Doc No

KGDMCH/AAC/02d
Issue No 01
Dr. K.G.Deshpande Memorial Rev No. 00
Centre for Open Heart Surgery,
Date 28/9/2019
Thoracic & Vascular Surgery
Page 1 of 3

Document Title : Patient Transfers

PREPARED BY: ---------------------------------------------

QUALITY COORDINATOR

APPROVED BY: --------------------------------------------

DIRECTOR

This document provides instruction and guidance to hospital

staff regarding transfer of stable and unstable patients to
SUMMARY
other facilities or to home.

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 Doc No
KGDMCH/AAC/02d
Issue No 01
Dr. K.G.Deshpande Memorial Rev No. 00
Centre for Open Heart Surgery,
Date 28/9/2019
Thoracic & Vascular Surgery
Page 2 of 3

Document Title : Patient Transfers

The policy defines the transfer of patients with support from

departments/ units under which they are admitted.
The policy defines handling patients during non-availability of
beds.
DISTRIBUTION To all departments, units and wards through the Hospital
Manual.

INTRODUCTION
The patient transfers are undertaken in both emergency and elective basis for referral of
complicated cases to other hospitals or based on the patient family request for shift to
other facilities due to cost and / or other considerations.
Patient transfers may be necessitated in emergency cases which cannot be handled by
the hospital like neurosurgical interventions or unavailability of schemes/insurance
etc.RTA cases or in cases which may deny admission due cost or legal considerations.
In these cases post provision of first aid and stabilization the patient is transferred to the
nearest hospital with the required facilities
PURPOSE AND SCOPE
The purpose of this policy is to guide the hospital staff in managing the process of
patients transfer to and from the hospital. The policies and procedures cover both
emergency and elective transfers.
RESPONSIBILITIES
Medical Officer: The on duty Medical Officer shall be responsible for organizing the
patient transfers arranging for medical / nursing personnel to assist the transfer process.

POLICIES
 The ordering consultant is responsible for patient transfer.

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 Doc No
KGDMCH/AAC/02d
Issue No 01
Dr. K.G.Deshpande Memorial Rev No. 00
Centre for Open Heart Surgery,
Date 28/9/2019
Thoracic & Vascular Surgery
Page 3 of 3

Document Title : Patient Transfers

 If the patient is stable, the transfer will be done by one paramedical staff. The
bystander is also allowed to accompany him.
 If the patient is unstable, having intravenous infusion, oxygen on flow one nursing
staff will accompany. If the patient is ventilated one doctor, one nurse and
paramedical staff will accompany.
 The staff members who transport knows Basic Life Support (BLS).
 Patient shifting during non-availability of beds.
Policies for the transfer of stable patient:
Stable patients may arrange for their own mode of transport or may be provided
transport in patient transport vehicles on request based on their availability. The stable
patients need not be accompanied by hospital staff.
For transferring unstable patient:
Consultant will be contacted, acceptance of the rescuing hospital obtained, transfer will
be done in ambulance, by a nursing team who monitor and documents patient status
during conveyance. And take the patient to the destination ward and hand over the
patient details (Discharge Summary, investigations) and get back the acceptance
signature.
MONITORING
Consultant will review the details of each case of transfer undertaken by the hospital. A
patient transfer form is maintained during the shift. The document will be filed at ED
after being scrutinized by the Consultant.
NON-AVAILABILITY OF BED
In case of emergencies, all efforts should be made by the hospital to accommodate
maximum patients by putting-up extra beds. If it is beyond the capacity, the patient shall
be referred.

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 Doc No
KGDMCH/AAC/02d
Issue No 01
Dr. K.G.Deshpande Memorial Rev No. 00
Centre for Open Heart Surgery,
Date 28/9/2019
Thoracic & Vascular Surgery
Page 4 of 3

Document Title : Patient Transfers

SUMMARY This document provides instruction and guidance to nurses

and others on how to manage transporting patients on
trolleys/wheelchairs in their department to diagnostics,
procedure areas and other wards of the hospital.
All ward in-charges are required to ensure compliance with the
policy

DISTRIBUTION To all departments, units and wards through the Hospital

Manual

INTRODUCTION
Patient transport using trolleys and wheel chairs are daily occurrence within the
hospital. Patients are routinely transferred to diagnostic areas and procedure rooms
from the ward and back. The relative of the patient is informed and then the patient is
transported to the area needed.
Ensuring dignity and safety of the patient during intra hospital transport is the key in
ensuring patient’s overall satisfaction with the hospital.
PURPOSE AND SCOPE
The purpose of this policy is to guide the hospital staff in ensuring safe transport of
patients within the hospital premises and ensuring that the patient’s dignity is
maintained during the process.

RESPONSIBILITIES
Staff Nurse / Ward In-charge

 The staff nurse / ward in-charge will initiate patient transportation based on Doctor’s
orders or as per appointment schedules of the OT, Imaging and other diagnostic
units.
 The staff nurse / ward in-charge will check with the concerned unit regarding the
appointments and will initiate the patient transport only on confirming the
appointment with the clinical unit.

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 Doc No
KGDMCH/AAC/02d
Issue No 01
Dr. K.G.Deshpande Memorial Rev No. 00
Centre for Open Heart Surgery,
Date 28/9/2019
Thoracic & Vascular Surgery
Page 5 of 3

Document Title : Patient Transfers

POLICIES

The ordering consultant is responsible for patient transfer. If the patient is stable, the
transfer will be done by one nursing staff. The bystander is also allowed to accompany
him.

If the patient is unstable, having intravenous infusion, oxygen on flow, one nursing staff
will accompany. If the patient is ventilated one nurse and paramedical staff will
accompany.

Policies while transported in a wheelchair:

Conveying Patients by Wheelchair

 All wheel chairs will have a belt which can secure the patient.

 The staff who transports will be trained in Basic Life Support (BLS).

 All trolleys/chairs must be checked before use for visual defects. In case any defect
identified it must be reported immediately by the ward in-charge to the Facility
Maintenance Engineer. The safety and welfare of the patient is of paramount
importance.

 Some patients are not at ease while being conveyed by wheelchair and reassurance
by the staff is an important factor. It is important that the staff should be conversant
with the various types of wheelchairs that are in use and any features which may be
special to them. It is important that the wheelchair should be pushed at all times,
and not pulled. Pulling the chair whilst occupied could result in the patient being
`Tipped Out`. Pushing the wheelchair is more dignified for the patient as they can
see where they are going! The staff must be able to assist the patient in/out of a
wheelchair, for example on or off a chair, bed or lavatory and in/out of a car.

 The staff must also know the correct methods of pushing a wheelchair down or up a
step, and special care must be taken when entering lift areas. For instance, make
sure the level of the floor and lift floor coincides.

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 Doc No
KGDMCH/AAC/02d
Issue No 01
Dr. K.G.Deshpande Memorial Rev No. 00
Centre for Open Heart Surgery,
Date 28/9/2019
Thoracic & Vascular Surgery
Page 6 of 3

Document Title : Patient Transfers

 It is important that the wheelchair brakes are applied when assisting the patient into
and out of the wheelchair. When `parking` an occupied wheelchair, the ward
boys/nurse should be careful not to leave the patient next to a hot radiator, in a
draught or facing a wall.

Policies while transported in a stretcher:

Any member of staff responsible for a patient on a trolley/chair must ensure that:
a. The cot sides are raised during transportation.
b. The cot sides are lowered only when the patient requires treatment/examination by
staff - but raised immediately afterwards.
c. If the patient trolley is of adjustable height, the trolley may be raised to workable
height to facilitate treatment/movement – but lowered immediately afterwards.
d. Anything that the patient may require should be placed within their reach
e. The wheels and brakes on the trolley/chair operate correctly.
f. That wheelchair footplate is operating correctly.
The suggestions outlined above for wheelchair patients apply equally to patients on
trolleys or in beds, except that more staff would be employed in movements of this kind.
Particular care should be exercised when moving patients to whom IV infusion line or
other life support equipment is attached. Any wheelchair, trolley or bed should have its
brakes applied while travelling in the lift. Every consideration should be given to the
patient’s’ safety, comfort and welfare. Also the paramedical staff shall be trained in BLS.
Patients in Lift:
While using lift for transport of patient on a wheel chair or trolley; members of the public
will be requested not to use the same lift along with the patient. Only the accompanying
hospital staff and accompanying patient family member will be allowed in the lift along
with the patient.

There will be a Hospital staff in patient transferring lift. He is also trained in BLS. All lifts
have a alarm [which will be pressed twice continuously to access for Code Blue in case
of emergency].

REFERENCES

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 Doc No
KGDMCH/AAC/02d
Issue No 01
Dr. K.G.Deshpande Memorial Rev No. 00
Centre for Open Heart Surgery,
Date 28/9/2019
Thoracic & Vascular Surgery
Page 7 of 3

Document Title : Patient Transfers

A. Standard Reference: AAC- 3A-3E, COP-2F

B. Document Reference: Patient Transfer form
C. Statutory Reference: Nil
APPENDICES
 RTA- Road Traffic Accidents

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