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SERAC Interfacility Transfer Guideline

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SERAC Interfacility Transfer Guideline Powered By Docstoc
					                                                             SERAC
                                                      Interfacility Transfer
                                                            Guideline

Purpose:
To ensure major trauma patient identification, treatment, and delivery to the most appropriate facility in the
least amount of time.


Policy:
I.           Criteria for Consideration of Transfer

             The attending Emergency Department physician of each facility is responsible for triage of the
             trauma patient, and must be aware of the resources and capabilities available to care for the
             patient. When the patient’s condition requires a level of care that exceeds available resources,
             swift movement of the patient through the trauma system is required. The American College of
             Surgeons Committee on Trauma, has established interhospital transfer criteria, based on high-risk
             clinical factors. These criteria, as listed below, will be used as guidelines for the decision to
             transfer a patient to the nearest Trauma Center.

             High-risk clinical factors
                     Age >55
                     Children
                     Pregnancy
                     Morbid obesity
                     Immunosuppression (ex: hx of speenectomy, HIV+, thrombocytopenia, chemotherapy)
                     Insulin-dependent diabetes
                     Cardiac or respiratory disease

             Multisystem injury
                     Head injury with face, chest abdominal, or pelvic injury
                     Injury to more that two body regions
                     Major burns, or burns with associated injuries
                     Multiple, proximal long bone fractures

             Secondary deterioration (late sequelae)
                    Mechanical ventilation requirement
                    Single or multiple organ system failure (deterioration in central nervous, cardiac,
                    pulmonary, hepatic, renal or coagulation systems)
                    Major tissue necrosis/sepsis

             Central nervous system
                     Head injury
                              Penetrating injury or depressed skull fracture
                              Open injury with or without CSF leak
                              GCS score <14 or GCS deterioration
                              Lateralizing signs
                     Spinal cord injury or major vertebral injury




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             Chest
                           Cardiac injury
                           Major chest wall injury or pulmonary contusion
                           Patients who may require prolonged ventilation
                           Widened mediastinum or signs of great vessel injury

             Pelvis/abdomen
                      Open pelvic fracture
                      Unstable pelvic ring disruption
                      Pelvic ring disruption with shock and evidence of continuing hemorrhage

             Extremity
                    Ischemia
                    Major crush injury
                    Severe open fracture
                    Complex articlular fractures
                    Traumatic amputation

II.          Mode of Transport

             The decision for mode of transport is based on the premise that the time to definitive care and
             quality of care are critical to survival. Factors of distance, injury severity, road conditions, and
             traffic patterns must be considered when choosing between air or ground transport. The skill level
             of the transport team must also be considered.

             When considering air transport, the amount of time saved should be significant enough to allow a
             potentially beneficial intervention to take place at the receiving facility. Time considerations
             should take into account arranging for ground transport, driving times, and packaging of the
             patient. Patients may require more extensive stabilization when transported by ground, due to
             longer out of hospital time.

             The referring physician will collaborate with the receiving physician and transport service
             providers, to determine the appropriate mode of transport, based on the patient’s condition, and the
             above mentioned factors.

III.         Initiating Transfer

             •      Call Regional Communications (1-800-282-5465) to inform the communication specialist of a
                    trauma patient transfer. The transferring physician will be connected with an Emergency
                    Department physician to give report. Do not call the on-call physician for a particular
                    specialty. It is an EMTALA violation to send a patient to another health care facility without
                    an accepting physician.

             •      A copy of all records should be sent with the patient and should include: EMTALA form,
                    EMS record, nurses record, physician’s record, EKG, lab reports, and either copy or report of
                    radiological studies.

             •      The primary nurse for the patient will call report to the receiving facility nurse. The primary
                    nurse will also provide report to the transport team.

             •      Pertinent information for the patient record includes: nature of the injury/event, time of
                    occurrence, prehospital interventions, patient demographics, names and phone numbers of




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             next of kin, status of family (will they accompany the patient), past medical history, medications,
             allergies, drug, alcohol, and tobacco use, patient valuables, code status or living will, any
             interventions or medications received at the referring facility, and patient’s condition at time of
             transfer.

IV.          Packaging the patient

             Care of the patient should be performed in accordance with recommended ATLS and TNCC
             standards. Preliminary studies may include: AP, lateral, and oblique c-spine x-rays, hemoglobin,
             hematocrit, electrolytes, arterial blood gas, type and crossmatch, pregnancy test on all females of
             childbearing age, and alcohol and drug tests. Diagnostic studies should not delay transport.
              Physical examination and initial management are aimed at medically stabilizing the patient and
             preparing for continuing resuscitative care.

             Patient preparation

             Immobilization
                                         Full immobilization of head, neck, thoracic and lumbar spine with c-collar, head
                                         blocks, backboard, and straps

             Airway
                                         Administer 100% oxygen by non-rebreather face mask
                                         Intubation if hypoxic, hypercarbic, unable to maintain patent airway, or
                                         unconscious (GCS<9)
                                         Confirm endotracheal tube placement by auscultation of epigastrium and lung
                                         fields, capnography, and chest x-ray
                                         Insert nasogastric/orogastric tube to reduce risk of aspiration
                                         Monitor oxygen saturation

             Breathing
                                         Administer mechanical ventilation and adjust as indicated
                                         Insert chest tube with autotransfusor as indicated

             Circulation
                                         Insert two large bore (18 gauge or greater) IVs or central venous lines
                                         Infuse Ringer’s Lactate or Normal Saline crystalloid solutions to establish
                                         adequate perfusion
                                         Transfuse PRBC’s if hypotension and poor perfusion persists after 2 liters of
                                         crystalloid solution
                                         Control external hemorrhage
                                         Insert urinary catheter to monitor urinary output
                                         Monitor cardiac rhythm, skin color and temperature, cap refill, blood pressure,
                                         and mental status

             Central Nervous System
                              Administer steroids as indicated for spinal cord injury with neuro deficit
                              (solumedrol: loading dose 30mg/kg, maintenance dose 5.4mg/kg for 24 hours if
                              begun within three hours of injury, and 48 hours if started between three and
                              eight hours of injury)

             Other considerations
                               Administer antibiotics and tetanus as indicated
                               Cover open wounds with appropriate dressing
                               Remove rings and other jewelry, documentation of disposition




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                                         Splint fractures
                                         Pain medication or sedation
                                         Provide opportunity for family to visit patient prior to transport
                                         Provide directions to trauma center for family, and do not allow them to leave
                                         prior to the patient leaving

V.           Transport

             The transporting team will continue to monitor the patient and provide any necessary life or limb
             saving interventions as needed while en route. The transporting team will function under the
             direction of the medical director as indicated by established protocols. The same level of care
             provided in the referring hospital will be maintained during transport, within the limitations
             imposed by the vehicle.




References

American College of Surgeons Committee on Trauma Advanced Trauma Life Support: Program for
doctors, 6th edition. Chicago: ACS, 1997.

Clancy, T. V. (2001). Preparation for patient transfer. In R. F. Sing, P. M. Reilly & W. J. Messick (Eds.),
Initial management of injuries an evidence based approach (pp. 264-268). London, England: BMJ Books.

Emergency Nurses Association. (2000). Trauma Nursing Core Course (5th ed.).

New Hanover Regional Medical Center Policy and Procedure, Airlink Transport Guidelines, May 2001.




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