Transitional Issues
Dr Paul Rolfe
Consultant 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 position
paper of the Society for Adolescent Medicine. J Adol Health 1993: 14; 570-6.
Benefits of Well Managed
Transition
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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
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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)
Transition coordinators for large
geographical
regions.
Lifelong Follow up
in Paediatric
Setting
Generic Transition
team
e.g. “On Trac”
On Trac – Taking Responsibility for
Adolescent/Adult Care
THEMES:
Self-advocacy
Independent health care behaviours
Sexual Health
Social supports
Educational/Vocational/Financial planning
Health & Lifestyle
Mid-adolescence
Ages 13-15
Gains understanding
Practices skills
Early Adolescence
Ages 10-12
Introduced to process
Begins to participate
in own care
Gathers information
Sets Goals
Late Adolescence
Ages 16-18
Prepare to leave
paediatric setting
with confidence
Uses independent
health care
behaviours and
consumer skills
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 delay
Femoral osteotomy.
Initial plan to care for in paediatric setting
DOSA – admitted to adult orthopaedic ward as
children's ward had no capacity
Adult trained orthopaedic surgeon
Adult trained anaesthetist
No regional techniques
Adult recovery care – severe pain
PCA morphine regimen prescribed
6 hours later found unresponsive with RR 6
Mother had been activating PCA
Given naloxone and sent to PHDU
Case illustration
19 year old man (weight 33kg)
Cerebral Palsy and global developmental delay
Femoral osteotomy.
Initial plan to care for in paediatric setting
DOSA – admitted to adult orthopaedic ward as
childrens ward had no capacity
Adult trained orthopaedic surgeon
Adult trained anaesthetist
No regional techniques
Adult recovery care – severe pain
PCA morphine regimen prescribed
6 hours later found unresponsive with RR 6
Mother had been activating PCA on son’s behalf
Given naloxone and sent to PHDU
Environment
Service constraints
Familiarity / Confidence
Training / Support
Technical ability
Appropriate techniques
Parental involvement
Nurse/Carer expectations
Education / training
Patient assessment
Clear communication
Themes that emerge
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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
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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