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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