Emergency Transport for Non-Improving Patients
Yes, emergency transport is warranted when a patient's condition is not improving with current interventions, particularly if the patient requires specialized care, resources, or expertise unavailable at the current location. 1, 2
Decision Framework for Emergency Transport
Immediate Transport Indications
When current interventions fail to stabilize or improve a patient, transport should be initiated based on:
Time-sensitive conditions requiring specialized centers: Patients with cardiac arrest, STEMI, stroke, major trauma, or other critical conditions should be transported directly to facilities with comprehensive capabilities when local resources are inadequate 1, 3
Clinical instability despite interventions: Patients showing physiological decline (hemodynamic instability, respiratory deterioration, neurological worsening) require immediate transport to higher-level care facilities 1, 2
Resource limitations at current facility: When critical resources such as ICU beds, specialized monitoring equipment, cardiac catheterization, neurosurgical capability, or specific expertise are unavailable, transport becomes medically necessary 2, 3
Target Transport Times
The on-scene time should not exceed 15-20 minutes to minimize delays in reaching definitive care 1, 4. For intra-hospital transport, total transport time should be minimized, with coordination essential to reduce waiting times that increase adverse event risk 1.
Pre-Transport Stabilization Requirements
Critical caveat: While stabilization is ideal, it should not significantly delay transport when time-sensitive interventions are needed 1, 2. The American College of Surgeons recommends:
- Secure intravenous access and airway assessment 2
- Initiation of appropriate stabilization measures before transfer 2
- Documentation that stabilization attempts were made, even if unsuccessful 2
However, inadequate stabilization before transport significantly increases transport-related morbidity and mortality 2, creating a clinical tension that must be balanced against the urgency of reaching specialized care.
Risk Assessment During Non-Improvement
Patient Factors Indicating Transport Need
Severity of illness: Higher APACHE scores and clinical instability are associated with increased adverse events during transport, but also indicate greater need for specialized care 1
Requirement for advanced support: Patients needing multiple vasopressors, high PEEP, or multiple infusion pumps require facilities capable of maintaining this level of support 1
Emergency context with rapid deterioration: Patients in the initial admission period or following recent destabilization have higher adverse event rates (7.8% vs 2.4% for pre-arranged transport) but often require urgent transfer 1
Transport Safety Considerations
The global incidence of adverse events during transport can reach 68%, with serious adverse events requiring intervention occurring in 4.2-8.9% of cases 1. Cardiac arrest during transport occurs in 0.34-1.6% of cases 1. These risks must be weighed against the risk of remaining at an inadequate facility.
Destination Selection
Specialized Centers vs. Nearest Facility
A regionalized approach with direct transport to specialized centers is reasonable when comprehensive care is unavailable locally 1. This applies to:
Cardiac arrest centers: For post-cardiac arrest patients requiring emergent cardiac catheterization, targeted temperature management, and neurological expertise 1
Stroke centers: For acute stroke patients needing thrombolytic therapy, endovascular intervention, or neurosurgical capability 1, 5
Trauma centers: For time-sensitive extremity injuries with neurovascular compromise or other major trauma 4
The American Heart Association notes that direct transport to specialized centers is associated with improved neurologically intact survival (6.7% vs 2.8% at non-specialized hospitals) 1.
When to Choose Nearest Facility
If transportation to a specialized center cannot be accomplished within the appropriate time for hyperacute interventions, transport to the closest hospital capable of providing immediate stabilization is appropriate, with consideration for secondary transfer once stabilized 1.
Communication and Coordination Requirements
Pre-Transport Coordination
- Identify and contact accepting physician at the receiving hospital before initiating transfer 2
- Confirm availability of necessary resources at the receiving facility (ICU beds, specialized equipment, surgical capability) 2
- Document medical necessity for transfer, including specific reasons the current facility cannot safely care for the patient 2
Transport Team Competence
83% of adverse events during transport result from human error 1. For mechanically ventilated patients, risk prevention depends heavily on escort competence 1. The transport team must have training and experience adapted to the patient's condition 1.
Common Pitfalls to Avoid
Delaying transport for prolonged stabilization attempts when time-sensitive interventions are needed at the receiving facility 1, 4
Failing to confirm bed availability at the receiving facility before initiating transfer, creating EMTALA compliance issues 2
Inadequate communication between facilities, leading to prolonged waiting times and increased adverse event risk 1
Insufficient escort personnel or equipment for the patient's level of acuity during transport 1
Special Populations
For elderly patients, geriatric-specific needs and risks associated with transfer must be documented 2. For patients with high mortality risk, ICU admission needs at the receiving facility should be specifically addressed 2.