What is the protocol for transferring a patient from a skilled nursing facility (SNF) to an emergency room (ER)?

Protocol for Transferring Patients from Skilled Nursing Facilities to Emergency Rooms

The SNF must establish physician-to-physician communication with the receiving emergency department before transfer, with the referring physician providing a complete description of the patient's condition and confirming that appropriate resources are available at the receiving facility. 1

Pre-Transfer Decision-Making

Determining Need for Transfer

Transfer from an SNF to an ED is indicated when any of the following conditions exist:

• The resident is clinically unstable and the resident or family goals indicate aggressive interventions should be initiated 1
• Critical diagnostic tests are not available in the SNF 1
• Necessary therapy or the mode of administration of therapy (frequency or monitoring) are beyond the capacity of the SNF 1
• Comfort measures cannot be assured in the SNF 1
• Specific infection-control measures are not available in the SNF 1

Advance Directives and Goals of Care

Before initiating any transfer, the SNF must review the patient's advance directives or physician orders for life-sustaining treatment (POLST), which should identify preferences for hospital transfer and resuscitation status. 1 These transportable medical orders are available in 23 states and have become the standard of care in SNFs. 1

Required Communication and Coordination

Physician-to-Physician Contact

The referring physician must identify and contact an admitting physician at the receiving hospital to accept the patient in transfer before the transfer occurs. 1 During this communication:

• Provide a full description of the patient's condition 1
• Request advice concerning treatment and stabilization before transport 1
• Confirm that appropriate higher-level resources are available at the receiving facility 1
• Determine the mode of transportation (ground or air) based on urgency of medical condition, patient stability, time savings, weather conditions, and availability of personnel and resources 1

Nursing Communication

A nurse-to-nurse report must be given by the referring SNF to the appropriate nursing unit at the receiving hospital, or alternatively by a transport team member at the time of arrival. 1

Documentation Requirements

Medical Records

A copy of the medical record, including a patient care summary and all relevant laboratory and radiographic studies, must accompany the patient. 1 However, the preparation of records should not delay patient transport—these records can be forwarded separately by facsimile or courier if urgency precludes their assemblage beforehand. 1

The AMDA provides sample transfer forms including a Universal Transfer Form and an Example of a Skilled Nursing Facility-to-Emergency Department transition document. 1

Essential Transfer Information

The transfer documentation should include:

• Complete diagnosis list 2
• Recent vital signs, laboratory results, and pending tests 2
• Current medications with thorough medication reconciliation 2
• Recent procedures, treatments, and current clinical status 2
• Advance care preferences including resuscitation status and hospital transfer preferences 2
• Cognitive status using standardized tools 2

Patient Stabilization Before Transfer

Initial Assessment and Stabilization

The SNF should begin appropriate evaluation and stabilization to the degree possible before transport to ensure patient safety during transfer. 1 There is no evidence to support a "scoop and run" approach for interhospital transport of critically ill patients. 1

Nonessential testing and procedures should be avoided as they will delay transfer. 1 Information and recommendations about stabilization can be requested from the accepting physician at the time of initial contact. 1

Specific Stabilization Measures

For critically ill patients requiring transfer:

• Secure intravenous access before transport (peripheral or central venous access if peripheral unavailable) 1
• Evaluate and secure the airway as indicated by endotracheal tube if airway intervention is likely to be needed en route 1
• Insert nasogastric tube in patients with ileus, intestinal obstruction, or those requiring mechanical ventilation 1
• Insert Foley catheter in patients requiring strict fluid management, for transports of extended duration, and for patients receiving diuretics 1
• Maintain all intravenous fluids and medications in plastic (not glass) containers 1

Transport Monitoring Requirements

Minimum Monitoring Standards

All critically ill patients undergoing interhospital transport must have, at a minimum, continuous pulse oximetry, electrocardiographic monitoring, and regular measurement of blood pressure and respiratory rate. 1

Selected patients based on clinical status may benefit from monitoring of intra-arterial blood pressure, central venous pressure, pulmonary artery pressure, intracranial pressure, and/or capnography. 1

Common Pitfalls and How to Avoid Them

Communication Failures

Failing to confirm bed availability and acceptance at the receiving facility before initiating transfer creates EMTALA compliance issues. 3 Always document that the receiving facility has confirmed both bed availability and acceptance of the patient. 3

Inadequate Stabilization

Inadequate stabilization before transport significantly increases transport-related morbidity and mortality. 3 Do not rush the transfer at the expense of appropriate stabilization measures. 1

Incomplete Documentation

Incomplete documentation of the medical necessity for transfer may lead to inadequate care at the receiving facility. 3 Ensure all essential clinical information accompanies the patient or is immediately transmitted. 1

Potentially Avoidable Transfers

One-third of patients discharged from hospitals to SNFs are sent back to the ED within 30 days, with many visits being potentially avoidable. 4 The most common reasons for potentially avoidable ED visits include mechanical falls (17.3%), postoperative problems (16.8%), and cardiac or pulmonary complaints (11.4%). 4 SNFs should consider providing access to timely outpatient lab and imaging services and postoperative follow-ups to decrease avoidable ED visits. 4

Special Considerations for SNF Populations

Elderly and Frail Patients

For elderly patients, document consideration of geriatric-specific needs and risks associated with transfer. 3 Transfers are linked to morbidity, mortality, and significant cost, especially when transfers result in hospital admissions. 5

Alternative Care Models

SNF-based telemedicine services provided by emergency physicians can significantly reduce ED transfers—only 27% of patients receiving SNF-based acute care required ED transport compared to 71% admission rate for those transferred to the ED. 5 This approach decreases risks associated with hospitalization including cognitive and functional decline, nosocomial infections, and falls. 5