Chapter 3 Jacob B. Keeperman Interfacility transport commonly refers to the transportation of a patient from one acute care setting to another. EMS personnel are frequently challenged with taking a patient to the “closest” versus the “most appropriate” receiving hospital and sometimes after initial work-up/treatment the patient needs to be transferred to another facility for further care. Additionally, patients may self-present to hospitals that are ill-equipped to provide necessary services and thus must be transferred. Reasons for transfer vary, but are often due to the need for specialized services based on a patient’s medical condition or mechanism of injury. This chapter will address issues related to interfacility transports. Specifically, the focus will be on the level of care during transport, potential risks of interfacility transport, legal issues surrounding transport decisions, specific medical indications for transport to specialized facilities, and medical oversight for interfacility transport. The sending physician is responsible for choosing the appropriate transport personnel, vehicle, and equipment. The patient’s condition, actual needs, and potential needs for care are essential for the sending physician to consider. The transporting service and the receiving facility also have some responsibility to ensure the transport is carried out in the best interests of the patient. Level of care determination needs to take into account human resource needs, economic considerations, space limitations, and legal requirements [1,2]. When deciding on the level of care for the transport of a given patient, the sending physician must consider a number of things before making a final determination. He or she must think about what resources are available for the entire service area and the implications of using a resource that may be needed elsewhere. The availability of personnel and vehicles must play an important role in the decision-making process. The more advanced training and experience a transport team has, the more likely they are to be a limited resource, leading to prolonged response times to the sending facility. In a rural area, sending the town’s only ambulance on an interfacility transport that will take hours may result in a serious degradation of available EMS for that period of time. Weather delays can affect personnel and vehicle availability. In addition to taking into account the total transport time, it is important to consider the out-of-hospital time. For example, one might have a BLS ambulance immediately available that will take the patient to the desired receiving facility with a 1-hour transport time; however, a critical care air transport team may have a 45-minute delay in getting to the patient but be able to perform the transport in 20 minutes, resulting in an increase in total transport time by 5 minutes but a decrease in out-of-hospital time by 40 minutes. In certain situations the total transport time is the most important factor and in others limiting the out-of-hospital time can have the most profound effect on the patient. Composition of the team should be based on the patient’s needs. It can vary from non-medically trained transport personnel to specialty trained critical care transport teams. Whatever personnel are chosen should be able to handle all anticipated needs of the patient en route. They must possess the necessary critical thinking skills, procedural competence, and out-of-hospital care experience to effectively evaluate and care for the patient. All personnel involved in the interfacility transportation of patients must be able to adapt to a variety of situations. They must be able to work as a team, improvise when needed, and perform with limited resources. Crew members who are not regularly involved in out-of-hospital care, such as emergency department and intensive care unit nurses, must get adequate orientation and training so they can be comfortable in the unique situations that EMS professionals face every day. While the scope of practice of EMS providers is discussed elsewhere in this text, the following briefly reviews these concepts as they uniquely relate to interfacility transport. Non-medical personnel can range from relatives or friends of the patient to cab drivers to police officers. While this is relatively rare, there are circumstances in which the patient simply needs to go from one location to another and will have no anticipated medical needs while en route. Emergency medical technicians can perform the majority of low-acuity interfacility transports as the patients are often stable and have few anticipated medical needs and only require basic routine monitoring. Paramedics conduct most interfacility transports, as they are able to perform routine and advanced monitoring, administer many medications, and intervene in emergency situations. Critical care teams are often made up of specially trained paramedics and nurses. They are able to provide advanced and invasive monitoring, administer an expanded list of medications and therapies, and have refined critical thinking skills. Specialty care teams are often made up of critical care teams who have training specific to a group of patients, such as pediatric, neonatal, obstetric, burn, extracorporeal membrane oxygenation (ECMO), intraaortic balloon pump (IABP). These teams sometimes also include other health care professionals such as respiratory care therapists, physicians, and perfusionists. Several types of vehicles can be used to transport patients between facilities. In choosing the most appropriate vehicle, one must consider speed, space availability, equipment needed, weather, distance, cost, and other factors [1,2]. While private vehicles are rarely used for interfacility transports, they serve an important role in moving patients who are not expected to require any medical monitoring or interventions while en route from one facility to another. The hazards associated with interfacility transport are similar to those experienced in scene response. Specific details about the hazards of each mode of transport are discussed in the Air Medical Services (Volume 2, Chapter 2) and Ambulance Safety and Crashes (Volume 2, Chapter 22) chapters. The routine use of lights and sirens in interfacility transports is inappropriate, though there are select cases in which this may be needed, perhaps in the case of a STEMI patient being transported from a small community hospital to a tertiary facility for cath lab intervention. Prior to any interfacility transport, the patient should be stabilized to the extent that the referring hospital is capable. If the patient is expected to have a decline in airway status then it should be managed while the patient is in the sending facility where there are more people around with more equipment and resources available to work in an environment that has significantly more physical space than a transport vehicle. There are times when the risk outweighs the benefit and the interfacility transport should not be completed.
Interfacility transportation
Introduction
Level of care
Personnel
Non-medical
Basic Life Support
Advanced Life Support
Critical care
Specialty care
Vehicle
Private vehicle
Cab
Wheelchair/stretcher van
Ground ambulance
Rotor-wing aircraft (helicopter)
Fixed-wing aircraft (airplane)
Hazards associated with interfacility transportation
Legal considerations in interfacility transportation
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