Tools
EMS Inter-Facility Transport
Introduction
Interfacility transport refers to the movement of patients between 2 healthcare facilities, typically using ground transportation or air vehicles. This process plays a crucial role in today’s healthcare system by enabling the transfer of patients who require specialized care that cannot be provided at their current facility. Financial constraints within integrated hospital systems and managed care organizations further necessitate interfacility transport, helping to maintain high standards of care while minimizing financial burdens.[1] Emergency medical services (EMS) interfacility transport ensures that patients receive timely and safe care. For clinicians, understanding the role of EMS services in transport is vital for appropriate use and referral.[2][3]
Issues of Concern
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Issues of Concern
Interfacility transport can be complicated, particularly in emergency settings. Healthcare providers must familiarize themselves with the system, understand its optimal uses, coordinate with administrative personnel for preplanning, and weigh the risks and benefits when considering a transfer.
Although interfacility transport can be effective even without established planning, research has shown that nonoptimal utilization does not necessarily lead to patient deterioration. An investigation using the delta Rapid Emergency Medicine Score (REMS) score indicated no significant association between nonoptimal use and patient deterioration.[4] However, preplanning and dry runs can mitigate preventable delays by establishing standardized protocols for transferring facilities, emergency medical services, and the receiving institution. Implementing these protocols has been shown to reduce the time paramedics spend at the transferring facility and overall transfer time to a tertiary care center.[5]
Several common factors are associated with transport delays, including patient equipment requirements, availability of certified transport personnel, access to a helipad, and the transferring facility’s classification.[6] Special consideration is needed for patients on ventilators and extracorporeal membrane oxygenation (ECMO) due to their unstable condition, the need for specialized teams, and an above-average risk for clinical deterioration.[7]
Another area with potential for improvement is the interfacility transportation system. A lack of research and literature makes the development of an optimal setup challenging. Improvements at the transport service level may not be as efficiently implemented as hospital safety programs due to limitations in data, management, and finances. Furthermore, simple interventions, such as checklists—ideal for operating rooms during a time-out—may not be as effective during emergencies.[8] More research and trials are needed to determine which safety measures can be effectively transferred to transportation systems.
Clinical Significance
Transferring a patient between medical facilities is a critical component of the healthcare system, ensuring continuity and appropriate levels of care. Patients may be transferred for various reasons, including regionalization, specialization, facility designation, and continuity of care. Despite the importance of these transfers in maintaining healthcare delivery, formal education on the topic is significantly lacking. Training in interfacility transport is especially beneficial when moving older patients, who often face challenges accessing specialized care during emergencies.[9]
This issue is particularly concerning for physicians, as they are legally responsible for selecting transport modalities and personnel.[10] The Emergency Medical Treatment and Active Labor Act (EMTALA), initially passed to prevent patient dumping, requires physicians to ensure patient stability before transfer. If the physician cannot stabilize the patient, the transport must be deemed medically necessary, and a request must be made by the patient or their representative. In such cases, the physician must inform the patient of the risks and benefits of the transfer and ensure that the receiving hospital has qualified personnel ready to accept the transfer while continuing appropriate medical treatment.
Transportation Designations and Modalities of Services
The National Highway Traffic Safety Administration categorizes patient transportation based on acuity level. Stable patients are classified into 4 levels of potential deterioration, while unstable patients are placed in a separate category. The National Highway Traffic Safety Administration's guide for interfacility transport provides detailed information on patient factors, equipment used, and further descriptions for each category.
Patient transportation can occur via air or ground.[11] Ground-based systems are the most commonly used when available, especially for short distances, where economic factors and geographical features allow for automobile transport. Air-based systems, such as helicopters, are more suitable in situations where a wheeled vehicle cannot reasonably transport a patient in a timely or safe manner.[12] However, air transport presents challenges, including atmospheric pressure changes, vibration, and limited space for equipment and personnel. Air transport has been associated with improved survival outcomes when appropriately used.[13]
A study by Thomas et al found that helicopter-based emergency transport is increasingly utilized in ischemic stroke cases, with earlier activations correlating with faster arrival times at receiving hospitals.[14] Moreover, helicopter transport has been linked to a reduction in the number of patients who are dead on arrival.[15]
Hospital Ownership, Private Companies, and the Use of 911 Systems
Interfacility transportation services are offered by different owners and operators. In regional hospital systems, the transportation units may be owned by the regional system or one of its subsidiaries. Private independent companies also frequently transport patients between facilities, either under contract or on a fee-for-service basis. Government-based emergency services may be used for interfacility transport, though less often.
Using government-based emergency services for transportation can pose challenges in some jurisdictions.[16] When the 911 system is used, resources allocated for transport may be unavailable for emergency calls. While careful planning and real-time management can mitigate the impact on response times, the potential for resource shortages still limits the use of 911 services to only the most time-sensitive emergencies. A study by Eckstein et al found that 911 services were primarily used for emergency department-to-emergency department transfers, particularly when the patient was being transported to a center certified for ST-elevation myocardial infarction (STEMI) care.[17]
Reasons for Typical Transfers
Interhospital transfers can occur in both emergent and nonemergent situations. An emergent transfer typically involves a patient who, although initially arriving at the closest hospital, requires care that the facility cannot provide due to a lack of expertise or equipment.[18][19] When a healthcare facility cannot effectively manage a patient's condition, transfer to a higher level of care, where specialized expertise and advanced interventions are available, becomes necessary. In emergent situations, where time is critical, the decision to transfer must be made swiftly to avoid delays that could push patients beyond the time window for specialty interventions. For example, transport times can impact the recommended door-to-balloon time of under 90 minutes for individuals with ST-elevation myocardial infarction.[20][21]
Nonemergent interhospital transfers involve stable patients, including individuals undergoing nonemergent surgeries or elective procedures, being relocated to hospitals designated for interregional care, or being moved to their desired location. The decision to transfer should carefully consider the cost-benefit factor and the risk of deterioration during transport.
Transfers between hospitals and other healthcare facilities are typically nonemergent. Common scenarios include transfers between a hospital and a skilled nursing facility or acute rehabilitation center. While most of these transfers occur without urgency or significant concern for patient deterioration, the potential for a patient's condition to worsen remains.
Transfers between nonhospital facilities also tend to be nonemergent or without urgency. For example, transfers between a nursing facility and a dialysis center can generally be managed with basic transport and fewer resources. However, potential adverse reactions to dialysis, such as hypotension, may require increased urgency, emergent transport, or a change in the destination.
References
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