Transfer To Definitive Care

Objective

• Identify injured patients who require transfer from a primary

care institution to a facility capable of providing the
necessary level of trauma care.
• Initiate procedures to optimally prepare trauma patients for
safe transfer to a higher-level trauma care facility via the
appropriate mode of transportation.
• The Advanced Trauma Life Support® course is designed
to train clinicians to be proficient in assessing,
stabilizing, and preparing trauma patients for definitive
care. Definitive care, whether support and monitoring in
an intensive care unit (ICU) or operative intervention,
requires the presence and active involvement of a
surgeon and trauma team
• If definitive care cannot be provided at a local hospital,
the patient requires transfer to a hospital that has the
resources and capabilities to care for him or her. Ideally,
this facility should be a verified trauma center, the level
of which depends on the patient’s needs.
• The decision to transfer a patient to another facility
depends on the patient’s injuries and the local
resources. Decisions as to which patients should be
transferred and when transfer should occur are based on
medical judgment. Evidence supports the view that
trauma outcome is enhanced if critically injured patients
are treated in trauma centers
• The decision to transfer a patient to another facility depends on
the patient’s injuries and the local resources. Decisions as to
which patients should be transferred and when transfer should
occur are based on medical judgment. Evidence supports the
view that trauma outcome is enhanced if critically
injuredpatients are treated in trauma centers.
• A major principle of trauma management is to do no further harm.
• Indeed, the level of care of trauma patients should consistently
improve with each step,from the scene of the incident to the
facility that can
• provide the patient with the necessary, proper treatment.
Determining the need for patient tranfer

• It is essential that clinicians assess their own capabilities and

limitations, as well as those of their.
• Once the need for transfer is recognized, arrangements should be
expedited and not delayed for diagnostic procedures (e.g.,
diagnostic peritoneal lavage [DPL] or CT scan) that do not change
the immediate plan of care.
Timeliness Of Transfer

• Patient outcome is directly related to the time elapsed

between injury and properly delivered definitive car.
• The timeliness of transfer is partly dependent on the how
quickly the doctor on call can reach the ED. Consequently,
effective communication with the prehospital system should
be developed to identify patients who require the presence
of a doctor in the ED at the time of arrival

ED = Emergency Departement
• The timing of interhospital transfer varies based on the
distance of transfer, the available skill levels for transfer,
circumstances of the local institution, and intervention that
is necessary before the patient can be transferred safely.
• If the resources are available and the necessary procedures
can be performed expeditiously,
• The timing of interhospital transfer varies based on the distance
of transfer, the available skill levels for transfer, circumstances of
the local institution, and intervention that is necessary before the
patient can be transferred safely. If the resources are available
and the necessary procedures can be performed expeditiously,
life-threatening injuries should be treated before patient
transport. This treatment may require operative intervention to
ensure that the patient is inthe best possible condition for
transfer.
• Interventionprior to transfer is a surgical decision.
PITFALL

• Delaying transfer for diagnostic tests that will not

change the need for transfer and only delay
definitive care.
Transfer Factor

• These factors also help clinicians decide which stable patients

might benefit from transfer
• Patients who exhibit evidence of shock, significant physiologic
deterioration, or progressive deteriorationin neurologic status
require the highest level of care and will likely benefit from
timely transfer
Table Interhospital Criteria

Category Specific Injuries and Other Factors

Central Nervous System • Head injury

–Penetrating injury or depressed skull
fracture
– Open injury with or without cerebrospinal fluid (CSF) leak
– GCS score <15 or neurologically abnormal
– Lateralizing signs
• Spinal cord injury or major vertebral injury
Chest • Widened mediastinum or signs suggesting great vessel injury
• Major chest wall injury or pulmonary contusion
• Cardiac injury
• Patients who may require prolonged ventilation
Pelvic/Abdomen • Unstable pelvic-ring disruption
• Pelvic-ring disruption with shock and evidence of
continuing hemorrhage
• Open pelvic injury
• Solid organ injury
Extremitas • Severe open fractures
• Traumatic amputation with potential for replantation
• Complex articular fractures
• Major crush injury
• Ischemia
Multisystem Injuries • Head injury with face, chest, abdominal, or pelvic injury
• Injury to more than two body regions
• Major burns or burns with associated injuries
• Multiple, proximal long-bone fractures
Comorbid Factors • Age >55 years
• Children < 5 years of age
• Cardiac or respiratory disease
• Insulin-dependent diabetes
• Morbid obesity
• Pregnancy
• Immunosuppression
Secondary Deterioration • Mechanical ventilation required
(Late Sequelae) • Sepsis
• Single or multiple organ system failure
(deterioration in central nervous, cardiac, pulmonary,
hepatic,renal, or coagulation systems)
• Major tissue necrosis
• Treatment of combative and uncooperative patients with an
altered level of consciousness is difficult and fraught with
hazards.
• These patients are often immobilizedin the supine position
with wrist/leg restraints.
• If sedation is required, the patient should be intubated.Therefore,
before administering any sedation, the treating doctor must:
• Ensure that the patient’s ABCDEs are appropriately managed.
• Relieve the patient’s pain if possible (e.g., splint fractures and administer
small doses of narcotics intravenously).
• Attempt to calm and reassure the patient.
• Remember, benzodiazepines, fentanyl (Sublimaze), propofol (Diprivan), and
ketamine (Ketaset) are all hazardous in patients with hypovolemia, Patient
Who Specific transfer responsibilities are held by both thereferring doctor
and the receiving doctor
• Abuse of alcohol and/or other drugs is common to all forms
of trauma and is particularly important to identify, because
these substances can alter pain perception and mask
significant physical findings. Alterations in the patient’s
responsiveness can be related to alcohol and/or drugs, but
the absence of cerebral injury should never be assumed in
the presence of alcohol or drugs. If the examining doctor is
unsure transfer to a higher-level facility may be
appropriate.
• Death of another individual involved in the incident suggests the
possibility of severe, occult injury in survivors. In these cases, a
thorough and careful evaluation of the patient, even in the
absence of obvious signs of severe injury, is mandatory.
REFERRING DOCTOR

• Where should I send the patient?

• The referring doctor is responsible for initiating transfer of the
patient to the receiving institution and selecting the appropriate
mode of transportation and level of care required for optimal
treatment of the patient en route.
• The referring doctor should consult with the receiving doctor and
should be thoroughly familiar with the transporting agencies, their
capabilities, and the arrangements for patient treatment during
transport.
• Stabilizing the patient’s condition before transfer
• Transfer agreements must be established to provide for the
consistent and efficient movement of patients between
institutions
• The interhospital transfer of a critically injured patient is
potentially hazardous unless the patient’s condition is optimally
stabilized before transport, transfer personnel are properly
trained, and provision has been made for managing unexpected
crises during transport.
• To ensure safe transfers, trauma surgeons must be involved in
training, continuing education, and quality improvement programs
designed for transfer personnel and procedures. Surgeons also
should be actively involved in the development and maintenance
of systems of trauma care.
PITFALL

• Failure to anticipate deterioration in the patient’s neurologic

condition or hemodynamic status during transport.
PITFALL

• Inadequate or inappropriate communication between

referring and accepting care providers resulting in loss of
information critical to the patient’s care.
Transfer Protocol

• INFORMATION FROM REFERRING DOCTOR

• The doctor who has determined that patient transfer is necessary
should speak directly to the surgeon accepting the patient at the
receiving hospital. The following information must be provided:
• Patient identification
• Brief history of the incident, including pertinent
• prehospital data
• Initial findings in the ED
• Patient’s response to the therapy administered
INFORMATION TO TRANSFERRING
PERSONNEL

• Information regarding the patient’s condition and needs during

transfer should be communicated to the transporting personnel.
This information includes, but is not limited to:
• Airway maintenance
• Fluid volume replacement
• Special procedures that may be necessary
• Revised Trauma Score, resuscitation procedures, and any changes that may
occur en route
TREATMENT PRIOR TO TRANSFER

• Patients should be resuscitated and attempts made to stabilize

their conditions as completely as possible based on the following
suggested outline:
• 1. Airway
• Insert an airway or endotracheal tube, if needed.
• Provide suction.
• Insert a gastric tube to reduce the risk of aspiration.
• 2. Breathing
• Determine rate and administer supplementary oxygen.
• Provide mechanical ventilation when needed.
• Insert a chest tube if needed.
• 3. Circulation
• Control external bleeding.
• Establish two large-caliber intravenous lines and begin
crystalloid solution infusion.
• Restore blood volume losses with crystalloid fluids or blood and
continue replacement during transfer.
• Insert an indwelling catheter to monitor urinary output.
• Monitor the patient’s cardiac rhythm and rate.
• 4. Central nervous system
• Assist respiration in unconscious patients.
• Administer mannitol, if needed.
• Immobilize any head, neck, thoracic, and lumbar spine
injuries.
• 5. Diagnostic studies (When indicated; obtaining these studies
should not delay transfer.)
• Obtain x-rays of chest, pelvis, and extremities.
• Sophisticated diagnostic studies, such as CT and aortography, are usually not
indicated.
• Order hemoglobin or hematocrit, type and crossmatch, and arterial blood
gas determinations for all patients; also order pregnancy tests for females
of childbearing age.
• Determine cardiac rhythm and haemoglobin saturation (electrocardiograph
[ECG] and pulse oximetry).
• 6. Wounds (Performing these procedures should not delay
transfer.)
• Clean and dress wounds after controlling external hemorrhage.
• Administer tetanus prophylaxis.
• Administer antibiotics, when indicated.

• 7. Fractures
• Apply appropriate splinting and traction.
TREATMENT DURING TRANSPORT

• The appropriate personnel should transfer the patient, based

on the patient’s condition and potential problems. Treatment
during transport typically includes:
• Monitoring vital signs and pulse oximetry
• Continued support of cardiorespiratory system
• Continued blood-volume replacement
• Use of appropriate medications as ordered by a doctor or as allowed by
written protocol
• Maintenance of communication with a doctor or institution during transfer
• Maintenance of accurate records during transfer
• The flurry of activity surrounding the initial evaluation, resuscitation,
and preparations for transfer of trauma patients often takes
precedence over other logistic details.
• This may result in the failure to include certain items in the
information that is sent with the patient, such as x-ray films,
laboratory reports, or narrative descriptions of the evaluation process
and treatment rendered at the local hospital.
• A checklist is helpful in this regard to make sure that all important
components of care have been addressed.
• Checklists can be printed or stamped on an x-ray jacket or the
patient’s medical record to remind thereferring doctor to include
all pertinent information
Tranfer Data

• The information accompanying the patient shouldi nclude both

demographic and historical information pertinent to the patient’s
injury. Uniform transmission of information is enhanced by the use
of an established transfer form, such as the example shown
• In addition to the information already outlined, space should be
provided for recording data in an organized, sequential fashion—
vital signs, central nervous system (CNS) function, and urinary
output— during the initial resuscitation and transport period.
PITFALL

• Endotracheal tubes may become dislodged or malpositioned

during transport.
• The necessary equipment for reintubation must accompany
the patient, and the transfer personnel must be capable of
performing the procedure.