What are the steps to take when internal medicine is consulted on an Emergency Room (ER) patient requesting a transfer?

Steps for Internal Medicine Consultation on Emergency Room Transfer Requests

When internal medicine is consulted on an ER patient requesting transfer, the referring physician must identify and contact an accepting physician at the receiving hospital before initiating transfer to confirm appropriate resources are available. 1

Initial Assessment and Communication

• Contact the receiving physician with a complete description of the patient's condition 1

  • Discuss treatment and stabilization needed before transport
  • Confirm availability of appropriate higher-level resources at receiving facility
  • Determine if transfer is medically necessary or for non-clinical reasons

• Establish command physician responsibility 1

  • If not accompanying the patient, ensure a designated physician will assume responsibility during transport
  • The command physician should receive a medical report before team departure

• Coordinate with nursing staff 1

  • Arrange nurse-to-nurse report between facilities
  • Ensure appropriate nursing unit at receiving hospital is notified

Patient Stabilization Before Transfer

• Perform appropriate evaluation and stabilization - avoid "scoop and run" approaches 1

  • Secure intravenous access (peripheral or central if needed)
  • Begin fluid resuscitation and inotropic support if required
  • Stabilize airway if needed before transport
  • Insert nasogastric tube for patients with ileus, obstruction, or requiring mechanical ventilation
  • Place Foley catheter for patients requiring strict fluid management
  • Perform chest decompression with chest tube if indicated

• Laboratory and imaging assessment 1

  • Obtain arterial blood gases, electrolytes, blood glucose (aim for 6-10 mmol/L)
  • Complete blood count and coagulation studies
  • Ensure all relevant imaging has been completed and transmitted to receiving facility

Transfer Logistics

• Determine mode of transportation 1

  • Consider urgency of medical condition
  • Evaluate patient stability
  • Assess weather conditions
  • Consider medical interventions needed during transfer
  • Evaluate availability of personnel and resources

• Prepare medical records 1

  • Compile patient care summary
  • Include all relevant laboratory and radiographic studies
  • If urgency precludes complete record assembly, forward critical information separately

• Arrange appropriate monitoring during transport 1

  • Continuous pulse oximetry
  • ECG monitoring
  • Regular blood pressure and respiratory rate measurements
  • Consider invasive monitoring for selected patients based on clinical status

Risk Mitigation

• Identify and address potential complications 2

  • Implement a safety checklist to detect and prevent adverse events
  • Ensure all necessary equipment and medications are available
  • Position patient appropriately (20-30° head-up tilt for neurological patients) 1

• Avoid common pitfalls 1

  • Never transfer hemodynamically unstable patients without addressing the cause
  • Avoid unnecessary delays with non-essential testing
  • Ensure adequate sedation for intubated patients
  • Maintain normothermia (36-37°C)
  • Secure all tubes and lines properly

Documentation Requirements

• Complete standardized transfer documentation 1

  • Document vital signs and neurological status during transfer
  • Maintain record of interventions performed
  • Keep a copy of transfer record for audit purposes

• Communicate with patient's family 1

  • Notify them about the transfer and reasons for it
  • Inform them of the ultimate ward/ICU destination
  • Provide guidance on how to reach the receiving facility

Special Considerations

• For critically ill patients 1, 3

  • Ensure appropriate medication management during transfer
  • Maintain adequate blood pressure (MAP ≥65 mmHg)
  • Consider vasopressors if needed to maintain blood pressure
  • Monitor for signs of deterioration

• For time-critical conditions 1

  • Prioritize rapid transfer while maintaining stabilization
  • Coordinate with receiving specialists for immediate intervention upon arrival

By following this structured approach, internal medicine consultants can ensure safe and efficient transfers while minimizing risks to patients during this vulnerable transition of care.