ED-to-ED Transfers: Optimizing Patient Safety

Emergency Department (ED)-to-ED transfers are a reality of practice in emergency medicine, and they can certainly present a tall order for ensuring patient safety. Challenges abound in getting the right patient to the right place at the right time by the right transportation method.¹ A critically ill patient becomes a metaphorical baton to be passed on, requiring the best care along the way--even when the patient is not completely aware of the reasons for the transfer of care. For some EDs, ED-to-ED transfers have become a common daily occurrence. The realities of freestanding EDs, hospital overcrowding, and subspecialty coverage gaps create challenges in direct hospital admission, necessitating a second ED stop before the patient reaches an appropriate destination and provider for definitive care.

The transfer of a patient is much more complex than arranging and carrying out an ambulance ride across town. If thought of as a process, with pre-transfer planning on the sending end, the transfer itself, and post-transfer assurance of care continuity on the receiving end, the quality of care and patient safety can be elevated. Emergency department-to-ED transfers require careful attention to communication, with important hand-offs between the sending facility, the ambulance personnel, and the receiving facility. To lead the discussion around the perils of interhospital ED-to-ED transfers, the following case reports illustrate some of the challenges encountered.

Case Scenarios

Case 1

A 58-year-old man presented to a freestanding ED at 10:30 am with an approximate 1-hour history of severe epigastric pain. He was in significant distress and complained of nausea, noting that he had never experienced anything similar in the past. His remote medical history was significant for high blood pressure (BP), and he had no prior abdominal surgeries. The patient admitted to significant near daily alcohol use, but he denied tobacco use. Vital signs at presentation were: heart rate (HR), 41 beats/min; respiratory rate (RR), 18 breaths/min; BP, 205/110 mm Hg; and temperature (T), 98.4°F. Oxygen saturation was 97% on room air. On physical examination, the patient’s abdomen was distended but nontender to palpation; distal pulses were symmetrical and equal in the upper and lower extremities.

The nursing staff obtained intravenous (IV) access, and blood samples were drawn. Parenteral pain control and antiemetics were administered while a computed tomography (CT) scan of the abdomen and pelvis with contrast was emergently in progress. Meanwhile, the laboratory test results included the following: lactate, 3.8 mmol/L; lipase 42 U/L; carbon monoxide, 14 mmol/L; white blood cell count (WBC), 12 x 10⁹/L without bandemia; serum creatinine, 1.0 mg/dL; liver function tests with a mild elevation of transaminases; and normal coagulation studies.  

After reviewing the CT scan, the radiologist called to report a hyperdensity in the lumen of the superior mesenteric artery, which might represent a subsegmental dissection or a partial occlusion or plaque, with no radiographic evidence of bowel ischemia. Vascular surgery service was consulted, and the decision to start IV heparin was agreed upon. The vascular surgeon requested that a mesenteric peripheral vascular laboratory examination (PVL) be arranged on arrival at the hospital ED, and an ED-to-ED transfer to the hospital was arranged. The case was discussed with the receiving day shift emergency physician (EP), who planned to order the mesenteric PVL immediately upon the patient’s arrival.

Emergent transportation via an advanced life support (ALS) ambulance was arranged. The nursing report was called in to the hospital ED at noon, and the ALS unit had arrived and was ready to transfer the patient. Repeat vital signs were obtained, revealing an HR of 45 beats/min and a BP of 200/100 mm Hg.

After an uneventful transport, the patient arrived at the hospital ED at 12:45 pm during a very high-volume, double EP-covered shift. The nursing staff notified the accepting EP of the patient’s arrival. The EP placed the order for the mesenteric PVL. Within an hour from arrival, the nursing staff noted that the patient had become diaphoretic and was complaining of a headache and notified the day shift EP. The day shift EP then placed an order for an emergent head CT scan without contrast, but did not evaluate the patient at the bedside. A work-shift change occurred at 2:00 pm while the patient was in the CT scanner. The oncoming evening shift provider team included a physician assistant (PA) and an attending EP. The PA arrived at the ED first that day and was approached by nursing to assist the patient; the PA immediately went to the patient’s bedside when he returned from the radiology department. The patient was drowsy, but communicated he was experiencing a bad headache with double vision. The PA moved the patient to the resuscitation room, and the oncoming EP immediately went to the bedside, stopped the heparin infusion, gave protamine, and intubated the patient. The CT scan of the head revealed an acute subarachnoid hemorrhage.