Rationalisaton of services means not all services and specialities are available in all hospitals. The most common example of this is the regionalisation of major trauma services, whereby most hospitals are designated either major trauma centres (MTS) or trauma units and patients with serious injuries bypass trauma units to the major trauma centres. Other specialised centres where patients are routinely transported by ambulance include specialist hospitals designated as “heart attack centres”, where primary cardiac interventions are undertaken, or stroke units, where thrombolysis is available. However, many patients do not avail themselves of the ambulance service and may attend their local hospital with conditions that require specialist care that is not available at that hospital.
When a patient presents to the Emergency Department with a condition that can’t be discharged and needs specialist care, the decision to transfer the patient to the specialist centre is a decision revolving around how the patient can best get access to the care they need. There are two options: the patient can either be transferred to the specialist for the care or, if their condition is unstable and there is a risk that transfer may lead to worsening of their condition or indeed death , then the specialist can be called to attend the patient where they are.
It is imperative that the patient be stabilized prior to a transfer. This is especially important when it comes to airway and breathing problems. These need to be sorted at the base hospital or will require a specialist to be called in, thus foregoing a transfer. Any immediate, life-threatening condition must be addressed before deciding on a transfer to minimize as much as possible the possibility of deterioration during transfer. Circulation problems may be suitable for transfer particularly, if the bleeding can be controlled before transfer. Stable patients with time critical conditions may require urgent transfer whereas those who can be managed less urgently may be able to be transferred only during daylight hours.
If it is determined that an immediate transfer is necessary and possible, there are several factors that need to be taken into account. These include the timing of the transfer and the personnel chosen to accompany the patient. There is high morbidity and mortality associated with the transfer of trauma patients, so these decisions can have a major impact. Often the team chosen to accompany a transfer patient is relatively junior, which can lead to an increase of the rate of critical incidents as they may not be properly equipped to handle issues that may occur during the transfer of a critically ill patient. Sometimes, the consideration of whom to send for a transfer also depends on staff availability and current needs; it is important that the transfer not impede the care of other critically ill patients receiving care at the outgoing facility. Sometimes, the best option may be to rely on a specialised retrieval service from the receiving ED and this is commoner for the transfer of paediatric patinets to specialist paediatric hospitals. However, this means the transfer will be delayed due to the need to wait for the transfer team to arrive. All these factors should be weighed when considering the logistics of the transfer as to best serve the needs of the patient.
Transferring patients is an inevitable part of an ED clinician’s work. It is essential that the clinician follows all steps to minimize morbidity and mortality in patients requiring a transfer, such as addressing any immediate, life-threatening concerns, determining whether the patient is stable enough to be transported or needs immediate specialist attention, making a decision on the appropriate team to conduct the transfer based on the condition of the patient. Following these steps will ensure that each patient receives the highest standard of care and that the clinician has acted to the best of their ability.
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