 hours at the referring hospital to the regional commissioners.
As per national guidance, CATS expect that children with a time-critical neurosurgical emergency (where urgent craniotomy is indicated as a life-saving procedure) are transferred by the referring hospital team. Rapid transfer by the local team ensures that the child reaches the regional neurosurgical centre as quickly as possible, without waiting for a transport team to be despatched.
Management pathway for a suspected neurosurgical emergency:
- Identify early that the child has a neurosurgical emergency (e.g. extradural haematoma on CT scan or signs of raised intracranial pressure with hydrocephalus).
- Refer patient urgently to regional paediatric neurosurgeon (Great Ormond Street Hospital in North Thames or Addenbrookes Hospital in East of England) or to CATS.
- If the patient is first referred to CATS, we will teleconference the appropriate neurosurgeon immediately.
- CATS will arrange a PICU bed at relevant centre and provide advice to the local transfer team.
- Refer to the CATS guideline Acute Neurosurgical Emergency Transfer
CATS transport over 40 critically ill children each year to PICUs by air.
Aeromedical transfer is just one component of the CATS team response, and in common with all other facets of our service, it is an integrated, controlled and risk-managed process. Aircraft use is carefully targeted by our CATS Consultants to provide maximal benefit to our patients. All CATS air transfers are reviewed by our multi-disciplinary team to ensure quality standards are met and examined in detail at quarterly CATS Risk Action Group (RAG) meetings.
Emergency aeromedical transfers are technically and logistically difficult – compared with land transfers there are many more steps involved. Despite this, aeromedical transfers can save time. This is vital when specialist expertise is needed at the bedside of a critically ill child; or when it shortens the time taken to get the child into a PICU.
From an operational perspective, since our staff working hours are tightly regulated, aeromedical transfer can also allow the team to be mobilised to a sick child later into a working shift.
