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10 trauma patient transfers


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10 trauma patient transfers

  1. 1. Trauma Patient Transfers What, When, How? Charles F. Rinker, II MD, FACS
  2. 2. ACSCOT <ul><li>Does not dictate whom to transfer </li></ul><ul><li>…but local statutes might </li></ul><ul><li>Publishes guidelines regarding clinical conditions that might warrant transfer </li></ul><ul><li>Expects trauma program to review outcomes, adjust accordingly </li></ul>
  3. 3. Basic Principles <ul><li>When in doubt…transfer </li></ul><ul><li>Do what is best for the patient </li></ul><ul><li>Be realistic about your ability to treat </li></ul><ul><ul><li>Personal capabilities </li></ul></ul><ul><ul><li>Institutional capabilities </li></ul></ul><ul><li>Understand EMTALA </li></ul><ul><li>Know state statutes/trauma system regulations </li></ul><ul><li>Transfers go upstream, not down </li></ul>
  4. 4. Be Prepared <ul><li>Trauma program with GS leadership </li></ul><ul><li>Involvement with EMS </li></ul><ul><li>Trauma team, activation criteria </li></ul><ul><ul><li>Scene transport </li></ul></ul><ul><ul><li>Bypass </li></ul></ul><ul><li>Collegial relationship with regional trauma center/participation in trauma system </li></ul><ul><li>Transfer agreements </li></ul><ul><li>Performance review </li></ul>
  5. 5. Define Your Trauma Patient <ul><li>Surgical, medical specialties </li></ul><ul><li>Imaging equipment </li></ul><ul><li>Operating room(s) </li></ul><ul><li>ICU </li></ul><ul><li>Ancillary services </li></ul><ul><li>Proximity to other trauma centers </li></ul><ul><li>Interhospital transfer capabilities </li></ul>
  6. 6. EMTALA <ul><li>Emergency Medical Treatment and Active Labor Act </li></ul><ul><li>Intended as “anti-dumping” legislation </li></ul><ul><li>Effectively a federal guarantee for access to emergency care </li></ul><ul><li>Draconian penalties </li></ul><ul><li>Law of unintended consequences </li></ul>
  7. 7. Compliance with EMTALA <ul><li>Early evaluation, Rx in ED </li></ul><ul><li>Identify, document need for transfer </li></ul><ul><li>Consult with receiving hospital, and assist in transfer arrangements </li></ul><ul><li>Stabilize to degree possible before transfer </li></ul><ul><li>Best defense: ability to demonstrate actions are in best interest of patient (i.e., pt needs exceed resources) </li></ul><ul><li>Potential loss of Medicare approval </li></ul>
  8. 8. Penalties <ul><li>Failure to properly evaluate emergency medical condition </li></ul><ul><li>Inappropriate transfer </li></ul><ul><ul><li>Medical condition not stabilized </li></ul></ul><ul><ul><li>Service could have been provided at transferring institution </li></ul></ul><ul><ul><li>Failure to receive approval from receiving institution </li></ul></ul><ul><li>Refusal to accept patient, despite apparent need for transfer </li></ul>
  9. 9. Treatment Options <ul><li>Stabilization and transfer to definitive care </li></ul><ul><li>Operative stabilization and transfer </li></ul><ul><li>Local definitive care </li></ul>
  10. 10. WHAT to Transfer? <ul><li>Patients at the extremes of age </li></ul><ul><li>Major burns </li></ul><ul><li>Multisystem trauma </li></ul><ul><li>Serious comorbidities </li></ul><ul><li>Patient or family request (if feasible) </li></ul><ul><li>Any condition or constellation of injuries that exceeds local resources (personnel, equipment, back-up) </li></ul>
  11. 11. WHEN to Transfer? <ul><li>As soon as </li></ul><ul><ul><li>Need is identified </li></ul></ul><ul><ul><li>Consultation with receiving hospital accomplished </li></ul></ul><ul><ul><li>Transport arrangements completed </li></ul></ul><ul><ul><li>Patient is properly stabilized (remember EMTALA) </li></ul></ul><ul><li>Avoid unnecessary tests, procedures, “wallet biopsies” </li></ul>
  12. 12. HOW to Transfer? <ul><li>Surface v. air: depends on </li></ul><ul><ul><li>Available resources </li></ul></ul><ul><ul><li>Patient condition/needs </li></ul></ul><ul><li>Accompanied by </li></ul><ul><ul><li>Appropriate personnel </li></ul></ul><ul><ul><li>Records, test results, images </li></ul></ul><ul><ul><li>Medications, blood, supportive equipment </li></ul></ul><ul><li>To higher level of care, preferably within a trauma system </li></ul>
  13. 13. HOW to Transfer? <ul><li>Transfers should not be viewed as loss of surgical manhood </li></ul><ul><li>Goal: efficiency and appropriateness </li></ul><ul><li>Resuscitate and arrange for transfer simultaneously rather than sequentially. </li></ul><ul><ul><li>Dispatch of transport vehicle is principal rate-limiting step </li></ul></ul>
  14. 14. Stabilization <ul><li>Proceed according to ATLS guidelines </li></ul><ul><ul><li>Controlled airway </li></ul></ul><ul><ul><li>Satisfactory ventilatory status with/without support </li></ul></ul><ul><ul><li>Hemodynamically normal </li></ul></ul><ul><ul><li>Neurologic status normal or improving </li></ul></ul><ul><ul><li>At or approaching normothermia </li></ul></ul><ul><ul><li>Fractures splinted, wounds dressed, other indicated interventions completed </li></ul></ul><ul><li>Now safe to transfer, if needed </li></ul>
  15. 15. Unstable Patients <ul><li>Must control airway, breathing before transfer </li></ul><ul><li>Hemodynamics </li></ul><ul><ul><li>Transient or non-responders: identify and control, if possible, source of hemorrhage (thoracotomy, laparotomy, wound exploration, ex-fixators, etc.) </li></ul></ul><ul><li>Intracranial mass lesion: consult with NS </li></ul><ul><ul><li>Ventilatory, pharmacologic maneuvers </li></ul></ul><ul><ul><li>Burr holes </li></ul></ul><ul><li>Hypothermia: various warming methods </li></ul>
  16. 16. Summary <ul><li>Identify the need for transfer early </li></ul><ul><li>Proceed efficiently </li></ul><ul><li>Know your limitations </li></ul><ul><li>Know the law </li></ul><ul><li>Do all within your power to stabilize prior to transfer </li></ul><ul><li>Act in the best interest of the patient </li></ul>
  17. 17. ?