EMS Inter-Facility Transport

Issues of Concern

Interfacility transport has the potential for complications, especially in an emergency setting. Healthcare providers must learn about the system, understand optimal uses, coordinate with administrative personnel for preplanning, and consider the risks versus benefits when contemplating transfer.

The use of interfacility transport is worthwhile even without established planning. Investigation of the benefit of interfacility transport services, using the delta Rapid Emergency Medicine Score (REMS) score, showed that nonoptimal utilization was not associated with patient deterioration.[3] Regardless, preplanning and dry runs can help mitigate preventable delays by establishing standardized protocols for transferring facilities, emergency medical services, and the receiving institution. Implementation of standardized protocols has been shown to reduce the time paramedics spend at the transferring facility and the overall transfer time to a tertiary care center.[4] Common factors associated with transport delay include patient equipment requirements, certified transport personnel availability, access to a helipad, and the transferring facility’s classification.[5] Special consideration should be given to patients on ventilators and extracorporeal membrane oxygenation (ECMO) due to their unstable condition, the need for specialized teams, and above-average risk for clinical deterioration.[3][6]

Another area with an opportunity for improvement is the interfacility transportation systems. A lack of research and literature makes the development of an optimal setup unlikely. Improvements at the level of the transport service may not be implemented as efficiently as hospital safety programs due to limited data, management, and finances.[7] Furthermore, simple interventions such as checklists, although ideal for the operating room during a time-out, may not work well during an emergency event.[7] More research and trials are needed to see what safety measures can be transferred to the transportation systems.

Clinical Significance

Transferring a patient between medical facilities is essential to the healthcare system, ensuring continuity and proper care levels. A patient may receive a transfer for many reasons, including regionalization, specialization, the designation of facilities, and continuity of care. Despite its commonality and significance in the continuity of healthcare delivery, there is a severe lack of formal education about the subject.[2] Training for interfacility transport may be particularly beneficial to older patients, as they typically experience lower use of specialized tertiary care centers during emergencies.[8]

This subject matter is especially concerning for physicians, as they are responsible, by law, for the selection of transport modalities and personnel.[9] The Emergency Medical Treatment and Active Labor Act (EMTALA) was initially passed to prevent dumping of patients and dictates that a physician must ensure the stability of the patient; if the physician is unable to stabilize the patient, the transport must be medically necessary and a request made by the patient or patient representative.[1] If a request is made, the physician must inform the patient of the risks and benefits of transferring. The physician must ensure that a receiving hospital has qualified personnel who are accepting of the transfer while continuing to maintain proper medical treatment.

Transportation Designations and Modalities of Services

The National Highway Traffic Safety Administration categorizes patient transportation by acuity level. Stable patients are separated into four levels of potential deterioration, and unstable patients are designated under an independent category. Patient factors, equipment used, and further descriptions for each category are available online in the National Highway Traffic Safety Administration's guide for interfacility transport.

Transportation of patients may occur by air or ground. Ground-based systems are the most commonly used when available. Ground-based transport systems are beneficial, particularly when the distance is short, economic responsibilities are considered, and geographical features allow an automobile to complete the task. Air-based systems, such as helicopters, are better suited for situations in which a wheeled vehicle could not reasonably transport a patient in a timely or safe manner. Air-based systems present some challenges for transportation, such as atmospheric pressure changes, vibration, and reduced space for equipment and personnel. When correctly employed, air transport has shown improved survival outcomes.[10] In a study by Thomas et al, helicopter-based emergency transport is increasingly being activated in the setting of ischemic stroke, with earlier activations correlating with faster arrival times to the receiving hospital.[11]

Hospital Ownership, Private Companies, and Use of 911 Systems

A variety of owners and operators may provide interfacility transportation. The regional system or one of its subsidiaries might own the transportation units in regional-based hospital systems. Private independent companies also commonly transport patients between facilities. These private companies may be under contract or used on a fee-for-service basis. Government-based emergency services are sometimes used as interfacility transports, though less often. 

Using government-based emergency services for transportation is a potential issue for some jurisdictions.[12] When using the 911 system, scarce resources used for transport may be unavailable for an emergency call. While planning and real-time management can reduce the effect on response times, the undeniable potential still precludes the use of 911 services, except in the most time-sensitive emergencies. In a study by Eckstein et al, 911 services were used mostly in emergency department–to–emergency department transfers when the patient was transferred to an ST-elevation myocardial infarction–certified center.[13]

Reasons for Typical Transfers

Interhospital transfer of a patient may occur in emergent and nonemergent situations. An emergent need typically involves transferring a patient. Although a patient may arrive at the closest hospital, that facility may not have the expertise or equipment to provide the appropriate care. When a healthcare facility cannot effectively manage a patient's condition, that patient must be transferred to a higher level of care where expertise, advanced interventions, and specially trained providers are available. In an emergent situation where time is critical, the decision to transfer must be made rapidly. Delaying transfer can put patients outside the allotted time window for specialty interventions. For example, the recommended goal of door-to-balloon time of under 90 minutes for a STEMI can be affected by transport times.[14][15]

Nonemergent interhospital transfers are for stable patients. Reasons for transfer include nonemergent surgery, elective procedures, interregional hospital designations, or nonacute patients who receive care closer to their desired location. The decision to transfer should weigh the cost-benefit factor and the chance for deterioration during transport.

Transfers between hospitals and other healthcare facilities are generally performed nonemergently. Typical scenarios include transfers between a hospital, skilled nursing facility, or acute rehabilitation center. Although most transfers occur without urgency or primary concern for deterioration, the potential for a patient's condition to worsen is still present.

In most cases, transfers between nonhospital facilities are completed on a nonemergent or without urgency. For example, transfers between a nursing facility and a dialysis center can typically be completed without more basic transport and fewer resources. Potential adverse reactions to dialysis, such as hypotension, can warrant increased urgency, emergent transport, or a possible change in destination.