Over the past several decades, advancements in medical care and technology have led to significant specialization in medical practice in many areas. These specialized services are often offered only at tertiary care centers where the resources exist to support the practice. In much the same way as trauma center designation occurred several decades ago, designation of specialized centers for stroke and cardiac care is seen in many areas.^1–4 Even when a formal designation process is not in place, consolidation of advanced services for many conditions is evident within regions and hospital systems. Smaller hospitals have taken on the role of identification and stabilization of conditions that require more advanced resources for definitive management.⁵ Once such a condition has been identified and the patient appropriately stabilized, transfer to the facility capable of providing definitive care is necessary.

Since the 1970s the emergency medical services (EMS) system has developed and evolved to meet the needs of patients requiring transport to the hospital from a prehospital environment. EMS providers have been trained to efficiently assess patients and provide stabilizing care and safe transport to the most appropriate facility. This ability to provide safe and expeditious transport makes the EMS system the most logical means to move a patient from one hospital to another in an emergent situation.

It may be obvious to some that the needs of a patient being moved from the scene of an accident to a hospital are significantly different than the needs of a patient who has been assessed and stabilized at a hospital and requires transport to a tertiary care center for further care. The hospitalized patient often will have a specific diagnosis and have advanced interventions in place at the time of transfer. Traditional training for EMS providers is focused on identification of symptoms and rapid stabilizing care during transport to the closest appropriate hospital. With rare exception, the ongoing management of specific diagnoses has not been addressed in standard EMS training.

EMS systems have begun to evolve to meet the needs of this new patient population. While there are recently published national guidelines for interfacility transfer (IFT), many areas are still evolving to meet the needs of this patient population.⁶ The involvement of a physician who understands the EMS system as well as the needs of the IFT patient is crucial in the development and management of a comprehensive IFT program. This chapter will review the history of interfacility transfers and discuss the different aspects of the system that the EMS physician must be familiar with.

• 
  

  Define interfacility transport.

  
  
• 
  

  Describe indications for patients to be transferred by EMS to other health care institutions.

  
  
• 
  

  Discuss how COBRA and EMTALA impact interfacility transfers.

  
  
• 
  

  Describe the development of interfacility transport specific protocols.

  
  
• 
  

  Discuss the role of advanced and ancillary medical providers used in specialty transport operations.

  
  
• 
  

  Discuss the role of the EMS physician with regard to interfacility transfers.

  
  
• 
  

  Discuss different modes of transport, including air versus ground units.

  
  
• 
  

  Describe specialty transport teams.

In the early 1980s it was not unusual for transfers to be motivated by not only the need for a higher level of care, but also for financial reasons. Hospitals might arrange a transfer of a patient with less ability to pay simply to avoid expending the resources when compensation was not likely. These hospitals may have had the resources to handle the patient’s medical needs, but recommended transfer for purely economic reasons. This practice was often referred to as “dumping” and was obviously not in the best interests of the patient’s medical needs in most cases.

In response to accumulating evidence of this economically driven denial of care throughout the country, in 1985 Congress enacted a law that was intended to prevent this unethical practice. The Emergency Medical Treatment and Active Labor Act (EMTALA) was a part of the Consolidated Omnibus Budget Reconciliation Act (COBRA), and while it has been amended a number of times it remains the most significant regulation ever enacted related to the emergency care and transfer of patients in the United States. It was the first law that provided a right to emergency medical care for every citizen.

The law defines a hospital’s responsibility to provide emergency care to anyone presenting with a request for help. It details the obligations of the hospital with regard to initial evaluation and management as well as with regard to transfer arrangements. Hospitals are obligated to obey these guidelines under penalty of hefty fines.

Shortly after this law was enacted that mandated the emergency care of any patient requesting such, a new problem emerged. The original language of EMTALA mandated the care that must be provided at the hospital to which the patient presents but did not address the responsibilities of higher level centers to which patients might be transferred. When hospitals attempted to transfer patients they felt were in need of care at another facility, they encountered difficulty in getting acceptance of these patients. This problem also appeared to have financial motivation in some cases. This is sometimes referred to as “reverse dumping” and is just as big an ethical issue as the original problem.

In 1989, EMTALA was amended to include language that required higher level hospitals to accept patients in transfer when they had the ability to manage the patients’ condition. The details of the many amendments of these laws are rather confusing; therefore, interpretive guidelines have been issued over the years clarifying hospitals’ responsibilities under the law.⁷

SENDING HOSPITAL OBLIGATIONS

Screen and Stabilize

The law requires that every hospital provide an appropriate screening examination to any patient who requests examination or treatment. This screening cannot be delayed for financially motivated reasons. If the screening examination reveals an emergency medical condition, the hospital is obligated to stabilize the patient, or if this is not possible, transfer the patient to a hospital that can. The interpretive guidelines issued over the years are extensive and have clarified many of the details regarding these responsibilities.

Affect an Appropriate Transfer

There are a number of requirements for sending hospitals when arranging the transfer of an unstable patient. First is the certification of medically necessity. The documentation of this may take many forms but must include a definition of the medical benefits expected from transfer as well as the risks that can reasonably be expected by the transfer. The sending facility must certify that the expected benefits outweigh the potential risks of the transfer.

Consent for transfer must always be obtained, whether directly from the patient or family member or implied under the emergency doctrine. This consent must be in writing and is often included as a part of the certification of risks and benefits.

The sending hospital has an obligation of arrange an “appropriate” transfer. There are five components to this outlined in the law:

1. 
   

   The hospital must provide treatment within their capacity to minimize the risks of transfer. This might range anywhere from initiating IV access to intubation or chest tube placement if it is felt that these interventions would reduce the risk of the transfer.

   
   
2. 
   

   Arrangements must be made for another hospital to accept the patient in transfer. Simply transferring a patient without having another hospital identified that it is willing and able to accept the patient would constitute a violation of the law.

   
   
3. 
   

   It is a legal obligation for the sending facility to ensure that relevant data be sent with the patient for use by the receiving staff in continuation of care. This includes documentation of care and radiographic studies performed.

   
   
4. 
   

   The transfer must be affected through qualified personnel and transportation equipment. It is important to recognize that the needs of the patient are not just what the patient needs at the time of the transfer, but has to include potential needs if the situation changes during the move. This must be based on the treating physician’s best estimate of what the patient may need during transfer. For example, if a patient with an acute coronary syndrome is being transferred, there is a good possibility that they may experience an arrhythmia during transport. The team chosen to complete that transfer must be qualified and have the equipment necessary (ie, medications and defibrillator) to effectively manage arrhythmias. Similarly, a patient with an acute stroke may deteriorate and require intubation during transport. The team accompanying the patient should be qualified and have appropriate equipment to offer this intervention if needed.

   
   

   The vehicle utilized should be that which is determined to be most appropriate for the patient’s condition at the judgment of the sending physician.

   
   
5. 
   

   It is also crucial to consider that the sending facility is legally responsible for the patient until care is assumed by the receiving facility. This includes the care provided by the transport agency. It seems imperative for the sending facility to have a proper understanding of the capabilities of the transport team. There should be prior communication and preplanning between hospitals and transport agencies in order to facilitate safe transport of these patients.

It is important to remember that the EMTALA regulations regarding transfers relate to unstable patients, those whose conditions have not been stabilized. Once a patient has been stabilized, these regulations do not apply and transfers can be arranged for economic reasons if desired. EMTALA defines “stabilized” as when it is determined that a patient will not likely deteriorate during transfer. An appropriate level of care for the patient’s current needs is obviously still required.

RECEIVING HOSPITAL OBLIGATIONS

Hospitals that offer specialized services have an obligation under EMTALA to accept patients in transfer if they have the ability and capacity to manage that patient’s condition at that time. This must be done without any consideration of the patient’s ability to pay for such care. Refusal to accept transfers is one of the largest areas of EMTALA violation investigations. This has led to very complicated algorithms in some hospitals to determine the hospital’s capacity at any given time for managing any given condition. If a hospital determines that it does not have the ability or capacity to manage a patient for whom transfer is requested, they can refuse without being in violation of the law. This would seem to be very reasonable, as it would not be safe to bring an unstable patient to a hospital that did not have the ability to safely manage their condition. In today’s age of hospital overcrowding, overfull emergency departments and lack of hospital beds may result in interfacility transfers that bypass one or more institutions that would have otherwise been able to manage a patient’s condition. This translates into what may be very long transport times for the IFT team.

TRANSPORT PROVIDER OBLIGATIONS

While the practice of an EMS provider during interfacility transfer is not directly detailed in this regulation, it is helpful to understand the background behind the details of the transfer process. It is clear that there are legal obligations for the transport agency and providers to affect a medically appropriate patient transport in the safest manner possible; however, they are not detailed under EMTALA. These regulations may differ from state to state and the EMS physician involved with a transport team should be familiar with the relevant local regulation.

It certainly makes sense for a transport service to meet with local hospitals for purposes of preplanning regarding IFT needs. The transport service should educate the hospital regarding the capabilities of the transport team and equipment. This knowledge will enable the facility to make appropriate decisions regarding staffing during a transfer. There may be times when it is necessary for hospital staff to accompany a patient during transfer. It is helpful to have some sort of collaborative training prior to this occurrence that enables the hospital staff to function safely in the transport vehicle. Clarification of the roles and responsibilities of each of the providers staffing the transport in this case is helpful.

In the United States today, EMS systems have evolved to accommodate the needs of the patients they encounter. The presence of technology assisted patients in the community has led to increased specialized training for EMS providers who will be called upon to transport them if the need arises. In much the same way, as hospitals within a community consolidate specific services to one regional center, the type of patient that requires transport between facilities will change. An EMS system should be aware of such changes within their region and take steps to ensure that the needs of the IFT patient are adequately met during transport. This may require additional training and equipment for EMS providers or it may require the development of a more advanced team that involves hospital-based resources. EMS systems around the country are widely disparate in their preparation for the IFT patient. Some systems are well tied in with regional hospitals and have advanced training and credentialing programs for providers while other systems offer less specific preparation to their providers. There are many factors to consider when developing an IFT program. The ultimate goal is to match patient need with appropriate knowledge, skills, equipment, and an infrastructure to enable safe, effective, and efficient IFT.⁶

Patients require transfer for any one of a number of reasons. These might include a need for specialized services not available at the original institution, desire for care by a particular physician or in a particular locale, or a need to move to a facility where a physical bed is available. Depending on the patient condition and reason for transfer, several ­categories of transfers should be discussed.

STABILIZED VERSUS NOT STABILIZED

As previously discussed, every hospital has a federal obligation to assess a patient who presents with a request for medical care. If the assessment reveals that the patient has an emergency medical condition, stabilization is required. A patient can be considered to be stabilized if they have been treated to a point where deterioration is felt to be unlikely during ­transfer. Depending on the patient’s condition and specific needs, the hospital may not have the ability to stabilize their condition, making transfer in an unstable condition necessary. The hospital has an obligation to do everything they can to make the patient as safe as possible for transfer.

Not Stabilized

The patient who remains unstable by definition has the possibility of deterioration during transport. The providers staffing the transport must have the training, equipment, and protocols to allow them to manage the deterioration that is predicted. An example of an unstable patient requiring transfer might be a patient with a ruptured abdominal aortic aneurysm who is at a hospital that does not have a vascular surgeon. This patient can be markedly unstable; however, despite that instability, transfer is necessary to offer definitive management. In this case, adequate intravenous access might be the necessary treatment provided by the hospital in order to best prepare the patient for emergent transfer. The transport team should have the ability to manage deterioration in this patient’s condition to include advanced airway management, additional intravenous access, administration of crystalloid, and blood products where necessary.

CONDITIONS REQUIRING TRANSFER

There are many conditions that might require a patient to be transferred from one facility to another. This will be largely depending on the resources available at the local hospital. Some common emergency conditions often requiring transfer from community hospitals to larger institutions are listed in Table 16-1.