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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