Guide for Interfacility Patient Transfer
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National Highway Trac Safety Administration
Guide For Interfacility Patient Transfer
Guide for Interfacility Patient Transfer
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National Highway Trac Safety Administration
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Major Topic #1: Denitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Major Topic #2: Meeting Patient Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Major Topic #3: Integration of Interfacility Transfer
Services into Existing Regional Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Major Topic #4: Medical Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Major Topic #5: Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Major Topic #6: Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Major Topic #7: Financial Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Major Topic #8: Policy Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Major Topic #9: Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Major Topic #10: Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Appendix A: Members of the IFT Guidelines Work Group . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Appendix B: References and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Appendix C: Elements of a Business Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Appendix D: EMTALA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Appendix E: Certicate of Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Appendix F: HIPAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Guide for Interfacility Patient Transfer
1
National Highway Trac Safety Administration
INTRODUCTION
Project Background
e transfer of patients from one medical facility to
another has become a national issue for Emergency
Medical Services (EMS). Patient transfers between
facilities or between facilities and a specialty care
resource have increased as a result of regionaliza-
tion, specialization, and facility designation by
payers. e emergence of specialty systems (e.g.,
cardiac centers, stroke centers) oen determines
the ultimate destination of patients rather than
proximity of facility. Transfer may be necessary
if payers provide reimbursement only for specic
facilities within their own plans.
Interfacility transfer (IFT) is provided by a variety
of levels and types of personnel and agencies. Key
issues include the IFT infrastructure, including the
qualications of those delivering the care. Meeting
patient needs and maintaining continuity of care
are only two of the many issues related to IFT.
Emergency Medical Services (EMS) at the National
Highway Trac Safety Administration (NHTSA)
convened key national stakeholders to identify
national EMS priority issues and to establish
consensus-based guidelines for the EMS commu-
nity. In January 2002, NHTSA convened an EMS
Interfacility Transfer Planning Group to consider
the current issues and to determine if national
consensus guidelines would be useful in addressing
these challenges. e planning group determined
that consensus guidelines would be very useful to
promote consistent high-quality patient care while
allowing variation to meet specic local needs.
e group identied the following areas that could
benet from such guidelines.
Ten Major Topics for IFT Guidelines:
n
Cost reimbursements and funding for services
n
Integration of IFT services in existing regional
health care systems
n
Research
n
Provider education
n
Liability
n
Medical direction
n
Human resources and stang
n
Legislation and regulation
n
Best practices
n
Denitions
A follow-up meeting of the Interfacility Transfer
Planning Group was held in Alexandria, Virginia,
on May 12-13, 2003. e NHTSA EMS Division
identied appropriate organizations and invited
their participation in the meeting. ese organiza-
tions included:
n
Air & Surface Transportation Nurses
Association
n
Air Medical Physician Association
n
American Ambulance Association
n
American College of Emergency Physicians
n
Commission for Accreditation of Ambulance
Services
n
Commission on Accreditation of Medical
Transport Systems
n
Emergency Nurses Association
n
Emergency Medical Services for Children
n
International Association of Flight Paramedics
(formerly known as the National Flight
Paramedics Association)
n
National Association of EMS Physicians
n
National Association of EMTs
n
National Association of State EMS Directors
n
National Association of State EMS Training
Coordinators
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
e president or executive director of each or-
ganization was asked to designate a representa-
tive to participate in a two-day meeting, and the
completion of the IFT Guidelines document. is
invitation resulted in the formation of the IFT
Guidelines Work Group (Appendix A).
Guidelines for Denitions and Provider Education
were completed as part of the agenda of the 2003
meeting. It was agreed that guidelines for the
remaining eight major topics would be completed
through an electronic process (eRoom). At several
points, the document was informally reviewed by
the organizations represented by the IFT Work
Group members. is document is the result of
that process. e guidelines contained in this doc-
ument are based upon a combination of available
objective evidence, a review of generally accepted
practices, and the consensus of expert opinions in
the eld of IFT — in short, the best information
available.
Purpose and Limitations of is
Document
e intended audience for this guide is the agency
providing IFT at the local, regional, or State level,
as well as those involved with planning for IFT
or dealing with IFT-related issues. is audience
may include a variety of decision makers, such as
program administrators, agencies with EMS juris-
diction, physicians providing medical oversight for
IFT, or hospitals dealing with IFT-related issues.
e intent of this document is to provide general
guidance. Given the variety of unique needs and
demands placed on programs, local communities,
and EMS systems, prescriptive standards would
not be useful. In addition, specic standards may
conict with existing regulations or administrative
rules. is document is not intended to serve as
a benchmark.
is document can be used to provide general
guidance, references and ideas for conducting a
systematic assessment of the processes and person-
nel supporting IFT and how they can be enhanced
to provide optimal delivery of care. e overarch-
ing principle adopted by the IFT Work Group was
that all decisions should be motivated by the desire
to optimize the process of IFT and the care given
during transport. e ultimate goal is to match
patient need with appropriate knowledge, skills,
equipment, and an infrastructure to enable safe,
eective, and ecient IFT.
Planning and Implementation
Considerations
As with any analysis of program status, it is
helpful to evaluate its current status before taking
action. e three core functions of public health,
published by the Institute of Medicine
1
, provide
a useful model for this process. ese three
functions are:
n
Assessment – to collect, assemble, analyze,
and make available relevant facts and gures
including existing data, identied needs, and
epidemiologic and other applicable information.
n
Policy Development – eorts to serve the public
interest in the development of comprehensive
policies by promoting the use of a scientic
knowledge base as a basis for decision-making,
and leading in developing comprehensive
policies.
n
Assurance – eorts to assure that services
necessary to achieve agreed-upon goals are
provided either by encouraging actions by
other entities, by requiring such action through
regulation, or by providing services directly.
Assessment
e IFT Guide developed by the IFT Work Group
can be used largely within the assessment phase,
where it can serve as a template against which a
State/region/locality could compare its own pro-
gram. Before this process is begun, it is strongly
recommended that the stakeholder group adopt a
goal and a mission statement to identify and agree
upon the ultimate goal for this and all other activi-
Guide for Interfacility Patient Transfer
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National Highway Trac Safety Administration
ties. An assessment tool can be developed once all
stakeholders agree upon the ultimate mission/goal,
and assessment strategies are established. e fol-
lowing represent general categories for assessment:
n
current IFT system components;
n
education and training of providers;
n
legal status/legal authority including liability;
n
medical oversight, including IFT protocols;
n
cost reimbursement, and funding for services;
n
integration of IFT services into existing health
care systems; and
n
stang requirements for IFT.
Once stakeholders have endorsed the goal, needs
are assessed and all relevant outcome and process
information has been assembled and analyzed, a
gap analysis will form the basis for action. A gap
analysis is a comparison of the current situation to
the desired state. A plan to move from the current
state to the desired state is developed. e level
of detail in the plan depends on the scope of the
project.
Policy Development
Based upon the desired goal, the assessment and
gap analysis form the basis for action. Strategies
are identied to bridge the gap between the current
situation and the desired state. Policy development
and planning includes:
n
informing, educating, and empowering people
about IFT issues;
n
mobilizing community and stakeholder partner-
ships to identify and solve IFT problems; and
n
developing policies and plans that support indi-
vidual and community eorts to improve IFT.
e strategies included for IFT policy development
may include:
n
legislation and administrative rule-making (for
providers, such as EMS boards, nursing boards,
medical boards, pharmacies, if needed, and oth-
ers, e.g., respiratory therapists);
n
legislation and administrative rule-making (for
services);
n
provider education:
o
meeting with organizations;
o
course development; and
o
other steps for policy;
n
medical oversight:
o
critical care versus emergency department
management;
o
IFT protocols;
o
destination protocols; and
o
other?
n
education of various organizations/disciplines;
n
cost reimbursement and funding:
o
meeting with third-party carriers; and
o
matching reimbursements with system design.
Assurance
Before strategies are deployed, performance mea-
sures should be established, which can be used to
measure progress. As the implementation process
moves forward, several surveillance methods can
be used to evaluate achievements:
n
data collection;
n
evaluation of eectiveness, accessibility, and
quality of IFT services and the infrastructure
that supports IFT;
n
enforcement of laws and regulations;
n
quality improvement;
n
ongoing system modication based on data; and
n
feedback loops.
ese three core functions may be repeated
multiple times. e process of assessing,
developing policy, and assuring is ongoing, and the
deployment plan altered to account for changes or
unanticipated circumstances. Utilizing the public
health model may provide a framework and a
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
useful roadmap for all stakeholders in enhancing
IFT. While most of this document’s contents
fall into the assessment category, some major
topics include strategies for policy and assurance
functions.
References
1. e Future of Public Health. (1988). Committee
for the Study of the Future of Public Health.
Division of Health Care Services. Institute of
Medicine. Washington, D.C. National Academy
Press.
Guide for Interfacility Patient Transfer
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National Highway Trac Safety Administration
Major Topic #1: Definitions
For the purpose of this document, the following
denitions were adopted:
Critical Care Transport — e level of transport
care that is provided to patients with an immediate
life-threatening illness or injuries associated with
single or multiple organ system failure. is level
of care requires an expert level of provider knowl-
edge and skills, a setting providing necessary
equipment, and the ability to handle the added
challenge of transport. Critical care transport
requires a high level of medical direction and
sophistication of care because of the patient’s com-
plex medical problems.
EMS System — A consolidated system of essential
components designed to provide a coordinated,
timely and eective response to medical emergen-
cies. A comprehensive EMS system has each of the
elements illustrated in the following diagram:
Facility — Licensed health care entity (e.g.,
hospital, clinic, rehab, nursing home)
Guideline — Something that is to be preferred,
but that does not have the force of a standard.
Providers/services are not held legally responsible
for acting at this level of performance. A sugges-
tion rather than a mandate.
Integrated Regional Health Care System – A
regionally based system that provides its commu-
nity members with seamless, comprehensive health
care, including all who directly provide preven-
tive services, acute care, and rehabilitation, as well
as the components of the health care system that
support their function. Examples of components
providing support may include: insurance carriers,
regulatory agencies, statutory public/government
entities, consumer groups, and professional associ-
ations. In an integrated regional health care system,
the eorts of all stakeholders are coordinated to
ensure the active involvement of all entities in the
process of planning, implementing, evaluating and
problem solving.
Integration – e consolidation and coordination
of separate units into a unied, harmonious whole.
Interfacility Transfer — Any transfer, aer initial
assessment and stabilization, from and to a health
care facility. Examples would include:
n
hospital to hospital;
n
clinic to hospital;
n
hospital to rehabilitation; and
n
hospital to long-term care.
Levels of Patient Acuity – In order to provide
safe and eective care, provider capabilities must
match the patient’s current and potential needs.
It is important to have consistent terminology to
dene the levels of patient acuity. For each level,
examples are provided of the types of needs the
patient might have and the level of care likely to be
required at each level.
n
Stable with no risk for deterioration —
Oxygen, monitoring of vital signs, saline lock,
basic emergency medical care).
n
Stable with low risk of deterioration —
Running IV, some IV medications including
pain medications, pulse oximetry, increased
need for assessment and interpretation skills
(advanced care).
n
Stable with medium risk of deterioration —
3-lead EKG monitoring, basic cardiac
medications, e.g., heparin or nitroglycerine
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
(advanced care +).
n
Stable with high risk of deterioration – Patients
requiring advanced airway but secured, intubat-
ed, on ventilator, patients on multiple vasoactive
medication drips (advanced care +), patients
whose condition has been initially stabilized,
but has likelihood of deterioration, based on
assessment or knowledge of provider regarding
specic illness/injury.
n
Unstable — Any patient who cannot be stabi-
lized at the transferring facility, who is deterio-
rating or likely to deteriorate, such as patients
who require invasive monitoring, balloon pump,
who are post-resuscitation, or who have sus-
tained multiple trauma (critical care or available
crew with time considerations).
Medical Oversight – Medical authority and
responsibility for all medical care provided by
the service, including active day-to-day role in
the function and management of the service as it
relates to patient care activities. ere are several
terms that refer to the activities involved in medi-
cal oversight:
Prospective O-line Indirect E.g., protocol
development
Concurrent On-line/
On-scene
Direct E.g., giving
orders via radio
Retrospective O-line Indirect E.g., quality
management
Outcome Evaluation — Examines the eective-
ness or ecacy of particular interventions on pa-
tient status. An outcome evaluation of IFT assesses
a particular clinical aspect of patient care during
IFT, and its impact on patient outcome.
Process Evaluation — Process evaluation focuses
on the quality of implementation — how well the
process was carried out. It examines operational
and system eciency. It would be dicult to ar-
rive at the conclusion that a specic intervention
caused a specic outcome if the process of achiev-
ing it was not carried out as intended.
Region – A particular area, zone, district, or terri-
tory. For the purpose of developing an IFT plan, a
region could be dened as the one EMS system or
a combination of several EMS systems. A region
can be dened and/or inuenced by numerous
determinants, such as:
n
jurisdictions;
n
geographic locations;
n
service areas of providers;
n
service areas of insurance carriers and
n
referral patterns.
Service Area – e dened response boundaries,
mutually agreed upon contractually and/or as des-
ignated by a regulatory body, to provide IFT within
a single or combination of several EMS systems. A
service area could be a region or part of a region,
and can be dened and/or inuenced by numerous
determinants, such as:
n
jurisdictions;
n
geographic locations;
n
service areas of providers; and
n
service areas of insurance carriers.
Specialty Care Transport (SCT) – As dened
by the Centers for Medicare & Medicaid Services
(CMS) — is IFT of a critically injured or ill ben-
eciary by a ground ambulance vehicle including
the provision of medically necessary supplies and
services, at a level of service beyond the scope of
the EMT-Paramedic. SCT is necessary when a
beneciary’s condition requires ongoing care that
must be furnished by one or more health profes-
sionals in an appropriate specialty area, for exam-
ple, emergency or critical care nursing, emergency
medicine, respiratory care, cardiovascular care, or
a paramedic with additional training.
Standard — Is described as a basis for compari-
son; a reference point against which other
things can be evaluated. Standards set a bench-
mark for subsequent work.
Transfer – e comprehensive infrastructure and
process involved before, during, and aer moving a
patient from one location to another.
Transport – e physical process of moving a
patient from one location to another.
Guide for Interfacility Patient Transfer
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National Highway Trac Safety Administration
Major Topic #2: Meeting Patient Needs
e overriding principle for all aspects of IFT is
matching patient needs with adequate provider
knowledge and skills, equipment and an infra-
structure that provides seamless patient ow dur-
ing transport. Any judgment should err on the side
of caution in providing care at the level likely to be
needed or potentially needed during IFT.
Interfacility transfer requires a unique set of skills
distinct from the training of most hospital-based
or prehospital providers. It is essential that person-
nel used to provide care during interfacility trans-
fer be properly trained, familiar with the demands
of providing care during ground or air transport,
legally authorized to perform these skills, and
prepared to handle the variety of patient contin-
gencies that may arise during transport. Additional
education will be needed to prepare all traditional
providers for interfacility care, whether hospital
or prehospital-based, but the specic focus of this
additional education may vary depending on the
provider’s existing knowledge and skill base.
e discussion about provider education should
start with a review of the questions to be asked:
n
What are the specic needs of the patient?
n
What types of practitioners are working in the
eld?
n
What are the skills and knowledge levels these
practitioners need for IFT?
n
What type of training is required?
n
What type of continuing education is necessary
to assure knowledge and skills?
Since a variety of practitioners could be involved
in interfacility transfer (paramedics, EMTs, nurses,
physicians, respiratory specialists, etc.), attention
should be focused on the knowledge, skills, and
abilities required to match patient needs, as well
as characteristics of eective education and train-
ing. Operational procedures and protocols must
comply with State and local requirements as well as
medical oversight.
Regardless of entry-level knowledge, skills, and
abilities, there are basic transport skills and knowl-
edge that anyone involved in IFT should possess:
Basic Knowledge and Skills:
Any health care professional providing care dur-
ing IFT should demonstrate knowledge and skills
related to:
n
radio and communication technology;
n
transport physiology;
n
safety operations to include the vehicle (ambu-
lance and/or aircra) the patient, equipment,
and all care providers on board;
n
transport equipment;
n
documentation;
n
transport logistics;
n
transfer protocol(s);
n
patient records;
n
physician orders;
n
patient “packaging” for safety and accessibility;
n
medical oversight; and
n
evaluation of level of care needed by patient
during transport.
Providers conducting interfacility transfers for pa-
tients in the “stable with low risk of deterioration”
and “stable with medium risk of deterioration”
should demonstrate knowledge, skills, and demon-
strated abilities that include:
Advanced Knowledge and Skills:
n
basic transport skills;
n
IV insertion, monitoring and maintenance;
including maintenance of central venous and
intraosseous lines;
n
all forms of medication administration;
n
pharmacology at the DOT EMT- Paramedic
National Standard Curriculum level;
n
advanced airway management;
n
ECG monitoring; and
n
debrillation, cardioversion, and transcu-
taneous pacing.
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
Providers involved in interfacility transfer of un-
stable, critically ill, or injured patients should have
the ability to continuously monitor and assess the
patient’s condition and to intervene appropriately.
At a minimum, this would require skill and knowl-
edge in the areas of:
Critical Care Knowledge and Skills:
n
advanced airway management;
n
ventilator management;
n
all forms of medication administration;
n
pharmacology at the DOT EMT- Paramedic
National Standard Curriculum level, plus
advanced knowledge of vasoactive and antiar-
rhythmic drugs; and
n
circulatory management and support.
Specialty Care Transport, as de-
ned by the Centers for Medicare &
Medicaid Services
1
Specialty care transport (SCT) is interfacility trans-
portation of a critically injured or ill beneciary by
a ground ambulance vehicle, including the provi-
sion of medically necessary supplies and services,
at a level of service beyond the scope of the EMT-
Paramedic. SCT is necessary when a beneciary’s
condition requires ongoing care that must be fur-
nished by one or more health professionals in an
appropriate specialty area, for example, emergency
or critical care nursing, emergency medicine, re-
spiratory care, cardiovascular care, or a paramedic
with additional training.
General IFT Provider Education
Guidelines
Existing resources that establish minimum guide-
lines on provider education can be incorporated
into education standards and guidelines. Desirable
characteristics for provider education programs
may include:
n
Training and education that provide the knowl-
edge and skills enabling providers to monitor
and provide necessary care to maintain the
stability of the patients’ condition. is includes
a working knowledge base and critical thinking
ability related to the likely and potential com-
plications associated with specic disease and
injury processes, as well as complications associ-
ated with specic interventions.
n
Sucient clinical and eld experience enabling
providers to deal with varying levels of patient
acuity.
n
Initial and continuing education and training
that is both didactic and hands-on, and of a suf-
cient time period to allow provider to demon-
strate adequate knowledge and skills.
n
Knowledge of assessment and intervention tech-
niques specic to the provision of care required
during IFT.
n
Additional minimum requirements determined
by the specic patient population being trans-
ported by providers.
n
Continuing education requirements based upon
data collected as part of a quality improvement/
management program. Quality improvement
data can include such information as frequency
of specic clinical presentations, low-frequency/
high-criticality interventions, patient outcomes,
and issues related to concurrent and retrospec-
tive quality improvement.
References
1. Program Memorandum Intermediaries/Carriers.
Transmittal AB-02/130. Subject: Denitions
of Ambulance Services. September 27, 2002.
Department of Health & Human Services.
Centers for Medicare and Medicaid Services.
Washington, DC.
Guide for Interfacility Patient Transfer
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National Highway Trac Safety Administration
Major Topic #3: Integration into Existing
Regional Health Care Systems
For the purposes of this document, two types of
integration were dened:
n
horizontal – integration within existing health
care system, and
n
vertical – integration with other/neighboring
health care systems.
Both are desirable in achieving seamless patient
ow during IFT.
Highly specialized health care services (e.g., stroke
centers, cardiac centers, trauma centers, high-risk
obstetrics) may be more expensive than those ser-
vices providing a general level of care. Integration
may also avoid redundancy and promote the most
ecient use of resources. IFT can be an important
means to support integration and regionalization
of health care services.
Considerations for a regional IFT plan include:
n
delineation of legal authority and responsibili-
ties;
n
a denition of integration and a descrip-
tion of a region the stakeholders agree to (see
Denitions, Major Topic #1);
n
what is meant by an integrated regional health
care system – components involved and how
they interoperate;
n
education of personnel in all system compo-
nents;
n
identifying synergies that can result from, and
the overall value of a regional approach to
integration of services;
n
the need for and problems caused by integra-
tion of services across State lines (as it applies to
IFT);
n
benets of open communication among stake-
holders, particularly with third-party payers;
n
the potential impact of regional integration on
competition and service duplication; and
n
transfer agreements and reciprocity of services
and personnel.
To determine the current level of regionalized care
and how IFT can be integrated, several questions
may be helpful:
n
What denes current practice related to region-
alized health care? Factors may include:
o
referral patterns and
o
legal requirements such as contracts,
agreements, memoranda of understanding.
n
What currently triggers IFT? What services
currently exist to ll this need? What needs
continue to exist?
n
What are current practices/processes regarding
decisions related to mode of patient transfer and
patient’s destination facility?
Potential or perceived challenges in develop-
ing a regional plan for IFT:
n
designated IFT providers may be perceived as
curtailing competition;
n
complications caused by interstate IFT system;
n
quantity and quality of personnel needed to
provide service;
n
in a free market system, providers may choose
not to participate, creating gaps in coverage; and
n
unique challenges of providing IFT in urban
areas and rural areas.
Potential or perceived benets of developing
a regional plan for IFT:
n
avoiding duplication of services;
n
leveraging limited resources;
n
maintaining optimal skills, knowledge and
abilities by assuring adequate patient volume;
n
synergy of well-coordinated process may be
applied to other EMS needs, e.g., disaster
management;
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
n
providing optimal care in a timely fashion, and
n
self-determined cooperation and collaboration.
Strategies for overcoming challenges:
n
open and constructive communication among
stakeholders;
n
education and active participation of all stake-
holders including service providers, payers,
administrators and regulators;
n
transfer agreements/partnerships, and
n
reciprocity among states for services and indi-
vidual licensing.
Guide for Interfacility Patient Transfer
11
National Highway Trac Safety Administration
Major Topic # 4: Medical Oversight
e Medical Director
e practice of critical care medicine is dier-
ent from the practice of emergency medicine.
Likewise, emergency medicine is dierent from
EMS, and IFT is dierent from the portion of
EMS providing prehospital care. Each is a distinct
specialty with focused knowledge, skills, and abili-
ties. Trying to nd one medical director to wear
all of these hats may not be easy, and it could take
several physicians working together to provide the
experience and expertise required for comprehen-
sive IFT service.
Physicians in medical specialty usually practice
within hospital walls (e.g., neonatology, thoracic
surgery) and may not be familiar with the opera-
tional aspects of the IFT process. Specialists are
more likely to require additional training to func-
tion eciently in the out-of-hospital environment,
and for them to function in medical direction
capacity. It may be easier for physicians/medical
directors who are familiar with EMS and/or IFT
(e.g., EMS Medical Directors) to assume leadership
of IFT programs. EMS physicians in general are
familiar with what is involved in caring for patients
in out-of-hospital settings.
e ideal IFT Medical Direction might be a cross-
trained physician or through a collaborative work-
ing relationship between two (or more) physicians.
If one physician is designated as medical director
for an IFT program, that physician should func-
tion as medical director for the IFT program using
other specialists as resources, rather than having
several physicians serving as multiple medical di-
rectors. ere should be assurance that the Medical
Direction arrangement is consistent with appli-
cable State laws and regulations.
Guidance for medical directors can also be found
from multiple sources, including:
Air Medical Physician Association
Medical Direction and Medical Control of Air
Medical Services
http://www.ampa.org/component/option,com_doc-
man/task,cat_view/gid,23/Itemid,42/
American College of Emergency Physicians
Interfacility Transportation of the Critical Care
Patient and Its Medical Direction (1999)
http://www.acep.org/webportal/PracticeResources/
PolicyStatements/
National Association of EMS Physicians
Medical Direction of Interfacility
Transports (2000)
Medical Direction for Air Medical Transport
Programs (2002)
Physician Medical Direction in EMS (1997)
(table of contents:)
http://www.naemsp.org/Position%20Papers/
Contents.html
Commission on Accreditation of Medical
Transport Systems
Best Practices: A Collection of Outstanding
Programs and Policies from Accredited
Transport Services
http://www.camts.org
Medical oversight in IFT may take multiple forms:
Prospective O-line Indirect
E.g., protocol
development
Concurrent
On-line/
On-scene
Direct
E.g., giving
direct orders
via radio/
telephone
Retrospective O-line Indirect
E.g., quality
management,
case review
O-Line Medical Direction
O-line medical direction includes those activi-
ties performed by the medical director that do not
occur during actual transport. ese duties are
usually performed before transport (e.g., training,
education, development of protocols) and aer
transport (e.g., chart review, case review, continu
-
ing or remedial education, quality improvement).
e medical director is ultimately responsible for
the care provided by the IFT service and should
be involved in all aspects of IFT that have a direct,
potential impact on patient care.
Role of Standardized IFT and
Destination Protocols
National Highway Trac Safety Administration
12
Guide for Interfacility Patient Transfer
Written orders from the transferring facility may
suce for the stable patient during most transfers,
but on-line medical direction should be available at
all times, in case unforeseen situations arise during
transport. O-line protocols can be developed as
a basis for care during transport, but complexity
of care for many patients seems to suggest that
they may be of limited usefulness. A standard
order sheet shared system-wide that can be indi-
vidualized by the transferring physician may be
more useful. Advance development of this form in
conjunction with referring and/or accepting physi-
cians may further facilitate the IFT process.
Unlike prehospital EMS, which may dictate that a
patient be taken to the closest or most appropri-
ate facility, IFT is a physician order to transport
a patient from one specic location to another.
erefore, destination protocols are of very limited
utility unless they address the event of a rapid de-
terioration of patient condition requiring transport
to the nearest appropriate facility.
Consultation with Specialty Care
e medical director is ultimately responsible for
the care provided by the IFT service. erefore,
it behooves the medical director to have access to
specialists and consultants who are available for
real-time (on-line medical direction) problem
solving, and for protocol development, case review
and post-transport consultation. It may be in the
patient’s best interest, and extremely helpful to
both crew and medical director, to seek the opin-
ions of those with extensive experience and ex-
pertise in medical specialties. One possible model
includes a single medical director who receives
input and assistance from other medical special-
ists (i.e., neonates, pediatrics, intra-aortic balloon
pump, etc.) in draing protocols, education, and
case review for IFT.
On-Line Medical Direction
On-line medical direction includes those activi-
ties performed by the medical director that occur
real time, during actual transport. On-line medical
direction should be available at all times, in case
unforeseen situations arise during transport.
Medical oversight and interfacility
transfers: which medical director
is liable for what part of inter-
facility transfer
Medical oversight is variable and depends on
State and local regulations. As per the Emergency
Medical Treatment and Labor Act (EMTALA), the
referring physician is responsible for the patient
being transferred from one facility to another, until
the patient arrives at the receiving facility. On-line
medical direction may be provided by the referring
physician, the accepting physician, the transfer-
ring agency medical director, the medical director’s
proxy for specialty care issues, or some combina-
tion of the above. is oen is determined by the
State and local regulations, and may dier between
jurisdictions. For example, in some jurisdictions,
if the transport vehicle is owned by the receiving
facility that liability begins when the crew assumes
care of the patient.
While on-line medical direction may be provided
by the referring physician, the accepting physician,
the transporting agency medical director, the med-
ical director’s proxy for specialty care issues, it is
essential that the roles of each are determined prior
to transport and while the IFT system is devel-
oped. It may require a contract, a memorandum of
understanding, or other legal documents between
the agencies or jurisdictions. Whatever the case, it
needs to be clearly dened in advance of transfer
and not decided while transport takes place.
To anticipate possible situations where there may
be confusion or dierence of opinion regarding the
bounds of responsibility and liability, IFT services
should develop and adopt protocols for how crew
members and the medical director will handle such
situations. is protocol should include provisions
to assure medical director responsibility is resolved
prior to patient transport. Advance knowledge of
this protocol by all stakeholders may be helpful in
proactively addressing potential situations con-
cerning medical oversight.
Guide for Interfacility Patient Transfer
13
National Highway Trac Safety Administration
Major Topic #5: Liability
Optimally, decisions regarding system or service
protocols and procedures, scope of practice of
transport personnel, interagency and inter-juris-
dictional agreements regarding transfer should be
made prior to the need for interfacility transfer.
e extent to which this is accomplished will make
decisions easier and the IFT process more ecient.
Potential liability has a major impact in making
these decisions, and it behooves all stakeholders
to have a strong working knowledge of the issue.
Laws addressing liability and their interpretation
vary widely from state to state. Specic informa-
tion within this document may therefore be of
limited use. It behooves those involved in IFT to
become familiar with State laws and court deci-
sions impacting liability in the jurisdiction(s) to
be served by the IFT service. is major topic
contains general information for consideration,
including: denitions, delineations of liability for
health care providers, regulations that aect liabil-
ity, and practice guidelines.
Denition of Liability
Liability is generally dened as legal responsibility
for one’s acts or omissions. ere are two forms:
n
Direct Liability - Liability imposed directly on
a person because of his or her own negligence,
default, or legal undertaking.
n
Indirect Liability - Liability that arises from
a legal obligation owed to an injured party to
pay damages for another’s failure to perform or
negligent act.
Liability of Each Health Care
Professional
Every health care professional has a legal duty to ex-
ercise that degree of knowledge, care, and skill that
is expected of a comparably trained practitioner in
the same class in which he or she belongs, acting
in the same or similar circumstances. e standard
of care is based on laws, administrative orders,
regulations, and guidelines established by entities or
individuals with the legal authority to do so.
Liability of Direct Care Providers
Each program, hospital, or service employing
health care professionals to provide direct care
for patients during IFT is responsible for ensur-
ing that policies, procedures, and protocols are
in place for the care provided by the transport
team. ese documents should be consistent with
laws, regulations, and administrative rules for the
jurisdiction(s) in which IFT occurs. e IFT ser-
vice should also maintain written policies address-
ing appropriate licensure and scope of practice for
each team member, based upon the local, regional,
and/or State laws and/or regulations in the geo-
graphical area(s) in which the team provides care
and performs transports.
e IFT transfer service/program is responsible for
the care rendered during transport. e program
should establish written policies/protocols for all
procedures, skills, or care the transport team mem-
bers provide. Written documentation of educa
-
tion, skills, training, demonstrated abilities, initial
and/or ongoing education, should be maintained,
and all transport personnel should be familiar with
program requirements. In addition, the transfer
service should establish an ongoing program for
quality assurance/quality management, which uses
patient and referring facility/physician satisfac-
tion surveys, chart reviews, case reviews, and peer
reviews to identify problems or areas needing
improvement as well as areas of strength that could
serve as models for other IFT services.
e individual caregivers are responsible for the
direct care they provide to the patient during
transport. It is imperative that these personnel be
familiar with the appropriate State practice acts
(e.g., Medical Practice Act, Nurse Practice Act,
EMS Act), licensing and/or certication regula-
tions, and the limitations and responsibilities of
their specic profession’s scope of practice. It is the
obligation of each licensed and/or certied profes-
sional to know and understand the standard to
National Highway Trac Safety Administration
14
Guide for Interfacility Patient Transfer
which he or she will be held. Individuals providing
direct care to the patient should not be pressured
into functioning beyond their intended role, and
must always function within the scope of practice
for which they are prepared, trained, and legally
authorized. Procedures should be in place that pro-
viders can use to handle situations placing them
in questionable situations. Direct care providers
may or may not choose to carry individual profes-
sional malpractice insurance in addition to what is
provided by their employers.
Liability of Medical Directors
Medical practice acts vary from State to State as
do statutes related to functions that may be per-
formed under a physician’s license. It is particularly
important for the prehospital professional who
functions under medical direction to understand
the purpose of the law in their jurisdiction(s), and
to be familiar with their State’s Medical Practice
Act, particularly as it pertains to liability and legal
responsibilities.
Obtaining Liability Insurance
Physicians and other medical professionals pay
insurance premiums to cover payments for awards
resulting from lawsuits. ey may need liability
insurance to practice medicine; in most cases hos-
pitals, physician groups, as well as many State laws
require it. e cost of medical liability coverage
varies by specialty and location. Physician special-
ists practicing emergency medicine, neurosurgery,
orthopedics, obstetrics, and gynecology oen have
the highest premiums, because they perform pro-
cedures that have more risks of complications or
because their patients have more serious illnesses
or injuries.
e medical liability crisis is reported to have
posed serious challenges to those physicians pro-
viding medical oversight, including those involved
with IFT. For more extensive information, refer to
Appendix D: Obtaining Liability Insurance.
Regulations that Aect Liability
EMTALA
Emergency Medical Treatment and
Labor Act
1
e Emergency Medical Treatment and Labor
Act is a Federal law enacted by Congress in 1986
as part of the Consolidated Omnibus Budget
Reconciliation Act (COBRA) of 1985 (42 U.S.C.
§1395dd). Referred to as the “anti-dumping” law,
it was designed to prevent hospitals from refusing
to treat patients or transferring them to charity
or county hospitals because they were unable to
pay or had Medicaid coverage. EMTALA requires
hospitals with emergency departments to provide
emergency medical care to everyone who needs
it, regardless of ability to pay or insurance status.
Under the law, patients with similar medical condi-
tions must be treated consistently. e law applies
to hospitals that accept Medicare reimbursement,
and to all their patients, not just those covered by
Medicare. For more information, refer to Appendix
E: EMTALA.
Certicate of Transfer
2
Certication of necessity for transfer is a re-
quirement for reimbursement by the Centers for
Medicare and Medicaid Services. e CMS deni-
tion of medical necessity is as follows:
Medical necessity is established when the patient’s
condition is such that use of any other method of
transportation is contraindicated. In any case, in
which some means of transportation other than
an ambulance could be used without endangering
the individual’s health, whether or not such other
transportation is actually available, no payment
may be made for ambulance service
It is possible (but not likely) that a patient may
require transfer and not meet the CMS denition
of medical necessity. For more information, refer
to Appendix F: Certicate of Transfer.
Guide for Interfacility Patient Transfer
15
National Highway Trac Safety Administration
HIPAA
Health Insurance Portability and
Accountability Act (HIPAA)
3
e Health Insurance Portability and
Accountability Act of 1996 is a law enacted to
combat fraud, waste, and abuse in health insurance
and the delivery of healthcare services; to improve
access to long-term care services and coverage, and
simplify the administration of health insurance.
e program sets standards for the use and disclo-
sure of protected health information along with
measures to ensure the secure transmission and
storage of medical records and other individually
identiable or demographic information. e regu
-
lations protect medical records and other individu-
ally identiable health information, whether it is
on paper, in computers or communicated orally.
HIPAA regulations have implications for all IFT
services transporting and transferring medical
records or medical information from one facility to
another. For more information on HIPAA, refer to
Appendix G: HIPAA.
Federal, State, and Interstate
Regulations
IFT providers are well advised to become familiar
with any Federal, State, or interstate regulations
that may have an impact on IFT service, as well as
their relative jurisdictions. While it is not possible
to include an exhaustive listing of these regula-
tions, examples may provide illustration of the
potential impact of regulations on IFT.
Example #1 – Federal Aviation
Administration (FAA)
e FAA strictly governs the operations of air-
cra in the United States under Title 14 of the
Federal Code of Regulations. ere are two Federal
Aviation Regulations (FAR) that are applicable
to air medical transport, FAR Part 91
4
and FAR
Part 135
5
. FAR Part 91 addresses the “General
Operating Flight Rules” and FAR Part 135 deals
with “Commuter and On-Demand Operations and
Rules Governing Persons on Board Such Aircra.”
Air medical transport programs are most com-
monly operating under Part 135. All commuter
and on demand aircra transporting passengers
are required to comply with all Federal Aviation
Regulations contained in Part 135.
Example #2 — State Regulation
EMS services usually derive their authority from
State laws or regulations. ese may include laws
that allow the provision of emergency care. ese
statutes dene scope of practice and frequently ad-
dress protocols, communication, and medical over-
sight. ere is great variation from State to State in
these laws and regulations. Some grant licensure
while others do not. It is important to be familiar
with the State laws and regulations as they pertain
to the practice of IFT within the jurisdiction(s)
where IFT services are provided.
In some cases and for certain circumstances, Fed-
eral agencies may have jurisdiction (e.g., EMTALA,
HIPAA, Federal Aviation Administration
regulations on aircra used as air ambulances).
Specic roles and responsibilities in interfacility
transfers will vary from State to State; it is impor-
tant to understand these responsibilities. In some
localities, the functions of IFT providers and/or
services are enabled by a specic law or regulation.
Example #3 — Interstate Issues
Because some geographic areas do not have rea-
sonable access to comprehensive or specialty ser-
vices within their own state, referral patterns may
exist that cross State lines. is situation makes it
necessary to consider issues of interstate coordi-
nation and cooperation. Interstate issues can also
arise for metropolitan areas that serve more than
one State. In some cases, interested parties can
develop ocial agreements under the auspices of
State or local government agencies. In other cases,
contractual or informal relationships develop
between referral centers and community hospitals
and EMS systems.
National Highway Trac Safety Administration
16
Guide for Interfacility Patient Transfer
e stability of both ocial and informal arrange-
ments depends on meeting the needs of all the
groups involved and on addressing key issues, such
as coordination of professional, legal, and regulato-
ry requirements. Neighboring States oen dier in
such matters as certication and licensing require-
ments for institutions and practitioners, scopes
of practice and guidelines for transfer. Interstate
transfer agreements can address some of these
dierences to ensure that consistent and accept-
able levels of care are rendered and that providers
do not face liability risks related to dierences in
practice standards.
Practice Guidelines
Various terms are used to outline the expectations
of performance within the EMS community. e
terms “standards” and “guidelines” are frequently
and erroneously used interchangeably.
e Health Improvement Institute provides a
generic denition for these similar terms.
6
A
standard (or protocol) is described as “a basis for
comparison; a reference point against which other
things can be evaluated; ‘they set the measure for
all subsequent work.’” A guideline is explained as
“something that is to be preferred, but that does
not have the force of a standard.” EMS standards
and guidelines can be written to reect a course of
action for clinical as well as operational/manage-
ment needs. For the purposes of this discussion,
standards create an expectation while guidelines
are generally thought to be a bit more exible.
e Institute of Medicine (IOM) denes clinical
practice guidelines as “systematically developed
statements to assist practitioner and patient
decisions about appropriate health care for specic
clinical circumstances.”
7
Frequently promulgated
by relevant professional organizations, societies,
health care organizations, or government agencies,
standards and guidelines are generally developed
using veriable, systematic literature searches
and reviews of existing evidence published in
peer-reviewed journals to establish best practice
recommendations.
Perceived advantages of establishing clinical prac-
tice guidelines for IFT include:
n
evidence-based reference for provider practice;
n
direct linkage with improvement in patient
clinical condition and outcome;
n
direct linkage with reduced risk of morbidity
and mortality;
n
established benchmark for measuring perfor-
mance;
n
direct linkage with enhanced patient safety;
n
comparison between agencies easier using simi-
lar guidelines;
n
provides public and referring physicians/facili-
ties a clearer understanding of the capabilities of
any one IFT provider and
n
gives provider a clear understanding of expecta-
tions and responsibilities.
Perceived disadvantages of establishing clinical
practice guidelines for IFT include:
n
use by the legal community to argue a breach
in the standard of care when litigation ensues
following a negative outcome (whether or not
medical negligence actually exists);
n
dicult and resource-intensive to develop and
maintain;
n
minimal exibility for individual preferences,
agency capabilities, changes in patient condi-
tion;
n
dicult to establish for patients with multiple,
complex diagnoses;
n
balance between optimal clarity and minimal
liability dicult to establish; may be too vague
to be useful or too narrow to be legally “safe”;
n
might force IFT provider to meet unrealistic
expectations regarding equipment, education,
and maintenance of skills and
n
guidelines do not have the force and eect of
the law.
Guide for Interfacility Patient Transfer
17
National Highway Trac Safety Administration
References
1. Emergency Medical Treatment and Labor
Act. State Operations Manual. Appendix V
– Interpretive Guidelines – Responsibilities of
Participating Hospitals in Emergency Cases.
(Rev. 1, 05-21-04). Department of Health &
Human Services. Centers for Medicare and
Medicaid Services. Washington, DC.
2. Certicate of Transfer.
Federal Register, June
22, 1994 (59FR32086). Department of Health
& Human Services. Centers for Medicare and
Medicaid Services. Washington, DC.
3. Health Insurance Portability and Accountability
Act. http://www.cms.hhs.gov/hipaa/.
Department of Health & Human Services.
Centers for Medicare and Medicaid Services.
Washington, DC.
4. Code of Federal Regulations, Part 91. General
Operating and Flight Rules.
http://ecfr.gpoaccess.
gov/cgi/t/text/text-idx?c=ecfr&sid=c3a8e0947420
81e734f4dafc1496bf36&tpl=/ecfrbrowse/Title14/
14cfr91_main_02.tpl. U.S. Government Printing
Oce. Washington, D.C.
5. Code of Federal Regulations, Part 135.
Operating Requirements: Commuter and On
Demand Operations and Rules Governing
Persons On Board Such Aircra. http://ecfr.
gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=c
3a8e094742081e734f4dafc1496bf36&tpl=/ec-
frbrowse/Title14/14cfr135_main_02.tpl. U.S.
Government Printing Oce. Washington, D.C.
6. Clinical Practice Guidelines: Directions for a
New Program, (1990), M.J. Field and K.N. Lohr
(editors) Washington, DC: National Academy
Press. Page 38.
7. Health Improvement Institute Quality Award.
Standards. Denitions and Abbreviations.
Health Improvement Institute. http://www.hii.
org/index.html
National Highway Trac Safety Administration
18
Guide for Interfacility Patient Transfer
Major Topic #6: Operations
e overriding principle for all aspects of
IFT is matching patient needs with adequate
provider knowledge and skills, equipment and
an infrastructure that provides seamless patient
ow during transport. Any judgment should err
on the side of caution in providing care at the
level likely to be needed or potentially needed
during IFT. Major Topics 2 and 4 address multiple
considerations in providing optimal patient care.
In addition to these, the operational aspects of IFT
should be closely managed, to facilitate seamless
patient ow during transport. Operations can
include crew selection, stang levels, the vehicle,
equipment, communications, and standard
operating procedures.
Crew Selection
Interfacility transfer requires a unique set of skills
that is distinct from the training of most hospi-
tal-based or prehospital providers. To provide
adequately for patient needs during IFT, selection
of the transport personnel/crew should include
a team capable of providing the level of care the
patient’s present condition requires; the likely and
the potential needs of the patient throughout the
transport. In many jurisdictions, prehospital and
hospital health care professionals are legally autho-
rized to perform tasks within a specic scope of
practice, which may or may not match the clinical
needs of the patient or the needs presented by the
operational IFT environment.
In IFT program development, it is advisable to
determine the knowledge, skills, and abilities
necessary for the IFT patient population. Under
the medical director’s guidance, recurring refer-
ral patterns, patient populations, and frequently
used modes of transportation should be assessed
to determine necessary qualications and training.
e need for specialty care transports (i.e., neona-
tal, intra-aortic balloon pump) should be analyzed
to make decisions on how to match patient needs
with provider knowledge, skills, and abilities.
It is essential that personnel utilized to provide care
during interfacility transfers be properly trained,
familiar with the unique demands of providing
care during ground or air transport, legally autho-
rized to perform the skills, and prepared to handle
the variety of patient contingencies. Multiple pro-
viders may be qualied to accompany the patient
depending on their education, skill level, and legal
authority. Additional education, under the guid-
ance of the Medical Director, will be needed to
prepare all traditional providers for interfacility
patient care, whether hospital or prehospital-based,
but the specic focus of this additional educa-
tion may vary depending on the provider’s exist-
ing knowledge base. Medical directors should be
involved in training, education, and evaluation of
crew knowledge, skills, and abilities, at each level of
care, on an ongoing basis.
e crew should be educated and trained to care
for the anticipated patient population using antici-
pated transport mode(s). Training can be provided
by the transport agency or other legally recognized
entity, but the medical director and transport agen-
cy should approve the level of education and train-
ing provided. Providers can also receive special-
ized education and training in specic areas (e.g.,
neonatal, cardiac, etc) appropriate for the patient
population(s) being transported. ere may also be
a need for the use of other healthcare professionals
(e.g., respiratory therapists) during transport. e
crew must be able to provide quality care within
their scope of practice including the use of trans-
port equipment in the transport environment.
Minimum requirements for sta
qualications
Minimum requirements can be exible without
compromising care. For extensive information
on suggestions for provider skills and knowledge,
refer to Major Topic #2, Provider Education, which
includes suggested knowledge, skills, and abilities
related to IFT.
Guide for Interfacility Patient Transfer
19
National Highway Trac Safety Administration
Stang Levels
e number and right combination of personnel
should be addressed in developing an IFT pro-
gram. Stang decisions should be determined by
clinical patient care needs and operational require-
ments. Recurring referral patterns, patient popula
-
tions, and frequently used modes of transportation
should be assessed to determine necessary quali-
cations and training. e highest potential acuity
level of the transported patient and the ability of
the sta to respond appropriately in the transport
environment should be a determinant of crew
composition.
Many transfer services use the team concept in
developing and deploying IFT. Predetermined
stang patterns with specic qualications can
be developed to match patient need and deployed
when patient need is identied. Determination
of the appropriate team composition can include
consideration of the following:
n
the availability of critical care and/or specialty
care transport teams within a reasonable
proximity;
n
the modes of transportation and/or transport
personnel available as options in the particular
geographic area;
n
specic circumstances associated with the
particular transport situation (e.g. inclement
weather, major media event, etc.);
n
anticipated response time of the most
appropriate team and/or personnel;
n
established State, local, and individual transfer
service standards/requirements;
n
combined level of expertise and specic duties/
responsibilities of the individual transporting
team members;
n
degree of supervision required by and available
to the transporting team members;
n
complexity of the patient’s condition;
n
anticipated degree of progression of the patient’s
illness/injury prior to and during transport;
n
technology and/or special equipment to be used
during transport; and
n
scope-of-practice of the various team members.
e transport team leader should possess appro-
priate clinical experience and expertise, as well as
the leadership skills necessary to direct the provi-
sion of patient care in the IFT environment. Unless
a physician is included as one of the transport team
members, a physician designated to provide medi-
cal direction should be available for consultation.
An acceptable exception to this requirement may
exist in those circumstances when, under supervi-
sion of the designated medical oversight physician,
the transport team follows established written poli-
cies, protocols, and procedures.
Filling Stang Needs
Although there may be variation in the minimum
requirements and core knowledge, skills, and abili-
ties that the members of the IFT team are required
to possess, their combined expertise should pro-
vide for accurate patient assessment, formulation
of an eective plan of care, implementation of ap-
propriate interventions for the actual and potential
patient problems that may be encountered, and
evaluation of the patient’s response to the care pro-
vided. Education and training specically related
to the characteristics and dierences of delivering
patient care in the transport environment must be
provided prior to any performance of independent
transport care activities by any member of the
transport team.
e content and extent of required training will
be dependent upon the job description and/or the
specic set of duties for which the individual team
member will be responsible. Qualied people may
be hired or training provided for existing sta.
Decisions favoring one approach over the other
involve the availability of qualied sta, possible
pay dierentials based on knowledge and skills,
providing training to existing sta, and the cost-
eectiveness of comparable models.
National Highway Trac Safety Administration
20
Guide for Interfacility Patient Transfer
e Vehicle
Vehicle selection should be driven by the IFT
mission prole. State licensing requirements
should be met, and the vehicle should be able to
accommodate the necessary equipment. Vehicle
selection should provide enough room for the
patient, caregivers, and potential additional
equipment and/or providers. As with any
transport, all safety standards should be met.
Redundant power, electrical, communication, and
lighting systems should be provided.
Equipment
As with crew vehicle selection, determination
of equipment should be based upon patient and
operational needs. Equipment should comply
with all minimum statutory and regulatory
requirements, and provide for accurate patient
assessment, implementation of appropriate
interventions for the actual and potential patient
problems that may be encountered, and evaluation
of the patient’s response to the care provided.
Equipment should also provide all necessary
functions to operate safely and accurately within
the transport environment. Equipment lists
are available from multiple sources. For more
information, refer to Appendix B: References &
Resources, References of General Interest.
Communication/Linkages Needed
Communication is essential for the safety of the
crew and the optimal care of the patient. e crew
must be able to communicate with the dispatch/
communication center, the receiving facility, the
local public safety providers — EMS, re and
police, and on-line medical direction.
Communication and data linkage should be
available throughout transport. A redundant
system should be in place in case the primary
communication system fails.
Administrative Protocols/Standard
Operating Procedures
A comprehensive IFT service requires
administrative protocols to provide seamless
patient ow during transport and to deal with
challenges IFT may pose. Standard operating
procedures are recommended to address such
issues as mutual aid, communications, weather,
and equipment maintenance and failure. More
information on standard operating procedures
can be found by referring to the Commission
on Accreditation of Ambulance Services
(CAAS). Both CAAS and the Commission on
Accreditation of Medical Transport Systems oer
helpful information as well as the opportunity for
accreditation, which may have practical benets for
IFT services. e CAAS Web site can be accessed
at: www.caas.org and the CAMTS Web site can be
accessed at: www.camts.org.
Guide for Interfacility Patient Transfer
21
National Highway Trac Safety Administration
Major Topic #7: Financial Considerations
Meeting the cost of IFT involves a thorough un-
derstanding of incurred expenses as well as mecha-
nisms for reimbursement. While most payers make
payment for services and equipment provided,
identication of alternative funding sources may
be necessary to cover the cost of providing “pre-
paredness” (the day-to-day xed and operating
costs of IFT service). is may require creativity
and collective thinking on the part of IFT stake-
holders. A careful, comprehensive assessment of
costs can be useful in meeting the nancial needs
for an ongoing IFT service.
Costs are incurred by an IFT service to assure a
constant state of readiness, even if no patients are
transported. IFT service assumes additional costs
every time a patient is transported. e following
is a list of considerations in determining xed and
other operating costs, and how these costs increase
once patient care is initiated.
Fixed costs/readiness/surge capacity
n
Labor — for those providers who are not
volunteer.
n
Equipment, medications, and supplies.
n
Vehicle maintenance.
n
Overhead for facility housing transport mode
and/or administration.
Other operating costs
n
Marketing – customer/hospital/facility educa-
tion regarding the availability and capabilities of
the IFT transfer services.
n
Billing.
n
Legal and accounting.
n
Educational and continuing education costs.
n
Licensure for providers.
n
Administrative personnel.
n
Field personnel --some services deal with this
cost by using personnel on an independent con-
tractor basis (to avoid this xed cost).
n
On-call pay.
n
Dispatch center functions.
n
Insurance.
n
Quality Improvement.
n
Infrastructure costs – additional costs related
to function as part of an EMS system, e.g.,
communication.
Adding the cost of patient care
ese costs include expenditures related to provid-
ing basic care to stable patients with very little or
no risk for deterioration; and additional variable
costs of fuel, supplies, equipment, and personnel.
Adding the cost of critical care
ese costs include expenditures related to pro-
viding advanced care to all patients whose acuity
surpasses that of stable patients and additional
variable costs of fuel, additional supplies, equip-
ment, and personnel to provide the required level
of care.
Supply and demand — “back-up”
capacity
Represents replacement (back-up/on call) crew,
equipment and other infrastructure costs when the
primary unit/ambulance is providing IFT services
and/or payment for additional or higher-level
medical personnel if needed, to assist in the trans-
port. For the purposes of this document, discus
-
sion of back-up capacity is limited to the day-to-
day capacity of any one IFT program to meet the
demand for its services. e discussion will
not
include the capacity to handle an epidemic illness
or injury, natural disaster, intentional acts of mass
injury, otherwise known as “surge capacity.”
Denition of level of service
1
(as dened by CMS, for service
provided)
It is important for IFT services to understand how
payers such as CMS dene levels of service
n
Basic Life Support (BLS) – where medically
necessary, the provision of basic life support ser-
vices as dened in the National EMS Education
and Practice Blueprint for the EMT-Basic
including the establishment of a peripheral
intravenous line
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
n
Advanced Life Support, Level 1 (ALS1) – where
medically necessary, the provision of an assess-
ment by an advance life support provider and/or
the provision of one or more ALS interven-
tions. An ALS provider is dened as a provider
trained to the level of the EMT-Intermediate
or Paramedic as dened in the National EMS
Education and Practice Blueprint. An ALS
intervention is dened as a procedure beyond
the scope of an EMT-Basic as dened in the
National EMS Education and Practice Blueprint.
n
Advance Life Support, Level 2 (ALS2) – where
medically necessary, the administration of at
least three dierent medications and/or the
provision of one or more of the following ALS
procedures: manual debrillation/cardioversion,
endotracheal intubation, central venous line,
cardiac pacing, chest decompression, surgical
airway, intraosseous line.
n
Specialty Care Transport (as dened by the
Centers for Medicare & Medicaid Services)
— SCT is interfacility transportation of a criti-
cally injured or ill beneciary by an ambulance,
including the provision of medically neces-
sary supplies and services, at a level of service
beyond the scope of the EMT-Paramedic. SCT
is necessary when a beneciary’s condition
requires ongoing care that must be furnished by
one or more health professionals in an appropri-
ate specialty area, for example, emergency or
critical care nursing, emergency medicine, respi-
ratory care, cardiovascular care, or a paramedic
with additional training.
n
Emergency – Emergency response is a BLS or
ALS1 level of service provided in immediate re-
sponse to a 9-1-1 call or the equivalent. e im-
mediate response is one in which the ambulance
provider/supplier begins as quickly as possible
to take steps necessary to respond to the call.
Business Plan
It may be helpful for IFT stakeholders to write a
business plan to develop strategies to meet the -
nancial needs of the IFT service. Writing a business
plan will provide essential information as well as
a tool to track, monitor, and evaluate the nancial
status of an IFT service. ere are many forms of
business plans, but most have three purposes: com-
munication, management, and planning. A com-
prehensive plan can be used to establish timelines
and milestones, gauge progress and compare your
projections to actual accomplishments, and it is a
living document to be modied as nancial con-
siderations evolve and change. For more specics
on writing a business plan, refer to Appendix C.
Considerations
When developing and deploying a business plan,
it is wise to consider circumstances specic to
your service, community, and situation. ese may
include:
Urban Services and Rural Services
Urban
n
While urban areas are assumed to have shorter
transport times, transport times and costs can
be increased by urban trac congestion and
diversion of ambulance patients by overcrowded
EDs and hospitals.
Rural
Many of the problems of an urban service can be
magnied in a rural service. Even including the
Rural Adjustment Factor (RAF), which is dened
by CMS as an adjustment rate applied to the pay-
ment amount for ambulance services when the
point of pick-up is in a rural area, rural services
may face additional nancial challenges:
n
Rural services may have diculty nding
trained and experienced personnel. Recruiting
can be dicult for rural services. Pay dieren-
tials may contribute to the diculty in recruit-
ing.
n
Training costs may include the additional cost of
travel, as personnel oen need to travel, either
to provide or receive necessary training.
Guide for Interfacility Patient Transfer
23
National Highway Trac Safety Administration
n
For IFT, the mileage and hourly expenses may
be magnied because transport is generally
over longer distances. e transporting service
must pay for fuel, wear and tear on the vehicle,
and the time of the personnel. Longer transport
times also mean that the personnel must be pre-
pared for more contingencies with the patient,
increasing the cost of readiness. is includes
the cost of such things as a larger quantity and
bigger selection of drugs and equipment.
n
Shipping, fuel, and maintenance cost more in a
rural environment. It is more dicult to get any
material into the area, and that usually translates
into higher prices.
n
Rural services may be low-volume, and not be
able to recoup xed costs as easily as busier
services.
Regional Planning
n
Regional planning for reimbursement models
can be key in minimizing cost. While reducing
competition, regional planning can also reduce
redundancy and resultant increase in expense.
n
Trying to insure coverage by linking services
within a designated locality can be facilitated by
the linkage of the appropriate reimbursement
plans.
Integrating CMS reimbursement rules with
third-party payers
EMS oces can involve both public- and private-
party payers in the IFT planning process. Medicare
patients make up a signicant portion of all
ambulance patients; therefore Medicare rules set
the standard for many payers and Medicare rules
should be reviewed in the IFT planning process.
For optimal simplicity and consistency, there
should be agreement among all payers, on deni-
tions and standards for medical necessity, service
levels, practitioner level denition, covered ser-
vices and other necessary elements of IFT.
Education and active participation
of stakeholders
In the IFT planning process, stakeholders can edu-
cate third-party payers about what the IFT system
includes and can involve them in the discussion
of providing IFT services. At a minimum, such
education includes:
n
the dierence among various payment levels;
n
the discrepancy between the cost of providing
preparedness versus fee for specic services
provided;
n
the dierence between subsidized versus non-
subsidized services and their impact on IFT
services; and
n
the dierence between volunteer versus paid (or
mixed) services — since xed personnel costs
would be dierent.
Signicant nancial gaps may be identied,
requiring creativity on the part of all stakeholders
to provide support for IFT. Billing of third-party
payers is only one strategy for revenue. Other
unconventional ideas may be useful in meeting
the costs of IFT:
n
in-kind support, such as contribution of equip-
ment and/or services (if allowed);
n
transition to an overall model of reimburse-
ment for IFT through hospitals and/or physi-
cians. Adopting this model may provide the IFT
program with a broader range of reimbursable
services than those included in transport reim-
bursement models.
References
1. Centers for Medicare and Medicaid Services.
Medicare Benet Policy Manual. Pub. 100-02.
Chapter 10. Ambulance Services.
http://www.cms.hhs.gov/center/ambulance.asp
National Highway Trac Safety Administration
24
Guide for Interfacility Patient Transfer
Major Topic #8: Policy Development
Policy development and planning includes
strategies to:
n
inform, educate, and empower people about IFT
issues;
n
mobilize State and community partnerships to
identify and solve IFT problems; and
n
develop policies and plans that support State
and community IFT eorts.
In many communities there is no entity with
authority or responsibility for management of
IFT issues. In some States/communities, formal
agreement among the stakeholders may be
sucient to implement IFT strategies. Frequently,
however, legislation and regulation are necessary.
Whether derived from government authority or
established through formal stakeholder agreement,
it is important the IFT policies, procedures,
authorities and responsibilities be articulated
carefully and communicated to all stakeholders.
Legislation, adopted by a governing body (e.g.
State legislature, county council), usually estab-
lishes which government entity is responsible
for management of IFT, delineates that agency’s
authority and responsibility and establishes other
IFT parameters potentially including the need for a
license. Frequently, the government agency, such
as a state or county health department or State
EMS Agency, is authorized to promulgate rules/
regulations that may establish IFT licensure
requirements including, for instance, personnel
education and certication, safety, reporting pro-
cedures, medical direction and license suspension
or revocation. Sometimes, these detailed require-
ments are determined by the governing body and
are included in the legislation. In some States, IFT
regulation authority may be contained in the State
EMS agency’s authorizing legislation.
A systematic process is recommended to assess
the current status of and potential need for IFT
legislation and regulation including nding the
answers to the following questions:
n
What local, State or Federal laws and regulations
directly impact IFTs in your community?
n
What agency has the authority and
responsibility for implementing and enforcing
these laws and regulations?
n
What processes does the agency use to develop
and to enforce regulations? How can you impact
regulation development or modication?
n
Do jurisdictions’ regulations compliment each
other or do they conict?
n
What gaps or issues can you identify in the
legislation or regulations?
n
Is there model legislation that may be helpful in
this analysis?
n
Do other jurisdictions have comparable
legislation that could provide comparison?
In evaluating the adequacy of existing agreements,
laws, regulations or policies, the following
considerations may be important:
n
denition of levels of patient acuity to assist
in determining appropriate personnel to use
during the IFT;
n
standards of care;
n
minimum requirements for education and
training of IFT personnel;
n
inter-jurisdictional transfer issues;
n
requirement for data collection or utilization of
data for performance improvement;
n
authority to enforce regulations.
Persons interested in developing legislation or
regulations for IFT should become familiar with
their jurisdiction’s system. For instance, visiting
Guide for Interfacility Patient Transfer
25
National Highway Trac Safety Administration
with and involving State EMS Agency sta may
be essential to improving IFT policy development
and implementation. e State EMS Agency can
usually provide good information on the status of
Legislation may be enabling. In June 2005,
New Hampshire law was amended to
enable alternative health care to participate
in interfacility transfer if the availability of
conventional providers exceeds 30 minutes,
enhancing the ability of New Hampshire
health care facilities to provide expedient
transfer to patients requiring such service
(S.B. 88). is law made it possible to use
multiple IFT strategies without requiring
any specic mode or crew composition.
IFT legislation, regulation and legal decisions.
Understanding of the State’s regulatory process
and gaining support for authorizing legislation or
regulations can reduce misunderstandings and
conict. For instance, many State EMS oces
have an advisory council that provides advice
on regulatory and EMS system issues. It may be
important to have an individual experienced and
interested in IFT issues attend the meetings and
provide information on IFT issues. An ad hoc
group can be formed to make recommendations
for advisory council consideration.
Educating and involving third party payers may
also be a key activity to improving your IFT
system.
To obtain more information on statutes and ad-
ministrative rules and how they aect EMS in your
State, contact the State EMS oce. A listing can be
found at www.nasemsd.org, the Web site for the
National Association for State EMS Ocials.
National Highway Trac Safety Administration
26
Guide for Interfacility Patient Transfer
Major Topic #9: Evidence
e guidelines contained in this document are
based upon a combination of available objective
evidence, a review of generally accepted practices,
and the consensus of expert opinions in the eld of
IFT — in short, the best information available. In
the current health care environment, however, the
eciency and ecacy of medical practice, policies,
and operations are held to a higher standard of
evidence than in the past. Ongoing evidence col-
lection is the key to ensuring that IFT provides the
best possible care in an optimal fashion.
e members of the IFT Workgroup concur with
the authors of the EMS National Research Agenda
who state, “...the lack of scientic knowledge about
optimal patient care has confused clinicians and
le them oundering to provide the best care
without the guidance of good science.” As with any
other area of emergency care, the practices and
processes involved in delivering IFT need objective
evaluation to determine their impact and cost-ef-
fectiveness.
Evidence assessing the status of IFT services can
range from “micro” to “macro” in scope. e level
of detail will be determined by the questions to be
answered, and may include some or all of the fol-
lowing strategies:
n
Tracking/Monitoring
n
Quality Management
n
Case Review
n
Performance Indicators
n
Surveillance Methods Used in Assurance Phase
n
Formal Research
Data Collection for IFT Evidence
n
Uniform data denitions are essential to collect
evidence that can enable multisite studies, and
true comparison of IFT practice and methods of
delivery.
n
Databases such as the National EMS Informa-
tion System (NEMSIS) and the National Trauma
Data Bank can be used to ensure standard data
elements and the optimal utility of data.
n
Because patient volume within any one IFT
service may be low, collaborative research can
be conducted and used to derive results that can
be applied to other groups of IFT patients and
other systems of IFT delivery.
n
e data for IFT research may require linkage
with prehospital data, ED data, hospital data,
and that of the institutions pre and post IFT, to
study outcomes as well as process.
n
e evidence collection process and data
elements to be used for assessment and
assurance are optimally identied as new/
updated IFT service is planned and before its
implementation, so data can be gathered before
and aer IFT is deployed.
Outcome and Process Evaluation
Assessing the status of the current practice of IFT
includes two areas of study: (1) outcomes evalua-
tion, and (2) process evaluation.
Outcome evaluation examines the eectiveness
or ecacy of particular interventions on patient
status. An outcome evaluation of IFT assesses a
particular clinical aspect of patient care during IFT,
and its impact on patient outcome. Examples of
prime candidates for outcome evaluation include:
n
Dening and ensuring adequate and eective
patient care during IFT. e EMS Outcomes
Project names six categories for patient out-
come:
1
o
survival
o
impaired physiology
o
limit disability
o
alleviate discomfort
o
satisfaction
o
cost-eectiveness
Guide for Interfacility Patient Transfer
27
National Highway Trac Safety Administration
n
Evaluation of best-model practices for dierent
levels of providers and for dierent geographic
areas
n
Timing of transfer — When is it too early or too
late to transfer patients?
n
What practices are most eective in preventing
infection during IFT?
n
Does constant availability of medical direction
make a dierence in outcomes?
n
Does the level of provider make a dierence in
outcome for particular acuity levels of patients?
Process Evaluation — It would be dicult to con-
clude that a specic intervention caused a specic
outcome, if the process of achieving it was not car-
ried out as intended.
Process evaluation focuses on the quality of imple-
mentation — how well the intended process was
carried out. It examines operational and system
eciency. Examples include:
n
Where can costs be reduced in operation and
equipment and still provide optimal care?
n
What system QI model works best to monitor
the outcomes of patients in a particular region/
State?
n
Regional resource assessment and management.
n
Additional training — what is important and
what's not?
n
Response time standards.
n
Were protocols adhered to? Why or why not
(related to system components)?
n
Dispatch issues — call-taking, triage, personnel
assignment, as they relate to IFT.
n
Tracking referral patterns and trends to deter-
mine future patient population.
References
1. Maio, Ronald. Emergency Medical Services
Outcomes Evaluation. U.S. Department of
Transportation, National Highway Trac Safety
Administration. July, 2003.
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
Major Topic #10: Lessons Learned
is publication is distributed by the U.S.
Department of Transportation, National Highway
Trac Safety Administration, in the interest of
information exchange. As part of the IFT project,
the IFT Work Group put out a call for information
on existing IFT programs from a wide variety of
organizations and individuals involved with IFT, in
an eort to illustrate examples of lessons learned
during the process of establishing and/or maintain-
ing IFT service. is section includes the results of
that call for information, and represents a self-se-
lected group of IFT programs that may function as
case studies to learn from, and/or act as resources
for a variety of IFT information. Certainly many
more programs could oer promising approaches
than could be included here. Resources prevented
an exhaustive and comparative selection process.
e respondents were contacted and extensively
interviewed following a standardized format. e
examples presented here had four characteristics in
common:
n
Replicable: Has the potential to be replicated
in other settings or provides a basis that others
could build upon.
n
Purposeful: Practices were developed inten-
tionally to address an identied problem or to
achieve a goal. In some cases, a formal quality
assurance program identied the need, in others
the program was mandated by legislation. Some
programs developed from grass-roots eorts.
n
Operational: Practices included here have all
been taken beyond the conceptual and planning
stages, and have been implemented.
n
Successful: Has some evidence that the plan
implemented is achieving desired results.
Measurement techniques vary with the nature
of the practice, program, and organization.
Evidence of success could be anecdotal report-
ing, a formal quality assurance program, or
published research involving control groups and
peer review.
Although not criteria for inclusion, two other
characteristics were present in these proles: col-
laboration and evolution. All success is shared:
Every organization interviewed beneted from and
valued the work of people who had come before
them. All programs continue to evolve as eective-
ness is studied and the results are used to improve
performance.
All those who submitted a prole of their IFT
program expressed a willingness to share their
information directly with other parties interested
in IFT; therefore, contact information is included
in each prole. e IFT Work Group hopes these
examples encourage cooperative eorts between
stakeholders in establishing IFT services.
e Work Group appreciates the participation of
the services providing information about their
programs. e examples oered are presented to
stimulate further eorts to improve IFT and to
support a network for sharing information. e
opinions, ndings, and conclusions expressed in
this section (and the other sections of this docu-
ment) are not necessarily those of the Department
of Transportation or the National Highway
Trac Safety Administration. e United States
Government assumes no liability for its contents
or use thereof. If trade, manufacturers’ or program
names are mentioned, it is only because they are
considered essential to the object of the publica-
tion and should not be construed as an endorse-
ment. e IFT Work Group and the United States
Government do not endorse specic products,
manufacturers or programs.
Guide for Interfacility Patient Transfer
29
National Highway Trac Safety Administration
Interfacility Transfer Guide:
Program
Children’s Hospital Medical Center of Akron
Akron Children’s Transport
1 Perkins Square
Akron, OH 44308
Contact Information
Traci R. Sheipline, R.N., EMT-B
330-543-3246
tsheip[email protected]rg
Organization and Mission
Children’s Hospital Medical Center of Akron (CHMCA) is a 253-bed freestanding pediatric facility. e
hospital includes a level 3 neonatal intensive care units (NICU) and a level 2 trauma center. CHMCA also
operates a burn unit that accepts all patients of all ages.
Akron’s Children’s Transport (ACT) operates three ground ambulances and works with other services
that provide rotor-wing and xed-wing air ambulances. ACT generally covers 22 counties in northeast
Ohio, but will transport children by xed-wing aircra back to CHMCA from anywhere in the continental
United States. e ambulances are staed with a nurse, paramedic and respiratory therapist. ACT provides
only interfacility transfer services.
More information is available at www.akronchildrens.org.
Systems Integration
In 2001, CHMCA implemented a centralized communications center to improve communications be-
tween referring physicians and CHMCA. CHMCA’s performance improvement process identied that the
prior system was ineective and inecient. Callers were getting lost in the system. Referring physicians
who called in with a patient to be transferred were being le on hold for lengthy periods of time.
Under the current system, all transport and EMS calls come in to the communication center. When inter-
facility transfer is required, the referring physician, transport nurse, and physician providing medical di-
rection at CHMCA confer about the patient. ey discuss criticality, patient needs, and appropriate mode
of transportation. Once the call is accepted, CHMCA handles all the coordination, even if the patient is
not being transported to CHMCA.
Implementation Strategy
Once the performance improvement process had identied the need for a better approach, a transport
steering committee consisting of management, the medical director for transportation, the vice president
of nursing, and representatives from pediatrics, NICU, trauma, respiratory therapy, and pharmacy met
monthly. e creation of the communications center was the result of the committee’s work.
Because CHMCA was working on what was perceived to be a problem and because all the relevant stake-
holders participated in developing the solution, the committee approach was successful in garnering inter-
nal support that has made the communications eective.
National Highway Trac Safety Administration
30
Guide for Interfacility Patient Transfer
Implementing the communications center required building and equipping a dedicated facility. In addi-
tion to the hardware requirements, CHMCA had to update its clinical and operational databases in order
for the system to work eectively. As a result, CHMCA is able to analyze 22 aspects of every transport: for
example, origin, diagnosis, call volumes, frequency and distribution of calls, sta deployment, and a range
of clinical and treatment variables.
Evaluation and Results
e communications center has been eective in decreasing response time from 15 minutes down to 10
minutes. In addition, because the whole team has the information necessary for that transport, it can set
up necessary care faster. With the implementation of the communications center, the whole process is
more ecient, particularly as it aects the referring physician. In the current system, a support sta mem-
ber can place the initial call. When the team is assembled, the referring physician can join the call, maxi-
mizing the time the physician can spend with the patient.
CHMCA regularly surveys the referring physicians and has received very positive feedback. Also, referring
physicians receive a letter describing where and to what service the patient was admitted. As a result the
volume of transports has increased from 900 in 1999 to 1,468 in 2004. Referring physicians report satisfac-
tion with their increased role in patient triage.
Education and Replication
One of the positive side eects of the improved working relationship has been requests by referring hos-
pitals for CHMCA to send a team to do outreach at their facilities. e team addresses the capabilities of
CHMCA and ACT. By going to the outlying facilities, the outreach team can work with the particular cir-
cumstances of the referring facility to enhance communication, preparation for transport, and follow-up.
Guide for Interfacility Patient Transfer
31
National Highway Trac Safety Administration
Interfacility Transfer Guide:
Program
Boston MedFlight
1727 Robins Street, Hangar 1727, Hanscom AFB
Bedford, MA 01730
Contact Information
Suzanne Wedel, M.D., Medical Director
781-863-2213
Suzanne.Wedel@bostonmedight.org
Organization and Mission
Boston MedFlight (BMF) is a 501(c)(3) non-prot organization based in Bedford, Massachusetts, whose
mission is to extend the tertiary care services of the major Boston hospitals to the citizens of Massachusetts
and New England. e service is available 24 hours a day and seven days a week. BMF was formed by a
consortium of Boston area hospitals to provide emergency medical critical care transport services. e
consortium includes Beth Israel Deaconess Medical Center, Boston Medical Center, Brigham and Women’s
Hospital, Children’s Hospital, Massachusetts General Hospital, Tus New England Medical Center. BMF
provides transport to the hospital deemed best able to meet the patient’s needs, regardless of whether that
hospital is a member of the consortium. BMF currently operates three helicopters, two ground ambulances
and one xed-wing air ambulance. Additional information is available at www.bostonmedight.org.
Systems Integration
BMF has created a system of critical care transport with the goal of getting the sickest patients to the best
care as fast as possible. BMF derives its strength and cost-eectiveness by functioning as a regional provid-
er. e existence of BMF spares the members of the consortium the expense of operating separate critical
care transport services. Earned revenue covers 92 percent of BMF expenses are covered by earned revenue;
the hospital consortium funds the remainder. Although BMF strives to be ecient, it has no nancial
incentive to generate additional business volumes just to cover expenses.
As a regional provider, BMF achieves a volume of utilization of approximately 2,700 transports annually, a
volume that would not be possible for an independent operator. e high volume means that BMF teams
encounter even unusual cases frequently enough to keep skills at high levels of prociency and its alia-
tion with the consortium of hospitals facilitates development and coordination of treatment and transpor-
tation protocols that strengthen the system and improve the quality of care. Having the choice of ground
or air vehicles means that BMF can choose the most appropriate and eective mode of transport for that
patient under the specic circumstances.
BMF has historically incorporated the quality assurance process into its operation. Every transport team
member is responsible for a quality assurance project. Structured training time is built into the operating
budget and schedule; team members are required to maintain their skills and certications through exten-
sive hands-on clinical training opportunities at all the member hospitals.
National Highway Trac Safety Administration
32
Guide for Interfacility Patient Transfer
Implementation Strategy
BMF celebrated its 20th anniversary in June 2005. e system has evolved over that period of time. e
genesis of BMF was a core group of surgeons and hospital executives who saw the need for helicop-
ter transportation in the Boston area. Massachusetts regulates the establishment of new health services
through its Determination of Need program and State health regulators expressed concern about the
potential for the proliferation of competing and inecient services. Hospital representatives also recog
-
nized that multiple providers meant less ecient operations, possibly encouraging the transfer of less acute
patients just to make operations nancially feasible. Hence, the six-hospital consortium formed BMF.
BMF has used its quality assurance process as a change agent to continually improve the quality of service
it provides and as a tool to identify additional services that were needed. One example of that is the evolv
-
ing recognition of critical care transport as a specialization separate from prehospital emergency medical
services. Quality assurance has also helped BMF operate eciently.
BMF has found that it needs to drive the development and acceptance of critical care transport protocols.
Consortium hospitals have willing and eective partners in developing those protocols. Standardization of
procedures has helped make the transport process achieve optimal clinical results while smoothing other
operational issues.
Evaluation and Results
BMF conducts structured quality assurance activities to monitor the appropriateness and eectiveness of
its services on an on-going basis. BMF’s high degree of appropriate utilization indicates that the regional
-
ization of the service eectively reduces the inappropriate utilization that is sometimes attributed to the
existence of redundant and competing providers. Boston MedFlight with support from the sponsoring
consortium hospitals has fostered an environment for research based practice. Since the inception of the
program, there have been changes in clinical standards and current clinical research which has helped
shape the BMF Standards of Care as well as its patient care policies and procedures. e BMF research
program has been one of the components that make BMF a leader in the transport community. It has
resulted in numerous publications and presentations at national and regional conferences.
Education and Replication
Boston MedFlight has worked with a number of organizations since its inception. Particularly in cases
where BMF and another provider serve contiguous or overlapping areas, reliance on similar protocols is
seen as a means of strengthening the system as a whole, as well as improving care on a case-by-case basis.
e New England rotor-wing programs have formed the New England Air Alliance, which is a unique
regional infrastructure designed to encourage collaboration instead of competition for critical care trans-
port.
BMF personnel have published a variety of articles relevant to interhospital transfer. A partial bibliography
can be found at www.bostonmedight.org/research.html.
Guide for Interfacility Patient Transfer
33
National Highway Trac Safety Administration
Interfacility Transfer Guide:
Program
Patient Transport Services
Children’s Medical Center Dallas
1935 Motor Street
Dallas, TX 75235
Contact Information
Jan Cody, R.N., L.P.
Director Patient Transport Services
214-456-8436
jan.cody@childrens.com
Organization and Mission
Children’s Medical Center Dallas is a 406-bed, non-prot tertiary care center and level I Trauma Center.
is includes a 52-bed pediatric intensive care unit (PICU), over 50 outpatient clinics, an emergency
department (ED) designed just for children, and a dedicated interfacility transport program. Children’s
service area is predominantly north central Texas, but it brings children to the hospital from all over the
southwest.
Children’s Transport Team was founded in 1989 when Children’s Medical Center recognized that there
were children in the community hospitals that needed pediatric specialized care before they arrived at
Children’s. e rst year the teams completed 330 missions. In 1999 Children’s Medical Center Dallas
Patient Transport Services was the rst pediatric transport team to be accredited by CAMTS and the rst
to be accredited in all three modes of transport: ground, xed-wing aircra (FWA), and rotor-wing aircra
(RWA). e program has grown throughout the years: the Children’s Transport Team currently has over 60
sta members, and in 2004 they completed 3,516 transports.
Transfer Center
Children’s Medical Center has established a transfer center that is staed 24 hours a day with
transfer coordinators (TCs) who are trained as EMTs or paramedics. e TCs are also certied ight
communicators by NAACS (National Association of Air Medical Communication Specialists).
e Transfer Center coordinates all transfers into Children’s. Transfer coordinators receive the initial
phone call from the referring hospital and guide the rest of the process — from identifying an accepting
physician to dispatching the team and ight following on RWA transports. Based on the information
gathered in the initial conversation with the referral facility, the TC categorizes the patient as BLS (Basic
Life Support), ALS-1 (Advanced Life Support), ALS-2, or SCT (Specialty Care Transport). ey then
determine the most appropriate destination for the child: Emergency Department (ED), Intensive Care
Unit (ICU), or inpatient oor. Once this has been determined the TC noties the appropriate accepting
physician and dispatches the appropriate team in the appropriate vehicle. CMC’s goal is to be out the door
within 10 minutes of receiving the call.
Children’s Medical Center uses a suite of soware to connect the functions within the department.
Computer-aided dispatch soware is used to document information gathered during the call-taking
process and dispatch of the teams. All clinical documentation is done using electronic charting soware.
National Highway Trac Safety Administration
34
Guide for Interfacility Patient Transfer
e computer-aided dispatch system, the electronic charting system, and a billing system are all connected
with a mobile data communication system. is suite of products makes report writing and data collection
simple and the possibilities almost unlimited.
Implementation Strategy
Patient Transport Services has reached out to referring hospitals to demonstrate the capabilities of the ser-
vices and to improve the coordination of the transport, assuring that the referring hospital, the responding
team, and the receiving hospital have a common set of expectations.
Patient Transport Services is a separate provider with its own Medicaid/Medicare number and it bills sepa-
rately for transport services. Billers and collectors work closely with management and the clinical sta to
provide payers with all needed information for claims processing.
CMCD decided to set up two levels of transport teams. Based on predened medical protocols a critical
care team consisting of a registered nurse, respiratory therapist, and emergency medical technician – cer-
tied emergency vehicle operator (EMT-CEVO) or a team of two paramedics might be dispatched. e
paramedic team transports patients who are categorized as BLS or ALS-1 and are within a 60-mile radius
of CMCD. All other patients are transported by the critical care teams.
e EMT-CEVO serves as safety ocer on all rotor-wing aircra transports. e CEVO gives position
reports, assists the pilots by watching for any obstacles, assists the team with loading and unloading the
patient, and briefs the family member prior to ight. All team members are trained as ight crewmembers
and follow duty time limits developed by the FAA when ying. Training for both the safety ocer’s role
and ight crewmembers was developed specically for the transport sta members by the RWA pilots as a
part of the implementation of the RWA program that went into service September 16, 2004.
Evaluation and Results
e dedicated billing function has signicantly increased reimbursement with a high percentage of claims
being paid the rst time they are submitted. is allows Patient Transport Services to document the rev-
enue it generates. Over the years this ability has enabled Patient Transport Services to garner the support
for new programs.
Operating two levels of service has enabled CMCD to operate at an ecient volume of cases while keeping
personnel expenses in line, due to the signicant cost savings found comparing a team of two paramedics
with the critical care team. Approximately a quarter of all transports are performed by the paramedic team.
Education and Replication
CMCD is aware that a number of other transport services have adopted the approach of dedicated trans-
port teams and of two levels of teams. Details of that implementation are likely to vary with the particular
needs of the operating organization (for instance, hospital-based or free standing) and with the scope of
practice regulations in a given State.
Guide for Interfacility Patient Transfer
35
National Highway Trac Safety Administration
Interfacility Transfer Guide:
Program
IHC Life Flight
250 North 2370 West
Salt Lake City, UT 84116
Contact Information
Renee S. Holleran, R.N., Ph.D., C.EN., C.C.R.N.,
C.F.R.N. Nurse Manager, Adult Transport Services
801-321-3322
reneeigh[email protected]m
Organization and Mission
Intermountain Health Care (IHC) is an integrated health system that includes 20 hospitals, numerous clin-
ics, and an insurance company. IHC serves Utah and southeastern Idaho. More information is available at
www.ihc.com.
IHC Life Flight operates three rotor-wing aircra 24 hours a day that provide scene and interfacility
response within 150 miles of its bases in Salt Lake City and Provo, Utah. e RWA also supports search-
and-rescue missions in the intermountain area. IHC operates three xed-wing aircra transporting
patients throughout the west. A specially designed neonatal critical care ambulance is stationed at Primary
Children’s Medical Center in Salt Lake City. Life Flight provides interfacility transfer services over a seven-
State area. Life Flight is accredited by CAMTS.
Medical Direction
Life Flight’s approach to medical direction involves two intensivists and one emergency medicine physi-
cian. Life Flight perceived that interfacility transfer was being impaired by inconsistent understanding and
expectations. In part this was due to the extreme variability in the size and nature of sending facilities and
in the professional credentials and experience of clinicians, ranging from a physician’s assistant in a very
remote setting to more sophisticated hospitals transferring patients to a tertiary facility. Also, because of
the large and sometimes sparsely populated service area, bringing clinicians to a central location for train-
ing was dicult logistically.
In part the inconsistency followed from the dierent levels of knowledge on the part of medical directors.
Several types of physicians are involved, representing emergency medicine and other forms of critical care.
Without specic training in medical direction of interfacility transfer, the physicians might lack a full un-
derstanding of the established protocols, optimal preparation for transfer, the capabilities and limitations
of the crew, and the capabilities and limitations of the equipment.
IHC addressed this problem by developing a training program for medical direction, the goal of which is
to improve the both the results and the process of the transfer. One concern was that the referring facility
not feel alienated or patronized. IHC treats the transfer as a teaching opportunity. e medical director
stays in contact with the referring facility while the aircra is en route, addressing clinical issues and assur-
ing that appropriate preparations are made so that the patient is as ready for transport as possible.
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
Implementation Strategy
Recognizing that gathering a group of physicians for training programs can be dicult logistically, IHC
has developed the program so it can be distributed on DVD. is technology makes the learning available
at a convenient time and place for the learner. Once the master is prepared reproduction and distribution
are very economical. One of the approaches IHC used to build condence in its service was to emphasize
timely response because IHC had found that physicians working in a tertiary hospital might not fully un-
derstand the sense of isolation and need for prompt assistance experienced by colleagues in remote areas.
Evaluation and Results
Life Flight has found that the program has been eective in achieving the desired consistency. e entire
team has greater condence in each other and in the system.
Education and Replication
Dr. Frank omas, the physician who developed the original training program, has presented all over the
world. e DVD format has made it easy and cost-eective to share with other organizations. e DVD
has been recognized by CAMTS as a best practice.
Guide for Interfacility Patient Transfer
37
National Highway Trac Safety Administration
Interfacility Transfer Guide:
Program
Children’s Hospital of San Diego
3020 Children’s Way
San Diego, CA 92123
Contact Information
Dana Patrick, R.N.
Emergency Transport Program Coordinator
858-966-5973
I T G:
Organization and Mission
Children’s Hospital of San Diego (CHSD) is the San Diego region’s only designated pediatric trauma center
and the only area hospital dedicated solely to pediatric care. Since CHSD rst opened its doors in 1954,
its mission has been “to restore, sustain and enhance the health and developmental potential of children.”
More information is available at www.chsd.org.
e Emergency Transport Program was started in 1972, rst for neonatal transport. When the hospital
opened a pediatric ICU a second team was added for pediatric transport. CHSD transports approximately
1,000 pediatric and 800 neonatal patients annually.
Meeting Patient Needs
About ve years ago, CHSD shied to teams made up of a nurse and a respiratory therapist. Both members
are completely cross-trained. With the approval from the respiratory care board, standard protocols were
approved in advance, allowing both RTs and RNs to expand the scope of their capabilities. Although the
nurse tends to be the primary sta member, they work as a team and responsibilities shi according to the
needs of the patient. CHSD believes that the RN/RT teams are more eective because each team member
understands the other’s functions. If necessary, it provides redundant capabilities within a single team.
Separate teams are dedicated to pediatrics and neonates and they are pre-assigned to transport responsi-
bilities. Although combining teams might be a means of leveling the workload, CHSD has found that it
provides better care by having dedicated teams. When teams are not involved in transport, they provide
dened supplemental stang within the hospital.
e RN/RT team approach was conceived to improve the quality of care and simplify the administration of
the service.
Implementation Strategy
Before changing the stang, it was necessary to convince the team medical directors of the benets, and
then the teams needed to be trained. Preconceptions about the capabilities of respiratory therapists were
addressed through training and testing and by setting high thresholds for prior experience. Teams went
through 48 hours of pediatric training followed by written and performance tests. Team members must
have ve years of experience before applying for a transport position.
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
Evaluation and Results
CHSD holds transport morbidity and mortality conferences with the medical director and medical control
ocer. ese conferences are held in a condential environment so all parties can speak candidly.
e RN/RT team concept has produced positive results and helped recruitment.
Education and Replication
e CHSD RN/RT team approach may have potential for replication by other services.
Guide for Interfacility Patient Transfer
39
National Highway Trac Safety Administration
Appendix A:
Members of IFT Guidelines Work Group
e EMS Program at the National Highway Trac Safety Administration gratefully acknowledges the
contributions made by the members of tie IFT Work Group. Without their generous donation of time and
expertise, the completion of this document would not have been possible.
Air Medical Physicians Association
Kenneth Robinson, M.D., FACEP
Air and Surface Transportation Nurses
Association
Ann Lystrup, R.N., B.S.N., C.F.R.N., C.E.N.,
C.C.R.N.
e American Ambulance Association
Kurt Krumperman, M.S., NREMT-P
American College of Emergency Physicians
& e Commission for Accreditation of
Ambulance Services
J. William Jermyn, D.O., FACEP (representing
both organizations)
e Commission on Accreditation of Medical
Transport Systems
Tamara Bauer, R.N., C.C.R.N., M.B.A.
Emergency Nurses Association
Kathy Robinson, R.N.
Emergency Medical Services for Children, HRSA
Dan Kavanaugh, M.S.W., L.C.S.W.-C., Program
Director
Emergency Services for Children, National
Resource Center
Jane Ball, R.N., Dr.P.H., Director
National Association of EMS Physicians
Jon Krohmer, M.D., FACEP
National Association of EMTs
Jerry Johnston, B.A., R.E.M.T.-P.
National Association of State EMS Directors
Mark King
Fergus Laughridge
National Association of State EMS Training
Coordinators
William Russell Crowley
National Flight Paramedics Association
T.J. Kennedy, E.M.T.-P., F.P.-C.
International Association of Flight Paramedics
Ron Walter, B.S., N.R.E.M.T.-P.
National Highway Trac Safety Administration
Drew Dawson, Director, Oce of EMS
Laurie Flaherty, R.N., M.S.
Oce of Rural Health Policy, HRSA
Blanca Fuertes, M.P.A.
National Highway Trac Safety Administration
40
Guide for Interfacility Patient Transfer
Appendix B:
References and Resources for IFT
Emergency Medical Treatment and
Labor Act
Health Law Resource Center
EMS & Helicopter Issues
www.medlaw.com/ems.htm
American College of Emergency Physicians
EMTALA – Main Points
http://www.acep.org/webportal/PracticeResources/
issues/emtala/default.htm
Appropriate Interhospital Patient Transfer
http://www.acep.org/webportal/PracticeResources/
issues/emtala/default.htm
Annals of Emergency Medicine
e EMTALA Paradox (2002)
http://www.annemergmed.com/issues#2002
eMedicine
COBRA Laws
www.emedicine.com/emerg/topic737.htm
Emergency Nurses Association
EMTALA Information (1998 – 2004)
www.ena.org/government/emtala/
Air Medical Physicians Association
Medical Condition List and Appropriate Use of
Air Medical Conditions (2002)
http://www.ampa.org/component/option,com_doc-
man/task,cat_view/gid,23/Itemid,42/
Centers for Medicare and Medicaid Services.
Appendix V of the State Operations Manual.
Interpretive Guidelines — Responsibilities of
Medicare Participating Hospitals in Emergency
Cases.
http://www.cms.hhs.gov/EMTALA/
U.S. General Accountability Oce
EMTALA Implementation and Enforcement
www.gao.gov/new.items/d01747.pdf
Examples of Federal Regulations
Federal Aviation Administration
Air medical services operate predominantly
under two distinct parts of the Code of Federal
Regulations (CFR), formerly known as the Federal
Aviation Regulations: CFR Part 91 and Part 135.
Part 91 regulates ight operations for aircra
ying within U.S. airspace
ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=dd
3aa7b9f3da5c3af094830596d3790b&rgn=div5&vie
w=text&node=14:2.0.1.3.10&idno=14
Part 135 provides specic regulations for
commuter and on demand air carriers, including
air ambulances
ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=dd
3aa7b9f3da5c3af094830596d3790b&rgn=div5&vie
w=text&node=14:2.0.1.3.23&idno=14
Guide for Interfacility Patient Transfer
41
National Highway Trac Safety Administration
Health Insurance Portability and
Accountability Act (HIPAA)
HIPAA.org
CMS has prepared a checklist to help you
get started.
www.hipaa.com/
American Medical Association
HIPAA
www.ama-assn.org/ama/pub/category/4234.html
American College of Emergency Physicians
HIPAA Compliance Information (Updated 2005)
http://www.acep.org/webportal/PracticeResources/
issues/admin/HIPAAComplianceInformation.html
Facts about Medical Liability Insurance Crisis
http://www.acep.org/webportal/PracticeResources/
issues/medliab/default.html
Oce for the Advancement of TeleHealth
Final HIPAA Privacy Rules (2001)
telehealth.hrsa.gov/pubs/hipaa.htm
Liability
American College of Emergency Physicians
Medical Professional Liability Insurance (2004)
www.acep.org/NR/rdonlyres/DD94E243-339F-
4A02-983D-7563D42BCE74/0/MPLIpaperApril
04.pdf
Facts about Medical Liability Insurance Crisis
www.acep.org/webportal/PatientsConsumers/
HealthSubjectsByTopic/MedicalLiabily/
correctrhtoric.htm
Emergency Nurses Association
Position Statement
Medical Professional Liability Insurance:
Malpractice Crisis (2003)
www.ena.org/about/position
U.S. Department of Health and Human Services
Special Update on Medical Liability Crisis (2002)
aspe.os.dhhs.gov/daltcp/reports/mlupd1.htm
National Council of State Legislatures
State Medical Liabilities Law Table (2002)
http://www.ncsl.org/programs/health/medmalncsl.
htm
LAW.com
Dictionary of Legal Terms
dictionary.law.com/
Position Statements
American Academy of Pediatrics
Guidelines for Air and Ground Transport of
Neonatal and Pediatric Patients
2nd Edition (1999)
www.aap.org/bst/showdetl.
cfm?&DID=15&Product_ID=912
American College of Emergency Physicians
Interfacility Transportation of the Critical Care
Patient and Its Medical Direction (1999)
http://www.acep.org/webportal/PracticeResources/
PolicyStatements/
Professional Liability Insurance for EMS Medical
Control Activities (1999)
www.acep.org/webportal/PracticeResources/
PolicyStatements/EMS/ProfessionalLiabilityInsuranc
eforEMSMedicalControlActivities.htm
American College of Surgeons/Committee
on Trauma
Interfacility Transfer of Injured Patients:
Guidelines for Rural Communities (2002)
https://web2.facs.org/timssnet464/acspub/frontpage.
cfm?product_class=trauma
Air Medical Physicians Association
Medical Direction and Medical Control of Air
Medical Services http://www.ampa.org/compo-
nent/option,com_docman/task,cat_view/gid,23/
Itemid,42/
National Highway Trac Safety Administration
42
Guide for Interfacility Patient Transfer
Air and Surface Transportation
Nurses Association
Stang of Critical Care Air Medical Transport
Services (2001)
www.astna.org/Position-papers/stang.htm
Association of Air Medical Services
Appropriate use of Critical Care Ground Transport
Services (2005)
www.aams.org/publications.html
Emergency Nurses Association
Care of the Critically Ill or Injured Patient During
Interfacility Transfer (2002)
http://www.ena.org/about/position/
Centers for Medicare and Medicaid Services.
Medicare Benet Policy Manual. Pub. 100-02.
Chapter 10. Ambulance Services.
http://www.cms.hhs.gov/center/ambulance.asp
Request for Medicare Payment – Ambulance.
CMS Form 1491.
http://www.cms.hhs.gov/center/ambulance.asp
National Association of EMS Physicians
Medical Direction of Interfacility
Transports (2000)
Medical Direction for Air Medical Transport
Programs (2002)
Physician Medical Direction in EMS (1997)
(Table of contents:)
www.naemsp.org/Position%20Papers/Contents.html
Society for Critical Care Medicine
Guidelines for the Intra and Interfacility Transport
of Critically Ill Patients. (2004).
http://www.sccm.org/professional_resources/guide-
lines/table_of_contents/index.asp
Pediatric Emergency Care
e state of pediatric interfacility transport:
Consensus of the Second National Pediatric
and Neonatal Interfacility Transport Medicine
Leadership Conference (2002)
www.pec-online.com/pt/re/pec/abstract.00006565-
200202000-00013.htm;jsessionid=B11uIWoslDR06a
wVX8h7HDSN8AnBCJPlyDfuLd1W3MRzwodSo
g!368654479!-949856031!9001!-1?index=1&results
=1&count=10&searchid=1&nav=search
References of General Interest
Air and Surface Transportation Nurses
Association
Standards for Critical Care and Specialty
Ground Transport
Standards for Critical Care and Specialty
Fixed-Wing Transport
Standards for Critical Care and Specialty
Rotor-Wing Transport
www.astna.org/pubs.html
Centers for Medicare and Medicaid Services
Navigating the Medicare Web Site
www.medscape.com/viewarticle/ 494892?src=mp
Denitions of Ambulance Services. Program
Memorandum. Transmittal AB-02-130
www.cms.hhs.gov/manuals/pm_trans/ab02130.pdf
Request for Medicare Payment – Ambulance.
CMS Form 1491.
www.cms.hhs.gov/providers/edi/cms1491.pdf
Commission on Accreditation of Ambulance
Services
Accreditation Standards (2004)
www.caas.org/index1.html
Guide for Interfacility Patient Transfer
43
National Highway Trac Safety Administration
Emergency Medical Services for Children
Trauma Triage, Transfer, and Transport
Guidelines (2002)
http://www.ems-c.org/Products/frameproducts.html
(Enter title into Title Search eld.)
Emergency Nurses Association
Certication for Ground Transport Nurses
http://www.ena.org/bcen/ctrn/
Institute of Medicine
Clinical Practice Guidelines: Directions for a
New Program, (1990), M.J. Field and K.N. Lohr
(editors) Washington, DC: National Academy
Press. Page 38.
books.nap.edu/catalog/1626.html
e Future of Public Health. (1988). Committee for
the Study of the Future of Public Health. Division
of Health Care Services. Institute of Medicine.
Washington, D.C. National Academy Press.
http://www.nap.edu/books/0309038308/html
Maryland Institute for Emergency Medical
Services Systems
Interhospital Transfer Guidelines Manual (2002)
www.miemss.org/Interhospital.pdf
Minnesota Department of Health, Community
Health Division
Public Health Core Functions, Essential Services,
and Goals
www.health.state.mn.us/divs/chs/pdf/gdlinebkgrd1.
pdf#search=’three%20core%20functions%20of%20p
ublic%20health
National Rural Health Association
Rural and Frontier Emergency Medical Services
Agenda for the Future (2004)
www.nrharural.org/groups/sub/EMS.html
National Highway Trac Safety Administration
Emergency Medical Services Agenda for the Future
www.nhtsa.dot.gov/people/injury/ems/agenda/ems-
man.html
Implementation Guide
www.nhtsa.dot.gov/people/injury/ems/agenda/in-
dex.html
Guide for Preparing Medical Directors
www.nhtsa.dot.gov/people/injury/ems/
2001GuideMedical.pdf
National EMS Research Agenda
http://www.nhtsa.dot.gov/portal/site/nhtsa/menuite
m.2a0771e91315babbbf30811060008a0c/DEMyPS4
zjvEasDAYBAlHs1Qm9ncn71vGM2plOk6RHZGrZ
D1YKNjuK%2128012360
NEMSIS
www.nemsis.org/
University of Maryland Baltimore County
Critical Care Emergency Medical Transport
Programtm
http://ehs.umbc.edu/CE/CCEMT-P/index.html
United States Small Business Administration
Elements of a Business Plan
http://www.sba.gov/starting_business/index.html
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
Appendix C:
Elements of a Business Plan
Before beginning, consider four core questions:
1. What service does your business provide and
what needs does it ll?
2. Who are the potential customers for your ser
-
vice and why will they contract with you?
3. How will you reach your potential customers?
4. Where will you get the nancial resources to
start your business?
Prepare by following 10 preliminary steps:
1. Ask yourself why you are writing a business
plan. Is it to raise capital or as a guide for run
-
ning the business?
2. List your goals for starting the business and
where you see the business in three to ve
years.
3. Clearly dene your target audience.
4. Write a table of contents so you’ll know exactly
which sections you will need to research and
nd data to support.
5. Make a list of the data you will need to re
-
search. For example, you will need statistics on
your demographic audience, your competition,
the market, and so on.
6. List research sources that will be most helpful.
7. List your management team. If you are unsure
of someone’s availability, this is the time to
determine whether or not they are on board.
Gather biographical data on each person.
8. Start compiling all of your key nancial docu
-
ments. You can determine later which ones
you will use in the business plan.
9. Read sample business plans. Since countless
business plans have preceded yours, there is no
need to reinvent the wheel. Look for business
plans for businesses most similar to yours as a
prototype to guide you. You can also talk with
other business owners who have written plans
before and seek out their expertise.
10. Determine which soware program you will
use to write your plan. You can use anything
from a basic word-processing program to
business plan soware. You will need to use
that which best suits your needs and level of
complexity.
Once you are ready, begin with the understanding
that the business plan is a work in progress and
there will be several to follow as well as ongoing
changes as your business progresses.
Elements of a Business Plan
1. Cover sheet
2. Statement of purpose
3. Table of contents
a. e business
i. Description of business
ii. Marketing
iii. Competition
iv. Operating procedures
v. Personnel
vi. Business insurance
Guide for Interfacility Patient Transfer
45
National Highway Trac Safety Administration
b. Financial Data
i. Loan applications
ii. Capital equipment and supply list
iii. Balance sheet (costs and revenues)
iv. Break-even analysis and nancial
gap analysis
v. Pro forma income projections (prot
and loss statements)
ree-year summary
Detail by month, rst year
Detail by quarters, second and third years
Assumptions upon which projections
were based
vi. Pro forma cash ow
c. Supporting Documents
i. Tax returns of principals for last
three years
ii. Personal nancial statements
iii. For franchised businesses, a copy of
franchise contract and all supporting
documents provided by franchisor
iv. Copy of proposed lease or purchase
agreement for building space
v. Copy of licenses and other legal
documents
vi. Copy of resumes of all principals
vii. Copies of letters of intent from all
suppliers, etc.
Reference
1. Business Plan Basics. http://www.sba.gov/start-
ing_business/planning/basic.html. U.S. Small
Business Administration. U.S. Department of
Commerce.
National Highway Trac Safety Administration
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Guide for Interfacility Patient Transfer
Appendix D:
EMTALA
e Emergency Medical Treatment and Labor
Act is a Federal law enacted by Congress in 1986
as part of the Consolidated Omnibus Budget
Reconciliation Act (COBRA) of 1985 (42 U.S.C.
§1395dd). Referred to as the “anti-dumping” law,
it was designed to prevent hospitals from refusing
to treat patients or transferring them to charity
or public hospitals because they were unable to
pay or had Medicaid coverage. EMTALA requires
hospitals with emergency departments to provide
emergency medical care to everyone who needs
it, regardless of ability to pay or insurance status.
Under the law, patients with similar medical
conditions must be treated consistently. e
law applies to hospitals that accept Medicare
reimbursement, and to all their patients, not just
those covered by Medicare.
Hospitals have three basic obligations under
EMTALA
n
First, they must provide all patients with a
medical screening examination to determine
whether an emergency medical condition exists
without regard for ability to pay for services.
n
Second, where an emergency medical condition
exists, they must either provide treatment until
the patient is stabilized, or if they do not have
the capability, transfer the patient to another
hospital.
n
ird, hospitals with specialized capabilities
are obligated to accept transfers if they have the
capabilities to treat them. Medical care cannot
be delayed by questions about methods of
payment or insurance coverage.
No further EMTALA obligations exist if an
appropriate medical screening examination
identies no emergency medical condition. No
further EMTALA obligations exist if an identied
emergency medical condition is stabilized.
Additionally, the latest regulations now recognize
that a patient with an emergency medical
condition may be discharged with a plan to have
subsequent treatment provided as an outpatient if
such a plan is consistent with medical routine and
does not jeopardize the patient’s health.
EMTALA governs how patients may be transferred
from one hospital to another. Under the law,
a patient is considered stable for transfer if
the treating physician determines no material
deterioration will occur during the movement
between facilities and that the receiving facility
has the capacity to manage the patient’s medical
condition. EMTALA does not control the
transfer of stable patients; however, patients
with incompletely stabilized emergency medical
conditions still may be transferred under EMTALA
if one of two conditions exists, as follows:
n
e patient (or someone acting on the patient's
behalf) provides a written request for transfer
despite being informed of the hospital's
EMTALA obligations to provide treatment.
n
A physician certies that medical benets
reasonably expected from transfer outweigh the
risk to the individual.
Once a decision is made to transfer the individual,
the following steps must be taken:
n
e transferring hospital must provide all
medical treatment within its capacity, which
minimizes the risk to the individual's health.
n
e receiving facility must accept the transfer
and must have space available and qualied
personnel to treat the individual.
n
e transferring hospital must send copies of
all medical records related to the emergency
medical condition. If the physician on call
refuses or fails to assist in the patient's care,
the physician's name and address must be
documented on the medical records provided to
the receiving facility.
Guide for Interfacility Patient Transfer
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National Highway Trac Safety Administration
n
Qualied personnel, with the appropriate medi-
cal equipment, must accompany the patient
during transfer. e transferring physician, by
law, has the responsibility of selecting the most
appropriate means of transport to include quali-
ed personnel and transport equipment.
Under EMTALA, patient care during transport is
the responsibility of the transferring physician/
hospital, until the patient arrives at the receiving
facility. e transferring physician is also respon-
sible for the order to transfer and for the treatment
orders to be followed during the transport. is
may conict with State statutes, which in some
instances, allow only authorized medical direc-
tion physicians to give orders to EMS personnel.
EMTALA does not reference the transport service
and its medical director, leaving ultimate medical
responsibility and its transition during transport
open for interpretation.
e legislation poses several additional complexi-
ties for individual hospitals and for an integrated
EMS system in which transfers can play a consid-
erable role:
n
First the level of service required before a pa-
tient transferred may not be clear; for hospitals
with comparatively minimal emergency depart-
ments or with extremely overcrowded EDs,
pressures for stang and equipment may be
intense.
n
Second, acceptable grounds for transfer need to
be clearly dened. In some cases, the primary
reason for transfer is explicitly dened, but
many other cases may be less conclusive.
n
ird, who makes the assessment to determine
that a patient is stable (and able to be trans-
ferred) or unstable may be a critical factor.
Decisions may dier depending on the level of
the practitioner, or between practitioners of the
same level, or between the responsible practitio-
ner at the transferring facility and the interfacil-
ity transfer team or its medical director.
As the scope of EMTALA has widened in an eort
to make the law more eective, existing weaknesses
in the delivery of care have created new problems:
In the binding regulations published in 1994, the
requirements for basic screening and stabilization
pertained to patients anywhere on hospital prop-
erty, including ambulances owned and operated by
the hospital.
Since EMTALA was enacted, the national ED
patient volume has increased and during the same
time period, the number of hospital EDs has de-
clined. As a result, fewer resources are available to
meet an increasing legal obligation.
e discussion in the interpretive guidelines and
case law obligated a hospital to accept an unstable
patient if it has the capacity and has any equip-
ment that the patient’s condition requires that the
referring hospital lacks. is disproportionately
expands the obligations of EDs with more sophis-
ticated capabilities, and increases the obligations
placed on on-call physicians. Although EMTALA
obligates hospitals to have a roster of on-call physi-
cians who can complete medical screening exami-
nations and provide stabilization for the services
the hospital oers to its community, many hospi-
tals are not able to ll their on-call rosters.
A recent decision by a Federal appeals court con-
cluded that a patient coming to the ED triggers
EMTALA obligations not only when the patient
is on hospital property, but also while traveling
toward the hospital. So, even when the decision to
divert ambulance patients is reasonable, the ED
may still be liable for EMTALA violation.
As providers grapple with new burdens, they
confront dicult challenges that are a logical
consequence of those new responsibilities. e net
impact of these changes has resulted in a decrease
in the availability of the services that the law was
intended to promote.
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Guide for Interfacility Patient Transfer
Appendix E:
Certicate of Transfer
Certication of necessity for transfer is a re-
quirement for reimbursement by the Centers for
Medicare and Medicaid Services. e CMS deni-
tion of medical necessity is as follows:
“Medical necessity is established when the patient’s
condition is such that use of any other method of
transportation is contraindicated. In any case, in
which some means of transportation other than an
ambulance could be utilized without endangering
the individual’s health, whether or not such other
transportation is actually available, no payment
may be made for ambulance service.”
It is possible (but not likely) that a patient may
require transfer and not meet the CMS denition
of medical necessity.
e Centers for Medicare and Medicaid Services
has issued regulations pertaining to the enforce-
ment of this law. Regulations go into much greater
detail than the statute. Proposed rules published in
1988 can be found in the Federal Register, June 16,
1988 (53FR22513). Interim nal rules can be found
in the Federal Register, June 22, 1994 (59FR32086).
e authority supporting the statute is the tax-
ing and spending clause of the Constitution. In
essence, Congress has the right to demand certain
services from vendors receiving Federal tax dollars.
In the EMTALA statute, obligations are tied to
hospitals’ participation in Medicare. In fact, a hos-
pital could relieve itself of EMTALA obligations by
dropping out of the Medicare program, although
this certainly would not be nancially benecial
for the hospital.
Guide for Interfacility Patient Transfer
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National Highway Trac Safety Administration
Appendix F:
HIPAA
Health Insurance Portability and Accountability
Act of 1996 is a law enacted to combat fraud,
waste, and abuse in health insurance and the de-
livery of healthcare services; to improve access to
long-term care services and coverage, and simplify
the administration of health insurance. e pro-
gram sets standards for the use and disclosure of
protected health information along with measures
to ensure the secure transmission and storage of
medical records and other individually identiable
or demographic information. e regulations pro-
tect medical records and other individually identi-
able health information, whether it is on paper, in
computers or communicated orally. Key provisions
of these new standards include:
n
Access to Medical Records. Patients generally
should be able to see and obtain copies of their
medical records and request corrections if they
identify errors and mistakes.
n
Notice of Privacy Practices. Covered health
plans, doctors, and other health care provid-
ers must provide a notice to their patients how
they may use personal medical information and
their rights under the new privacy regulation.
Patients also may ask covered entities to re-
strict the use or disclosure of their information
beyond the practices included in the notice, but
the covered entities would not have to agree to
the changes.
n
Limits on Use of Personal Medical
Information. e privacy rule sets limits on
how health plans and covered providers may
use individually identiable health informa-
tion. In addition, patients would have to sign
a specic authorization before a covered entity
could release their medical information to a life
insurer, a bank, a marketing rm or another
outside business for purposes not related to
their health care.
n
Prohibition on Marketing. e nal privacy
rule sets new restrictions and limits on the use
of patient information for marketing purposes.
Pharmacies, health plans and other covered
entities must rst obtain an individual’s specic
authorization before disclosing their patient
information for marketing.
n
Stronger State Laws. e new Federal privacy
standards do not aect State laws that provide
additional privacy protections for patients. e
condentiality protections are cumulative; the
privacy rule will set a national “oor” of privacy
standards that protect all Americans, and any
State law providing additional protections would
continue to apply. When a State law requires
a certain disclosure — such as reporting an
infectious disease outbreak to the public health
authorities — the Federal privacy regulations
would not preempt the State law.
n
Condential communications. Under the pri-
vacy rule, patients can request that their doctors,
health plans, and other covered entities take
reasonable steps to ensure that their communi-
cations with the patient are condential.
n
Complaints. Consumers may le a formal
complaint regarding the privacy practices of a
covered health plan or provider.
HIPAA for Health Plans and Providers
e privacy rule requires health plans, pharma-
cies, doctors, and other covered entities to establish
policies and procedures to protect the condential-
ity of protected health information about their pa-
tients. ese requirements are exible and scalable
to allow dierent covered entities to implement
them as appropriate for their businesses or prac-
tices. Covered entities must provide all the protec-
tions for patients cited above, such as providing a
notice of their privacy practices and limiting the
use and disclosure of information as required un-
der the rule. In addition, covered entities must take
some additional steps to protect patient privacy:
n
Written Privacy Procedures. e rule requires
covered entities to have written privacy proce-
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Guide for Interfacility Patient Transfer
dures, including a description of sta that has
access to protected information, how it will be
used and when it may be disclosed. Covered
entities generally must take steps to ensure that
any business associates who have access to pro-
tected information agree to the same limitations
on the use and disclosure of that information.
n
Employee Training and Privacy Ocer.
Covered entities must train their employees in
their privacy procedures and must designate
an individual to be responsible for ensuring the
procedures are followed. If covered entities learn
an employee failed to follow these procedures,
they must take appropriate disciplinary action.
n
Public Responsibilities. In limited circum-
stances, the nal rule permits — but does not
require — covered entities to continue certain
existing disclosures of health information for
specic public responsibilities. ese permitted
disclosures include: emergency circumstances;
identication of the body of a deceased per-
son, or the cause of death; public health needs;
research that involves limited data or has been
independently approved by an institutional
review board or privacy board; oversight of the
health care system; judicial and administrative
proceedings; limited law enforcement activities;
and activities related to national defense and
security. e privacy rule generally establishes
new safeguards and limits on these disclosures.
Where no other law requires disclosures in these
situations, covered entities may continue to use
their professional judgment to decide whether
to make such disclosures based on their own
policies and ethical principles.
HIPAA Considerations for Prehospital
Care Providers
n
Communications
Anyone involved in prehospital emergency
medical service must take precautions to ensure
that a patient’s protected health information
is protected and communicated to others
strictly on a “need-to-know basis” — or as
dened in the HIPAA standards, “Minimum
Necessary.” e regulation does not specically
state the mode of disclosure/transmission,
so it is acceptable to pass on information in a
written form, oral communication — discretion
and a low voice is always advised when
communicating orally and in a public setting, or
via radio for the purposes of providing a radio
“patch” to the receiving medical facility. In order
to protect protected health information during
a radio patch, information should be limited to
what the receiving facility needs to know about
the patient to prepare for the patent’s arrival
and treatment.
n
Exchanging Protected Health Information
with Medical Facilities
As required under the Ryan White Act, prehos
-
pital care providers are mandated to provide a
copy of their patient care report to the receiving
medical facility upon arrival. is practice is
permitted under HIPAA and does not violate
the standards established in the privacy rule.
Additionally, the HIPAA standards published
in the nal rule permit covered entities to share
and exchange information with each other
for the purposes of providing care/treatment,
obtaining information for payment, and using
the information for health care operations (i.e.,
quality assessment/quality improvement, educa-
tion, etc.) without the consent or authorization
of the patient or the patient’s personal repre-
sentative. us medical facilities may provide
prehospital care providers with face sheets and
other records for these purposes without patient
consent or authorization.
n
Safeguarding Patient Information
As a standard practice, all covered entities must
have systems in place that assures the secure
handling and safe storage of patient’s records
containing protected health information.
DOT HS 810 599
April 2006
