Emergency Inter-Hospital Transfer (Protocol 37)

Aims of this presentation Protocol 37 is a quality improvement project, designed to enhance patient safety and quality of care by optimising the process and timeliness of emergency interhospital patient transfers. The presentation will cover: Types of Inter-Hospital Transfer Issues around emergency inter-hospital transfers Introduce Protocol 37 Summary

Types of Inter-Hospital Transfer An inter-hospital transfer is defined as a patient transfer between any two model 2, 3 or 4 hospitals. This can be; a clinically time critical transfer or a system urgent transfer or a routine transfer.

System urgent A system urgent inter-hospital transfer is defined as: The transfer of a patient to facilitiate an intervention being carried out when an opportunity is unexpectedly presented at the receiving hospital or a bed management process requires the transfer of a patient. Protocol 37 does not apply to system urgent inter-hospital transfers

An emergency inter-hospital transfer An emergency inter-hospital transfer is defined as; The transfer of a patient for a clinically time critical intervention not available at the transferring hospital. Protocol 37 applies to Emergency inter-hospital transfers.

What are the issues around emergency inter-hospital transfers?

Emergency Inter-Hospital Transfers Issue 1; A patient at hospital A presents with or develops an acute episode. Clinical assessment identifies that the patient requires an intervention that must be completed within a short defined timeframe (time critical) to reduce mortality or morbidity. The clinical expertise and/or equipment to enable the intervention to be completed is not available at hospital A. The clinical expertise and equipment is available at hospital B. Therefore the patient must be transferred to hospital B with minimum delay.

Emergency Inter-Hospital Transfers Issue 2 The communication link between hospital and National Ambulance Service is often the challenge

Emergency Inter-Hospital Transfers Hospital A Hospital B

Emergency Inter-Hospital Transfers The Difference Inter Facility Patient Transport Pre-hospital emergency care

Emergency Inter-Hospital Transfers The perception Inter Facility Patient Transport Pre-hospital emergency care This patient is in hospital and medical and nursing care is available This patient requires hospital care and should not be delayed on scene

Emergency Inter-Hospital Transfers The perceived reality Inter Facility Patient Transport Pre-hospital emergency care This patient has been assessed by medical staff and the requirement for a critical intervention identified This patient may be stable and may not even require admission Fact Probability

These two calls for an ambulance could come in at the exact same time Emergency Inter-Hospital Transfers The actual reality Inter Facility Patient Transport Pre-hospital emergency care Please, please send an ambulance as soon as possible, I think she is dying! What do you mean you don’t have an ambulance, the neurosurgeon is waiting for this patient right now! These two calls for an ambulance could come in at the exact same time

Emergency Inter-Hospital Transfers The problem Inter Facility Patient Transport Pre-hospital emergency care How to prioritise these two apparently equally emergent patients against one another

The work volume in The National Emergency Operations Centre (NEOC) 339,709+ emergency medical incidents responded to in 2015 =930 incidents a day =39 incidents per hour

What is Protocol 37 Protoc0l 37 is a mechanism that enables Emergency Call Takers in NEOC carry out a prescribed interrogation of the caller based on the Emergency Inter-Hospital Transfer request pro forma and allocate an ambulance resource for an emergency inter- hospital transfer in a timely manner.

Pro forma

The purpose of Protocol 37 The purpose of this protocol is to put in place a process that enables the primary clinical decision maker to access NEOC decision making in a way that will identify their emergency inter-hospital patient transfer request as an emergency call at the same level as a 112 (999) emergency call in the community.

Caution All hospital based healthcare personnel should be aware of the opportunity cost of tasking an ambulance for an emergency transfer. It results in the withdrawing of an ambulance for availability to respond to local community emergencies.

Protocol 37 aims to: Provide patients with an Emergency Inter-Hospital Transfer facility that is appropriate and timely Enable hospital staff to order an Emergency Inter- Hospital Transfer in a clear and focused manner Help Emergency Call-Takers filter and prioritise requests for an Emergency Inter-Hospital Transfer

using scripted questions The current Priority Dispatch Process Following a 112 (999) call the interrogation by Emergency Call-Takers commence with questions that could determine the highest priority early in the process. - Is the patient Conscious? - Is the patient Breathing? If no to both of these questions the patient is allocated the highest priority; – Cardiac or respiratory arrest. Echo If no to the first questions and yes to the second question the patient is allocated the next highest priority; – Life threatening (other than cardiac or respiratory arrest) Delta The interrogation continues using scripted questions

The Priority Dispatch Decision Process Following a 112 call the interrogation by Emergency Call-Takers commence with questions that could determine the highest priority early in the process. - Is the patient Conscious? - Is the patient Breathing normally? For an emergency inter-hospital transfer (Protocol 37) this interrogation process is redundant as a medical practitioner has identified the patient’s needs and the requirement from the National Ambulance Service is transfer and not triage. If no to both of these questions the patient is allocated the highest priority; – Cardiac or respiratory arrest. Echo If no to the first questions and yes to the second question the patient is allocated the next highest priority; – Life threatening (other than cardiac or respiratory arrest) Delta The interrogation continues using scripted questions

‘an emergency inter-hospital transfer, Protocol 37’. To by-pass the standard interrogation by call-takers state that you require ‘an emergency inter-hospital transfer, Protocol 37’. An emergency inter-hospital transfer request will always be allocated a Delta response, ensuring that it is given the highest priority (other than an arrest) EMS priority levels

filter and prioritise requests for Emergency Inter-Hospital Transfers Protocol 37 How to help NEOC staff filter and prioritise requests for Emergency Inter-Hospital Transfers

The requesting clinician decides on when the ambulance is required Emergency Inter-Hospital Transfer The requesting clinician decides on when the ambulance is required The timeframe is based on predetermined time intervals to avoid the patient waiting for an ambulance or having an ambulance waiting while the patient is being stabilised or escorting staff are being organised Agreed Time Bands Immediate Response Response within 30 minutes Response between 30 and 60 minutes

Emergency Inter-Hospital Transfer Protocol 37 Activation Process I require an emergency inter-hospital transfer, Protocol 37 please. Activation CNM/ Nurse in Charge Registrar or Consultant To ensure correct application of Protocol 37 the request for an emergency inter-hospital transfer may only be made by a Consultant, a Registrar or Clinical Nurse Manager/Nurse in Charge.

Activation of Emergency Services I require an emergency inter-hospital transfer, Protocol 37 please. Gardaí Call goes direct to An Emergency Call Centre Ambulance Ask for HSE National Ambulance Service Use the Protocol 37 request template Fire Ring 112 (999) and ask for ‘HSE National Ambulance Service’ This way the call is answered before the standard ambulance control number (used for non emergency transports)

Clinical levels of National Ambulance Service personnel: Emergency Medical Technician (EMT) Basic life support, used primarily for routine transfer of patients. Paramedic (P) Intermediate life support, used primarily for response to emergency 112 (999) incidents. Advanced Paramedic (AP) Advanced life support, used primarily for response to life threatening emergencies. See www.phecc.ie or detailed information on various clinical levels.

Emergency Inter-Hospital Transfer Clinical Crews For most Protocol 37 transfers from Model 3 and 4 hospitals, the transferring hospital must supply the clinical staff and appropriate equipment and medications for the journey. ????????????????????????

Emergency Inter-Hospital Transfer By using Protocol 37 it gets the hospital based patient onto the priority stack competing directly with all other community based life threatening calls

Emergency Inter-Hospital Transfer Working together we can transfer our patient in a timely manner to the correct hospital.

Protocol 37 will supersede all other previous codes used for emergency transfers such as ‘Code STEMI’. These codes will no longer be utilised.

Questions ?

Summary

Decision Distinguish between Clinical time critical (Protocol 37 applies to this category of patient only) and System Urgent or bed availability

Ring 112/999 and ask for ‘The HSE National Ambulance Service’’ The First Steps Ring 112/999 and ask for ‘The HSE National Ambulance Service’’ This way the call is answered before the standard ambulance control number (used for non emergency transports) When through to NEOC state “I require an emergency inter-hospital transfer, Protocol 37 please”. This will avoid an unnecessary triage interrogation process.

Who can implement this Protocol: The following staff must be from the unit/ ward requesting the Emergency transfer The treating Consultant or Registrar or Clinical Nurse Manager/Nurse in Charge  

The Procedure for Success Ring 112/999 Ask for HSE National Ambulance Service. The Emergency Call- Taker will then take you through a series of specific questions.

The Procedure for Success Specific questions from Emergency Call-Taker What is your Phone No? What is your Location? What is the reason for the transfer? What is the patient’s age? What is the Patient’s gender? Is the patient awake?

The Procedure for Success Specific questions from Emergency Call-Taker contd. Will any special equipment be necessary? When will the patient be ready to leave your hospital? What is the patient’s name? Who is the referring doctor?

The Procedure for Success Specific questions from Emergency Call-Taker contd. Who is the referring nurse? Where is the receiving hospital? What is the receiving ward/ unit? Who is the accepting Consultant?

Template for Protocol 37 form Task Details Ring 112 (999) Ask for HSE National Ambulance Service The Emergency Call-Taker will then take you through a series of specific questions. What is your phone No? Provide a contact number for call back What is your Location? State the transferring hospital name and ward/unit What is the reason for the transfer? State clearly; “I require an emergency inter-hospital transfer, protocol 37 please” Patient’s age? State age of the patient Patient’s gender? State gender of the patient Is the patient awake? Verify; Yes / No Will any special equipment be necessary? Please specify any special equipment required during the transfer. When will the patient be ready to leave your hospital? Give an estimated timeframe when all clinical procedures to stabilise the patient will be complete and the patient will be ready for transfer to the ambulance. The options are: Immediate (Delta), In 30 mins (Charlie), between 30 mins and 1 hour (Bravo) What is the patient’s name? State the name of the patient Who is the referring Doctor? State name of the referring Consultant. Who is the referring Nurse? State name of the Nurse responsible for the patient Where is the receiving hospital? State the receiving hospital What is the receiving ward/unit? State the receiving ward/unit Who is the accepting consultant? State the name of accepting consultant Template for Protocol 37 form