ED-to-ED Transfers: Optimizing Patient Safety

Emergency department transfers are costly and place patients and transport staff at a certain degree of risk. Both ground and air transfer include the possibility of collision, and ED-to-ED transfers should be reserved only for patients who need it. Furthermore, inappropriate transfers remove a transport vehicle and team from use by another patient in true need, resulting in added cost for no value to the patient, and negatively impact the receiving EP, who is left to answer the patient’s questions regarding why they had to be transferred.

An additional point to consider is the management of patient’s expectations when they are being transferred to a facility for more specialized care. At times, patients are led to believe they are being transferred for a certain test or procedure, yet when they arrive at the receiving facility, it is determined that intervention is no longer needed. Better patient communication on the part of the sending facility could help lessen the burden to the staff of the receiving facility when they need to explain why a certain test or procedure was actually not needed, despite the patient’s transfer. This is especially important in rare circumstances when the sending facility is staffed only by a PA or NP and not an ED attending.

Opportunities for Patient Safety Improvement. Active involvement of supervising attending physicians can mitigate the risk of inappropriate ED-to-ED transfers. The active supervisory role of attending EPs in patient care administered by physician extenders and residents is a serious responsibility that deserves priority. Communication with patients regarding their expectations should be initiated by the sending ED provider prior to transport.

Case 3

A primigravid 19-year-old woman at 24 weeks gestation with no prior prenatal care presented to a community hospital ED at 1:50 pm for evaluation of lower abdominal cramping. In addition to cramping, the patient further noted that she had been experiencing vaginal discharge of clear fluid since 6 am, and had been feeling fetal movement. On a gentle sterile speculum examination, the cervix was dilated at 4 cm and revealed visible membranes.

Since this community hospital had closed its obstetrical unit and moved all obstetrical and pediatric services to a sister hospital approximately 9 miles (13 minutes) away, the EP on duty immediately started IV fluids, ordered fetal heart tones (there was no fetal monitoring capability in the hospital), paged the obstetrician (OB) at the sister hospital, and activated an ALS ground transfer unit, all in parallel sequence. The OB on duty returned the page at 2:20 pm as the transporting ambulance arrived; however, he refused to accept transfer of this patient, who was in active preterm labor, stating transfer of any patient in active labor was an Emergency Medical Treatment and Labor Act (EMTALA) violation.

The discussion between the OB and EP included the risks and benefits of immediate transfer in the antenatal period versus the postpartum period; from the perspective of the EP, who had no access to safe fetal monitoring, labor and delivery support, or neonatal intensive care unit (NICU)/pediatric services, such transport was indicated. The EP felt strongly that the benefit of antenatal transfer outweighed the risk of delivering a late second-trimester fetus in an unsupported environment. However, the OB remained firm in his stance, and stated the patient was unstable and therefore could not be transferred under the law.

Hospital administration at the receiving hospital was paged to assist. The hospital administrator on duty returned the EP’s call at 2:57 pm, and agreed that it was safer to transfer the patient, and he would communicate this to the OB. However, by this time, the patient’s contractions had progressed. On reassessment, a fetal foot was evident on the perineum, and the fetus was delivered with an initial Apgar of 3 in the first minute. The nursing staff immediately paged anesthesiology services. After suctioning, the baby girl was immediately intubated by the EP, by which time an anesthesiologist had responded to the call. Intravenous access was obtained, and cardiac monitoring and a warm environment were established. Endotracheal (ET) tube placement confirmation was made by auscultating bilateral breath sounds and chest X-ray. The mother was transported to the community hospital, and arrangements were made to transfer the baby to the pediatric hospital NICU.

The specialized pediatric transport team, with medical control from the pediatric hospital, arrived to transport the premature neonate in critical condition. Care was transferred to the transport team, but while preparing to load the patient into the transport incubator, the team questioned the position of the ET tube; they decided to extubate and reintubate the patient using their specialized equipment. The EP was not made aware of this decision. Unfortunately, after extubation, the transport team was unable to reintubate the neonate, who went into cardiopulmonary arrest and expired in the ED.