Checklist for Interhospital Transfers

Category	Action Needed	Status
Decision to transfer
	Is there an appropriate reason for transfer?
	Do the potential benefits of transfer outweigh the potential risks?
	Has a screening medical examination been completed?
	Is the patient stabilized for transfer?
	Does transfer comply with EMTALA requirements?
	Has a transfer risk assessment been done?
	Physician-to-physician communication has taken place
	RN-to-RN communication has taken place
	Receiving hospital has agreed to accept patient
	Patient agrees to transfer and has signed informed consent
	Patients family or significant other has been made aware of transfer
Mode of transport
	Is mode of transport appropriate? (BLS- vs ALS-ambulance vs. air transport vs. other)
	Any contraindications to mode of transport chosen?
	If air transport chosen, are environmental conditions safe for flight?
	If ground ambulance chosen, are environmental conditions safe for prompt transport?
	Has anticipated route been checked for delays?
	Is level of transport vehicle appropriate?
	Must staff accompany the patient? If so, is their level of expertise/training appropriate?
	Location of dropoff site (ED, ICU, bed, etc.) and receiving doctor known
	Transfer documentation prepared
	Receiving unit advised of departure time and estimated time of arrival
	Telephone numbers of referring and receiving units available
	Contingency plan for alternate destinations in case of unanticipated delays or other unanticipated events
Preparing the patient for transport
	Has a screening medical examination been completed?
	Is the patient stabilized for transfer?
	Patient agrees to transfer and has signed informed consent
	Patients family or significant other has been made aware of transfer
Communicating with receiving hospital
	Is there an adequate note from sending physicians?
	Are full medical records available?
	Are results of all pertinent lab information included?
	Are all reports of imaging studies included?
	Are copies of imaging studies included?
	Physician-to-physician communication has taken place
	RN-to-RN communication has taken place
	Has the physician entered an order to transfer the patient?
Preparing staff for transport
	Level of staff training is appropriate for this patient’s transport
	Is it necessary for a physician to accompany the patient?
	Mobile phone, fully charged
	Money, in case of emergency
	Are all staff seat-belted or otherwise safely secured?
	Staff are aware of their personal risks during transport
	Arrangements made for transport back to hospital of origin
Preparation for departure
	Location of dropoff site (ED, ICU, bed, etc.) and receiving doctor known
	Transfer documentation prepared
	Has anticipated route been checked for delays?
	Telephone numbers of referring and receiving units available
	Whom to contact for in-transit issues
	Contingency plan for alternate destinations in case of unanticipated delays or other unanticipated events
	Is oxygen supply adequate for expected duration and for unexpected delays?
	Are battery charges sufficient? Backup? Does ambulance have accessible power supply?
	Is there adequate IV access?
	Blankets (or other) to prevent patient hypothermia (infants may need warming device)
	Are all monitoring devices secured? Do they have adequate power supply? Are their alarm thresholds and volumes appropriately configured?
	All anticipated drugs available
	Pre-drawn up medication syringes appropriately labelled and capped
	Patient secured safely in vehicle
	Is all equipment for resuscitation operable?
	If mechanically ventilated, are settings appropriate?
	Is a change in oxygenation likely to be needed? (eg. with pressure changes as altitude changes in flights)
	Is eye care (eg. lubricants) needed during transport?
	Blankets available to keep patient warm?
	Receiving unit advised of departure time and estimated time of arrival
In-transit
	Receiving unit advised of departure time and estimated time of arrival
	Location of dropoff site (ED, ICU, bed, etc.) and receiving doctor known
	Has anticipated route been checked for delays?
	Telephone numbers of referring and receiving units available
	Contingency plan for alternate destinations in case of unanticipated delays or other unanticipated events
	Whom to contact for in-transit issues
	What to do if barrier delays transport (eg. vehicle breakdown, traffic jam)
	Have alternate hospitals been identified in the event of serious in-transit emergency?
	Monitoring of all patient parameters ongoing
	Needed care administered
	Ancillary care (eg. eye care) administered as needed
	Patient kept warm
	Receiving unit will be updated on patient status and estimated time of arrival
Delivering the patient
	Arrival at receiving hospital announced
	Location of dropoff site (ED, ICU, bed, etc.) and receiving doctor known
	Patient delivered
	All accompanying medical information and images delivered
	Transport documentation completed
Post-transport actions
	Transport documentation provided to both receiving and sending hospitals
	Staff returned to hospital of origin if necessary
	Equipment returned to hospital of origin
	Expended supplies restocked
	Batteries recharged
	Infection control measures taken as appropriate (eg. cleaning of all surfaces and equipment)
Followup and quality improvement activities
	Transport documentation reviewed
	Receiving hospital communicates with sending hospital regarding patient outcome and any issues related to the transfer
	Sending hospital aggregates information about all transfers/transports and reviews at monthly quality improvement session at least the following: Duration of transport Did patient arrive within any therapeutic window? Did receiving hospital consider transfer appropriate? Did receiving hospital consider info adequate? Any issues arising during transfer

Checklist for Interhospital Transfers

Category	Action Needed	Status
Decision to transfer
	Is there an appropriate reason for transfer?
	Do the potential benefits of transfer outweigh the potential risks?
	Has a screening medical examination been completed?
	Is the patient stabilized for transfer?
	Does transfer comply with EMTALA requirements?
	Has a transfer risk assessment been done?
	Physician-to-physician communication has taken place
	RN-to-RN communication has taken place
	Receiving hospital has agreed to accept patient
	Patient agrees to transfer and has signed informed consent
	Patients family or significant other has been made aware of transfer

Checklist for Interhospital Transfers

Category	Action Needed	Status
Mode of transport
	Is mode of transport appropriate? (BLS- vs ALS-ambulance vs. air transport vs. other)
	Any contraindications to mode of transport chosen?
	If air transport chosen, are environmental conditions safe for flight?
	If ground ambulance chosen, are environmental conditions safe for prompt transport?
	Has anticipated route been checked for delays?
	Is level of transport vehicle appropriate?
	Must staff accompany the patient? If so, is their level of expertise/training appropriate?
	Location of dropoff site (ED, ICU, bed, etc.) and receiving doctor known
	Transfer documentation prepared
	Receiving unit advised of departure time and estimated time of arrival
	Telephone numbers of referring and receiving units available
	Contingency plan for alternate destinations in case of unanticipated delays or other unanticipated events

Checklist for Interhospital Transfers

Category	Action Needed	Status
Preparing the patient for transport
	Has a screening medical examination been completed?
	Is the patient stabilized for transfer?
	Patient agrees to transfer and has signed informed consent
	Patients family or significant other has been made aware of transfer

Checklist for Interhospital Transfers

Category	Action Needed	Status
Communicating with receiving hospital
	Is there an adequate note from sending physicians?
	Are full medical records available?
	Are results of all pertinent lab information included?
	Are all reports of imaging studies included?
	Are copies of imaging studies included?
	Physician-to-physician communication has taken place
	RN-to-RN communication has taken place
	Has the physician entered an order to transfer the patient?

Checklist for Interhospital Transfers

Category	Action Needed	Status
Preparing staff for transport
	Level of staff training is appropriate for this patient’s transport
	Is it necessary for a physician to accompany the patient?
	Mobile phone, fully charged
	Money, in case of emergency
	Are all staff seat-belted or otherwise safely secured?
	Staff are aware of their personal risks during transport
	Arrangements made for transport back to hospital of origin

Checklist for Interhospital Transfers

Category	Action Needed	Status
Preparation for departure
	Location of dropoff site (ED, ICU, bed, etc.) and receiving doctor known
	Transfer documentation prepared
	Has anticipated route been checked for delays?
	Telephone numbers of referring and receiving units available
	Whom to contact for in-transit issues
	Contingency plan for alternate destinations in case of unanticipated delays or other unanticipated events
	Is oxygen supply adequate for expected duration and for unexpected delays?
	Are battery charges sufficient? Backup? Does ambulance have accessible power supply?
	Is there adequate IV access?
	Blankets (or other) to prevent patient hypothermia (infants may need warming device)
	Are all monitoring devices secured? Do they have adequate power supply? Are their alarm thresholds and volumes appropriately configured?
	All anticipated drugs available
	Pre-drawn up medication syringes appropriately labelled and capped
	Patient secured safely in vehicle
	Is all equipment for resuscitation operable?
	If mechanically ventilated, are settings appropriate?
	Is a change in oxygenation likely to be needed? (eg. with pressure changes as altitude changes in flights)
	Is eye care (eg. lubricants) needed during transport?
	Blankets available to keep patient warm?
	Receiving unit advised of departure time and estimated time of arrival

Checklist for Interhospital Transfers

Category	Action Needed	Status
In-transit
	Receiving unit advised of departure time and estimated time of arrival
	Location of dropoff site (ED, ICU, bed, etc.) and receiving doctor known
	Has anticipated route been checked for delays?
	Telephone numbers of referring and receiving units available
	Contingency plan for alternate destinations in case of unanticipated delays or other unanticipated events
	Whom to contact for in-transit issues
	What to do if barrier delays transport (eg. vehicle breakdown, traffic jam)
	Have alternate hospitals been identified in the event of serious in-transit emergency?
	Monitoring of all patient parameters ongoing
	Needed care administered
	Ancillary care (eg. eye care) administered as needed
	Patient kept warm
	Receiving unit will be updated on patient status and estimated time of arrival

Checklist for Interhospital Transfers

Category	Action Needed	Status
Delivering the patient
	Arrival at receiving hospital announced
	Location of dropoff site (ED, ICU, bed, etc.) and receiving doctor known
	Patient delivered
	All accompanying medical information and images delivered
	Transport documentation completed

Checklist for Interhospital Transfers

Category	Action Needed	Status
Post-transport actions
	Transport documentation provided to both receiving and sending hospitals
	Staff returned to hospital of origin if necessary
	Equipment returned to hospital of origin
	Expended supplies restocked
	Batteries recharged
	Infection control measures taken as appropriate (eg. cleaning of all surfaces and equipment)

Checklist for Interhospital Transfers

Category	Action Needed	Status
Followup and quality improvement activities
	Transport documentation reviewed
	Receiving hospital communicates with sending hospital regarding patient outcome and any issues related to the transfer
	Sending hospital aggregates information about all transfers/transports and reviews at monthly quality improvement session at least the following: Duration of transport Did patient arrive within any therapeutic window? Did receiving hospital consider transfer appropriate? Did receiving hospital consider info adequate? Any issues arising during transfer

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