Trauma Patient Transfers

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Trauma Patient Transfers

• What, When, How?

Charles F. Rinker, II MD, FACS
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ACSCOT

• Does not dictate whom to transfer
• but local statutes might
• Publishes guidelines regarding clinical
  conditions that might warrant transfer
• Expects trauma program to review outcomes, adjust
  accordingly

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Basic Principles

• When in doubttransfer
• Do what is best for the patient
• Be realistic about your ability to treat
• Personal capabilities
• Institutional capabilities
• Understand EMTALA
• Know state statutes/trauma system regulations
• Transfers go upstream, not down

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Be Prepared

• Trauma program with GS leadership
• Involvement with EMS
• Trauma team, activation criteria
• Scene transport
• Bypass
• Collegial relationship with regional trauma
  center/participation in trauma system
• Transfer agreements
• Performance review

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Define Your Trauma Patient

• Surgical, medical specialties
• Imaging equipment
• Operating room(s)
• ICU
• Ancillary services
• Proximity to other trauma centers
• Interhospital transfer capabilities

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EMTALA

• Emergency Medical Treatment and Active Labor Act
• Intended as anti-dumping legislation
• Effectively a federal guarantee for access to
  emergency care
• Draconian penalties
• Law of unintended consequences

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Compliance with EMTALA

• Early evaluation, Rx in ED
• Identify, document need for transfer
• Consult with receiving hospital, and assist in
  transfer arrangements
• Stabilize to degree possible before transfer
• Best defense ability to demonstrate actions are
  in best interest of patient (i.e., pt needs
  exceed resources)
• Potential loss of Medicare approval

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Penalties

• Failure to properly evaluate emergency medical
  condition
• Inappropriate transfer
• Medical condition not stabilized
• Service could have been provided at transferring
  institution
• Failure to receive approval from receiving
  institution
• Refusal to accept patient, despite apparent need
  for transfer

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Treatment Options

• Stabilization and transfer to definitive care
• Operative stabilization and transfer
• Local definitive care

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WHAT to Transfer?

• Patients at the extremes of age
• Major burns
• Multisystem trauma
• Serious comorbidities
• Patient or family request (if feasible)
• Any condition or constellation of injuries that
  exceeds local resources (personnel, equipment,
  back-up)

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WHEN to Transfer?

• As soon as
• Need is identified
• Consultation with receiving hospital accomplished
• Transport arrangements completed
• Patient is properly stabilized (remember EMTALA)
• Avoid unnecessary tests, procedures, wallet
  biopsies

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HOW to Transfer?

• Surface v. air depends on
• Available resources
• Patient condition/needs
• Accompanied by
• Appropriate personnel
• Records, test results, images
• Medications, blood, supportive equipment
• To higher level of care, preferably within a
  trauma system

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HOW to Transfer?

• Transfers should not be viewed as loss of
  surgical manhood
• Goal efficiency and appropriateness
• Resuscitate and arrange for transfer
  simultaneously rather than sequentially.
• Dispatch of transport vehicle is principal
  rate-limiting step

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Stabilization

• Proceed according to ATLS guidelines
• Controlled airway
• Satisfactory ventilatory status with/without
  support
• Hemodynamically normal
• Neurologic status normal or improving
• At or approaching normothermia
• Fractures splinted, wounds dressed, other
  indicated interventions completed
• Now safe to transfer, if needed

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Unstable Patients

• Must control airway, breathing before transfer
• Hemodynamics
• Transient or non-responders identify and
  control, if possible, source of hemorrhage
  (thoracotomy, laparotomy, wound exploration,
  ex-fixators, etc.)
• Intracranial mass lesion consult with NS
• Ventilatory, pharmacologic maneuvers
• Burr holes
• Hypothermia various warming methods

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Summary

• Identify the need for transfer early
• Proceed efficiently
• Know your limitations
• Know the law
• Do all within your power to stabilize prior to
  transfer
• Act in the best interest of the patient

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