Medical Direction of Interfacility Patient Transfers. Policy Resource and. Education Paper. American College of Emergency Physicians

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1 Medical Direction of Interfacility Patient Transfers Policy Resource and Education Paper American College of Emergency Physicians Robert A. Swor DO, FACEP Dan Storer MD, FACEP Robert Domeier MD, FACEP Richard Hunt MD, FACEP Jon Krohmer MD, FACEP Nicholas Benson MD, FACEP Dean Stueland MD, FACEP John Raife MD, FACEP Carl Schultz MD, FACEP 1

2 Medical Direction of Interfacility Patient Transfers I. INTRODUCTION The transfer of patients between facilities is a fundamental component of the health care system. It allows access to various levels of care (emergent, critical, and specialty) for individuals and communities that may not otherwise receive such care. It also facilitates the existence of integrated health care systems, such as occurs in a managed care environment. Many authors have identified both risks and benefits associated with interfacility transfer Transfer of patients was originally identified as one of 15 essential components of Emergency Medical Service (EMS) system design. 13 Transfers are most often managed by ground ambulance personnel, whose primary practice is the provision of EMS care. Transfers may also be performed by air ambulances, especially when critical care or distance issues arise. Transfers occur with the expectation that complications en route may be adequately handled by EMS personnel. Paradoxically, the relationship and authority between the local EMS system and the system to handle interfacility transfer is not well delineated. Currently, the authority to oversee the care of transferred patients is fragmented. EMS systems and their medical directors are knowledgeable regarding system capabilities, but are unclear of the system's role regarding transfer. Referring and receiving physicians know the problems and needs of patients requiring transfer, but are not always cognizant of the capabilities of transferring units and personnel. As a result, patients are sometimes transferred by personnel who are not educated or trained to handle potential patient deterioration or complications of treatment. Patients 2

3 may be transported while using devices or receiving medications (e.g. blood products, thrombolytic agents) beyond the scope of the education of the transferring provider. As health care reform progresses, the demand to regionalize resources and move patients to those resources will increase. The objective of this paper is to discuss the relationship between EMS systems, and the provision of interfacility patient transfer to assist with medical decision-making in the care of the transferred patient. II. RATIONALE FOR PATIENT TRANSFER The medical transportation of patients between health care facilities serves a vital function in the integration and utilization of the health care system. The health system concept of primary, secondary and tertiary care facilities mandates that these resources be tied together by a transport and communication linkage. The volume of this transport is substantial, with an estimated 175,000 annual transports by air alone. 14 The reasons for the transfer of patients between institutions are many, and confer benefit to the individual patient and to the health care system as a whole. Those reasons may be classified as emergent care, continuity of patient care (for both medical and economic reasons) and tertiary care. For the emergent patient, reasons for transfer seem self-evident. Patients may be able to access physicians, technologies, and systems of care at tertiary care facilities that are often not accessible at primary care facilities. Surgical sub-specialties such as cardiovascular and neurosurgery are frequently not available at local institutions, and may only be accessed by patient transfer. Similarly, emergent transport may be required to access technologies such as computerized tomography (CT) and angiography for evaluation and stabilization of the critical 3

4 patient. Baxt and others have documented improved outcomes with emergent transfer of critical trauma patients. 15 Transfer of patients for definitive care, although not on an emergent basis, may be necessary to provide a level of service higher than might otherwise be available to the patient. Definitive care may be at a tertiary care facility or at a nearby institution with services that are not available at the initial hospital. An additional reason for transfer includes continuity of care, by which a patient may receive initial emergent care at a nearby facility and then be transferred to the care of a personal physician. Finally, there may be no medical imperative for transfer at all, with transfer being motivated purely by patient preference. The benefits of transfer to the health care system and society as a whole are readily apparent. Transfer allows the system to avoid needless duplication of health care resources. It allows resources to be planned and developed on a regional basis to maximize efficiency. As managed care systems evolve, transfer will play an integral role to prevent the duplication of resources. The ability to provide a full range of services while controlling cost will be a pivotal issue as health care systems mature. All of these presumptions regarding patient transfer are founded on the premise that transfer can be performed safely. There is a significant body of literature documenting this safety, even when transferring unstable or potentially unstable patients. 2,4,16,17,18 Though some transfers are unavoidable due to a lack of capabilities at the sending facility, Reed documented that a number of those patients could have been more fully stabilized before transfer at the sending facility. 8 Common omissions prior to transport included failure to perform gastric decompression, failure to 4

5 adequately immobilize the cervical spine, inadequate vascular access and poor documentation of patient status. 6 Literature generated in the mid-l980's documented an alarming frequency of transfer for economic reasons, including the transfer of some unstable patients. These transfers potentially placed patients at significant risk during their transport. 8,9,10,19 III. AUTHORITY The regulations governing out-of-hospital emergency medical care vary considerably from state to state. Nearly every state regulates the vehicles, equipment, and personnel which are used to provide both out-of-hospital emergency and transfer care. In some states, the regulations applied to vehicles and personnel responding to calls for EMS differ from those relating to interfacility transports. The regulatory differences may involve the level of education of the personnel, the complexity of monitoring equipment required, and the types of medications and procedures which may be performed. While each state regulates medical care delivered within its borders, it defers the authority for actually establishing the services to local governments, hospital facilities or other organizations. Thus, county commissioners or hospitals may have a significant role in establishing or overseeing an interfacility transfer service. No matter what the authority, typically there are requirements for minimum staffing, communications and other equipment, and medical oversight, ensuring that a licensed physician has overall responsibility for the quality of care. Responsibilities of that physician include implementation of patient care protocols, provision of on-line medical direction, and evaluation of care rendered. In 1986, with amendments in l990 and l994, Congress enacted the "Federal Anti-Dumping Legislation" (COBRA, the Consolidated Omnibus Budget Reconciliation Act, PL , and subsequently EMTLA, Examination and Treatment For Emergency Medical 5

6 Conditions and Women in Labor Act), which were designed to prevent the transfer of patients from one facility to another based solely upon their ability to pay. 20 This legislation outlined specific steps that the transferring physician and transferring facility must perform prior to effecting the transfer. It seeks to ensure that the patient is clinically stable, has consented to the transfer, and may benefit from care available at the receiving hospital that is not available at the referring hospital. IV. RESPONSIBILITY FOR MEDICAL CARE DURING TRANSPORT According to COBRA/EMTLA, patient care during transport until delivery to the receiving facility, unless otherwise specified, is the responsibility of the transferring physician and hospital. The transferring physician is responsible for writing transfer orders, identifying the receiving hospital, method of transport, necessary personnel to accompany the patient, necessary life support equipment to accompany the patient, and medical treatment and drug orders for the duration of the transfer to cover any reasonably foreseeable complications during transfer. This mandate requires knowledge of local statute. In Arizona, for instance, only an authorized medical direction physician may give orders to an EMT. All care rendered during the transport is the responsibility of the local, or agency medical director unless non-ems personnel are utilized. Medical responsibility during transport should be arranged at the time of initial contact between receiving and referring physicians, and transfer orders should be written after consultation between them. Options for medical responsibility during transfer include: (1) transferring physician assumes medical control, (2) receiving physician assumes medical control, (3) medical director of the transport unit assumes medical control, and (4) a shared predefined responsibility with a transfer of control en route when transport distances exceed communication capabilities. 20 Several factors determine the most appropriate individual to exercise medical responsibility. The selection may be primarily based on communication capabilities. If only one physician can maintain direct communication with the transport vehicle during transfer, medical responsibility should be with that physician. If more than one physician has communication capabilities, it is appropriate to assign medical responsibility based on mutual agreement of the referring and receiving physicians. When possible, the determination of medical responsibility should be made in advance by the hospital's transfer committee (if one exists), and should be included in a resource manual as a guide to transfer procedures for the designated receiving hospital. 6

7 A. Legal Implications of COBRA/EMTLA COBRA/EMTLA carries major financial disincentives for physicians and facilities who fail to comply. Failure to comply with each individual component carries a potential personal penalty of $50,000. For physicians and hospitals, continued reimbursement for services provided to Medicare patients may be curtailed or eliminated. (See appendix). Compliance with COBRA/EMTLA requires the following specific assurances: the receiving facility has available space and qualified personnel for the patient; the receiving facility has agreed to accept the patient in transfer; the receiving facility receives appropriate copies of the patient's medical record, including radiographs; the patient is transferred by qualified personnel and appropriate equipment; and the patient is stabilized to the fullest extent capable by the referring facility prior to the transfer. The most frequent area of action against physicians or referring facilities resulting from COBRA thus far has dealt with women in labor. COBRA/EMTLA provides rather broad language of what constitutes active labor, in its attempt to provide every possible protection for women in labor. Federal statutes addressing interfacility transfer of patients primarily focus on the transfer of indigent patients, but have implications that effect how all interfacility transfers are made. Review of the statutory and other legal controls over interhospital transfers have recently been precipitated by amendments to COBRA, and the fining of a Texas physician for transferring a high-risk obstetric patient without following statutory guidelines (Inspector General vs. Burditt). 21 In the Burditt case, the patient was transferred in "active labor," but the ambulance in which she was transferred did not have fetal monitoring and the patient was not accompanied by a physician trained in emergency delivery. What is disturbing about this violation, is that the administrative judge interpreted the 7

8 statute to require a more sophisticated ambulance transfer than is generally available. If this interpretation is in fact correct and "qualified personnel and transportation equipment" requires a higher level of care than what is generally available, then the statute establishes a very stringent standard for transport. A transfer will be judged appropriate only if preparations are made to make the transfer as safe as possible for a given condition, regardless of what resources are typically used or available. Responsibility for interfacility transfer then, appears to be shared: The EMS system and its medical director are responsible for obtaining licensure, developing operational standards, and defining the scope of practice of the personnel (off-line medical direction), and the transferring physician is responsible for the care of the individual patient during transfer (on-line direction). For those services whose sole function is patient transfer, such as air medical services, and hospital based critical care transport services, the off-line direction becomes the responsibility of the service medical director and the on-line direction also becomes the responsibility of medical director or his/her designee. B. On-Line Medical Direction On-line medical direction for interfacility transport carries the same importance as on-line medical direction for EMS systems involved primarily in out-of-hospital emergency medical care. The online medical direction system allows the physician to give direct orders to manage those conditions not addressed by standing orders or protocols. To be effective, there must be a system available to allow voice communication from the transport team to an appropriate physician. On-line medical direction capability is essential for medical personnel functioning outside the hospital. When continuous communication is not available during transport, written transfer orders must include 8

9 sufficient instructions to allow the personnel attending the patient to respond appropriately to medical crises and changing patient status. Standing orders or protocols may be developed off-line to meet these needs. The referring physician must consider that the existing out-of-hospital protocols found in EMS systems may not be automatically transferable to the environment of the interhospital transfer. C. Off-line Medical Direction Off-line medical direction represents the foundation of physician responsibility and involvement with interfacility transfer as it does with traditional EMS systems. Any transport service that provides medical care during transport must have a medical director. The off-line medical director assumes responsibility for the overall quality of health care delivered by an interfacility transport system. The medical director must have authority commensurate with that responsibility, including ultimate authority in medical matters. This includes, but is not limited to, the establishment of standing orders and protocols for treatment of patients during transfer. Additionally, the medical director must have the authority to approve transfer team composition, credential team members and set standards for training requirements. It should be noted that off-line medical direction may not currently exist for basic services in some states, where medical direction at that level is not required. The ideal off-line medical director is a trained emergency physician who is active in the practice of emergency medicine and has a particular interest and expertise in EMS systems and interfacility patient transfer. Treatment protocols are an essential component of off-line medical direction. They are documents that define the scope of practice for personnel during patient transfer and provide the basis for a uniform quality of care throughout a system. Treatment protocols become the basis for the initial training and continuing education for transfer team members. Additionally, they form the basis for ongoing monitoring of the system. They define the scope of health care delivery within the interfacility transport system, providing transferring facilities and physicians with information regarding the skills and knowledge of the transfer team. Accordingly, these protocols are the responsibility of the off-line medical director. Frequently, treatment protocols and standing orders are developed by medical advisory committees, which include representatives from various specialties whose areas of expertise include disease processes that might be encountered during the interfacility transport. Standing orders define the out-of-hospital interventions that are authorized prior to receiving on-line medical direction. They are more specific than treatment protocols, and are included in a protocol for 9

10 situations in which a delay in treatment might have a deleterious effect on outcome. An example would be authorization in a cardiac arrest to defibrillate, start an IV, and intubate before establishing radio communication with on-line medical direction. Because standing orders authorize nonphysicians to perform invasive procedures in the absence of direct orders, they must be developed and signed by the off-line medical director. Standing orders should be standardized throughout the system to ensure uniformity and prevent confusion. Because most EMS system protocols are crafted to address the scope of emergent interventions, basic transfer protocols and standing orders should be similar to protocols developed by the local EMS system. V. PATIENT CARE DURING TRANSFER The decision to transfer a patient must be preceded by an analysis of the potential benefits of the transfer measured against the potential risks. There are risks during transport to not only the patient but to the transport personnel as well. 22 Whenever possible, the patient must be involved early in the transfer decision. If the patient's condition makes this impractical, the family must be involved with the decision. 9,23,24 The risk/benefit analysis should include a determination of the patient's current medical problems and the most suitable facility for management. In addition, the patient's likelihood for deterioration without transfer, the urgency of definitive management, and the availability of tertiary resources must be factored into the decision to transfer. There is significant risk of deterioration during the transfer of critically ill patients. 5,6,7,16 Prior to initiation of a transfer, the patient should be adequately monitored and stabilized. The extent to which this can be accomplished is dependent on the resources available at the transferring 10

11 institution, the type of medical problem and the age of the patient. In some cases, such as seriously ill pediatric and neonatal patients, adequate stabilization prior to transfer may be best accomplished by a specialty transport team. 17,25 To achieve stability trauma patients may require interventions unavailable at the referring facility. 6,26 Obstetric patients and women in labor present special problems and considerations. 27 To avoid the potential complications of a delivery during transfer, patients in active labor should generally be delivered prior to transfer, even in the case of high risk pregnancy. Resources to care for mother and child at the referring facility are far superior to that available in any transporting unit. Once delivered, mother and child can be more safely transferred if necessary. A. Methods and Level of Transfer Important considerations in choosing the mode of transport and level of care during transfer include time and distance. For the unstable critical patient, rapid interfacility transport to a more comprehensive facility is required. In contrast, non-emergent interfacility transfer may not require speed or sophisticated transfer services. Interstate, as well as international transports, require significantly more complex planning. B. Air vs. Ground Transport Air medical transport services include fixed and rotor-wing aircraft. Like ground services, air medical services have diverse equipment and personnel configurations. Some aircraft may carry equipment as sophisticated as neonatal isolettes or intra-aortic balloon pumps, while others are equipped as basic life support units. The medical crew configuration is most commonly a combination of a registered nurse and a paramedic; however, personnel range from basic EMTs to physicians. 28 Most air medical services have on-line and off-line medical direction, and most are hospital based. The Commission on Accreditation of Air Medical Services' (CAAMS) voluntary accreditation standards address equipment, personnel and medical direction for four levels of care: 11

12 critical care, advanced life support, basic life support, and specialty care. 29 Factors that distinguish air from ground interfacility transport are speed, crew composition and capabilities, the ability of the aircraft to cover a larger service area, and the potential for weather to restrict air transport. If ground and air medical services have equivalent trained personnel and identical equipment, then the speed of transport required becomes the determining factor for mode of transport. Speed also confers benefit to patient care by decreasing out of hospital time. In addition, most air medical services have at least a registered nurse/paramedic crew configuration which commonly provides a higher level of care compared to ground EMS services. Other factors, including safety and cost are important in guiding appropriate utilization of air medical services. Safety of air medical transport should be compared to the safety of ground transport. The cost of an individual patient flight is higher than the same transport by ground. However, a recent study has shown that to provide the same level of care to the same coverage area, an air medical service with one helicopter would be less costly than a ground service which would require six vehicles. 30 To assist transferring physicians with transfer decisions, The Association of Air Medical Services' Medical Advisory Committee has published a Position Paper on the Appropriate Use of Emergency Air Medical Services. 14 It should be noted that there is no clear data demonstrating improved outcomes for interfacility transfer of patients by air when compared to ground. C. Equipment Most equipment that is used for monitoring and treatment of patients in critical care and emergency settings can be transported or has transportable equivalents. The equipment necessary for a transfer will vary depending on the severity of illness of the patient. Minimum necessary 12

13 equipment includes: Oxygen and equipment for airway control 2. Cardiac monitor/defibrillator 3. BP cuff or monitor 4. Suction apparatus 5. Standard ALS drug box 6. Communications equipment to allow contact with either the referring and receiving hospitals. As the severity of illness increases more advanced equipment is required. Intubated patients can usually be safely transferred short distances with manual ventilation. 31 However, as reliable transport ventilators are becoming more economical they are becoming more widely used. 32 Intubated patients should have continuous pulse oximetry, and end-tidal CO 2 monitoring available for transport. 22 Other more complex equipment that can be transported, usually in conjunction with a specialty transport team, include balloon pumps (relatively lightweight units are available for ground and air transport), and Extra-corporeal membrane Oxygenator (ECMO) for pediatric and adult patients. The ideal interfacility patient transport would be staffed to continue the evaluation and treatment of the patient en route to ensure continued improvement or stabilization of the patient condition. This is usually not feasible. What can be expected, however, is a transfer with sufficient equipment and personnel to assure little or no deterioration of the patient due to preventable causes during transfer. With adequate personnel and preparation, a wide variety of seriously ill patients can 13

14 be transported safely. 2,7,16,33 Personnel needed to provide an appropriate level of care during the transport are often not available at, or cannot be spared from the sending facility. Specialty transport teams can be used to supplement appropriate personnel for a transfer. These teams usually have personnel who are specially trained and more importantly have significant experience in the management of critical care transports. 16,34,35,36 The level of training required for interfacility transport depends on the severity of illness. EMTs and paramedics transport the vast majority of all interfacility transports, the largest share of these being stable patients. 11 As the severity of illness of the patient increases, the level of training of the transport personnel must also increase. Specially trained paramedics or nurses provide the majority of staffing for seriously ill patients. As the scope of practice of paramedics expands, so will their use in transferring seriously ill patients. 37 The need to use physicians in air medical and pediatric transport teams has been questioned. 17,38 The need for physicians during transport is probably limited to the most serious patients requiring frequent interventions. In several areas specially trained paramedics have been utilized to provide critical care transport services traditionally provided by either hospital nursing personnel or air ambulance transport services. The paramedics are trained in the use of portable ventilators, intravenous drip pumps, the care of patients with invasive monitoring lines and chest tubes, and intravenous pacemaker maintenance. These paramedic-staffed mobile intensive care units can provide quality care to patients undergoing interfacility transfer. 37 Strong medical direction, clear patient selection guidelines, quality monitoring and continuing education are vital for the success of any interfacility 14

15 transport program. VI. EMS SYSTEM IMPLICATIONS Interfacility transports have multiple implications for an EMS system. If a local EMS system is responsible for interfacility transport, taking an emergency response unit and its personnel out of service may decrease the EMS system's ability to respond to emergency calls. This is especially true when the EMS system is staffed by volunteers. The EMS system's involvement in interfacility transport should be considered to ensure adequate resources to meet the demands of both emergency calls and interfacility transport needs. The system will need to be responsive with personnel, equipment and vehicles to meet the specific needs of interfacility transport; frequently, the needs are quite different from those of emergency responses. 39 VII. DOCUMENTATION As with all other areas of medical care, documentation, data collection and reporting to appropriate health care providers, is critical to ensuring proper medical care and medicolegal protection. The format for documentation of interhospital facility transfer information should be established by the off-line medical direction system and should focus on physiologic monitoring, patient care interventions, and general changes in patient condition during transfer. VIII. QUALITY MANAGEMENT Quality management is essential to the design of off-line and on-line medical direction systems and provides the ongoing review of the existing system of care. Programs must be tailored to each service, and should focus on the processes of patient transport as well as the individual patient care rendered. Data sources will include on-site observation by physicians or supervisors, review of tapes and written records, retrospective or prospective studies of patient outcomes, or 15

16 computer-aided reviews for educational planning. IX. SUMMARY It is clear that hospitals and physicians that arrange for the transfer of patients by ground or air ambulance, do so with the expectation that a system is in place for appropriate patient care during that transport. This expectation is based on experience with the day to day functioning of organizations within EMS systems. EMS system providers must render their customary scope of practice to transferred patients, as defined by policies and protocols. This scope of practice must be defined for referring hospitals and physicians, so that appropriate provision for care can be made for each individual patient. The definition of this scope of practice and the assurance that patient care is rendered consistent with it are essential off-line medical direction functions. Unless an alternative system for off-line medical direction is in place, such as hospital based critical care transport or air medical services, off-line medical direction for interfacility transfer of patients is the responsibility of the EMS system and its medical director. The direct responsibility for patient care is the responsibility of the referring hospital and physician. All these groups must be knowledgeable regarding the needs of the transfer patient and the capabilities of the system utilized to transfer them. 16

17 Appendix EXAMINATION AND TREATMENT FOR EMERGENCY MEDICAL CONDITIONS AND WOMEN IN LABOR Section 1867 (2) APPROPRIATE TRANSFER - An appropriate transfer to a medical facility is a transfer: (A) in which the transferring hospital provides the medical treatment within its capacity which minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child; (B) in which the receiving facility (I) has available space and qualified personnel for the treatment of the individual, and (ii) has agreed to accept transfer of the individual and to provide appropriate medical treatment; (C) in which the transferring hospital sends to the receiving facility all medical records (or copies thereof), related to the emergency condition for which the individual has presented, available at the time of the transfer, including records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests and the informed written consent or 17

18 certification (or copy thereof) provided under paragraph (1)(A), and the name and address of any on-call physician (described in subsection (d)(1)(c) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; (D) in which the transfer is effected through qualified personnel and transportation equipment, as required including the use of necessary and medically appropriate life support measures during the transfer, and (E) which meets such other requirements as the Secretary may find necessary in the interest of the health and safety of individuals transferred. 18

19 Bibliography 1. Braman SS., Dunn SM., Amico CA, et al. Complications of intra hospital transport in critically ill patients. Ann Int Med 1987;107: Ehrenwerth J., Sorbo S., Hackel A. Transport of critically ill adults. Crit Care Med 1986; 14: Andrews P., Piper I. Dearden N., Miller J. Secondary insults during intra hospital transport of head-injured patients. Lancet, (1990) 335, Kanter R., Tompkins J. (1989) Adverse events during interhospital transport: physiologic deterioration associated with pre-transport severity of illness. Pediatrics, 84(1), Katz V. & Hansen. A. (1990) Complications in the emergency transport of pregnant women. Southern Medical Journal, 83(1), Martin, G., Cogbill, T., Landercasper, J. & Strutt, P. (1990) Prospective analysis of rural interhospital transfer of injured patients to a referral trauma center. Journal of Trauma, 30(8), Valenzuela, T., Criss, E., Copass, M., Luna, G., & Rice, C. (1990) Critical care air transportation of the severely injured: Does long distance transport adversely affect survival? Annals of Emergency Medicine, 19(2), / Reed WG, Cawley KA, Anderson PJ. The effect of a public hospital's transfer policy on patient care. N Engl J Med. 1986; Kellermann AL, Hackman BB. Emergency department patient 'dumping': An analysis of interhospital transfers to the regional medical center at Memphis, Tennessee. Am J Public Health. 1988;78: Schiff RL, Ansell DA, Schlosser JE, Idris AH, Morrison A, Whitman S. Transfer to a public hospital: A prospective study of 467 patients. N Engl J Med. 1986;314: Wuerz R, Meador S. Adverse events during interfacility transfer by ground advanced life support services. Prehosp Dis Med 1994;9(1): Kerr HD, Byrd JC: Community hospital transfers to a VA Medical Center. JAMA 1989;262: Boyd, DR. The history of emergency medical services (EMS) systems in the United 19

20 States of America. Systems Approach to Emerg Med Care 1983;1: Association of air medical services. Position paper on the appropriate use of emergency air medical services. Journal of Air Medical Transport, September 1990; Baxt WG. The impact of a rotor craft aeromedical emergency care service on trauma mortality. JAMA 1983;249: Gore JM., Feasibility and safety of emergency interhospital transport of patients during early hours of acute myocardial infarction. Arch Int Med 1989;149: McCloskey, K., King, WL & Byron L. (1989) Pediatric critical care transport: Is a physician always needed on the team? Annals of Emergency Medicine: 18(3), Waddell G, Scott PDR, Lees NW, Ledingham IM: Effects of ambulance transport in critically ill patients. BR Med J 1975; 1: Himmelstein DU, Woolhandler S, Harnly M, et al. Patient transfers: medical practice as social triage. Am J Public Health, 1984;74: Frew S: Patient Transfers: How to comply with the law. Dallas: American College of Emergency Physicians, Burditt v US Department of Health and Human Services, 934 Federal 2nd District Court 1362, 5th Circuit, Society of Critical Care Medicine: Guidelines for the transfer of critically ill patients. Crit Care Med 1993; 21(6): American College of Emergency Physicians: Principles of appropriate patient transfer. Ann Emerg Med 1990; 19: American College of Emergency Physicians: Appropriate interhospital patient transfer. Ann Emerg Med 1993; 22: Interhospital Transport of Patients. In resources for optimal care of the injured patient. American College of Surgeons. Chicago: Sternbach G., Sumchai AP: Is aeromedical transport of patients during acute myocardial infarction safe? Am J Emerg Med 1989;7: Hackel A, Simon JE, Wingert WA, Bergeson PS: Guidelines for air and ground transportation of pediatric patients. Pediatrics 1986; 78:

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