ER Nurse Responsibilities for Patient Transfer When Hospital Cannot Provide Care
The ER nurse's primary responsibility is to provide information to the incident manager or transferring physician about patients who could be safely transferred to other institutions, while maintaining continuous patient assessment and stabilization until transfer is completed. 1
Core Nursing Responsibilities in the Transfer Process
Information Provision and Communication
- Inform the hospital incident manager or designated transfer coordinator about the patient's status, capacity needs, and which patients could be safely transferred to other institutions. 1
- Provide detailed clinical information including vital signs (blood pressure, heart rate, oxygen saturation, temperature, urine output), current interventions, and level of care required during transport. 1, 2
- Communicate directly with the receiving facility's nursing staff to ensure seamless handoff, as nurses are often the first point of contact for transferred patients. 3
Patient Stabilization and Preparation
- Maintain the six essential nursing competencies during the pre-transfer phase: infection control, airway management (always first priority), vital signs monitoring, physical care activities, Foley catheter care, and medication/nutrition delivery. 2
- Ensure the patient is appropriately stabilized before transfer, recognizing that the transferring physician holds ultimate responsibility for determining the appropriate level of care needed during transport. 1
- Secure reliable IV access for potential rapid interventions during transfer. 4
EMTALA Compliance
- Understand that as an agent of the hospital, you are responsible for maintaining compliance with Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, which mandate appropriate medical screening, stabilization, and transfer regardless of patient insurance status. 5
- The hospital—not individual nurses—bears the legal responsibility for ensuring safe transfer, but nurses must follow established protocols. 1
Hierarchical Decision Framework
When Transfer is Indicated
The nurse should recognize and communicate when patients require transfer based on:
- Hemodynamic instability requiring vasopressors that exceed hospital capabilities 6
- Need for mechanical ventilation when ICU beds are unavailable 6
- Specialized services not available at the facility (neurosurgery, interventional cardiology, pediatric subspecialty care) 1
- Post-operative complications from complex procedures beyond hospital scope 4, 6
Coordination with Hospital Systems
- Work within the established incident command structure where the hospital incident manager has overall decision-making authority for implementing transfers. 1
- Collaborate with the designated consultant responsible for secondary transfers who oversees logistics, training, and planning. 1
- Utilize pre-established coordination agreements with regional healthcare facilities and ambulance services. 1
Critical Nursing Actions During Transfer Process
Pre-Transfer Phase
- Continuously assess airway patency, oxygen saturation, respiratory rate, work of breathing, hemodynamic status, and mental status. 4, 2
- Gather and organize all essential patient information including imaging studies, laboratory results, medication administration records, and procedural documentation. 1, 3
- Prepare equipment and supplies needed for safe transport based on patient acuity. 1
Transfer Phase
- Provide structured handoff communication to the transport team, including current clinical status, interventions performed, medications administered, and anticipated complications. 3, 7
- Ensure transfer of information, responsibility, and control occurs explicitly between sending and receiving teams. 7
- Document all transfer-related communications and patient status at time of departure. 3
Post-Transfer Responsibilities
- Complete documentation of the transfer process including reason for transfer, patient condition, and receiving facility information. 3
- Participate in multidisciplinary review of transferred cases to evaluate appropriateness and identify opportunities for improvement. 1
Common Pitfalls and How to Avoid Them
Communication Failures
- Avoid delayed or incomplete handoff reports by using standardized communication tools and checklists. 3, 7
- Do not assume the receiving facility has access to all patient information; explicitly transfer critical data. 3
- Ensure timely identification of and access to admitting clinicians at the receiving facility. 3
Scope of Practice Issues
- Recognize that while nurses provide critical information and patient care, the transferring physician—not the nurse—determines the appropriate level of care during transfer and makes the final transfer decision. 1
- Do not practice outside your approved scope during transfer preparation. 1
- Understand that "our hands are tied until your doctor gets here" reflects the reality that physicians must provide orders and assume responsibility for transfer decisions. 3
Resource and Timing Issues
- Anticipate that transfer coordination may be delayed during surge situations when multiple facilities are at capacity. 1
- Prepare the environment and gather information proactively to avoid delays once transfer is approved. 3
- Recognize that transfers carry increased risk of morbidity and mortality, making thorough preparation essential. 8
Special Considerations
Surge Capacity Situations
- During mass casualty or pandemic situations, participate in resource-balancing decisions where expedient patient transfer to facilities with available resources provides optimal care. 1
- Understand that triage decisions should be guided by the principle of helping the greatest number of people survive, which may affect transfer priorities. 1, 2
Pediatric Transfers
- Recognize that pediatric patients have unique needs requiring size-appropriate equipment and specialized expertise, making early transfer coordination particularly important. 1
- Ensure compliance with policies addressing when pediatric patients should be referred and what information must accompany them. 1