Intrahospital Transfer

STANDARD OPERATING PROCEDURE (SOP) FOR INTRAHOSPITAL PATIENT TRANSFER
IN THE EMERGENCY DEPARTMENT

FOR DR. PIXLEY KA ISAKA SEME MEMORIAL HOSPITAL
Mr/Ms/Dr....................................... Date approved_________________
Chief Executive Office __________________________
Dr………………………………… Date approved________________
Head of Department Emergency Medicine
Compiled by (author): ..............................
Date for next review: …………………

Table of Contents
1. Purpose of SOP
2. Introduction
3. General Protocol
4. Critically ill patient transfer
5. References
LIST OF ANNEXURES
Checklist-Nurses and Doctors

Intrahospital transfer
The transfer of patients within the hospital setting requires pre-planning and a low threshold for
suspecting anticipated complications. This SOP attempts to broadly establish a method to facilitate
this process in a standardised way.
AIM:
1. Minimise morbidity and mortality associated with Inter-hospital and intra-hospital patient
transfer of ED patients.
2. Ensure a general checklist of SOP regarding the safe transfer of the patient.
General Protocol:
Questions to answer?
1. The patient factors:

Is the pt fit enough for transfer?
Often the transfer is necessary to advance the patient’s care urgently and they may be
unstable however –there are immediate interventions that need to be performed as part of
the patient’s resuscitation.
2. Anticipated problems?
Time delays-lifts/receiving staff(porters)/obtaining necessary staff and working equipment.
On route- If the patient deteriorates, Extubating occurs? Contingency plan interventions?
-Portable ED kit (resus meds) and defibrillator
-Drugs and infusions: Ensure will not run out and pre labelled drawn out resus meds.
-Ensure equipment has enough power and 02 to facilitate transfer.
3. The Provider factors?

Is the accompanying provider at the right level of skill to deal with the level of critical illness
of the patient.
IN GENERAL: A-H?
A – airway secured?
B – both lungs up? Both gases (O2, CO2) good?
C – control haemorrhage (splinting, clotting – TXA), connect blood or fluid so you can easily give a
bolus
D – disability (check pupils), drugs (sedation, analgesia, paralysis)
E – equipment for emergencies
F – family briefed? “Fone” numbers (how will you get help from ED if you need to return in a hurry?)
G – general radiology details- Preloaded on the PACS system for scan Consent Allergy+U+E ??
H – heroic needs? Let the destination know you don’t want to be waiting in the corridor
Transfer a critically ill intubated patient
 Ensure the patients airway is maintained

 Pre-departure ABG: Optimised
 Ensure all equipment working no leak exclude DOPES if ETT insitu
 Ensure adequate 02 available
 Resus drugs +Defib available on Transfer
Transfer a critically ill Non-intubated patient
 See above general.
Transfer a critically ill To radiology
 Ensure the patient is adequately resuscitated

 Inform the radiologist and radiographer and get time when the patient can be
accommodated
 Ensure: allergic status +-U+E, consent and exclude contraindications before transfer with a
working green jelco the site determined eg:angio
Protocol:
Red code patients
 Patient to be on a monitored bed.

 Patient physiology optimised as much as possible
 Repeat set of vitals:Pulse BP Sats +-Capno Glu ABG prior to departemure
 Invasive monitoring as needed (IVI,CVP,Chest drains,Cathters checked in right place working
and secured)
 The unit pre informed of transfer and the receiving unit Dr and Nurse and consultants name
time date recorded with regards to when the patient can be received
 Staff with the level of skill that corelates to the degree of care and predicted level of care
required should the patient deteriorate should accompany the patient. One doctor-ED or
base disciple, Porter, One nurse.
 Complete check list
 All necessary equipment: Resus meds.ED ER Kit ,AED+-Defib, Mointers
 Ensure 02 cylinder working and has adequate 02 for transfer.
 At arrival at the receiving site brief handover doctor to doctor nurse to nurse.
 Secure the airway 5-6 person transfer to bed.
 Transfer of monitors
Yellow -Orange code patients
 Patient to be on a monitored bed.

 Patient physiology optimised as much as possible
 Repeat set of vitals :Pulse BP Sats +-Capno Glu ABG prior to departure
 The unit pre informed of transfer and the receiving unit Dr and Nurse and consultants name
time date recorded with regards to when the patient can be received
 Staff with the level of skill that corelates to the degree of care and predicted level of care
required should the patient deteriorate should accompany the patient. One doctor-ED or
base disciple, Porter, One nurse.
 Complete check list
 Ensure 02 cylinder working and has adequate 02 for transfer.
 At arrival at the receiving site brief handover doctor to doctor nurse to nurse.
Green code patients:
 Ensure the patient has been optimised as much as possible

 Ensure stable vital signs and a repeat set prior to leaving the ED.
 Counsel the patient for the need for transfer pt to transported by a
wheelchair(Relative/Porter) if walking to ensure that the patient is aware where to go
(directions) and the receiving unit is aware of the patients referral.
ANEXTURE A:
ANEXTURE B:
References:
 https://www.stemlynsblog.org/ed-transfer/
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966347/
 https://www.archivesofmedicalscience.com/Intrahospital-critical-patient-transport-
from-the-emergency-department,97210,0,2.html

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STANDARD OPERATING PROCEDURE (SOP) FOR INTRAHOSPITAL PATIENT TRANSFER

IN THE EMERGENCY DEPARTMENT

Mr/Ms/Dr....................................... Date approved_________________

Chief Executive Office __________________________

Dr………………………………… Date approved________________

Head of Department Emergency Medicine

Compiled by (author): ..............................

Date for next review: …………………

4. Critically ill patient transfer

Checklist-Nurses and Doctors

1. The patient factors:

3. The Provider factors?

B – both lungs up? Both gases (O2, CO2) good?

D – disability (check pupils), drugs (sedation, analgesia, paralysis)

E – equipment for emergencies

Transfer a critically ill intubated patient

 Ensure the patients airway is maintained

Transfer a critically ill Non-intubated patient

 See above general.

Transfer a critically ill To radiology

 Ensure the patient is adequately resuscitated

Red code patients

 Patient to be on a monitored bed.

Yellow -Orange code patients

 Patient to be on a monitored bed.

Green code patients:

 Ensure the patient has been optimised as much as possible

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