Abstract P-329: THE TRANSITONAL CARE TEAM IN THE PAEDIATRIC INTENSIVE CARE UNIT CASE MANAGES COMPLEX LONG TERM PATIENTS

Abstract

Aims & Objectives: The paediatric intensive care unit (PICU) Transitional Care Team (TCT) case-manages complex or long-term patients requiring intensive care using an individualised plan of care for each patient and family. PICU patients often have multiple treating teams, and the TCT coordinates care to provide a fully integrated approach for complex admissions. The overall goal is to enhance communication and decision-making between treating services, the PICU and families to achieve discharge from PICU to the community or to other inpatient areas. This is achieved by: 1) advanced discharge planning either within LCCH or home; 2) promotion of family-centred care principles; 3) early identification and management of needs associated with long-term PICU admission; and 4) incorporation of evidence into practice related to this patient population. Methods We reviewed our clinical practice for the previous 2 years. An Excel spreadsheet was used to track the daily census, admissions and discharges. Results In 2016, 10 patients were supported by the TCT service. The average length of stay for these patients was 212 days (total 2124 PICU days), although some continued into 2017. A total of 31 multidisciplinary team meetings were planned, attended and followed up. Four of the patients were tracheostomy/ventilator dependent, one relied on non-invasive ventilator support, and five had high-flow nasal oxygen cannulae. Conclusions The PICU TCT service is an integral part of managing long-stay and technology-dependent children in PICU. The service will also audit practice and participate in research projects. We will continue to work with PICU colleagues and build relationships with other clinical services.