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10 trauma patient transfers

10 trauma patient transfers






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    10 trauma patient transfers 10 trauma patient transfers Presentation Transcript

    • Trauma Patient Transfers What, When, How? Charles F. Rinker, II MD, FACS
    • ACSCOT
      • Does not dictate whom to transfer
      • …but local statutes might
      • Publishes guidelines regarding clinical conditions that might warrant transfer
      • Expects trauma program to review outcomes, adjust accordingly
    • Basic Principles
      • When in doubt…transfer
      • Do what is best for the patient
      • Be realistic about your ability to treat
        • Personal capabilities
        • Institutional capabilities
      • Understand EMTALA
      • Know state statutes/trauma system regulations
      • Transfers go upstream, not down
    • Be Prepared
      • Trauma program with GS leadership
      • Involvement with EMS
      • Trauma team, activation criteria
        • Scene transport
        • Bypass
      • Collegial relationship with regional trauma center/participation in trauma system
      • Transfer agreements
      • Performance review
    • Define Your Trauma Patient
      • Surgical, medical specialties
      • Imaging equipment
      • Operating room(s)
      • ICU
      • Ancillary services
      • Proximity to other trauma centers
      • Interhospital transfer capabilities
    • EMTALA
      • Emergency Medical Treatment and Active Labor Act
      • Intended as “anti-dumping” legislation
      • Effectively a federal guarantee for access to emergency care
      • Draconian penalties
      • Law of unintended consequences
    • Compliance with EMTALA
      • Early evaluation, Rx in ED
      • Identify, document need for transfer
      • Consult with receiving hospital, and assist in transfer arrangements
      • Stabilize to degree possible before transfer
      • Best defense: ability to demonstrate actions are in best interest of patient (i.e., pt needs exceed resources)
      • Potential loss of Medicare approval
    • Penalties
      • Failure to properly evaluate emergency medical condition
      • Inappropriate transfer
        • Medical condition not stabilized
        • Service could have been provided at transferring institution
        • Failure to receive approval from receiving institution
      • Refusal to accept patient, despite apparent need for transfer
    • Treatment Options
      • Stabilization and transfer to definitive care
      • Operative stabilization and transfer
      • Local definitive care
    • WHAT to Transfer?
      • Patients at the extremes of age
      • Major burns
      • Multisystem trauma
      • Serious comorbidities
      • Patient or family request (if feasible)
      • Any condition or constellation of injuries that exceeds local resources (personnel, equipment, back-up)
    • WHEN to Transfer?
      • As soon as
        • Need is identified
        • Consultation with receiving hospital accomplished
        • Transport arrangements completed
        • Patient is properly stabilized (remember EMTALA)
      • Avoid unnecessary tests, procedures, “wallet biopsies”
    • HOW to Transfer?
      • Surface v. air: depends on
        • Available resources
        • Patient condition/needs
      • Accompanied by
        • Appropriate personnel
        • Records, test results, images
        • Medications, blood, supportive equipment
      • To higher level of care, preferably within a trauma system
    • HOW to Transfer?
      • Transfers should not be viewed as loss of surgical manhood
      • Goal: efficiency and appropriateness
      • Resuscitate and arrange for transfer simultaneously rather than sequentially.
        • Dispatch of transport vehicle is principal rate-limiting step
    • Stabilization
      • Proceed according to ATLS guidelines
        • Controlled airway
        • Satisfactory ventilatory status with/without support
        • Hemodynamically normal
        • Neurologic status normal or improving
        • At or approaching normothermia
        • Fractures splinted, wounds dressed, other indicated interventions completed
      • Now safe to transfer, if needed
    • Unstable Patients
      • Must control airway, breathing before transfer
      • Hemodynamics
        • Transient or non-responders: identify and control, if possible, source of hemorrhage (thoracotomy, laparotomy, wound exploration, ex-fixators, etc.)
      • Intracranial mass lesion: consult with NS
        • Ventilatory, pharmacologic maneuvers
        • Burr holes
      • Hypothermia: various warming methods
    • Summary
      • Identify the need for transfer early
      • Proceed efficiently
      • Know your limitations
      • Know the law
      • Do all within your power to stabilize prior to transfer
      • Act in the best interest of the patient
    • ?