Care pathway for a child being discharged home on mechanical ventilation

Transcription

1 Care pathway for a child being discharged home on mechanical ventilation Contents SECTION 1 Clinical assessments/requirements page 1 SECTION 2 Clinical assessments/desirable baseline parameters page 2 SECTION 3 Multi-professional/partnership working page 3 SECTION 4 Outcome of multi-professional discharge page 4 SECTION 5 Housing assessment page 5 SECTION 6 Play, development and education page 8 SECTION 7 Funding page 9 SECTION 8 Parent/carer training and competencies page 10 SECTION 9 Benefits page 17 SECTION 10 Identified equipment needs page 18 SECTION 11 Oxygen requirements page 20 SECTION 12 Respite and support provision page 21 SECTION 13 Trail home visit page 22 SECTION 14 Discharge home page 23 SECTION 15 Contact sheet (including professional codes) page 25 SECTION 16 Variance tracking sheet page 30

2 SECTION 1 HOSPITAL NUMBER: : ADDRESS: TEL: DOB: DATE: DATE OF ADMISSION: ESTIMATED DATE OF DISCHARGE: DATE CONSULTANT APPROVED DISCHARGE: _ CONSULTANT : _ CONSULTANT SIGNATURE: _ CHILD LIKES TO BE CALLED: S OF PARENTS: S OF SIBLINGS: FAMILY AWARE OF, AND INVOLVED IN DISCHARGE PLANNING YES NO BEGIN CARE PATHWAY 1 CLINICAL ASSESSMENTS/REQUIREMENTS WEEK 1 DATE SIGNATURE 1a AIRWAY TRACHEOSTOMY TYPE: SIZE: LENGTH: PICU Nurse FREQUENCY OF ELECTIVE CHANGE: 1b VENTILATOR TYPE: SETTINGS: FREQUENCY OF CIRCUIT CHANGE: HOURS ON/OFF: ON OFF PORTABLE VENTILATOR TYPE 1c HUMIDITY TYPE: TEMPERATURE: FREQUENCY OF H 2 O CHANGE: TYPE OF HUMIDIVENT IF USED TYPE OF PORTABLE HUMIDITY 1d SUCTION TYPE: LENGTH: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 1 of 30

3 SECTION 2 :_DOB: HOSPITAL NUMBER: 2 CLINICAL ASSESSMENTS/DESIRABLE BASELINE PARAMETERS WEEK 1 DATE SIGNATURE 2a WEIGHT:_ HEIGHT: PICU Nurse 2b USUAL VITAL SIGNS RESPIRATIONS: HEART RATE: TEMPERATURE: to per min to per min to OXYGEN SATURATION to BLOOD PRESSURE: to 2c IMMUNISATIONS UP TO DATE: HAD: NEEDS: 2d INVESTIGATIONS PENDING DATE DUE RESULT 2e MEDICATIONS DRUG DOSE ROUTE FREQUENCY PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 2 of 30

4 SECTION 3 :_DOB: HOSPITAL NUMBER: 3 PROFESSIONAL /PARTNERSHIP WORKING WEEK 1 3 3a PROFESSIONAL REFERRAL MADE GENERAL PRACTICIONER DATE SIGNATURE HEALTH VISTOR CHILDREN'S COMMUNITY NURSE OCCUPATIONAL THERAPIST PHYSIOTHERAPY DIETICIAN PLAY THERAPY SPEECH & LANGUAGE THERAPY CHILD DEVELOPMENT CENTRE SOCIAL WORKER FAMILY SUPPORT WORKER FOR RESPITE AND SUPPORT SERVICES PLEASE COMPLETE SECTION 12, PAGE 21 3b MULTI-PROFESSIONAL DISCHARGE PLANNING MEETING ARRANGED DATE: TIME: VENUE: PARENTS INVITED PROFESSIONALS AWARE FOR OUTCOME OF MULTI-PROFESSIONAL DISCHARGE PLANNING MEETING PLEASE COMPLETE SECTION 4, PAGE 4 PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 3 of 30

5 SECTION 4 :_DOB: HOSPITAL NUMBER: 4 OUTCOME OF MULTI-PROFESSIONAL DISCHARGE PLANNING MEETING WEEK 1 4 4a ALLOCATION OF CARE CO-ORDINATORS SERVICE DESIGNATION ACUTE COMMUNITY DATE SIGNATURE PICU NURSE CCN 4b NEGOTIATED CARE PACKAGE CARE HOURS REQUESTED BY PARENTS hours per day CCN _ 4c TEAM LEADER CARERS REQUIRED (WTE) APPLY FOR FUNDING APPLY FOR FUNDING BEGIN RECRUITMENT WHEN FUNDING AGREED 4d ROLES AND RESPONSIBILITIES (JOB DESCRIPTION) OF PROFESSIONALS CLEAR AND UNAMBIGUOUS RECRUITMENT PLAN: CCN _ SW _ RN _ CCN PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 4 of 30

6 SECTION 5 : DOB: HOSPITAL NUMBER: 5 HOUSING ASSESSMENT WEEK 1 4 DATE SIGNATURE 5a JOINT HOME VISIT PLANNED (OT/CCN) JOINT HOME VISIT COMPLETED MAJOR ADAPTATIONS REQUIRED OUTLINE OF PLAN: (INCLUDE DETAILED REPORT IN NOTES) OT _ CCN 5b MOVING AND HANDLING IS A BUGGY USER TYPE OF BUGGY/PRAM ADEQUATE TO HOLD EQUIPMENT ADEQUATE ACCESS TO HOUSE ADEQUATE ACCESS IN HOUSE PLAN: FUNDING SOUGHT DATE: FUNDING AGREED DATE: RAMP ORDERED DATE: RAMP RECEIVED DATE: 5c HOIST / TRACKING HOIST / TRACKING SYSTEM REQUIRED PLAN: FUNDING SOUGHT FUNDING AGREED HOIST/TRACKING ORDERED DATE: DATE: DATE: OT _ HOIST/TRACKING INSTALLED DATE: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 5 of 30

7 SECTION 5 : DOB: HOSPITAL NUMBER:_ 5 HOUSING ASSESSMENT continued WEEK 1 4 DATE SIGNATURE 5d SLEEPING ADEQUATE ROOM FOR BED/COT BED/COT HIGHT ADJUSTABLE BED/COT REQUIRED PLAN: : FUNDING SOUGHT DATE: FUNDING AGREED DATE: BED/COT ORDERED DATE: CCN BED/COT RECEIVED DATE: 5e HOME SEATING ADEQUATE SEATING SEATING REQUIRED PLAN: : FUNDING SOUGHT DATE: FUNDING AGREED DATE: SEATING ORDERED DATE: OT _ SEATING RECEIVED DATE: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 6 of 30

8 SECTION 5 : DOB: HOSPITAL NUMBER: 5 HOUSING ASSESSMENT continued WEEK 1 4 DATE SIGNATURE 5f CAR SEATING CAR SEAT ADEQUATE / SAFE CAR SEAT REQUIRED PLAN: : PARENTAL CONTRIBUTION DATE: ADDITIONAL FUNDING SOUGHT DATE: ADDITIONAL FUNDING AGREED DATE: CAR SEAT ORDERED DATE: CAR SEAT RECEIVED DATE: OT 5g HYGIENE / TOILETTING ACCESS TO BATHROOM / TOILET AIDS REQUIRED PLAN: : FUNDING SOUGHT DATE: FUNDING AGREED DATE: AIDS ORDERED DATE: AIDS RECEIVED DATE: OT 5h CARERS NEEDS HAS THE CARER ACCESS TO TOILET /KITCHEN PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 7 of 30

9 SECTION 6 : DOB: HOSPITAL NUMBER: 6 PLAY, DEVELOPMENT AND EDUCATION WEEK 1 12 DATE SIGNATURE 6a PLAY SPECILAIST/OT VISIT PLANNED PLAY SPECIALIST/OT VISIT COMPLETED SPECIALIST TOYS/EQUIPMENT RECOMMENDED (PLEASE SPECIFY) FUNDING (PLEASE SPECIFY) PARENTAL CONTRIBUTION: CHARITABLE FUNDS: OTHER: TOY LIBRARY APPROACHED FLEDGLINGS APPROACHED PS _ PLANET (PLAY ADVICE NETWORK) APROACHED OT 6b EDUCATION DOES ATTEND SCHOOL IF SO, WHERE: APPROPRIATE TO RETURN IF 'NO' STATE PLAN: STATEMENT FOR SPECIAL EDUCATION NEEDS IN PROGRESS COMM/PAED DATE COMMENCED: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 8 of 30

10 SECTION 7 : DOB: HOSPITAL NUMBER: 7 FUNDING WEEK 1 8 (OR UNTIL FUNDING APPROVED) DATE SIGNATURE 7a FORMULATE BUSINESS PLAN STATE ANNUAL COST OF: HUMAN RESOURCES (NURSING, CARERS ) per annum EQUIPMENT SUPPLIES TOTAL COST per annum per annum per annum CCN CCNM 7b APPLICATION FOR FUNDING MADE TO: PRIMARY CARE TRUST SOCIAL SERVICES OT JOINT COMMISSIONING CHARITABLE FUNDS 7c FUNDING APPROVAL FUNDING APPROVED IF 'YES' PROCEED TO SECTION 8 IF 'NO' FOLLOW THIS PROCEDURE: a) INFORM PARENTS (COMMENCE TRAINING OF PARENTS) b) INFORM MULIT-PROFESSIONAL TEAM c) REPEAT APPLICATION(S) CCN CCNM OT d) REVIEW FUNDING ARRANGEMENT PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 9 of 30

11 SECTION 8 : DOB: HOSPITAL NUMBER: 8 PARENT/CARER TRAINING AND COMPETENCIES WEEK a BREATHING: ANATOMY AND PHYSIOLOGY DATE SIGNATURE TRAINER/ GUIDELINE/PROTOCOL INCLUDED IN NOTES OTHER EVIDENCE BASE INCLUDED IN NOTES DESIGNATION TRAINER,S /DESIGNATION PARENTS CARERS TRAINING INITIATED C1 C2 C3 C4 C5 TRAINING PROGRESSING C1 (If Training Not Progressing, Review Process and Repeat) C2 C3 C4 C5 TRAINING COMPLETED C1 C2 C3 RE-ASSESS IN 3 MONTHS C4 C5 DATE FOR RE-ASSESSMENT: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 10 of 30

12 SECTION 8 : DOB: HOSPITAL NUMBER: 8 PARENT/CARER TRAINING AND COMPETENCIES CONTINUED WEEK b HUMIDITY DATE SIGNATURE TRAINER/ GUIDELINE/PROTOCOL INCLUDED IN NOTES OTHER EVIDENCE BASE INCLUDED IN NOTES DESIGNATION TRAINER /DESIGNATION PARENTS CARERS TRAINING INITIATED C1 C2 C3 C4 C5 TRAINING PROGRESSING C1 (If Training Not Progressing, Review Process and Repeat) C2 C3 C4 C5 TRAINING COMPLETED C1 C2 C3 RE-ASSESS IN 3 MONTHS C4 C5 DATE FOR RE-ASSESSMENT: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 11 of 30

13 SECTION 8 : DOB: HOSPITAL NUMBER: 8 PARENT/CARER TRAINING AND COMPETENCIES CONTINUED WEEK c CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) DATE SIGNATURE TRAINER/ GUIDELINE/PROTOCOL INCLUDED IN NOTES OTHER EVIDENCE BASE INCLUDED IN NOTES DESIGNATION TRAINER /DESIGNATION PARENTS CARERS TRAINING INITIATED C1 C2 C3 C4 C5 TRAINING PROGRESSING C1 C2 (If Training Not Progressing, Review Process and Repeat) C3 C4 C5 TRAINING COMPLETED C1 C2 C3 RE-ASSESS IN 3 MONTHS C4 C5 DATE FOR RE-ASSESSMENT: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 12 of 30

14 SECTION 8 : DOB: HOSPITAL NUMBER: 8 PARENT/CARER TRAINING AND COMPETENCIES CONTINUED WEEK d TRACHEOSTOMY CARE: CHANGING TRACHEOSTOMY/TUBE (ELECTIVELY AND IN AN EMERGENCY), CLEANING AND DAILY CARE DATE SIGNATURE GUIDELINE/PROTOCOL INCLUDED IN NOTES OTHER EVIDENCE BASE INCLUDED IN NOTES TRAINER/ DESIGNATION TRAINER /DESIGNATION PARENTS CARERS TRAINING INITIATED C1 C2 C3 C4 C5 TRAINING PROGRESSING (If Training Not Progressing, C1 Review Process and Repeat) C2 C3 C4 C5 TRAINING COMPLETED C1 C2 C3 C4 RE-ASSESS IN 3 MONTHS C5 DATE FOR RE-ASSESSMENT: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 13 of 30

15 SECTION 8 : DOB: HOSPITAL NUMBER: 8 PARENT/CARER TRAINING AND COMPETENCIES CONTINUED WEEK 1 10 DATE SIGNATURE 8e SUCTIONING GUIDELINE/PROTOCOL INCLUDED IN NOTES OTHER EVIDENCE BASE INCLUDED IN NOTES TRAINER /DESIGNATION TRAINER/ DESIGNATION PARENTS CARERS TRAINING INITIATED C1 C2 C3 C4 C5 TRAINING (If Training PROGRESSING Not Progressing, Review Process and Repeat) C1 C2 C3 C4 C5 TRAINING COMPLETED C1 C2 C3 C4 RE-ASSESS IN 3 MONTHS C5 DATE FOR RE-ASSESSMENT: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 14 of 30

16 SECTION 8 : DOB: HOSPITAL NUMBER: 8 PARENT/CARER TRAINING AND COMPETENCIES CONTINUED WEEK 1 10 DATE SIGNATURE 8f CARDIO-PULMONARY RESUSCITATION (CPR) GUIDELINE/PROTOCOL INCLUDED IN NOTES OTHER EVIDENCE BASE INCLUDED IN NOTES TRAINER /DESIGNATION TRAINER/ DESIGNATION PARENTS CARERS TRAINING INITIATED C1 C2 C3 C4 C5 TRAINING (If Training Not PROGRESSING Progressing, Review Process and Repeat) C1 C2 C3 C4 C5 TRAINING COMPLETED C1 C2 C3 C4 RE-ASSESS IN 3 MONTHS C5 DATE FOR RE-ASSESSMENT: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 15 of 30

17 SECTION 8 : DOB: HOSPITAL NUMBER: 8 PARENT/CARER TRAINING AND COMPETENCIES CONTINUED WEEK g GASTROSTOMY/NASO-GASTRIC FEEDING CHANGING TUBE, BOLUS FEED, PUMP FEED DATE SIGNATURE TRAINER/ GUIDELINE/PROTOCOL INCLUDED IN NOTES OTHER EVIDENCE BASE INCLUDED IN NOTES DESIGNATION TRAINER /DESIGNATION PARENTS CARERS TRAINING INITIATED C1 C2 C3 C4 C5 TRAINING PROGRESSING C1 (If Training Not Progressing, Review Process and Repeat) C2 C3 C4 C5 TRAINING COMPLETED C1 C2 C3 C4 RE-ASSESS IN 3 MONTHS C5 DATE FOR RE-ASSESSMENT: PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 16 of 30

18 SECTION 9 : DOB: HOSPITAL NUMBER: 9 BENEFITS WEEK 1 10 DATE SIGNATURE 9a DISABILITY LIVING ALLOWANCE (DLA) (CHILD > 3 MONTHS) SW/CCN APPLIED FOR APPROVED 9b CARERS BENEFITS APPLIED FOR APPROVED 9c MOBILITY COMPONENT OF DLA PARENTS AWARE OF CAR HIRE/PURCHASE 9d DOES FAMILY RECEIVE INCOME SUPPORT IF 'YES' SOCIAL FUND BUDETTING LOAN REQUIRED (INTEREST FREE LOAN FOR EXPENCES INCURRED) APPLIED FOR APPROVED 9e BLUE BADGE PARKING SCHEME (CHILD >2 YEARS) APPLIED FOR APPROVED 9f ROAD TAX EXPEMPTION APPLIED FOR APPROVED 9g PARENTS AWARE OF: DIRECTION PLUS (BENEFITS & FUNDING ADVICE) FAMILY FUND TRUST (HELPING WITH FINDING CERTAIN ITEMS) PLEASE RECORD ANY VARIANCES ON TRACKING SHEET PAGE 17 of 30

19 SECTION 10 : DOB: HOSPITAL NUMBER: 10 IDENFIFIED EQUIPMENT NEEDS WEEK a QTY TYPE ORDER NO. COST ORDERED RECEIVED VENTILATOR x2 BATTERY PACK VENTILATOR TUBES* TRACHEOSTOMY TUBES AND TAPES* PORTABLE SUCTION UNIT MAINS SUCTION UNIT SWEDISH NOSES/HUMIDIVENTS* HUMIDIFIER STERILE WATER (1 LITRE)* SUCTION CATHTERS* SUCTION TUBING* APNOEA ALARM APNOEA SENSORS* PLUSE OXIMETER PLUSE OXIMETER PROBE* TRACHEAL DILATORS SALINE SACHETS* CAVILON LYOFOAM/DRESSING* DISPOSABLE GLOVES* SCISSORS (ROUND ENDED) KY JELLY SACHETS* GAUZE* *calculate monthly CCN SIGNATURE PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 18 of 30

20 SECTION 10 : DOB: HOSPITAL NUMBER: 10 IDENFIFIED EQUIPMENT NEEDS CONTINUED WEEK b EMERGENCY BAG QTY TYPE ORDER NO. COST ORDERED RECEIVED TRACHEOSTOMY TUBE TRACHEOSTOMY TUBE (ONE SIZE SMALLER) TRACHEOSTOMY TAPES TRACHEAL DILATORS SCISSORS (ROUND ENDED) SUCTION CATHETERS (VARIOUS SIZES) RE-BREATHING CIRCUIT BAG ITSELF CCN SIGNATURE PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 19 of 30

21 SECTION 11 : DOB: HOSPITAL NUMBER: 11 OXYGEN REQUIREMENTS WEEK a EQUIPMENT REQUIRED OXYGEN CONCENTRATOR ORDERED RECEIVED DATE SIGNATURE LOW FLOW METER OXYGEN CYLINDER SIZE F(BACKUP) PORTABLE OXYGEN CYLINDER LOW FLOW METER FOR CYLINDERS CONTACT GP FOR ABOVE REQUIREMENTS AND REQUEST A FP10 PRESCRIPTION TREM (TRANSPORT EMERGENCY) CARD CCN _ 11b RISK ASSESSMENT AND MANAGEMENT PARENTS CARERS AWARE AWARE DANGERS OF SMOKING IN VICINITY OF OXYGEN NO OXYGEN IN VICINITY OF GAS/FIRE/BOILER/COOKER SAFE STORAGE IN CAR CALCULATING AMOUNT OF OXYGEN REQUIRED ON OUTINGS CCN 11c AUTHORITIES INFORMED FIRE SERVICE AMBULANCE SERVICE HOUSE & CAR INSURANCE (SHOULD NOT AFFECT POLICIES) ELECTRICITY SUPPLIER (PRIORITY CUSTOMERS) (PRIORITY CUSTOMERS) LOCAL CHEMIST CCN PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 20 of 30

22 SECTION 12 : DOB: HOSPITAL NUMBER: 12 RESPITE AND SUPPORT PROVISION WEEK a PLEASE OUTLINE FAMILIES WISHES AND EXPECTATIONS OF RESPITE CARE AND SUPPORT DATE SIGNATURE _ CCN _ 12b RESPITE PROVIDER REFERRAL REFERRAL MADE ACCEPTED CROSSROADS EACH HOSPICE LAURELS CAMBRIDGE LINK SCHEME OTHER (PLEASE SPECIFY) 12c SUPPORT GROUPS Please see copy of Useful contacts in the back of the folder PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 21 of 30

23 SECTION 13 : DOB: HOSPITAL NUMBER: 13 TRIAL HOME VISIT WEEK 16+ (WHEN OTHER SECTIONS COMPLETED) PROFESSIONAL(S) ORGANISING/PARTICIPATING IN TRIAL HOME VISIT 13a PROPOSED DATE: DATE 13b DATE AGREED WITH PARENTS/CHILD/FAMILY 13c MEDICALLY WELL ENOUGH TO LEAVE UNIT 13d EQUIPMENT READY VENTILATOR PORTABLE OXYGEN PORTABLE SUCTION (OR MAINS SUCTION AT HOME) EMERGENCY BAG (SEE SECTION 10b, PAGE 19) MOBILE PHONE (CHARGED AND IN CREDIT) CAR SEAT 13f HOME VISIT SUCCESSFUL IF YES: IF NO: a) PROCEED TO DEFINITE a) IDENTIFY AREAS OF DISCHARGE DATE CONCERN b) MULTI-PROFESSIONAL b) FORMULATE ACTION MEETING TO ENSURE ALL PLAN TO RECTIFY THE AGENCIES AWARE OF ABOVE IMPENDING DISCHARGE c) RE-ASSESS SITUATION DATE AND TO CLARIFY ROLES/RESPONSIBILITIES d) REPEAT TRIAL HOME VISIT WHEN APPROPRIATE e) EVALUATE PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 22 of 30

24 SECTION 14 : DOB: HOSPITAL NUMBER: 14 DISCHARGE HOME WEEK 16+ (WHEN TRIAL HOME VISIT SUCCESSFUL) DATE SIGNATURE 14a PROPOSED DATE: (NOT A FRIDAY OR WEEKEND) PICU/N DATE DISCUSSED AND AGREED WITH PARENTS/CHILD/FAMILY AND ALL AGENCIES CCN READY FOR DISCHARGE PCONS FAMILY PREPARED FOR DISCHARGE CCN _ ALL AGENCIES INFORMED CCN _ EQUIPMENT ORGANISED (INCLUDING EMERGENCY BAG SEE SECTION 10b, PAGE 19 CCN _ OPEN ACCCESS ARRANGED TO WARD PCONS OPEN ACCESS ARRANGED TO PICU PCONS OPEN ACCESS ARRANGED TO A & E PCONS 24 HOUR CONTACT WITHH CNNs CCN _ LOCAL AMBULANCE STATION INFORMED CCN _ TTOs P/REG ENOUGH SUPPLIES TO LAST 1 MONTH PICU/N LOCAL CHEMIST INFORMED OF SPECIAL CCN _ REQUIREMENTS PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 23 of 30

25 SECTION 14 : DOB: HOSPITAL NUMBER: 14 DISCHARGE HOME CONTD WEEK 16+ (WHEN TRIAL HOME VISIT SUCCESSFUL) 14b OUTPATIENT/HOSPITAL APPOINTMENTS APPOINTMENT REQUESTED CLINIC TIME DATE PARENTS AWARE PICU FOLLOW-UP ENT BRONCHOSCOPY LARYNOSCOPY SLEEP STUDY SIGNATURE DIETICIAN RN CHILD DEV CENTRE PREG 14c COMMUNITY VISITS BOOKED WHEREVER POSSIBLE, PLEASE TRY TO COINCIDE AND MINIMISE DISRUPTION COMMUNITY PROFESSIONAL TIME DATE PARENTS AWARE CHILDREN'S COMMUNITY NURSE CCN OCCUPATIONAL THERAPIST OT SOCIAL WORKER SW GENERAL PRACTICIONER CCN HEALTH VISITOR HV OTHER (PLEASE SPECIFY) PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 24 of 30

26 SECTION 15 : DOB: HOSPITAL NUMBER: 15 CONTACT SHEET (COPY TO PARENTS) ROLE PARENT(S) CODE P ROLE PICU CODE P/CONS ROLE PICU REGISTRAR CODE P/REG ROLE PICU SENIOR HOUSE OFFICER CODE P/SHO ROLE PICU MANAGER CODE PMAN ROLE PICU SISTER/CHARGE NURSE CODE PS/PCN 24 = AVAILABLE 24 HOURS PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 25 of 30

27 SECTION 15 : DOB: HOSPITAL NUMBER: 15 CONTACT SHEET CONTINUED (COPY TO PARENTS) ROLE PICU NURSE (CO-ORDINATOR) CODE PICU/N ROLE ENT CONSULTANT CODE ENTC ROLE COMMUNITY PAEDIATRICIAN CODE COMM/PAED ROLE CHILDREN'S COMMUNITY NURSE CODE CCN ROLE CCN MANAGER CODE CCNM ROLE OCCUPATIONAL THERAPIST CODE OT

28 24 = AVAILABLE 24 HOURS PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 26 of 30

29 SECTION 15 : DOB: HOSPITAL NUMBER: 15 CONTACT SHEET CONTINUED (COPY TO PARENTS) ROLE PHYSIOTHERAPIST CODE PHYS ROLE PLAY WORKER CODE PLAY ROLE SOCIAL WORKER CODE SW ROLE GENERAL PRACTICTIONER CODE GP ROLE SPEECH & LANUUAGE THERAPIST CODE S & LT ROLE DIETICIAN CODE D 24 = AVAILABLE 24 HOURS PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 27 of 30

30 SECTION 15 : DOB: HOSPITAL NUMBER: 15 CONTACT SHEET CONTINUED (COPY TO PARENTS) ROLE PHYSIOTHERAPIST CODE PHYS ROLE OCCUPATIONAL THERAPY CLINIC CODE OPC ROLE TRACHEOSTOMY SPECIALIST NURSE CODE TRA/N ROLE JOINT EQUIPMENT CODE JE ROLE FAMILY SUPPORT CODE FS ROLE LOCAL CHEMIST CODE LC

31 24 = AVAILABLE 24 HOURS PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 28 of 30 SECTION 15 Care pathway for a child being : DOB: HOSPITAL NUMBER: 15 CONTACT SHEET CONTINUED (COPY TO PARENTS) ROLE OXYGEN SUPPLIER ROLE HOME CARE TEAM LEADER ROLE CARER 1 ROLE CARER 2 ROLE CARER 3 ROLE CARER 4 CODE O 2 CODE HCTL CODE C1 CODE C2 CODE C3 CODE C4

32 24 = AVAILABLE 24 HOURS ROLE CARER 5 CODE C5 PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 29 of 30 Care pathway for a child being SECTION 16 : DOB: HOSPITAL NUMBER: 16 VARIANCE TRACKING SHEET RATIONAL FOR 'NO' RESPONSES, ACTION TAKEN AND ANY OTHER COMMENTS DATE SIGNATURE

33 PLEASE RECORD ANY VARIENCES ON TRACKING SHEET PAGE 30 of 30 This page can be copied, if extra sheets are required