Difference between revisions of "Harbor:Incoming transfers"

(Text replacement - "Harbor:Operations manual" to "Harbor:Main")
(Overview)
 
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==Overview==
 
==Overview==
 
There are generally four types of transfers that come into the emergency department:
 
There are generally four types of transfers that come into the emergency department:
*"STEMI 911" and "Trauma 911" Transfers - these are transfers from other emergency departments in our area that are not Trauma Centers or STEMI centers. Since we are both a Trauma Center and a STEMI center we have agreed to take urgent transfers from other emergency departments if they feel their patient needs these services. The sending facility may contact you directly. We rarely say "no" to these cases as long as we are "open" to trauma and STEMI patients (ask the MICN/Radio Nurse or Charge Nurse about our status), and just take information and activate the appropriate resources within our facility. The sending facility is responsible for calling EMS and arranging for the emergent transfer. Note: these transfers are from the emergency department, and should not be from the inpatient units of the sending hospital.  
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*'''STEMI 911''' and '''Trauma 911''' Transfers
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** From nearby EDs that are not Trauma Centers or STEMI centers
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** Ensure we are "open" to trauma and STEMI patients (ask the MICN), and activate the appropriate resources within our facility
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** The sending facility is responsible for calling EMS and arranging for the emergent transfer.  
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** Note: these transfers are from the emergency department, and should not be from the inpatient units of the sending hospital.  
  
 
* Transfers should be ED to ED;  if there are extenuating circumstances where an inpatient requires transfer to Harbor ED, do what is in the best interest of the patient;  the DEM Chair will happily provide advice or address any questions/concerns 24/7
 
* Transfers should be ED to ED;  if there are extenuating circumstances where an inpatient requires transfer to Harbor ED, do what is in the best interest of the patient;  the DEM Chair will happily provide advice or address any questions/concerns 24/7
  
*EMTALA or "Higher Level of Care": we consider accepting these as long as we are open to "EMTALA Transfers" - check with the charge nurse. Depends on our Surge status. In order for us to accept these transfers from other emergency departments, they must be approved by all of the following:
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*EMTALA or '''Higher Level of Care''': we accept these as long as we are not in Surge status.
**The subspecialty service that will likely be involved in the care of the patient (they determine if they have the right personnel and equipment to care for the patient.) The trauma service may serve as approval authority for all surgical patients, whether trauma or not.
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** Prior to us accepting the patient, they should be approved by:
**The Patient Flow Facilitator ("PFF" - he or she determines if we have the right bed type available - the bed must be currently open)
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*** The subspecialty service that will likely be involved in the care of the patient
**The Emergency Department (we determine if we are uncrowded enough to safely take another patient). A general approach is to look at how many ESI 2 patients are waiting to be seen, and how far backed up we are with triaging, and to a lesser extent how many total patients are waiting to be seen.
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***The trauma service may serve as approval authority for ALL surgical patients
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***The Patient Flow Facilitator determines if we have the right bed type available
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**The ED Attending must make sure the ED has safe capacity
  
 
==The usual process==
 
==The usual process==

Latest revision as of 19:39, 8 February 2019

Overview

There are generally four types of transfers that come into the emergency department:

  • STEMI 911 and Trauma 911 Transfers
    • From nearby EDs that are not Trauma Centers or STEMI centers
    • Ensure we are "open" to trauma and STEMI patients (ask the MICN), and activate the appropriate resources within our facility
    • The sending facility is responsible for calling EMS and arranging for the emergent transfer.
    • Note: these transfers are from the emergency department, and should not be from the inpatient units of the sending hospital.
  • Transfers should be ED to ED; if there are extenuating circumstances where an inpatient requires transfer to Harbor ED, do what is in the best interest of the patient; the DEM Chair will happily provide advice or address any questions/concerns 24/7
  • EMTALA or Higher Level of Care: we accept these as long as we are not in Surge status.
    • Prior to us accepting the patient, they should be approved by:
      • The subspecialty service that will likely be involved in the care of the patient
      • The trauma service may serve as approval authority for ALL surgical patients
      • The Patient Flow Facilitator determines if we have the right bed type available
    • The ED Attending must make sure the ED has safe capacity

The usual process

  • The sending facility contacts the Medical Alert Center or MAC, which is the clearinghouse for transfers within the County of Los Angeles. Any facilities that contact you directly for EMTALA transfers should be redirected to the MAC (unless it is one of the other types of transfers)
  • The MAC contacts the Patient Flow Facilitator first, who determines if we have the right bed available, and then the PFF or MAC (preferably the PFF) contacts the subspecialty service to get approval before contacting the emergency department. If these two approvals occur, then
  • The PFF calls the emergency department to talk to the ED attending to get acceptance. If the emergency department is too crowded or for other reasons cannot accommodate the transfer, then inform the PFF that the ED has "No Capacity" and state why.

If the MAC contacts you first about a transfer, you should redirect them to the patient flow facilitator. All transfers are seen first by the emergency department, and then appropriate subspecialty services are contacted. Subspecialty services are not expected to primarily evaluate the patients.

  • "Lateral Transfers" - these are transfers of patients who do not require a higher level of care, but generally have no funding so the sending facilities are referring them to the County. To accept these we should be open to "Lateral Transfers". The process is the same as EMTALA transfers.
  • "Impending Deterioration" transfers from our sister facility, Olive View-UCLA Medical Center. This is another County hospital that lacks some services that we have, including neurosurgery, orthopedics, and trauma services. Although generally transfers from this facility would go through the same procedures as above for EMTALA transfers (even to us), we have a special agreement for patients they think are likely to decompensate acutely if not transferred immediately. These are generally neurosurgical cases. These are pretty rare, and we take these regardless of our open or closed status. Emergency physicians from Olive View will generally contact you directly rather than going through the MAC.

Dir OPS 1/9/17

Responding to a Helicopter Landing

  • Requires 2-3 trained individuals, does NOT require a physician, though one may elect to go.
  • Only individuals with helicopter safety training should respond to a helicopter landing.
  • Must wear following (available in radio room):
    • Eye protection
    • Gloves
    • Ear plugs
  • FOR SAFETY:
    • Secure loose equipment, they may become a projectile.
    • Face shields are not permitted.
    • Stethoscopes are not to be worn around the neck.
    • Items are not to be left on top of the gurney

Clinic Referrals to ED

Occasionally you will get a call from a clinic either directly or through MAC to "transfer" a patient. These are not considered transfers under EMTALA, and should be considered simply "referrals". Clinic physicians can refer their patients wherever they like; we can't really "refuse" these patients. It's recommended that you listen to the clinical situation, advise the clinic doctor on whether or not the emergency department visit is likely to be helpful for the situation, and advise the clinic doctor if you think the patient needs to come by ambulance. In the end all of these decisions belong to the clinic physician. Also, depending on the complaint, I give the clinic doctor a rough estimate of the time the patient will wait to be seen. (Clinic patients do not necessarily get priority over other patients that are waiting in the waiting room, who may be sicker.) I ask the clinic doctor to advise the patient of the possible wait so they can make an informed decision about coming to the emergency department. (They may want to go elsewhere if we are highly impacted.) This hopefully helps prevent the clinic doctor from falsely informing the patient that they will seen "right away". If the clinic is one of our in-house clinics at Harbor (these calls are often taken by the senior resident), in order to maintain good working relationships with other hospital services we request that there be attending involvement if a decision is made to send such a patient to wait in the waiting room. This decision should be documented in the EHR the same way we document ambulance patients sent out the waiting room. We don't have a rule that states clinic patients jump to the head of the line; you are free to use your judgment, as again there may be sicker patients in the waiting room. Do consider however that this patient has in essence already been triaged by a (clinic) physician in most cases. Special note: transfers from the hospital in the city of Avalon on Santa Catalina Island are generally viewed as referrals from a clinic, so we normally accept them without question due to their extremely limited facilities on the island. These transfers almost always come by helicopter.

Dir OPS 1/9/17


See Also

References