What are the indications for transferring patients to a higher level of care?

From the Guidelines

Transferring patients for a higher level of care should occur when the patient's medical needs exceed the capabilities of the current facility, and the benefit of the transfer outweighs the potential risk, as mandated by the Emergency Medical Treatment and Labor Act (EMTALA) 1. When considering transfer, the decision should be made promptly when a patient requires specialized treatment, advanced monitoring, or interventions not available at the present location. The transfer process begins with stabilizing the patient as much as possible, which may include the use of equipment such as a transport ventilator, and then contacting the receiving facility to confirm bed availability and acceptance, ensuring that appropriate higher level resources are available 1. Complete documentation, including vital signs, medications administered, treatments performed, and the patient's response, should accompany the patient, and a formal handoff using the SBAR (Situation, Background, Assessment, Recommendation) technique ensures critical information is communicated. During transport, appropriate personnel such as paramedics, nurses, or physicians should accompany the patient based on acuity level, with necessary equipment including oxygen, cardiac monitors, and emergency medications, as outlined in guidelines for the inter- and intrahospital transport of critically ill patients 1. Family members should be informed about the reason for transfer, destination, and estimated arrival time. This structured approach to patient transfers is essential because delays in obtaining appropriate care can lead to worse outcomes, while proper communication prevents treatment gaps and medication errors during transitions of care. Key considerations in the transfer process include:

• Pretransport coordination and communication between the referring and receiving physicians to ensure a smooth transition of care 1
• The mode of transportation, which is usually determined by the transferring physician in consultation with the receiving physician, based on factors such as the urgency of the medical condition and the availability of personnel and resources 1
• The importance of stabilizing the patient before transfer, while not delaying the transfer unnecessarily, as the preparation of records should not delay patient transport 1

From the Research

Transferring Patients for Higher Level of Care

• Transferring patients to a higher level of care can be beneficial for certain patients, such as those with severe injuries or specific medical conditions 2, 3.
• Studies have shown that interfacility transfer to a higher level of care can be associated with improved outcomes, including reduced mortality and morbidity 2, 3.
• However, delays in transfer time can be associated with increased odds of mortality and major complications 2.
• Patients who benefit from transfer to a higher level of care include those with traumatic brain injury, pelvic fracture, penetrating mechanism, solid organ injury, great vessel injury, respiratory distress, and tachycardia 3.
• Intra-hospital transfers to a higher level of care can also be beneficial, but may be associated with excess mortality and length of stay 4.

Factors to Consider When Transferring Patients

• The decision to transfer a patient to a higher level of care should be based on individual patient needs and circumstances 2, 3.
• Factors to consider include the patient's injury severity, medical condition, and potential benefits of transfer 2, 3.
• The mode of transport and estimated transfer time should also be considered when deciding whether to transfer a patient 2.
• Patients who are transferred to a higher level of care should receive ongoing monitoring and care to ensure optimal outcomes 2, 3.

Modes of Care for Transferred Patients

• Mechanical ventilation may be necessary for patients undergoing surgical procedures or those with respiratory distress 5.
• The choice of ventilation mode and settings should be individualized based on patient needs and circumstances 5.
• Protective mechanical ventilation with low tidal volume and low levels of positive end-expiratory pressure (PEEP) may be beneficial for patients undergoing surgery 5.
• However, the routine administration of high PEEP levels should be avoided, as this may lead to hemodynamic impairment and fluid overload 5.