Back To Search Results

EMS Inter-Facility Transport

Editor: Melissa D. Kohn Updated: 9/26/2022 5:43:28 PM


Interfacility transport is defined as the transport of patients between two healthcare facilities. The process is generally accomplished through ground transportation or air vehicles. Interfacility 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 interfacility transport to help maintain high practice standards and reduce financial burdens.[1] Emergency medical services (EMS) interfacility transport ensures that patients receive the care they need in a time-efficient and safe manner. For clinicians, understanding the role EMS services play in transport is essential for the proper use and referral.[2]

Issues of Concern

Register For Free And Read The Full Article
Get the answers you need instantly with the StatPearls Clinical Decision Support tool. StatPearls spent the last decade developing the largest and most updated Point-of Care resource ever developed. Earn CME/CE by searching and reading articles.
  • Dropdown arrow Search engine and full access to all medical articles
  • Dropdown arrow 10 free questions in your specialty
  • Dropdown arrow Free CME/CE Activities
  • Dropdown arrow Free daily question in your email
  • Dropdown arrow Save favorite articles to your dashboard
  • Dropdown arrow Emails offering discounts

Learn more about a Subscription to StatPearls Point-of-Care

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.



Blackwell TH. Interfacility transports. Seminars in respiratory and critical care medicine. 2002 Feb:23(1):11-8     [PubMed PMID: 16088593]


Becker TK, Skiba JF, Sozener CB. An educational measure to significantly increase critical knowledge regarding interfacility patient transfers. Prehospital and disaster medicine. 2015 Jun:30(3):244-8. doi: 10.1017/S1049023X15000266. Epub 2015 Mar 19     [PubMed PMID: 25786539]


Nolan B, Tien H, Sawadsky B, Haas B, Saskin R, Ahghari M, Nathens A. Risk Factors for Non-optimal Resource Utilization for Emergent Interfacility Transfers by Air Ambulance in Ontario. Prehospital emergency care. 2020 Jan-Feb:24(1):55-63. doi: 10.1080/10903127.2019.1610531. Epub 2019 May 17     [PubMed PMID: 31010361]


Kodankandath TV,Wright P,Power PM,De Geronimo M,Libman RB,Kwiatkowski T,Katz JM, Improving Transfer Times for Acute Ischemic Stroke Patients to a Comprehensive Stroke Center. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2017 Jan;     [PubMed PMID: 27743926]


Nolan B, Haas B, Tien H, Saskin R, Nathens A. Causes of Delay During Interfacility Transports of Injured Patients Transported by Air Ambulance. Prehospital emergency care. 2020 Sep-Oct:24(5):625-633. doi: 10.1080/10903127.2019.1683662. Epub 2019 Nov 11     [PubMed PMID: 31638458]


Ellinger F Jr, Wydro G. Critical transport issues. Interfacility transportation of a patient on ECMO. EMS magazine. 2009 Oct:38(10):71-3     [PubMed PMID: 19856781]


Bigham BL, Buick JE, Brooks SC, Morrison M, Shojania KG, Morrison LJ. Patient safety in emergency medical services: a systematic review of the literature. Prehospital emergency care. 2012 Jan-Mar:16(1):20-35. doi: 10.3109/10903127.2011.621045. Epub     [PubMed PMID: 22128905]

Level 1 (high-level) evidence


Garwe T,Stewart K,Stoner J,Newgard CD,Scott M,Zhang Y,Cathey T,Sacra J,Albrecht RM, Out-of-hospital and Inter-hospital Under-triage to Designated Tertiary Trauma Centers among Injured Older Adults: A 10-year Statewide Geospatial-Adjusted Analysis. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2017 Nov-Dec;     [PubMed PMID: 28661712]


Shelton SL, Swor RA, Domeier RM, Lucas R. Medical direction of interfacility transports: National Association of EMS Physicians Standards and Clinical Practice Committee. Prehospital emergency care. 2000 Oct-Dec:4(4):361-4     [PubMed PMID: 11045419]

Level 1 (high-level) evidence


Nolan B, Tien H, Sawadsky B, Rizoli S, McFarlan A, Phillips A, Ackery A. Comparison of Helicopter Emergency Medical Services Transport Types and Delays on Patient Outcomes at Two Level I Trauma Centers. Prehospital emergency care. 2017 May-Jun:21(3):327-333. doi: 10.1080/10903127.2016.1263371. Epub 2017 Jan 19     [PubMed PMID: 28103121]


Thomas SH, Kociszewski C, Schwamm LH, Wedel SK. The evolving role of helicopter emergency medical services in the transfer of stroke patients to specialized centers. Prehospital emergency care. 2002 Apr-Jun:6(2):210-4     [PubMed PMID: 11962569]

Level 2 (mid-level) evidence


Robinson V,Goel V,Macdonald RD,Manuel D, Inter-facility patient transfers in ontario: do you know what your local ambulance is being used for? Healthcare policy = Politiques de sante. 2009 Feb;     [PubMed PMID: 19377355]


Eckstein M, Schlesinger SA, Sanko S. Interfacility Transports Utilizing the 9-1-1 Emergency Medical Services System. Prehospital emergency care. 2015:19(4):490-5. doi: 10.3109/10903127.2015.1005258. Epub 2015 Apr 24     [PubMed PMID: 25909809]


Nehme Z,Andrew E,Smith K, Factors Influencing the Timeliness of Emergency Medical Service Response to Time Critical Emergencies. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2016 Nov-Dec;     [PubMed PMID: 27487018]


Karkabi B, Jaffe R, Halon DA, Merdler A, Khader N, Rubinshtein R, Goldstein J, Zafrir B, Zissman K, Ben-Dov N, Gabrielly M, Fuks A, Shiran A, Adawi S, Hellman Y, Shahla J, Halabi S, Flugelman MY, Cohen S, Bergman I, Kassem S, Shapira C. An Intervention to Reduce the Time Interval Between Hospital Entry and Emergency Coronary Angiography in Patients with ST-Elevation Myocardial Infarction. The Israel Medical Association journal : IMAJ. 2017 Sep:19(9):547-552     [PubMed PMID: 28971637]