EMS, Inter-Facility Transport

Article Author:
Joseph Heaton
Article Editor:
Melissa Kohn
3/15/2020 1:51:16 PM
PubMed Link:
EMS, Inter-Facility Transport


Inter-facility transport is the process of transporting a patient between two healthcare facilities. The process is generally accomplished through ground transportation or air vehicles. Inter-facility transport is a crucial part of today's healthcare system that allows facilities to transfer patients needing specialized care that cannot be adequately performed at their current facility. Financial constraints of integrated hospital systems and managed care organizations also necessitate the use of inter-facility transport to maintain high practice standards and reduce financial burdens.[1] Through the use of emergency medical services (EMS), inter-facility transport ensures that a patient receives the care they need in a time-efficient and safe manner. For clinicians, understanding the role of emergency medical services is essential for the proper use and referral.[2]

Issues of Concern

Inter-facility transport is a valuable tool which adds the potential for complication, especially in an emergency setting. Thus, a provider needs to learn about the system, understand optimal uses, coordinate with administrative personnel for preplanning, and consider the risk-benefits when contemplating transfer.

The use of inter-facility transport is worthwhile even without established planning. Investigation of this phenomenon using the delta REMS score showed that non-optimal utilization was not associated with patient deterioration.[3] Nevertheless, preplanning and dry runs can help mitigate preventable delays by establishing protocols that standardize the process for the sending institution, emergency medical services, and the receiving institution. Such implementations have been shown to reduce the time spent at the sending facility by paramedics, which reduces the overall transfer time to a tertiary center.[4] Common factors associated with transport delay include patient equipment requirements, certified transport personnel, availability of an accessible helipad, and the sending facility’s classification.[5] Special consideration should be given to patients on ventilators and ECMO, due to their unstable state, need for specialized teams, and above-average risk for deterioration.[3][6][3]

Another issue of concern is the improvement if inter-facility transportation systems. Due to a lack of research and literature for clinicians, optimal setup and use may be years away. 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, while ideal for the operating room during a time-out, may not work well during an emergency event.[7] More research and trials will be needed to see what safety measures can be transferred to the transportation systems.

Clinical Significance

Transferring a patient between medical facilities is an essential aspect of the healthcare system, which ensures continuity and proper levels of care. A patient may receive a transfer due to a multitude of 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 the use of inter-facility 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 the transportation of patients 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 can be found under the National Highway Traffic Safety Administration's guide for interfacility transport available online.

The act of transportation may take place using a ground or air-based system. Ground systems are most common when the resource is readily available, distance is short, economic responsibilities are considered, and geographical features allow for an automobile to complete the task. Air systems, such as helicopters, are better suited for situations in which an automobile could not reasonably transport a patient in a timely or safe manner, possibly due to geographical or timeliness constraints. Air systems add additional limitations for transportation, such as atmospheric pressure changes, vibration, and reduced space for equipment and personnel. However, air transport has still shown improved survival outcomes.[10] In a study by Thomas et al., helicopter-based emergency transport is being increasingly activated in the setting of ischemic stroke, with earlier activations correlating with earlier arrival times for the receiving hospital.[11]

Hospital ownership, private companies, and use of 911 systems

A variety of owners and operators may provide inter-facility transportation. In regional-based hospital systems, ownership of the transportation units might be by the regional system or one of its subsidiaries. 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 inter-facility transports, though significantly less often. 

The use of government-based emergency services for transportation is a touching issue for concerned jurisdictions.[12] When using the 911 system, scarce resources are taken away from potential use in an emergency call. While planning and real-time management can reduce the effect on response times, the undeniable potential still precludes its use except in the most time-sensitive emergencies. In a study by Eckstein et al., 911 services were used mostly in the setting of ED-to-ED transfers when the patient was going to a STEMI certified center.[13]

The Reasoning of Typical Transfers

Inter-hospital transferring of a patient may be completed in emergent and non-emergent situations. An emergent situation typically involves transferring a patient to a tertiary care hospital for evaluation and treated by specialists. Commonly, this is seen in patients experiencing a stroke or acute cardiac event. While a patient may arrive at a hospital proximal to their location, that facility may not have the expertise nor the equipment to handle the event appropriately. Thus, it becomes necessary for that patient to be transferred to a specialty center to undergo more advanced interventions and be cared for by specially trained units. The decision to transfer must be made rapidly, as delaying transfer can put patients outside the allotted time window for specialty interventions; emergent transfer to a STEMI center is beneficial in maintaining a commonly utilized goal of door-to-balloon-time under 90 minutes.[14][15]

Non-emergent inter-hospital transfers are for stable patients. Reasons for transfer include non-emergent surgery, elective procedures, inter-regional hospital designations, or for non-acute patients who will 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 on a non-emergent basis. Typical scenarios include transfers between a hospital and a skilled nursing facility or an acute rehabilitation center. Although most transfers occur without urgency or primary concern for deterioration, the potential for such is still present.

Transfers between non-hospital facilities also complete without urgency in most cases. Transfers between a nursing facility and a dialysis center, for example, can typically be completed without extraneous measures. Potential adverse reactions of dialysis, such as hypotension, can warrant increased urgency and a possible change in destination.


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