Guide For Interfacility Patient Transfer: National Highway Traffic Safety Administration

Guide For Interfacility Patient Transfer
National Highway Traffic Safety Administration
Guide for Interfacility Patient Transfer

Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Major Topic #1: Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Major Topic #2: Meeting Patient Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Major Topic #3: Integration of Interfacility Transfer

Services into Existing Regional Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Major Topic #4: Medical Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Major Topic #5: Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Major Topic #6: Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Major Topic #7: Financial Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Major Topic #8: Policy Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Major Topic #9: Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Major Topic #10: Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Appendix A: Members of the IFT Guidelines Work Group . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Appendix B: References and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Appendix C: Elements of a Business Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Appendix D: EMTALA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Appendix E: Certificate of Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Appendix F: HIPAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Guide for Interfacility Patient Transfer iii

INTRODUCTION
Project Background Ten Major Topics for IFT Guidelines:
n Cost reimbursements and funding for services
The transfer of patients from one medical facility to
n Integration of IFT services in existing regional
another has become a national issue for Emergency
Medical Services (EMS). Patient transfers between health care systems
n Research
facilities or between facilities and a specialty care
n Provider education
resource have increased as a result of regionaliza-
n Liability
tion, specialization, and facility designation by
n Medical direction
payers. The emergence of specialty systems (e.g.,
n Human resources and staffing
cardiac centers, stroke centers) often determines
n Legislation and regulation
the ultimate destination of patients rather than
n Best practices
proximity of facility. Transfer may be necessary
n Definitions
if payers provide reimbursement only for specific
facilities within their own plans.
A follow-up meeting of the Interfacility Transfer
Interfacility transfer (IFT) is provided by a variety Planning Group was held in Alexandria, Virginia,
of levels and types of personnel and agencies. Key on May 12-13, 2003. The NHTSA EMS Division
issues include the IFT infrastructure, including the identified appropriate organizations and invited
qualifications of those delivering the care. Meeting their participation in the meeting. These organiza-
patient needs and maintaining continuity of care tions included:
are only two of the many issues related to IFT.
n Air & Surface Transportation Nurses
Emergency Medical Services (EMS) at the National Association
n Air Medical Physician Association
Highway Traffic Safety Administration (NHTSA)
n American Ambulance Association
convened key national stakeholders to identify
n American College of Emergency Physicians
national EMS priority issues and to establish
n Commission for Accreditation of Ambulance
consensus-based guidelines for the EMS commu-
nity. In January 2002, NHTSA convened an EMS Services
n Commission on Accreditation of Medical
Interfacility Transfer Planning Group to consider
the current issues and to determine if national Transport Systems
n Emergency Nurses Association
consensus guidelines would be useful in addressing
n Emergency Medical Services for Children
these challenges. The planning group determined
n International Association of Flight Paramedics
that consensus guidelines would be very useful to
promote consistent high-quality patient care while (formerly known as the National Flight
allowing variation to meet specific local needs. Paramedics Association)
n National Association of EMS Physicians
The group identified the following areas that could
n National Association of EMTs
benefit from such guidelines.
n National Association of State EMS Directors
n National Association of State EMS Training
Coordinators

The president or executive director of each or- nel supporting IFT and how they can be enhanced
ganization was asked to designate a representa- to provide optimal delivery of care. The overarch-
tive to participate in a two-day meeting, and the ing principle adopted by the IFT Work Group was
completion of the IFT Guidelines document. This that all decisions should be motivated by the desire
invitation resulted in the formation of the IFT to optimize the process of IFT and the care given
Guidelines Work Group (Appendix A). during transport. The ultimate goal is to match
patient need with appropriate knowledge, skills,
Guidelines for Definitions and Provider Education equipment, and an infrastructure to enable safe,
were completed as part of the agenda of the 2003 effective, and efficient IFT.
meeting. It was agreed that guidelines for the
remaining eight major topics would be completed Planning and Implementation
through an electronic process (eRoom). At several Considerations
points, the document was informally reviewed by
the organizations represented by the IFT Work As with any analysis of program status, it is
Group members. This document is the result of helpful to evaluate its current status before taking
that process. The guidelines contained in this doc- action. The three core functions of public health,
ument are based upon a combination of available published by the Institute of Medicine1, provide
objective evidence, a review of generally accepted a useful model for this process. These three
practices, and the consensus of expert opinions in functions are:
the field of IFT — in short, the best information n Assessment – to collect, assemble, analyze,
available. and make available relevant facts and figures
including existing data, identified needs, and
Purpose and Limitations of This epidemiologic and other applicable information.
Document n Policy Development – efforts to serve the public
The intended audience for this guide is the agency interest in the development of comprehensive
providing IFT at the local, regional, or State level, policies by promoting the use of a scientific
as well as those involved with planning for IFT knowledge base as a basis for decision-making,
or dealing with IFT-related issues. This audience and leading in developing comprehensive
may include a variety of decision makers, such as policies.
program administrators, agencies with EMS juris- n Assurance – efforts to assure that services
diction, physicians providing medical oversight for necessary to achieve agreed-upon goals are
IFT, or hospitals dealing with IFT-related issues. provided either by encouraging actions by
other entities, by requiring such action through
The intent of this document is to provide general regulation, or by providing services directly.
guidance. Given the variety of unique needs and
demands placed on programs, local communities, Assessment
and EMS systems, prescriptive standards would
not be useful. In addition, specific standards may The IFT Guide developed by the IFT Work Group
conflict with existing regulations or administrative can be used largely within the assessment phase,
rules. This document is not intended to serve as where it can serve as a template against which a
a benchmark. State/region/locality could compare its own pro-
gram. Before this process is begun, it is strongly
This document can be used to provide general recommended that the stakeholder group adopt a
guidance, references and ideas for conducting a goal and a mission statement to identify and agree
systematic assessment of the processes and person- upon the ultimate goal for this and all other activi-

ties. An assessment tool can be developed once all n legislation and administrative rule-making (for
stakeholders agree upon the ultimate mission/goal, services);
and assessment strategies are established. The fol- n provider education:
lowing represent general categories for assessment:
o meeting with organizations;
n current IFT system components;
o course development; and
n education and training of providers;
o other steps for policy;
n legal status/legal authority including liability;
n medical oversight:
n medical oversight, including IFT protocols;
o critical care versus emergency department
n cost reimbursement, and funding for services; management;
n integration of IFT services into existing health o IFT protocols;
care systems; and
o destination protocols; and
n staffing requirements for IFT.
o other?
Once stakeholders have endorsed the goal, needs n education of various organizations/disciplines;
are assessed and all relevant outcome and process n cost reimbursement and funding:
information has been assembled and analyzed, a
gap analysis will form the basis for action. A gap o meeting with third-party carriers; and
analysis is a comparison of the current situation to o matching reimbursements with system design.
the desired state. A plan to move from the current
state to the desired state is developed. The level Assurance
of detail in the plan depends on the scope of the
Before strategies are deployed, performance mea-
project.
sures should be established, which can be used to
measure progress. As the implementation process
Policy Development moves forward, several surveillance methods can
Based upon the desired goal, the assessment and be used to evaluate achievements:
gap analysis form the basis for action. Strategies n data collection;
are identified to bridge the gap between the current
n evaluation of effectiveness, accessibility, and
situation and the desired state. Policy development
and planning includes: quality of IFT services and the infrastructure
that supports IFT;
n informing, educating, and empowering people
n enforcement of laws and regulations;
about IFT issues;
n quality improvement;
n mobilizing community and stakeholder partner-
ships to identify and solve IFT problems; and n ongoing system modification based on data; and
n developing policies and plans that support indi- n feedback loops.
vidual and community efforts to improve IFT.
These three core functions may be repeated
The strategies included for IFT policy development multiple times. The process of assessing,
may include: developing policy, and assuring is ongoing, and the
n legislation and administrative rule-making (for deployment plan altered to account for changes or
providers, such as EMS boards, nursing boards, unanticipated circumstances. Utilizing the public
medical boards, pharmacies, if needed, and oth- health model may provide a framework and a
ers, e.g., respiratory therapists);

useful roadmap for all stakeholders in enhancing

IFT. While most of this document’s contents
fall into the assessment category, some major
topics include strategies for policy and assurance
functions.
References
1. The Future of Public Health. (1988). Committee
for the Study of the Future of Public Health.
Division of Health Care Services. Institute of
Medicine. Washington, D.C. National Academy
Press.

Major Topic #1: Definitions

For the purpose of this document, the following nity members with seamless, comprehensive health
definitions were adopted: care, including all who directly provide preven-
tive services, acute care, and rehabilitation, as well
Critical Care Transport — The level of transport
as the components of the health care system that
care that is provided to patients with an immediate
support their function. Examples of components
life-threatening illness or injuries associated with
providing support may include: insurance carriers,
single or multiple organ system failure. This level
regulatory agencies, statutory public/government
of care requires an expert level of provider knowl-
entities, consumer groups, and professional associ-
edge and skills, a setting providing necessary
ations. In an integrated regional health care system,
equipment, and the ability to handle the added
the efforts of all stakeholders are coordinated to
challenge of transport. Critical care transport
ensure the active involvement of all entities in the
requires a high level of medical direction and
process of planning, implementing, evaluating and
sophistication of care because of the patient’s com-
problem solving.
plex medical problems.
Integration – The consolidation and coordination
EMS System — A consolidated system of essential
of separate units into a unified, harmonious whole.
components designed to provide a coordinated,
timely and effective response to medical emergen- Interfacility Transfer — Any transfer, after initial
cies. A comprehensive EMS system has each of the assessment and stabilization, from and to a health
elements illustrated in the following diagram: care facility. Examples would include:
n hospital to hospital;
n clinic to hospital;
n hospital to rehabilitation; and
n hospital to long-term care.
Levels of Patient Acuity – In order to provide

safe and effective care, provider capabilities must
match the patient’s current and potential needs.
It is important to have consistent terminology to
define the levels of patient acuity. For each level,
examples are provided of the types of needs the
patient might have and the level of care likely to be
required at each level.
n Stable with no risk for deterioration —
Oxygen, monitoring of vital signs, saline lock,
Facility — Licensed health care entity (e.g., basic emergency medical care).
hospital, clinic, rehab, nursing home) n Stable with low risk of deterioration —
Guideline — Something that is to be preferred, Running IV, some IV medications including

but that does not have the force of a standard. pain medications, pulse oximetry, increased
Providers/services are not held legally responsible need for assessment and interpretation skills
for acting at this level of performance. A sugges- (advanced care).
tion rather than a mandate. n Stable with medium risk of deterioration —
3-lead EKG monitoring, basic cardiac
Integrated Regional Health Care System – A
medications, e.g., heparin or nitroglycerine
regionally based system that provides its commu-

(advanced care +). region could be defined as the one EMS system or
n Stable with high risk of deterioration – Patients a combination of several EMS systems. A region
requiring advanced airway but secured, intubat- can be defined and/or influenced by numerous
ed, on ventilator, patients on multiple vasoactive determinants, such as:
medication drips (advanced care +), patients n jurisdictions;
whose condition has been initially stabilized, n geographic locations;
but has likelihood of deterioration, based on n service areas of providers;
assessment or knowledge of provider regarding n service areas of insurance carriers and
specific illness/injury.
n referral patterns.
n Unstable — Any patient who cannot be stabi-
lized at the transferring facility, who is deterio- Service Area – The defined response boundaries,
rating or likely to deteriorate, such as patients mutually agreed upon contractually and/or as des-
who require invasive monitoring, balloon pump, ignated by a regulatory body, to provide IFT within
who are post-resuscitation, or who have sus- a single or combination of several EMS systems. A
tained multiple trauma (critical care or available service area could be a region or part of a region,
crew with time considerations). and can be defined and/or influenced by numerous
determinants, such as:
Medical Oversight – Medical authority and
n jurisdictions;
responsibility for all medical care provided by
the service, including active day-to-day role in n geographic locations;
the function and management of the service as it n service areas of providers; and
relates to patient care activities. There are several n service areas of insurance carriers.
terms that refer to the activities involved in medi-
cal oversight: Specialty Care Transport (SCT) – As defined
by the Centers for Medicare & Medicaid Services
Prospective Off-line Indirect E.g., protocol (CMS) — is IFT of a critically injured or ill ben-
development eficiary by a ground ambulance vehicle including
Concurrent On-line/ Direct E.g., giving the provision of medically necessary supplies and
On-scene orders via radio services, at a level of service beyond the scope of
Retrospective Off-line Indirect E.g., quality the EMT-Paramedic. SCT is necessary when a
management beneficiary’s condition requires ongoing care that
must be furnished by one or more health profes-
Outcome Evaluation — Examines the effective- sionals in an appropriate specialty area, for exam-
ness or efficacy of particular interventions on pa-
ple, emergency or critical care nursing, emergency
tient status. An outcome evaluation of IFT assesses
medicine, respiratory care, cardiovascular care, or
a particular clinical aspect of patient care during
a paramedic with additional training.
IFT, and its impact on patient outcome.
Standard — Is described as a basis for compari-
Process Evaluation — Process evaluation focuses son; a reference point against which other
on the quality of implementation — how well the
things can be evaluated. Standards set a bench-
process was carried out. It examines operational
mark for subsequent work.
and system efficiency. It would be difficult to ar-
rive at the conclusion that a specific intervention Transfer – The comprehensive infrastructure and
caused a specific outcome if the process of achiev- process involved before, during, and after moving a
ing it was not carried out as intended. patient from one location to another.
Region – A particular area, zone, district, or terri- Transport – The physical process of moving a
tory. For the purpose of developing an IFT plan, a patient from one location to another.

Major Topic #2: Meeting Patient Needs

The overriding principle for all aspects of IFT is Regardless of entry-level knowledge, skills, and
matching patient needs with adequate provider abilities, there are basic transport skills and knowl-
knowledge and skills, equipment and an infra- edge that anyone involved in IFT should possess:
structure that provides seamless patient flow dur- Basic Knowledge and Skills:
ing transport. Any judgment should err on the side
of caution in providing care at the level likely to be Any health care professional providing care dur-
needed or potentially needed during IFT. ing IFT should demonstrate knowledge and skills
related to:
Interfacility transfer requires a unique set of skills n radio and communication technology;
distinct from the training of most hospital-based n transport physiology;
or prehospital providers. It is essential that person-
n safety operations to include the vehicle (ambu-
nel used to provide care during interfacility trans-
lance and/or aircraft) the patient, equipment,
fer be properly trained, familiar with the demands
and all care providers on board;
of providing care during ground or air transport,
n transport equipment;
legally authorized to perform these skills, and
prepared to handle the variety of patient contin- n documentation;
gencies that may arise during transport. Additional n transport logistics;
education will be needed to prepare all traditional n transfer protocol(s);
providers for interfacility care, whether hospital n patient records;
or prehospital-based, but the specific focus of this
n physician orders;
additional education may vary depending on the
n patient “packaging” for safety and accessibility;
provider’s existing knowledge and skill base.
n medical oversight; and
The discussion about provider education should n evaluation of level of care needed by patient
start with a review of the questions to be asked: during transport.
n What are the specific needs of the patient?
n What types of practitioners are working in the

Providers conducting interfacility transfers for pa-
field? tients in the “stable with low risk of deterioration”
and “stable with medium risk of deterioration”
n What are the skills and knowledge levels these
should demonstrate knowledge, skills, and demon-
practitioners need for IFT? strated abilities that include:
n What type of training is required?
n What type of continuing education is necessary

Advanced Knowledge and Skills:
to assure knowledge and skills? n basic transport skills;
n IV insertion, monitoring and maintenance;
Since a variety of practitioners could be involved including maintenance of central venous and
in interfacility transfer (paramedics, EMTs, nurses, intraosseous lines;
physicians, respiratory specialists, etc.), attention
n all forms of medication administration;
should be focused on the knowledge, skills, and
n pharmacology at the DOT EMT- Paramedic
abilities required to match patient needs, as well
as characteristics of effective education and train- National Standard Curriculum level;
ing. Operational procedures and protocols must n advanced airway management;
comply with State and local requirements as well as n ECG monitoring; and
medical oversight. n defibrillation, cardioversion, and transcu-
taneous pacing.

Providers involved in interfacility transfer of un- characteristics for provider education programs
stable, critically ill, or injured patients should have may include:
the ability to continuously monitor and assess the n Training and education that provide the knowl-
patient’s condition and to intervene appropriately. edge and skills enabling providers to monitor
At a minimum, this would require skill and knowl- and provide necessary care to maintain the
edge in the areas of: stability of the patients’ condition. This includes
a working knowledge base and critical thinking
Critical Care Knowledge and Skills: ability related to the likely and potential com-
n advanced airway management; plications associated with specific disease and
injury processes, as well as complications associ-
n ventilator management;
ated with specific interventions.
n all forms of medication administration;
n Sufficient clinical and field experience enabling
n pharmacology at the DOT EMT- Paramedic providers to deal with varying levels of patient
National Standard Curriculum level, plus acuity.
advanced knowledge of vasoactive and antiar-
n Initial and continuing education and training
rhythmic drugs; and
that is both didactic and hands-on, and of a suf-
n circulatory management and support. ficient time period to allow provider to demon-
strate adequate knowledge and skills.
Specialty Care Transport, as de- n Knowledge of assessment and intervention tech-
fined by the Centers for Medicare & niques specific to the provision of care required
Medicaid Services1 during IFT.
Specialty care transport (SCT) is interfacility trans- n Additional minimum requirements determined
portation of a critically injured or ill beneficiary by by the specific patient population being trans-
a ground ambulance vehicle, including the provi- ported by providers.
sion of medically necessary supplies and services, n Continuing education requirements based upon
at a level of service beyond the scope of the EMT- data collected as part of a quality improvement/
Paramedic. SCT is necessary when a beneficiary’s management program. Quality improvement
condition requires ongoing care that must be fur- data can include such information as frequency
nished by one or more health professionals in an of specific clinical presentations, low-frequency/
appropriate specialty area, for example, emergency high-criticality interventions, patient outcomes,
or critical care nursing, emergency medicine, re- and issues related to concurrent and retrospec-
spiratory care, cardiovascular care, or a paramedic tive quality improvement.
with additional training.
References
General IFT Provider Education
1. Program Memorandum Intermediaries/Carriers.
Guidelines Transmittal AB-02/130. Subject: Definitions
Existing resources that establish minimum guide- of Ambulance Services. September 27, 2002.
lines on provider education can be incorporated Department of Health & Human Services.
into education standards and guidelines. Desirable Centers for Medicare and Medicaid Services.
Washington, DC.

Major Topic #3: Integration into Existing

Regional Health Care Systems
For the purposes of this document, two types of n transfer agreements and reciprocity of services
integration were defined: and personnel.
n horizontal – integration within existing health
To determine the current level of regionalized care
care system, and
and how IFT can be integrated, several questions
n vertical – integration with other/neighboring
may be helpful:
health care systems. n What defines current practice related to region-
Both are desirable in achieving seamless patient
alized health care? Factors may include:
flow during IFT.
o referral patterns and
Highly specialized health care services (e.g., stroke o legal requirements such as contracts,
centers, cardiac centers, trauma centers, high-risk agreements, memoranda of understanding.
obstetrics) may be more expensive than those ser- n What currently triggers IFT? What services
vices providing a general level of care. Integration currently exist to fill this need? What needs
may also avoid redundancy and promote the most continue to exist?
efficient use of resources. IFT can be an important n What are current practices/processes regarding
means to support integration and regionalization decisions related to mode of patient transfer and
of health care services. patient’s destination facility?
Considerations for a regional IFT plan include: Potential or perceived challenges in develop-
n delineation of legal authority and responsibili- ing a regional plan for IFT:
ties; n designated IFT providers may be perceived as
n a definition of integration and a descrip- curtailing competition;
tion of a region the stakeholders agree to (see n complications caused by interstate IFT system;
Definitions, Major Topic #1); n quantity and quality of personnel needed to
n what is meant by an integrated regional health provide service;
care system – components involved and how n in a free market system, providers may choose
they interoperate;
not to participate, creating gaps in coverage; and
n education of personnel in all system compo-
n unique challenges of providing IFT in urban
nents;
areas and rural areas.
n identifying synergies that can result from, and
the overall value of a regional approach to Potential or perceived benefits of developing
integration of services; a regional plan for IFT:
n the need for and problems caused by integra- n avoiding duplication of services;
tion of services across State lines (as it applies to n leveraging limited resources;
IFT);
n maintaining optimal skills, knowledge and
n benefits of open communication among stake-
abilities by assuring adequate patient volume;
holders, particularly with third-party payers;
n synergy of well-coordinated process may be
n the potential impact of regional integration on
applied to other EMS needs, e.g., disaster
competition and service duplication; and management;

n providing optimal care in a timely fashion, and

n self-determined cooperation and collaboration.
Strategies for overcoming challenges:

n open and constructive communication among
stakeholders;
n education and active participation of all stake-
holders including service providers, payers,
administrators and regulators;
n transfer agreements/partnerships, and
n reciprocity among states for services and indi-
vidual licensing.
10 National Highway Traffic Safety Administration

Major Topic # 4: Medical Oversight

The Medical Director American College of Emergency Physicians
Interfacility Transportation of the Critical Care
The practice of critical care medicine is differ- Patient and Its Medical Direction (1999)
ent from the practice of emergency medicine. http://www.acep.org/webportal/PracticeResources/
Likewise, emergency medicine is different from PolicyStatements/
EMS, and IFT is different from the portion of
EMS providing prehospital care. Each is a distinct National Association of EMS Physicians
specialty with focused knowledge, skills, and abili- Medical Direction of Interfacility
ties. Trying to find one medical director to wear Transports (2000)
all of these hats may not be easy, and it could take Medical Direction for Air Medical Transport
several physicians working together to provide the Programs (2002)
experience and expertise required for comprehen- Physician Medical Direction in EMS (1997)
sive IFT service. (table of contents:)
http://www.naemsp.org/Position%20Papers/
Physicians in medical specialty usually practice Contents.html
within hospital walls (e.g., neonatology, thoracic Commission on Accreditation of Medical
surgery) and may not be familiar with the opera- Transport Systems
tional aspects of the IFT process. Specialists are Best Practices: A Collection of Outstanding
more likely to require additional training to func- Programs and Policies from Accredited
tion efficiently in the out-of-hospital environment, Transport Services
and for them to function in medical direction http://www.camts.org
capacity. It may be easier for physicians/medical
directors who are familiar with EMS and/or IFT Medical oversight in IFT may take multiple forms:
(e.g., EMS Medical Directors) to assume leadership
of IFT programs. EMS physicians in general are E.g., protocol
Prospective Off-line Indirect development
familiar with what is involved in caring for patients
E.g., giving
in out-of-hospital settings. On-line/ direct orders
Concurrent Direct
On-scene via radio/
The ideal IFT Medical Direction might be a cross- telephone
trained physician or through a collaborative work- E.g., quality
ing relationship between two (or more) physicians. Retrospective Off-line Indirect management,
If one physician is designated as medical director case review
for an IFT program, that physician should func-
tion as medical director for the IFT program using
Off-Line Medical Direction
other specialists as resources, rather than having Off-line medical direction includes those activi-
several physicians serving as multiple medical di- ties performed by the medical director that do not
rectors. There should be assurance that the Medical occur during actual transport. These duties are
Direction arrangement is consistent with appli- usually performed before transport (e.g., training,
cable State laws and regulations. education, development of protocols) and after
transport (e.g., chart review, case review, continu-
Guidance for medical directors can also be found ing or remedial education, quality improvement).
from multiple sources, including: The medical director is ultimately responsible for
Air Medical Physician Association the care provided by the IFT service and should
Medical Direction and Medical Control of Air be involved in all aspects of IFT that have a direct,
Medical Services potential impact on patient care.
http://www.ampa.org/component/option,com_doc-
man/task,cat_view/gid,23/Itemid,42/
Role of Standardized IFT and
Destination Protocols
Guide for Interfacility Patient Transfer 11
Written orders from the transferring facility may Medical oversight and interfacility
suffice for the stable patient during most transfers, transfers: which medical director
but on-line medical direction should be available at is liable for what part of inter-
all times, in case unforeseen situations arise during facility transfer
transport. Off-line protocols can be developed as
a basis for care during transport, but complexity Medical oversight is variable and depends on
of care for many patients seems to suggest that State and local regulations. As per the Emergency
they may be of limited usefulness. A standard Medical Treatment and Labor Act (EMTALA), the
order sheet shared system-wide that can be indi- referring physician is responsible for the patient
vidualized by the transferring physician may be being transferred from one facility to another, until
more useful. Advance development of this form in the patient arrives at the receiving facility. On-line
conjunction with referring and/or accepting physi- medical direction may be provided by the referring
cians may further facilitate the IFT process. physician, the accepting physician, the transfer-
ring agency medical director, the medical director’s
Unlike prehospital EMS, which may dictate that a proxy for specialty care issues, or some combina-
patient be taken to the closest or most appropri- tion of the above. This often is determined by the
ate facility, IFT is a physician order to transport State and local regulations, and may differ between
a patient from one specific location to another. jurisdictions. For example, in some jurisdictions,
Therefore, destination protocols are of very limited if the transport vehicle is owned by the receiving
utility unless they address the event of a rapid de- facility that liability begins when the crew assumes
terioration of patient condition requiring transport care of the patient.
to the nearest appropriate facility.
While on-line medical direction may be provided
Consultation with Specialty Care by the referring physician, the accepting physician,
the transporting agency medical director, the med-
The medical director is ultimately responsible for
ical director’s proxy for specialty care issues, it is
the care provided by the IFT service. Therefore,
essential that the roles of each are determined prior
it behooves the medical director to have access to
to transport and while the IFT system is devel-
specialists and consultants who are available for
oped. It may require a contract, a memorandum of
real-time (on-line medical direction) problem
understanding, or other legal documents between
solving, and for protocol development, case review
the agencies or jurisdictions. Whatever the case, it
and post-transport consultation. It may be in the
needs to be clearly defined in advance of transfer
patient’s best interest, and extremely helpful to
and not decided while transport takes place.
both crew and medical director, to seek the opin-
ions of those with extensive experience and ex- To anticipate possible situations where there may
pertise in medical specialties. One possible model be confusion or difference of opinion regarding the
includes a single medical director who receives bounds of responsibility and liability, IFT services
input and assistance from other medical special- should develop and adopt protocols for how crew
ists (i.e., neonates, pediatrics, intra-aortic balloon members and the medical director will handle such
pump, etc.) in drafting protocols, education, and situations. This protocol should include provisions
case review for IFT. to assure medical director responsibility is resolved
prior to patient transport. Advance knowledge of
On-Line Medical Direction this protocol by all stakeholders may be helpful in
On-line medical direction includes those activi- proactively addressing potential situations con-
ties performed by the medical director that occur cerning medical oversight.
real time, during actual transport. On-line medical
direction should be available at all times, in case
unforeseen situations arise during transport.

Major Topic #5: Liability

Optimally, decisions regarding system or service Liability of Direct Care Providers
protocols and procedures, scope of practice of
transport personnel, interagency and inter-juris- Each program, hospital, or service employing
dictional agreements regarding transfer should be health care professionals to provide direct care
made prior to the need for interfacility transfer. for patients during IFT is responsible for ensur-
The extent to which this is accomplished will make ing that policies, procedures, and protocols are
decisions easier and the IFT process more efficient. in place for the care provided by the transport
Potential liability has a major impact in making team. These documents should be consistent with
these decisions, and it behooves all stakeholders laws, regulations, and administrative rules for the
to have a strong working knowledge of the issue. jurisdiction(s) in which IFT occurs. The IFT ser-
Laws addressing liability and their interpretation vice should also maintain written policies address-
vary widely from state to state. Specific informa- ing appropriate licensure and scope of practice for
tion within this document may therefore be of each team member, based upon the local, regional,
limited use. It behooves those involved in IFT to and/or State laws and/or regulations in the geo-
become familiar with State laws and court deci- graphical area(s) in which the team provides care
sions impacting liability in the jurisdiction(s) to and performs transports.
be served by the IFT service. This major topic
contains general information for consideration, The IFT transfer service/program is responsible for
including: definitions, delineations of liability for the care rendered during transport. The program
health care providers, regulations that affect liabil- should establish written policies/protocols for all
ity, and practice guidelines. procedures, skills, or care the transport team mem-
bers provide. Written documentation of educa-
tion, skills, training, demonstrated abilities, initial
Definition of Liability and/or ongoing education, should be maintained,
Liability is generally defined as legal responsibility and all transport personnel should be familiar with
for one’s acts or omissions. There are two forms: program requirements. In addition, the transfer
n Direct Liability - Liability imposed directly on service should establish an ongoing program for
a person because of his or her own negligence, quality assurance/quality management, which uses
default, or legal undertaking. patient and referring facility/physician satisfac-
n Indirect Liability - Liability that arises from tion surveys, chart reviews, case reviews, and peer
a legal obligation owed to an injured party to reviews to identify problems or areas needing
pay damages for another’s failure to perform or improvement as well as areas of strength that could
negligent act. serve as models for other IFT services.
Liability of Each Health Care The individual caregivers are responsible for the
Professional direct care they provide to the patient during
transport. It is imperative that these personnel be
Every health care professional has a legal duty to ex- familiar with the appropriate State practice acts
ercise that degree of knowledge, care, and skill that (e.g., Medical Practice Act, Nurse Practice Act,
is expected of a comparably trained practitioner in EMS Act), licensing and/or certification regula-
the same class in which he or she belongs, acting tions, and the limitations and responsibilities of
in the same or similar circumstances. The standard their specific profession’s scope of practice. It is the
of care is based on laws, administrative orders, obligation of each licensed and/or certified profes-
regulations, and guidelines established by entities or sional to know and understand the standard to
individuals with the legal authority to do so.

which he or she will be held. Individuals providing Regulations that Affect Liability
direct care to the patient should not be pressured
into functioning beyond their intended role, and EMTALA
must always function within the scope of practice Emergency Medical Treatment and
for which they are prepared, trained, and legally Labor Act1
authorized. Procedures should be in place that pro-
The Emergency Medical Treatment and Labor
viders can use to handle situations placing them
Act is a Federal law enacted by Congress in 1986
in questionable situations. Direct care providers
as part of the Consolidated Omnibus Budget
may or may not choose to carry individual profes-
Reconciliation Act (COBRA) of 1985 (42 U.S.C.
sional malpractice insurance in addition to what is
§1395dd). Referred to as the “anti-dumping” law,
provided by their employers.
it was designed to prevent hospitals from refusing
to treat patients or transferring them to charity
Liability of Medical Directors or county hospitals because they were unable to
Medical practice acts vary from State to State as pay or had Medicaid coverage. EMTALA requires
do statutes related to functions that may be per- hospitals with emergency departments to provide
formed under a physician’s license. It is particularly emergency medical care to everyone who needs
important for the prehospital professional who it, regardless of ability to pay or insurance status.
functions under medical direction to understand Under the law, patients with similar medical condi-
the purpose of the law in their jurisdiction(s), and tions must be treated consistently. The law applies
to be familiar with their State’s Medical Practice to hospitals that accept Medicare reimbursement,
Act, particularly as it pertains to liability and legal and to all their patients, not just those covered by
responsibilities. Medicare. For more information, refer to Appendix
E: EMTALA.
Obtaining Liability Insurance
Certificate of Transfer2
Physicians and other medical professionals pay
insurance premiums to cover payments for awards Certification of necessity for transfer is a re-
resulting from lawsuits. They may need liability quirement for reimbursement by the Centers for
insurance to practice medicine; in most cases hos- Medicare and Medicaid Services. The CMS defini-
pitals, physician groups, as well as many State laws tion of medical necessity is as follows:
require it. The cost of medical liability coverage Medical necessity is established when the patient’s
varies by specialty and location. Physician special- condition is such that use of any other method of
ists practicing emergency medicine, neurosurgery, transportation is contraindicated. In any case, in
orthopedics, obstetrics, and gynecology often have which some means of transportation other than
the highest premiums, because they perform pro- an ambulance could be used without endangering
cedures that have more risks of complications or the individual’s health, whether or not such other
because their patients have more serious illnesses transportation is actually available, no payment
or injuries. may be made for ambulance service
It is possible (but not likely) that a patient may
The medical liability crisis is reported to have require transfer and not meet the CMS definition
posed serious challenges to those physicians pro- of medical necessity. For more information, refer
viding medical oversight, including those involved to Appendix F: Certificate of Transfer.
with IFT. For more extensive information, refer to
Appendix D: Obtaining Liability Insurance.

HIPAA Air medical transport programs are most com-

Health Insurance Portability and monly operating under Part 135. All commuter
Accountability Act (HIPAA)3 and on demand aircraft transporting passengers
are required to comply with all Federal Aviation
The Health Insurance Portability and Regulations contained in Part 135.
Accountability Act of 1996 is a law enacted to
combat fraud, waste, and abuse in health insurance Example #2 — State Regulation
and the delivery of healthcare services; to improve
access to long-term care services and coverage, and EMS services usually derive their authority from
simplify the administration of health insurance. State laws or regulations. These may include laws
The program sets standards for the use and disclo- that allow the provision of emergency care. These
sure of protected health information along with statutes define scope of practice and frequently ad-
measures to ensure the secure transmission and dress protocols, communication, and medical over-
storage of medical records and other individually sight. There is great variation from State to State in
identifiable or demographic information. The regu- these laws and regulations. Some grant licensure
lations protect medical records and other individu- while others do not. It is important to be familiar
ally identifiable health information, whether it is with the State laws and regulations as they pertain
on paper, in computers or communicated orally. to the practice of IFT within the jurisdiction(s)
HIPAA regulations have implications for all IFT where IFT services are provided.
services transporting and transferring medical
records or medical information from one facility to In some cases and for certain circumstances, Fed-
another. For more information on HIPAA, refer to eral agencies may have jurisdiction (e.g., EMTALA,
Appendix G: HIPAA. HIPAA, Federal Aviation Administration
regulations on aircraft used as air ambulances).
Federal, State, and Interstate Specific roles and responsibilities in interfacility
transfers will vary from State to State; it is impor-
Regulations tant to understand these responsibilities. In some
IFT providers are well advised to become familiar localities, the functions of IFT providers and/or
with any Federal, State, or interstate regulations services are enabled by a specific law or regulation.
that may have an impact on IFT service, as well as
their relative jurisdictions. While it is not possible Example #3 — Interstate Issues
to include an exhaustive listing of these regula-
Because some geographic areas do not have rea-
tions, examples may provide illustration of the
sonable access to comprehensive or specialty ser-
potential impact of regulations on IFT.
vices within their own state, referral patterns may
exist that cross State lines. This situation makes it
Example #1 – Federal Aviation necessary to consider issues of interstate coordi-
Administration (FAA) nation and cooperation. Interstate issues can also
arise for metropolitan areas that serve more than
The FAA strictly governs the operations of air- one State. In some cases, interested parties can
craft in the United States under Title 14 of the develop official agreements under the auspices of
Federal Code of Regulations. There are two Federal State or local government agencies. In other cases,
Aviation Regulations (FAR) that are applicable contractual or informal relationships develop
to air medical transport, FAR Part 914 and FAR between referral centers and community hospitals
Part 1355. FAR Part 91 addresses the “General and EMS systems.
Operating Flight Rules” and FAR Part 135 deals
with “Commuter and On-Demand Operations and
Rules Governing Persons on Board Such Aircraft.”

The stability of both official and informal arrange- Perceived advantages of establishing clinical prac-
ments depends on meeting the needs of all the tice guidelines for IFT include:
groups involved and on addressing key issues, such n evidence-based reference for provider practice;
as coordination of professional, legal, and regulato- n direct linkage with improvement in patient
ry requirements. Neighboring States often differ in
clinical condition and outcome;
such matters as certification and licensing require-
n direct linkage with reduced risk of morbidity
ments for institutions and practitioners, scopes
of practice and guidelines for transfer. Interstate and mortality;
transfer agreements can address some of these n established benchmark for measuring perfor-
differences to ensure that consistent and accept- mance;
able levels of care are rendered and that providers n direct linkage with enhanced patient safety;
do not face liability risks related to differences in n comparison between agencies easier using simi-
practice standards. lar guidelines;
n provides public and referring physicians/facili-
Practice Guidelines ties a clearer understanding of the capabilities of
Various terms are used to outline the expectations any one IFT provider and
of performance within the EMS community. The n gives provider a clear understanding of expecta-
terms “standards” and “guidelines” are frequently tions and responsibilities.
and erroneously used interchangeably.
The Health Improvement Institute provides a Perceived disadvantages of establishing clinical
generic definition for these similar terms.6 A practice guidelines for IFT include:
standard (or protocol) is described as “a basis for n use by the legal community to argue a breach
comparison; a reference point against which other in the standard of care when litigation ensues
things can be evaluated; ‘they set the measure for following a negative outcome (whether or not
all subsequent work.’” A guideline is explained as medical negligence actually exists);
“something that is to be preferred, but that does
n difficult and resource-intensive to develop and
not have the force of a standard.” EMS standards
and guidelines can be written to reflect a course of maintain;
action for clinical as well as operational/manage- n minimal flexibility for individual preferences,
ment needs. For the purposes of this discussion, agency capabilities, changes in patient condi-
standards create an expectation while guidelines tion;
are generally thought to be a bit more flexible. n difficult to establish for patients with multiple,
complex diagnoses;
The Institute of Medicine (IOM) defines clinical n balance between optimal clarity and minimal
practice guidelines as “systematically developed liability difficult to establish; may be too vague
statements to assist practitioner and patient to be useful or too narrow to be legally “safe”;
decisions about appropriate health care for specific n might force IFT provider to meet unrealistic
clinical circumstances.”7 Frequently promulgated
expectations regarding equipment, education,
by relevant professional organizations, societies,
and maintenance of skills and
health care organizations, or government agencies,
n guidelines do not have the force and effect of
standards and guidelines are generally developed
using verifiable, systematic literature searches the law.
and reviews of existing evidence published in
peer-reviewed journals to establish best practice
recommendations.

References 5. Code of Federal Regulations, Part 135.

Operating Requirements: Commuter and On
1. Emergency Medical Treatment and Labor Demand Operations and Rules Governing
Act. State Operations Manual. Appendix V Persons On Board Such Aircraft. http://ecfr.
– Interpretive Guidelines – Responsibilities of gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=c
Participating Hospitals in Emergency Cases. 3a8e094742081e734f4dafc1496bf36&tpl=/ec-
(Rev. 1, 05-21-04). Department of Health & frbrowse/Title14/14cfr135_main_02.tpl. U.S.
Human Services. Centers for Medicare and Government Printing Office. Washington, D.C.
Medicaid Services. Washington, DC.
6. Clinical Practice Guidelines: Directions for a
2. Certificate of Transfer. Federal Register, June New Program, (1990), M.J. Field and K.N. Lohr
22, 1994 (59FR32086). Department of Health (editors) Washington, DC: National Academy
& Human Services. Centers for Medicare and Press. Page 38.
Medicaid Services. Washington, DC.
7. Health Improvement Institute Quality Award.
3. Health Insurance Portability and Accountability Standards. Definitions and Abbreviations.
Act. http://www.cms.hhs.gov/hipaa/. Health Improvement Institute. http://www.hii.
Department of Health & Human Services. org/index.html
Centers for Medicare and Medicaid Services.
Washington, DC.
4. Code of Federal Regulations, Part 91. General
Operating and Flight Rules. http://ecfr.gpoaccess.
gov/cgi/t/text/text-idx?c=ecfr&sid=c3a8e0947420
81e734f4dafc1496bf36&tpl=/ecfrbrowse/Title14/
14cfr91_main_02.tpl. U.S. Government Printing
Office. Washington, D.C.

Major Topic #6: Operations

The overriding principle for all aspects of It is essential that personnel utilized to provide care
IFT is matching patient needs with adequate during interfacility transfers be properly trained,
provider knowledge and skills, equipment and familiar with the unique demands of providing
an infrastructure that provides seamless patient care during ground or air transport, legally autho-
flow during transport. Any judgment should err rized to perform the skills, and prepared to handle
on the side of caution in providing care at the the variety of patient contingencies. Multiple pro-
level likely to be needed or potentially needed viders may be qualified to accompany the patient
during IFT. Major Topics 2 and 4 address multiple depending on their education, skill level, and legal
considerations in providing optimal patient care. authority. Additional education, under the guid-
In addition to these, the operational aspects of IFT ance of the Medical Director, will be needed to
should be closely managed, to facilitate seamless prepare all traditional providers for interfacility
patient flow during transport. Operations can patient care, whether hospital or prehospital-based,
include crew selection, staffing levels, the vehicle, but the specific focus of this additional educa-
equipment, communications, and standard tion may vary depending on the provider’s exist-
operating procedures. ing knowledge base. Medical directors should be
involved in training, education, and evaluation of
Crew Selection crew knowledge, skills, and abilities, at each level of
Interfacility transfer requires a unique set of skills care, on an ongoing basis.
that is distinct from the training of most hospi-
tal-based or prehospital providers. To provide The crew should be educated and trained to care
adequately for patient needs during IFT, selection for the anticipated patient population using antici-
of the transport personnel/crew should include pated transport mode(s). Training can be provided
a team capable of providing the level of care the by the transport agency or other legally recognized
patient’s present condition requires; the likely and entity, but the medical director and transport agen-
the potential needs of the patient throughout the cy should approve the level of education and train-
transport. In many jurisdictions, prehospital and ing provided. Providers can also receive special-
hospital health care professionals are legally autho- ized education and training in specific areas (e.g.,
rized to perform tasks within a specific scope of neonatal, cardiac, etc) appropriate for the patient
practice, which may or may not match the clinical population(s) being transported. There may also be
needs of the patient or the needs presented by the a need for the use of other healthcare professionals
operational IFT environment. (e.g., respiratory therapists) during transport. The
crew must be able to provide quality care within
In IFT program development, it is advisable to their scope of practice including the use of trans-
determine the knowledge, skills, and abilities port equipment in the transport environment.
necessary for the IFT patient population. Under
the medical director’s guidance, recurring refer- Minimum requirements for staff
ral patterns, patient populations, and frequently qualifications
used modes of transportation should be assessed
to determine necessary qualifications and training. Minimum requirements can be flexible without
The need for specialty care transports (i.e., neona- compromising care. For extensive information
tal, intra-aortic balloon pump) should be analyzed on suggestions for provider skills and knowledge,
to make decisions on how to match patient needs refer to Major Topic #2, Provider Education, which
with provider knowledge, skills, and abilities. includes suggested knowledge, skills, and abilities
related to IFT.

Staffing Levels n technology and/or special equipment to be used

during transport; and
The number and right combination of personnel
n scope-of-practice of the various team members.
should be addressed in developing an IFT pro-
gram. Staffing decisions should be determined by The transport team leader should possess appro-
clinical patient care needs and operational require- priate clinical experience and expertise, as well as
ments. Recurring referral patterns, patient popula- the leadership skills necessary to direct the provi-
tions, and frequently used modes of transportation sion of patient care in the IFT environment. Unless
should be assessed to determine necessary qualifi- a physician is included as one of the transport team
cations and training. The highest potential acuity members, a physician designated to provide medi-
level of the transported patient and the ability of cal direction should be available for consultation.
the staff to respond appropriately in the transport An acceptable exception to this requirement may
environment should be a determinant of crew exist in those circumstances when, under supervi-
composition. sion of the designated medical oversight physician,
the transport team follows established written poli-
Many transfer services use the team concept in
cies, protocols, and procedures.
developing and deploying IFT. Predetermined
staffing patterns with specific qualifications can Filling Staffing Needs
be developed to match patient need and deployed
when patient need is identified. Determination Although there may be variation in the minimum
of the appropriate team composition can include requirements and core knowledge, skills, and abili-
consideration of the following: ties that the members of the IFT team are required
n the availability of critical care and/or specialty
to possess, their combined expertise should pro-
care transport teams within a reasonable vide for accurate patient assessment, formulation
proximity; of an effective plan of care, implementation of ap-
propriate interventions for the actual and potential
n the modes of transportation and/or transport
patient problems that may be encountered, and
personnel available as options in the particular evaluation of the patient’s response to the care pro-
geographic area; vided. Education and training specifically related
n specific circumstances associated with the to the characteristics and differences of delivering
particular transport situation (e.g. inclement patient care in the transport environment must be
weather, major media event, etc.); provided prior to any performance of independent
n anticipated response time of the most transport care activities by any member of the
appropriate team and/or personnel; transport team.
n established State, local, and individual transfer
The content and extent of required training will
service standards/requirements; be dependent upon the job description and/or the
n combined level of expertise and specific duties/ specific set of duties for which the individual team
responsibilities of the individual transporting member will be responsible. Qualified people may
team members; be hired or training provided for existing staff.
n degree of supervision required by and available Decisions favoring one approach over the other
to the transporting team members; involve the availability of qualified staff, possible
n complexity of the patient’s condition; pay differentials based on knowledge and skills,
n anticipated degree of progression of the patient’s
providing training to existing staff, and the cost-
effectiveness of comparable models.
illness/injury prior to and during transport;

The Vehicle Administrative Protocols/Standard

Vehicle selection should be driven by the IFT Operating Procedures
mission profile. State licensing requirements A comprehensive IFT service requires
should be met, and the vehicle should be able to administrative protocols to provide seamless
accommodate the necessary equipment. Vehicle patient flow during transport and to deal with
selection should provide enough room for the challenges IFT may pose. Standard operating
patient, caregivers, and potential additional procedures are recommended to address such
equipment and/or providers. As with any issues as mutual aid, communications, weather,
transport, all safety standards should be met. and equipment maintenance and failure. More
Redundant power, electrical, communication, and information on standard operating procedures
lighting systems should be provided. can be found by referring to the Commission
on Accreditation of Ambulance Services
Equipment (CAAS). Both CAAS and the Commission on
As with crew vehicle selection, determination Accreditation of Medical Transport Systems offer
of equipment should be based upon patient and helpful information as well as the opportunity for
operational needs. Equipment should comply accreditation, which may have practical benefits for
with all minimum statutory and regulatory IFT services. The CAAS Web site can be accessed
requirements, and provide for accurate patient at: www.caas.org and the CAMTS Web site can be
assessment, implementation of appropriate accessed at: www.camts.org.
interventions for the actual and potential patient
problems that may be encountered, and evaluation
of the patient’s response to the care provided.
Equipment should also provide all necessary
functions to operate safely and accurately within
the transport environment. Equipment lists
are available from multiple sources. For more
information, refer to Appendix B: References &
Resources, References of General Interest.
Communication/Linkages Needed
Communication is essential for the safety of the
crew and the optimal care of the patient. The crew
must be able to communicate with the dispatch/
communication center, the receiving facility, the
local public safety providers — EMS, fire and
police, and on-line medical direction.
Communication and data linkage should be
available throughout transport. A redundant
system should be in place in case the primary
communication system fails.

Major Topic #7: Financial Considerations

Meeting the cost of IFT involves a thorough un- n Quality Improvement.
derstanding of incurred expenses as well as mecha- n Infrastructure costs – additional costs related
nisms for reimbursement. While most payers make to function as part of an EMS system, e.g.,
payment for services and equipment provided, communication.
identification of alternative funding sources may
be necessary to cover the cost of providing “pre- Adding the cost of patient care
paredness” (the day-to-day fixed and operating These costs include expenditures related to provid-
costs of IFT service). This may require creativity ing basic care to stable patients with very little or
and collective thinking on the part of IFT stake- no risk for deterioration; and additional variable
holders. A careful, comprehensive assessment of costs of fuel, supplies, equipment, and personnel.
costs can be useful in meeting the financial needs
for an ongoing IFT service. Adding the cost of critical care
Costs are incurred by an IFT service to assure a These costs include expenditures related to pro-
constant state of readiness, even if no patients are viding advanced care to all patients whose acuity
transported. IFT service assumes additional costs surpasses that of stable patients and additional
every time a patient is transported. The following variable costs of fuel, additional supplies, equip-
is a list of considerations in determining fixed and ment, and personnel to provide the required level
other operating costs, and how these costs increase of care.
once patient care is initiated.
Supply and demand — “back-up”
Fixed costs/readiness/surge capacity capacity
n Labor — for those providers who are not Represents replacement (back-up/on call) crew,
volunteer. equipment and other infrastructure costs when the
n Equipment, medications, and supplies.
primary unit/ambulance is providing IFT services
and/or payment for additional or higher-level
n Vehicle maintenance.
medical personnel if needed, to assist in the trans-
n Overhead for facility housing transport mode
port. For the purposes of this document, discus-
and/or administration. sion of back-up capacity is limited to the day-to-
day capacity of any one IFT program to meet the
Other operating costs demand for its services. The discussion will not
n Marketing – customer/hospital/facility educa- include the capacity to handle an epidemic illness
tion regarding the availability and capabilities of or injury, natural disaster, intentional acts of mass
the IFT transfer services. injury, otherwise known as “surge capacity.”
n Billing.
n Legal and accounting.
Definition of level of service1
n
(as defined by CMS, for service
Educational and continuing education costs. provided)
n Licensure for providers.
n Administrative personnel. It is important for IFT services to understand how
payers such as CMS define levels of service
n Field personnel --some services deal with this
n Basic Life Support (BLS) – where medically
cost by using personnel on an independent con-
tractor basis (to avoid this fixed cost). necessary, the provision of basic life support ser-
n On-call pay. vices as defined in the National EMS Education
and Practice Blueprint for the EMT-Basic
n Dispatch center functions.
including the establishment of a peripheral
n Insurance. intravenous line

n Advanced Life Support, Level 1 (ALS1) – where plan will provide essential information as well as
medically necessary, the provision of an assess- a tool to track, monitor, and evaluate the financial
ment by an advance life support provider and/or status of an IFT service. There are many forms of
the provision of one or more ALS interven- business plans, but most have three purposes: com-
tions. An ALS provider is defined as a provider munication, management, and planning. A com-
trained to the level of the EMT-Intermediate prehensive plan can be used to establish timelines
or Paramedic as defined in the National EMS and milestones, gauge progress and compare your
Education and Practice Blueprint. An ALS projections to actual accomplishments, and it is a
intervention is defined as a procedure beyond living document to be modified as financial con-
the scope of an EMT-Basic as defined in the siderations evolve and change. For more specifics
National EMS Education and Practice Blueprint. on writing a business plan, refer to Appendix C.
n Advance Life Support, Level 2 (ALS2) – where
medically necessary, the administration of at Considerations
least three different medications and/or the When developing and deploying a business plan,
provision of one or more of the following ALS it is wise to consider circumstances specific to
procedures: manual defibrillation/cardioversion, your service, community, and situation. These may
endotracheal intubation, central venous line, include:
cardiac pacing, chest decompression, surgical
airway, intraosseous line.
n Specialty Care Transport (as defined by the
Urban Services and Rural Services
Centers for Medicare & Medicaid Services) Urban
— SCT is interfacility transportation of a criti- n While urban areas are assumed to have shorter
cally injured or ill beneficiary by an ambulance, transport times, transport times and costs can
including the provision of medically neces- be increased by urban traffic congestion and
sary supplies and services, at a level of service diversion of ambulance patients by overcrowded
beyond the scope of the EMT-Paramedic. SCT EDs and hospitals.
is necessary when a beneficiary’s condition
requires ongoing care that must be furnished by Rural
one or more health professionals in an appropri- Many of the problems of an urban service can be
ate specialty area, for example, emergency or magnified in a rural service. Even including the
critical care nursing, emergency medicine, respi- Rural Adjustment Factor (RAF), which is defined
ratory care, cardiovascular care, or a paramedic by CMS as an adjustment rate applied to the pay-
with additional training. ment amount for ambulance services when the
n Emergency – Emergency response is a BLS or point of pick-up is in a rural area, rural services
ALS1 level of service provided in immediate re- may face additional financial challenges:
sponse to a 9-1-1 call or the equivalent. The im- n Rural services may have difficulty finding
mediate response is one in which the ambulance trained and experienced personnel. Recruiting
provider/supplier begins as quickly as possible can be difficult for rural services. Pay differen-
to take steps necessary to respond to the call. tials may contribute to the difficulty in recruit-
ing.
Business Plan n Training costs may include the additional cost of
It may be helpful for IFT stakeholders to write a travel, as personnel often need to travel, either
business plan to develop strategies to meet the fi- to provide or receive necessary training.
nancial needs of the IFT service. Writing a business

n For IFT, the mileage and hourly expenses may Education and active participation
be magnified because transport is generally of stakeholders
over longer distances. The transporting service In the IFT planning process, stakeholders can edu-
must pay for fuel, wear and tear on the vehicle, cate third-party payers about what the IFT system
and the time of the personnel. Longer transport includes and can involve them in the discussion
times also mean that the personnel must be pre- of providing IFT services. At a minimum, such
pared for more contingencies with the patient, education includes:
increasing the cost of readiness. This includes
n the difference among various payment levels;
the cost of such things as a larger quantity and
bigger selection of drugs and equipment. n the discrepancy between the cost of providing
n Shipping, fuel, and maintenance cost more in a

preparedness versus fee for specific services
provided;
rural environment. It is more difficult to get any
material into the area, and that usually translates n the difference between subsidized versus non-
into higher prices. subsidized services and their impact on IFT

n Rural services may be low-volume, and not be
services; and
able to recoup fixed costs as easily as busier n the difference between volunteer versus paid (or
services. mixed) services — since fixed personnel costs

would be different.
Regional Planning
Significant financial gaps may be identified,
n Regional planning for reimbursement models
requiring creativity on the part of all stakeholders
can be key in minimizing cost. While reducing
to provide support for IFT. Billing of third-party
competition, regional planning can also reduce
payers is only one strategy for revenue. Other
redundancy and resultant increase in expense.
unconventional ideas may be useful in meeting
n Trying to insure coverage by linking services
the costs of IFT:
within a designated locality can be facilitated by n in-kind support, such as contribution of equip-
the linkage of the appropriate reimbursement
ment and/or services (if allowed);
plans.
n transition to an overall model of reimburse-
Integrating CMS reimbursement rules with ment for IFT through hospitals and/or physi-
cians. Adopting this model may provide the IFT
third-party payers
program with a broader range of reimbursable
EMS offices can involve both public- and private- services than those included in transport reim-
party payers in the IFT planning process. Medicare bursement models.
patients make up a significant portion of all
ambulance patients; therefore Medicare rules set
the standard for many payers and Medicare rules
References
should be reviewed in the IFT planning process. 1. Centers for Medicare and Medicaid Services.
For optimal simplicity and consistency, there Medicare Benefit Policy Manual. Pub. 100-02.
should be agreement among all payers, on defini- Chapter 10. Ambulance Services.
tions and standards for medical necessity, service http://www.cms.hhs.gov/center/ambulance.asp
levels, practitioner level definition, covered ser-
vices and other necessary elements of IFT.

Major Topic #8: Policy Development

Policy development and planning includes A systematic process is recommended to assess
strategies to: the current status of and potential need for IFT
n inform, educate, and empower people about IFT legislation and regulation including finding the
issues; answers to the following questions:
n mobilize State and community partnerships to n What local, State or Federal laws and regulations
identify and solve IFT problems; and directly impact IFTs in your community?
n develop policies and plans that support State n What agency has the authority and
and community IFT efforts. responsibility for implementing and enforcing
these laws and regulations?
In many communities there is no entity with n What processes does the agency use to develop
authority or responsibility for management of and to enforce regulations? How can you impact
IFT issues. In some States/communities, formal regulation development or modification?
agreement among the stakeholders may be n Do jurisdictions’ regulations compliment each
sufficient to implement IFT strategies. Frequently,
other or do they conflict?
however, legislation and regulation are necessary.
n What gaps or issues can you identify in the
Whether derived from government authority or
established through formal stakeholder agreement, legislation or regulations?
it is important the IFT policies, procedures, n Is there model legislation that may be helpful in
authorities and responsibilities be articulated this analysis?
carefully and communicated to all stakeholders. n Do other jurisdictions have comparable
legislation that could provide comparison?
Legislation, adopted by a governing body (e.g.
State legislature, county council), usually estab- In evaluating the adequacy of existing agreements,
lishes which government entity is responsible laws, regulations or policies, the following
for management of IFT, delineates that agency’s considerations may be important:
authority and responsibility and establishes other n definition of levels of patient acuity to assist
IFT parameters potentially including the need for a in determining appropriate personnel to use
license. Frequently, the government agency, such during the IFT;
as a state or county health department or State
n standards of care;
EMS Agency, is authorized to promulgate rules/
n minimum requirements for education and
regulations that may establish IFT licensure
requirements including, for instance, personnel training of IFT personnel;
education and certification, safety, reporting pro- n inter-jurisdictional transfer issues;
cedures, medical direction and license suspension n requirement for data collection or utilization of
or revocation. Sometimes, these detailed require- data for performance improvement;
ments are determined by the governing body and n authority to enforce regulations.
are included in the legislation. In some States, IFT
regulation authority may be contained in the State Persons interested in developing legislation or
EMS agency’s authorizing legislation. regulations for IFT should become familiar with
their jurisdiction’s system. For instance, visiting

with and involving State EMS Agency staff may IFT legislation, regulation and legal decisions.
be essential to improving IFT policy development Understanding of the State’s regulatory process
and implementation. The State EMS Agency can and gaining support for authorizing legislation or
usually provide good information on the status of regulations can reduce misunderstandings and
conflict. For instance, many State EMS offices
have an advisory council that provides advice
Legislation may be enabling. In June 2005, on regulatory and EMS system issues. It may be
New Hampshire law was amended to important to have an individual experienced and
enable alternative health care to participate interested in IFT issues attend the meetings and
in interfacility transfer if the availability of provide information on IFT issues. An ad hoc
conventional providers exceeds 30 minutes, group can be formed to make recommendations
enhancing the ability of New Hampshire for advisory council consideration.
health care facilities to provide expedient
transfer to patients requiring such service Educating and involving third party payers may
also be a key activity to improving your IFT
(S.B. 88). This law made it possible to use
system.
multiple IFT strategies without requiring
any specific mode or crew composition. To obtain more information on statutes and ad-
ministrative rules and how they affect EMS in your
State, contact the State EMS office. A listing can be
found at www.nasemsd.org, the Web site for the
National Association for State EMS Officials.

Major Topic #9: Evidence

The guidelines contained in this document are n Databases such as the National EMS Informa-
based upon a combination of available objective tion System (NEMSIS) and the National Trauma
evidence, a review of generally accepted practices, Data Bank can be used to ensure standard data
and the consensus of expert opinions in the field of elements and the optimal utility of data.
IFT — in short, the best information available. In n Because patient volume within any one IFT
the current health care environment, however, the service may be low, collaborative research can
efficiency and efficacy of medical practice, policies, be conducted and used to derive results that can
and operations are held to a higher standard of be applied to other groups of IFT patients and
evidence than in the past. Ongoing evidence col- other systems of IFT delivery.
lection is the key to ensuring that IFT provides the n The data for IFT research may require linkage
best possible care in an optimal fashion.
with prehospital data, ED data, hospital data,
and that of the institutions pre and post IFT, to
The members of the IFT Workgroup concur with
study outcomes as well as process.
the authors of the EMS National Research Agenda
n The evidence collection process and data
who state, “...the lack of scientific knowledge about
optimal patient care has confused clinicians and elements to be used for assessment and
left them floundering to provide the best care assurance are optimally identified as new/
without the guidance of good science.” As with any updated IFT service is planned and before its
other area of emergency care, the practices and implementation, so data can be gathered before
processes involved in delivering IFT need objective and after IFT is deployed.
evaluation to determine their impact and cost-ef-
fectiveness. Outcome and Process Evaluation
Assessing the status of the current practice of IFT
Evidence assessing the status of IFT services can includes two areas of study: (1) outcomes evalua-
range from “micro” to “macro” in scope. The level tion, and (2) process evaluation.
of detail will be determined by the questions to be
answered, and may include some or all of the fol- Outcome evaluation examines the effectiveness
lowing strategies: or efficacy of particular interventions on patient
n Tracking/Monitoring status. An outcome evaluation of IFT assesses a
n Quality Management particular clinical aspect of patient care during IFT,
n Case Review
and its impact on patient outcome. Examples of
prime candidates for outcome evaluation include:
n Performance Indicators
n Defining and ensuring adequate and effective
n Surveillance Methods Used in Assurance Phase
patient care during IFT. The EMS Outcomes
n Formal Research Project names six categories for patient out-
come:1
Data Collection for IFT Evidence o survival
n Uniform data definitions are essential to collect o impaired physiology
evidence that can enable multisite studies, and o limit disability
true comparison of IFT practice and methods of o alleviate discomfort
delivery. o satisfaction
o cost-effectiveness

n Evaluation of best-model practices for different n What system QI model works best to monitor
levels of providers and for different geographic the outcomes of patients in a particular region/
areas State?
n Timing of transfer — When is it too early or too n Regional resource assessment and management.
late to transfer patients? n Additional training — what is important and
n What practices are most effective in preventing what's not?
infection during IFT? n Response time standards.
n Does constant availability of medical direction n Were protocols adhered to? Why or why not
make a difference in outcomes? (related to system components)?
n Does the level of provider make a difference in n Dispatch issues — call-taking, triage, personnel
outcome for particular acuity levels of patients? assignment, as they relate to IFT.
n Tracking referral patterns and trends to deter-
Process Evaluation — It would be difficult to con-
mine future patient population.
clude that a specific intervention caused a specific
outcome, if the process of achieving it was not car-
ried out as intended.
References
1. Maio, Ronald. Emergency Medical Services
Process evaluation focuses on the quality of imple- Outcomes Evaluation. U.S. Department of
mentation — how well the intended process was Transportation, National Highway Traffic Safety
carried out. It examines operational and system Administration. July, 2003.
efficiency. Examples include:
n Where can costs be reduced in operation and
equipment and still provide optimal care?

Major Topic #10: Lessons Learned

This publication is distributed by the U.S. Evidence of success could be anecdotal report-
Department of Transportation, National Highway ing, a formal quality assurance program, or
Traffic Safety Administration, in the interest of published research involving control groups and
information exchange. As part of the IFT project, peer review.
the IFT Work Group put out a call for information
on existing IFT programs from a wide variety of Although not criteria for inclusion, two other
organizations and individuals involved with IFT, in characteristics were present in these profiles: col-
an effort to illustrate examples of lessons learned laboration and evolution. All success is shared:
during the process of establishing and/or maintain- Every organization interviewed benefited from and
ing IFT service. This section includes the results of valued the work of people who had come before
that call for information, and represents a self-se- them. All programs continue to evolve as effective-
lected group of IFT programs that may function as ness is studied and the results are used to improve
case studies to learn from, and/or act as resources performance.
for a variety of IFT information. Certainly many
more programs could offer promising approaches All those who submitted a profile of their IFT
than could be included here. Resources prevented program expressed a willingness to share their
an exhaustive and comparative selection process. information directly with other parties interested
in IFT; therefore, contact information is included
The respondents were contacted and extensively in each profile. The IFT Work Group hopes these
interviewed following a standardized format. The examples encourage cooperative efforts between
examples presented here had four characteristics in stakeholders in establishing IFT services.
common:
n Replicable: Has the potential to be replicated The Work Group appreciates the participation of
in other settings or provides a basis that others the services providing information about their
could build upon. programs. The examples offered are presented to
n Purposeful: Practices were developed inten-
stimulate further efforts to improve IFT and to
support a network for sharing information. The
tionally to address an identified problem or to
opinions, findings, and conclusions expressed in
achieve a goal. In some cases, a formal quality
this section (and the other sections of this docu-
assurance program identified the need, in others
ment) are not necessarily those of the Department
the program was mandated by legislation. Some
of Transportation or the National Highway
programs developed from grass-roots efforts.
Traffic Safety Administration. The United States
n Operational: Practices included here have all
Government assumes no liability for its contents
been taken beyond the conceptual and planning or use thereof. If trade, manufacturers’ or program
stages, and have been implemented. names are mentioned, it is only because they are
n Successful: Has some evidence that the plan considered essential to the object of the publica-
implemented is achieving desired results. tion and should not be construed as an endorse-
Measurement techniques vary with the nature ment. The IFT Work Group and the United States
of the practice, program, and organization. Government do not endorse specific products,
manufacturers or programs.

Interfacility Transfer Guide:

Program Contact Information
Children’s Hospital Medical Center of Akron Traci R. Sheipline, R.N., EMT-B
Akron Children’s Transport 330-543-3246
1 Perkins Square tsheipline@chmca.org
Akron, OH 44308
Organization and Mission

Children’s Hospital Medical Center of Akron (CHMCA) is a 253-bed freestanding pediatric facility. The
hospital includes a level 3 neonatal intensive care units (NICU) and a level 2 trauma center. CHMCA also
operates a burn unit that accepts all patients of all ages.
Akron’s Children’s Transport (ACT) operates three ground ambulances and works with other services
that provide rotor-wing and fixed-wing air ambulances. ACT generally covers 22 counties in northeast
Ohio, but will transport children by fixed-wing aircraft back to CHMCA from anywhere in the continental
United States. The ambulances are staffed with a nurse, paramedic and respiratory therapist. ACT provides
only interfacility transfer services.
More information is available at www.akronchildrens.org.
Systems Integration
In 2001, CHMCA implemented a centralized communications center to improve communications be-
tween referring physicians and CHMCA. CHMCA’s performance improvement process identified that the
prior system was ineffective and inefficient. Callers were getting lost in the system. Referring physicians
who called in with a patient to be transferred were being left on hold for lengthy periods of time.
Under the current system, all transport and EMS calls come in to the communication center. When inter-
facility transfer is required, the referring physician, transport nurse, and physician providing medical di-
rection at CHMCA confer about the patient. They discuss criticality, patient needs, and appropriate mode
of transportation. Once the call is accepted, CHMCA handles all the coordination, even if the patient is
not being transported to CHMCA.
Implementation Strategy
Once the performance improvement process had identified the need for a better approach, a transport
steering committee consisting of management, the medical director for transportation, the vice president
of nursing, and representatives from pediatrics, NICU, trauma, respiratory therapy, and pharmacy met
monthly. The creation of the communications center was the result of the committee’s work.
Because CHMCA was working on what was perceived to be a problem and because all the relevant stake-
holders participated in developing the solution, the committee approach was successful in garnering inter-
nal support that has made the communications effective.

Implementing the communications center required building and equipping a dedicated facility. In addi-
tion to the hardware requirements, CHMCA had to update its clinical and operational databases in order
for the system to work effectively. As a result, CHMCA is able to analyze 22 aspects of every transport: for
example, origin, diagnosis, call volumes, frequency and distribution of calls, staff deployment, and a range
of clinical and treatment variables.
Evaluation and Results

The communications center has been effective in decreasing response time from 15 minutes down to 10
minutes. In addition, because the whole team has the information necessary for that transport, it can set
up necessary care faster. With the implementation of the communications center, the whole process is
more efficient, particularly as it affects the referring physician. In the current system, a support staff mem-
ber can place the initial call. When the team is assembled, the referring physician can join the call, maxi-
mizing the time the physician can spend with the patient.
CHMCA regularly surveys the referring physicians and has received very positive feedback. Also, referring
physicians receive a letter describing where and to what service the patient was admitted. As a result the
volume of transports has increased from 900 in 1999 to 1,468 in 2004. Referring physicians report satisfac-
tion with their increased role in patient triage.
Education and Replication

One of the positive side effects of the improved working relationship has been requests by referring hos-
pitals for CHMCA to send a team to do outreach at their facilities. The team addresses the capabilities of
CHMCA and ACT. By going to the outlying facilities, the outreach team can work with the particular cir-
cumstances of the referring facility to enhance communication, preparation for transport, and follow-up.


Boston MedFlight Suzanne Wedel, M.D., Medical Director
1727 Robins Street, Hangar 1727, Hanscom AFB 781-863-2213
Bedford, MA 01730 Suzanne.Wedel@bostonmedflight.org

Boston MedFlight (BMF) is a 501(c)(3) non-profit organization based in Bedford, Massachusetts, whose
mission is to extend the tertiary care services of the major Boston hospitals to the citizens of Massachusetts
and New England. The service is available 24 hours a day and seven days a week. BMF was formed by a
consortium of Boston area hospitals to provide emergency medical critical care transport services. The
consortium includes Beth Israel Deaconess Medical Center, Boston Medical Center, Brigham and Women’s
Hospital, Children’s Hospital, Massachusetts General Hospital, Tufts New England Medical Center. BMF
provides transport to the hospital deemed best able to meet the patient’s needs, regardless of whether that
hospital is a member of the consortium. BMF currently operates three helicopters, two ground ambulances
and one fixed-wing air ambulance. Additional information is available at www.bostonmedflight.org.
Systems Integration
BMF has created a system of critical care transport with the goal of getting the sickest patients to the best
care as fast as possible. BMF derives its strength and cost-effectiveness by functioning as a regional provid-
er. The existence of BMF spares the members of the consortium the expense of operating separate critical
care transport services. Earned revenue covers 92 percent of BMF expenses are covered by earned revenue;
the hospital consortium funds the remainder. Although BMF strives to be efficient, it has no financial
incentive to generate additional business volumes just to cover expenses.
As a regional provider, BMF achieves a volume of utilization of approximately 2,700 transports annually, a
volume that would not be possible for an independent operator. The high volume means that BMF teams
encounter even unusual cases frequently enough to keep skills at high levels of proficiency and its affilia-
tion with the consortium of hospitals facilitates development and coordination of treatment and transpor-
tation protocols that strengthen the system and improve the quality of care. Having the choice of ground
or air vehicles means that BMF can choose the most appropriate and effective mode of transport for that
patient under the specific circumstances.
BMF has historically incorporated the quality assurance process into its operation. Every transport team
member is responsible for a quality assurance project. Structured training time is built into the operating
budget and schedule; team members are required to maintain their skills and certifications through exten-
sive hands-on clinical training opportunities at all the member hospitals.

BMF celebrated its 20th anniversary in June 2005. The system has evolved over that period of time. The
genesis of BMF was a core group of surgeons and hospital executives who saw the need for helicop-
ter transportation in the Boston area. Massachusetts regulates the establishment of new health services
through its Determination of Need program and State health regulators expressed concern about the
potential for the proliferation of competing and inefficient services. Hospital representatives also recog-
nized that multiple providers meant less efficient operations, possibly encouraging the transfer of less acute
patients just to make operations financially feasible. Hence, the six-hospital consortium formed BMF.
BMF has used its quality assurance process as a change agent to continually improve the quality of service
it provides and as a tool to identify additional services that were needed. One example of that is the evolv-
ing recognition of critical care transport as a specialization separate from prehospital emergency medical
services. Quality assurance has also helped BMF operate efficiently.
BMF has found that it needs to drive the development and acceptance of critical care transport protocols.
Consortium hospitals have willing and effective partners in developing those protocols. Standardization of
procedures has helped make the transport process achieve optimal clinical results while smoothing other
operational issues.

BMF conducts structured quality assurance activities to monitor the appropriateness and effectiveness of
its services on an on-going basis. BMF’s high degree of appropriate utilization indicates that the regional-
ization of the service effectively reduces the inappropriate utilization that is sometimes attributed to the
existence of redundant and competing providers. Boston MedFlight with support from the sponsoring
consortium hospitals has fostered an environment for research based practice. Since the inception of the
program, there have been changes in clinical standards and current clinical research which has helped
shape the BMF Standards of Care as well as its patient care policies and procedures. The BMF research
program has been one of the components that make BMF a leader in the transport community. It has
resulted in numerous publications and presentations at national and regional conferences.

Boston MedFlight has worked with a number of organizations since its inception. Particularly in cases
where BMF and another provider serve contiguous or overlapping areas, reliance on similar protocols is
seen as a means of strengthening the system as a whole, as well as improving care on a case-by-case basis.
The New England rotor-wing programs have formed the New England Air Alliance, which is a unique
regional infrastructure designed to encourage collaboration instead of competition for critical care trans-
port.
BMF personnel have published a variety of articles relevant to interhospital transfer. A partial bibliography
can be found at www.bostonmedflight.org/research.html.


Patient Transport Services Jan Cody, R.N., L.P.
Children’s Medical Center Dallas Director Patient Transport Services
1935 Motor Street 214-456-8436
Dallas, TX 75235 jan.cody@childrens.com

Children’s Medical Center Dallas is a 406-bed, non-profit tertiary care center and level I Trauma Center.
This includes a 52-bed pediatric intensive care unit (PICU), over 50 outpatient clinics, an emergency
department (ED) designed just for children, and a dedicated interfacility transport program. Children’s
service area is predominantly north central Texas, but it brings children to the hospital from all over the
southwest.
Children’s Transport Team was founded in 1989 when Children’s Medical Center recognized that there
were children in the community hospitals that needed pediatric specialized care before they arrived at
Children’s. The first year the teams completed 330 missions. In 1999 Children’s Medical Center Dallas
Patient Transport Services was the first pediatric transport team to be accredited by CAMTS and the first
to be accredited in all three modes of transport: ground, fixed-wing aircraft (FWA), and rotor-wing aircraft
(RWA). The program has grown throughout the years: the Children’s Transport Team currently has over 60
staff members, and in 2004 they completed 3,516 transports.
Transfer Center
Children’s Medical Center has established a transfer center that is staffed 24 hours a day with
transfer coordinators (TCs) who are trained as EMTs or paramedics. The TCs are also certified flight
communicators by NAACS (National Association of Air Medical Communication Specialists).
The Transfer Center coordinates all transfers into Children’s. Transfer coordinators receive the initial
phone call from the referring hospital and guide the rest of the process — from identifying an accepting
physician to dispatching the team and flight following on RWA transports. Based on the information
gathered in the initial conversation with the referral facility, the TC categorizes the patient as BLS (Basic
Life Support), ALS-1 (Advanced Life Support), ALS-2, or SCT (Specialty Care Transport). They then
determine the most appropriate destination for the child: Emergency Department (ED), Intensive Care
Unit (ICU), or inpatient floor. Once this has been determined the TC notifies the appropriate accepting
physician and dispatches the appropriate team in the appropriate vehicle. CMC’s goal is to be out the door
within 10 minutes of receiving the call.
Children’s Medical Center uses a suite of software to connect the functions within the department.
Computer-aided dispatch software is used to document information gathered during the call-taking
process and dispatch of the teams. All clinical documentation is done using electronic charting software.

The computer-aided dispatch system, the electronic charting system, and a billing system are all connected
with a mobile data communication system. This suite of products makes report writing and data collection
simple and the possibilities almost unlimited.
Patient Transport Services has reached out to referring hospitals to demonstrate the capabilities of the ser-
vices and to improve the coordination of the transport, assuring that the referring hospital, the responding
team, and the receiving hospital have a common set of expectations.
Patient Transport Services is a separate provider with its own Medicaid/Medicare number and it bills sepa-
rately for transport services. Billers and collectors work closely with management and the clinical staff to
provide payers with all needed information for claims processing.
CMCD decided to set up two levels of transport teams. Based on predefined medical protocols a critical
care team consisting of a registered nurse, respiratory therapist, and emergency medical technician – cer-
tified emergency vehicle operator (EMT-CEVO) or a team of two paramedics might be dispatched. The
paramedic team transports patients who are categorized as BLS or ALS-1 and are within a 60-mile radius
of CMCD. All other patients are transported by the critical care teams.
The EMT-CEVO serves as safety officer on all rotor-wing aircraft transports. The CEVO gives position
reports, assists the pilots by watching for any obstacles, assists the team with loading and unloading the
patient, and briefs the family member prior to flight. All team members are trained as flight crewmembers
and follow duty time limits developed by the FAA when flying. Training for both the safety officer’s role
and flight crewmembers was developed specifically for the transport staff members by the RWA pilots as a
part of the implementation of the RWA program that went into service September 16, 2004.

The dedicated billing function has significantly increased reimbursement with a high percentage of claims
being paid the first time they are submitted. This allows Patient Transport Services to document the rev-
enue it generates. Over the years this ability has enabled Patient Transport Services to garner the support
for new programs.
Operating two levels of service has enabled CMCD to operate at an efficient volume of cases while keeping
personnel expenses in line, due to the significant cost savings found comparing a team of two paramedics
with the critical care team. Approximately a quarter of all transports are performed by the paramedic team.

CMCD is aware that a number of other transport services have adopted the approach of dedicated trans-
port teams and of two levels of teams. Details of that implementation are likely to vary with the particular
needs of the operating organization (for instance, hospital-based or free standing) and with the scope of
practice regulations in a given State.


IHC Life Flight Renee S. Holleran, R.N., Ph.D., C.EN., C.C.R.N.,
250 North 2370 West C.F.R.N. Nurse Manager, Adult Transport Services
Salt Lake City, UT 84116 801-321-3322
reneeflightnurse@msn.com

Intermountain Health Care (IHC) is an integrated health system that includes 20 hospitals, numerous clin-
ics, and an insurance company. IHC serves Utah and southeastern Idaho. More information is available at
www.ihc.com.
IHC Life Flight operates three rotor-wing aircraft 24 hours a day that provide scene and interfacility
response within 150 miles of its bases in Salt Lake City and Provo, Utah. The RWA also supports search-
and-rescue missions in the intermountain area. IHC operates three fixed-wing aircraft transporting
patients throughout the west. A specially designed neonatal critical care ambulance is stationed at Primary
Children’s Medical Center in Salt Lake City. Life Flight provides interfacility transfer services over a seven-
State area. Life Flight is accredited by CAMTS.
Medical Direction
Life Flight’s approach to medical direction involves two intensivists and one emergency medicine physi-
cian. Life Flight perceived that interfacility transfer was being impaired by inconsistent understanding and
expectations. In part this was due to the extreme variability in the size and nature of sending facilities and
in the professional credentials and experience of clinicians, ranging from a physician’s assistant in a very
remote setting to more sophisticated hospitals transferring patients to a tertiary facility. Also, because of
the large and sometimes sparsely populated service area, bringing clinicians to a central location for train-
ing was difficult logistically.
In part the inconsistency followed from the different levels of knowledge on the part of medical directors.
Several types of physicians are involved, representing emergency medicine and other forms of critical care.
Without specific training in medical direction of interfacility transfer, the physicians might lack a full un-
derstanding of the established protocols, optimal preparation for transfer, the capabilities and limitations
of the crew, and the capabilities and limitations of the equipment.
IHC addressed this problem by developing a training program for medical direction, the goal of which is
to improve the both the results and the process of the transfer. One concern was that the referring facility
not feel alienated or patronized. IHC treats the transfer as a teaching opportunity. The medical director
stays in contact with the referring facility while the aircraft is en route, addressing clinical issues and assur-
ing that appropriate preparations are made so that the patient is as ready for transport as possible.

Recognizing that gathering a group of physicians for training programs can be difficult logistically, IHC
has developed the program so it can be distributed on DVD. This technology makes the learning available
at a convenient time and place for the learner. Once the master is prepared reproduction and distribution
are very economical. One of the approaches IHC used to build confidence in its service was to emphasize
timely response because IHC had found that physicians working in a tertiary hospital might not fully un-
derstand the sense of isolation and need for prompt assistance experienced by colleagues in remote areas.

Life Flight has found that the program has been effective in achieving the desired consistency. The entire
team has greater confidence in each other and in the system.

Dr. Frank Thomas, the physician who developed the original training program, has presented all over the
world. The DVD format has made it easy and cost-effective to share with other organizations. The DVD
has been recognized by CAMTS as a best practice.


Children’s Hospital of San Diego Dana Patrick, R.N.
3020 Children’s Way Emergency Transport Program Coordinator
San Diego, CA 92123 858-966-5973
dpatrick@chsd.org

Children’s Hospital of San Diego (CHSD) is the San Diego region’s only designated pediatric trauma center
and the only area hospital dedicated solely to pediatric care. Since CHSD first opened its doors in 1954,
its mission has been “to restore, sustain and enhance the health and developmental potential of children.”
More information is available at www.chsd.org.
The Emergency Transport Program was started in 1972, first for neonatal transport. When the hospital
opened a pediatric ICU a second team was added for pediatric transport. CHSD transports approximately
1,000 pediatric and 800 neonatal patients annually.
Meeting Patient Needs

About five years ago, CHSD shifted to teams made up of a nurse and a respiratory therapist. Both members
are completely cross-trained. With the approval from the respiratory care board, standard protocols were
approved in advance, allowing both RTs and RNs to expand the scope of their capabilities. Although the
nurse tends to be the primary staff member, they work as a team and responsibilities shift according to the
needs of the patient. CHSD believes that the RN/RT teams are more effective because each team member
understands the other’s functions. If necessary, it provides redundant capabilities within a single team.
Separate teams are dedicated to pediatrics and neonates and they are pre-assigned to transport responsi-
bilities. Although combining teams might be a means of leveling the workload, CHSD has found that it
provides better care by having dedicated teams. When teams are not involved in transport, they provide
defined supplemental staffing within the hospital.
The RN/RT team approach was conceived to improve the quality of care and simplify the administration of
the service.
Before changing the staffing, it was necessary to convince the team medical directors of the benefits, and
then the teams needed to be trained. Preconceptions about the capabilities of respiratory therapists were
addressed through training and testing and by setting high thresholds for prior experience. Teams went
through 48 hours of pediatric training followed by written and performance tests. Team members must
have five years of experience before applying for a transport position.


CHSD holds transport morbidity and mortality conferences with the medical director and medical control
officer. These conferences are held in a confidential environment so all parties can speak candidly.
The RN/RT team concept has produced positive results and helped recruitment.

The CHSD RN/RT team approach may have potential for replication by other services.

Appendix A:
Members of IFT Guidelines Work Group
The EMS Program at the National Highway Traffic Safety Administration gratefully acknowledges the
contributions made by the members of tie IFT Work Group. Without their generous donation of time and
expertise, the completion of this document would not have been possible.
Air Medical Physicians Association National Association of EMS Physicians

Kenneth Robinson, M.D., FACEP Jon Krohmer, M.D., FACEP

Air and Surface Transportation Nurses National Association of EMTs
Association Jerry Johnston, B.A., R.E.M.T.-P.
Ann Lystrup, R.N., B.S.N., C.F.R.N., C.E.N.,
C.C.R.N. National Association of State EMS Directors
Mark King
The American Ambulance Association Fergus Laughridge
Kurt Krumperman, M.S., NREMT-P
National Association of State EMS Training
American College of Emergency Physicians Coordinators
& The Commission for Accreditation of William Russell Crowley
Ambulance Services
J. William Jermyn, D.O., FACEP (representing National Flight Paramedics Association
both organizations) T.J. Kennedy, E.M.T.-P., F.P.-C.
The Commission on Accreditation of Medical International Association of Flight Paramedics

Transport Systems Ron Walter, B.S., N.R.E.M.T.-P.
Tamara Bauer, R.N., C.C.R.N., M.B.A.
Emergency Nurses Association Drew Dawson, Director, Office of EMS
Kathy Robinson, R.N. Laurie Flaherty, R.N., M.S.
Emergency Medical Services for Children, HRSA Office of Rural Health Policy, HRSA
Dan Kavanaugh, M.S.W., L.C.S.W.-C., Program Blanca Fuertes, M.P.A.
Director

Emergency Services for Children, National
Resource Center
Jane Ball, R.N., Dr.P.H., Director


Appendix B:
References and Resources for IFT
Emergency Medical Treatment and Centers for Medicare and Medicaid Services.
Appendix V of the State Operations Manual.
Labor Act
Interpretive Guidelines — Responsibilities of
Medicare Participating Hospitals in Emergency
Health Law Resource Center
Cases.
EMS & Helicopter Issues
http://www.cms.hhs.gov/EMTALA/
www.medlaw.com/ems.htm
U.S. General Accountability Office
American College of Emergency Physicians
EMTALA Implementation and Enforcement
EMTALA – Main Points
www.gao.gov/new.items/d01747.pdf
http://www.acep.org/webportal/PracticeResources/
issues/emtala/default.htm
Examples of Federal Regulations
Appropriate Interhospital Patient Transfer
http://www.acep.org/webportal/PracticeResources/ Federal Aviation Administration
issues/emtala/default.htm Air medical services operate predominantly
under two distinct parts of the Code of Federal
Annals of Emergency Medicine Regulations (CFR), formerly known as the Federal
The EMTALA Paradox (2002) Aviation Regulations: CFR Part 91 and Part 135.
http://www.annemergmed.com/issues#2002
Part 91 regulates flight operations for aircraft
eMedicine flying within U.S. airspace
COBRA Laws ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=dd
www.emedicine.com/emerg/topic737.htm 3aa7b9f3da5c3af094830596d3790b&rgn=div5&vie
w=text&node=14:2.0.1.3.10&idno=14
Emergency Nurses Association
EMTALA Information (1998 – 2004) Part 135 provides specific regulations for
www.ena.org/government/emtala/ commuter and on demand air carriers, including
air ambulances
Air Medical Physicians Association ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=dd
Medical Condition List and Appropriate Use of 3aa7b9f3da5c3af094830596d3790b&rgn=div5&vie
Air Medical Conditions (2002) w=text&node=14:2.0.1.3.23&idno=14
http://www.ampa.org/component/option,com_doc-
man/task,cat_view/gid,23/Itemid,42/

Health Insurance Portability and U.S. Department of Health and Human Services
Accountability Act (HIPAA) Special Update on Medical Liability Crisis (2002)
aspe.os.dhhs.gov/daltcp/reports/mlupd1.htm
HIPAA.org
CMS has prepared a checklist to help you National Council of State Legislatures
get started. State Medical Liabilities Law Table (2002)
www.hipaa.com/ http://www.ncsl.org/programs/health/medmalncsl.
htm
American Medical Association
HIPAA LAW.com
www.ama-assn.org/ama/pub/category/4234.html Dictionary of Legal Terms
dictionary.law.com/
HIPAA Compliance Information (Updated 2005) Position Statements
http://www.acep.org/webportal/PracticeResources/
issues/admin/HIPAAComplianceInformation.html American Academy of Pediatrics
Guidelines for Air and Ground Transport of
Facts about Medical Liability Insurance Crisis Neonatal and Pediatric Patients
http://www.acep.org/webportal/PracticeResources/ 2nd Edition (1999)
issues/medliab/default.html www.aap.org/bst/showdetl.
cfm?&DID=15&Product_ID=912
Office for the Advancement of TeleHealth
Final HIPAA Privacy Rules (2001) American College of Emergency Physicians
telehealth.hrsa.gov/pubs/hipaa.htm Interfacility Transportation of the Critical Care
Patient and Its Medical Direction (1999)
Liability http://www.acep.org/webportal/PracticeResources/
PolicyStatements/
Medical Professional Liability Insurance (2004) Professional Liability Insurance for EMS Medical
www.acep.org/NR/rdonlyres/DD94E243-339F- Control Activities (1999)
4A02-983D-7563D42BCE74/0/MPLIpaperApril www.acep.org/webportal/PracticeResources/
04.pdf PolicyStatements/EMS/ProfessionalLiabilityInsuranc
eforEMSMedicalControlActivities.htm
Facts about Medical Liability Insurance Crisis
www.acep.org/webportal/PatientsConsumers/ American College of Surgeons/Committee
HealthSubjectsByTopic/MedicalLiabily/ on Trauma
correctrhtoric.htm Interfacility Transfer of Injured Patients:
Guidelines for Rural Communities (2002)
Emergency Nurses Association https://web2.facs.org/timssnet464/acspub/frontpage.
Position Statement cfm?product_class=trauma
Medical Professional Liability Insurance:
Malpractice Crisis (2003) Air Medical Physicians Association
www.ena.org/about/position Medical Direction and Medical Control of Air
Medical Services http://www.ampa.org/compo-
nent/option,com_docman/task,cat_view/gid,23/
Itemid,42/

Air and Surface Transportation Pediatric Emergency Care

Nurses Association
Staffing of Critical Care Air Medical Transport The state of pediatric interfacility transport:
Services (2001) Consensus of the Second National Pediatric
www.astna.org/Position-papers/staffing.htm and Neonatal Interfacility Transport Medicine
Leadership Conference (2002)
Association of Air Medical Services www.pec-online.com/pt/re/pec/abstract.00006565-
Appropriate use of Critical Care Ground Transport 200202000-00013.htm;jsessionid=B11uIWoslDR06a
Services (2005) wVX8h7HDSN8AfknBCJPlyDfuLd1W3MRzwodSo
www.aams.org/publications.html g!368654479!-949856031!9001!-1?index=1&results
=1&count=10&searchid=1&nav=search
Emergency Nurses Association
Care of the Critically Ill or Injured Patient During References of General Interest
Interfacility Transfer (2002)
http://www.ena.org/about/position/ Air and Surface Transportation Nurses
Association
Centers for Medicare and Medicaid Services. Standards for Critical Care and Specialty
Medicare Benefit Policy Manual. Pub. 100-02. Ground Transport
Chapter 10. Ambulance Services. Standards for Critical Care and Specialty
http://www.cms.hhs.gov/center/ambulance.asp Fixed-Wing Transport
Standards for Critical Care and Specialty
Request for Medicare Payment – Ambulance. Rotor-Wing Transport
CMS Form 1491. www.astna.org/pubs.html
http://www.cms.hhs.gov/center/ambulance.asp
Centers for Medicare and Medicaid Services
National Association of EMS Physicians Navigating the Medicare Web Site
Medical Direction of Interfacility www.medscape.com/viewarticle/ 494892?src=mp
Transports (2000)
Medical Direction for Air Medical Transport Definitions of Ambulance Services. Program
Programs (2002) Memorandum. Transmittal AB-02-130
Physician Medical Direction in EMS (1997) www.cms.hhs.gov/manuals/pm_trans/ab02130.pdf
(Table of contents:)
www.naemsp.org/Position%20Papers/Contents.html Request for Medicare Payment – Ambulance.
CMS Form 1491.
Society for Critical Care Medicine www.cms.hhs.gov/providers/edi/cms1491.pdf
Guidelines for the Intra and Interfacility Transport
of Critically Ill Patients. (2004). Commission on Accreditation of Ambulance
http://www.sccm.org/professional_resources/guide- Services
lines/table_of_contents/index.asp Accreditation Standards (2004)
www.caas.org/index1.html

Emergency Medical Services for Children National Rural Health Association

Trauma Triage, Transfer, and Transport Rural and Frontier Emergency Medical Services
Guidelines (2002) Agenda for the Future (2004)
http://www.ems-c.org/Products/frameproducts.html www.nrharural.org/groups/sub/EMS.html
(Enter title into Title Search field.)
Emergency Nurses Association Emergency Medical Services Agenda for the Future
Certification for Ground Transport Nurses www.nhtsa.dot.gov/people/injury/ems/agenda/ems-
http://www.ena.org/bcen/ctrn/ man.html
Institute of Medicine Implementation Guide

Clinical Practice Guidelines: Directions for a www.nhtsa.dot.gov/people/injury/ems/agenda/in-
New Program, (1990), M.J. Field and K.N. Lohr dex.html
(editors) Washington, DC: National Academy
Press. Page 38. Guide for Preparing Medical Directors
books.nap.edu/catalog/1626.html www.nhtsa.dot.gov/people/injury/ems/
2001GuideMedical.pdf
The Future of Public Health. (1988). Committee for
the Study of the Future of Public Health. Division National EMS Research Agenda
of Health Care Services. Institute of Medicine. http://www.nhtsa.dot.gov/portal/site/nhtsa/menuite
Washington, D.C. National Academy Press. m.2a0771e91315babbbf30811060008a0c/DEMyPS4
http://www.nap.edu/books/0309038308/html zjvEasDAYBAlHs1Qm9ncn71vGM2plOk6RHZGrZ
D1YKNjuK%2128012360
Maryland Institute for Emergency Medical
Services Systems NEMSIS
Interhospital Transfer Guidelines Manual (2002) www.nemsis.org/
www.miemss.org/Interhospital.pdf
University of Maryland Baltimore County
Minnesota Department of Health, Community Critical Care Emergency Medical Transport
Health Division Programtm
Public Health Core Functions, Essential Services, http://ehs.umbc.edu/CE/CCEMT-P/index.html
and Goals
www.health.state.mn.us/divs/chs/pdf/gdlinebkgrd1. United States Small Business Administration
pdf#search=’three%20core%20functions%20of%20p Elements of a Business Plan
ublic%20health http://www.sba.gov/starting_business/index.html

Appendix C:
Elements of a Business Plan
Before beginning, consider four core questions: 9. Read sample business plans. Since countless
1. What service does your business provide and business plans have preceded yours, there is no
what needs does it fill? need to reinvent the wheel. Look for business
plans for businesses most similar to yours as a
2. Who are the potential customers for your ser-
prototype to guide you. You can also talk with
vice and why will they contract with you?
other business owners who have written plans
3. How will you reach your potential customers? before and seek out their expertise.
4. Where will you get the financial resources to 10. Determine which software program you will
start your business? use to write your plan. You can use anything
from a basic word-processing program to
Prepare by following 10 preliminary steps: business plan software. You will need to use
1. Ask yourself why you are writing a business that which best suits your needs and level of
plan. Is it to raise capital or as a guide for run- complexity.
ning the business?
2. List your goals for starting the business and Once you are ready, begin with the understanding
where you see the business in three to five that the business plan is a work in progress and
years. there will be several to follow as well as ongoing
3. Clearly define your target audience. changes as your business progresses.
4. Write a table of contents so you’ll know exactly
which sections you will need to research and
Elements of a Business Plan
find data to support. 1. Cover sheet
5. Make a list of the data you will need to re- 2. Statement of purpose
search. For example, you will need statistics on 3. Table of contents
your demographic audience, your competition,
the market, and so on. a. The business
6. List research sources that will be most helpful. i. Description of business
7. List your management team. If you are unsure ii. Marketing
of someone’s availability, this is the time to iii. Competition
determine whether or not they are on board. iv. Operating procedures
Gather biographical data on each person. v. Personnel
8. Start compiling all of your key financial docu- vi. Business insurance
ments. You can determine later which ones
you will use in the business plan.

b. Financial Data ii. Personal financial statements

i. Loan applications iii. For franchised businesses, a copy of
ii. Capital equipment and supply list franchise contract and all supporting
iii. Balance sheet (costs and revenues) documents provided by franchisor
iv. Break-even analysis and financial iv. Copy of proposed lease or purchase
gap analysis agreement for building space
v. Pro forma income projections (profit v. Copy of licenses and other legal
and loss statements) documents
Three-year summary vi. Copy of resumes of all principals
Detail by month, first year vii. Copies of letters of intent from all
Detail by quarters, second and third years suppliers, etc.
Assumptions upon which projections
were based Reference
vi. Pro forma cash flow
1. Business Plan Basics. http://www.sba.gov/start-
c. Supporting Documents ing_business/planning/basic.html. U.S. Small
i. Tax returns of principals for last Business Administration. U.S. Department of
three years Commerce.

Appendix D:
EMTALA
The Emergency Medical Treatment and Labor that a patient with an emergency medical
Act is a Federal law enacted by Congress in 1986 condition may be discharged with a plan to have
as part of the Consolidated Omnibus Budget subsequent treatment provided as an outpatient if
Reconciliation Act (COBRA) of 1985 (42 U.S.C. such a plan is consistent with medical routine and
§1395dd). Referred to as the “anti-dumping” law, does not jeopardize the patient’s health.
it was designed to prevent hospitals from refusing
to treat patients or transferring them to charity EMTALA governs how patients may be transferred
or public hospitals because they were unable to from one hospital to another. Under the law,
pay or had Medicaid coverage. EMTALA requires a patient is considered stable for transfer if
hospitals with emergency departments to provide the treating physician determines no material
emergency medical care to everyone who needs deterioration will occur during the movement
it, regardless of ability to pay or insurance status. between facilities and that the receiving facility
Under the law, patients with similar medical has the capacity to manage the patient’s medical
conditions must be treated consistently. The condition. EMTALA does not control the
law applies to hospitals that accept Medicare transfer of stable patients; however, patients
reimbursement, and to all their patients, not just with incompletely stabilized emergency medical
those covered by Medicare. conditions still may be transferred under EMTALA
if one of two conditions exists, as follows:
Hospitals have three basic obligations under n The patient (or someone acting on the patient's
EMTALA behalf) provides a written request for transfer
n First, they must provide all patients with a despite being informed of the hospital's
medical screening examination to determine EMTALA obligations to provide treatment.
whether an emergency medical condition exists n A physician certifies that medical benefits
without regard for ability to pay for services. reasonably expected from transfer outweigh the
n Second, where an emergency medical condition risk to the individual.
exists, they must either provide treatment until
the patient is stabilized, or if they do not have Once a decision is made to transfer the individual,
the capability, transfer the patient to another the following steps must be taken:
hospital. n The transferring hospital must provide all
n Third, hospitals with specialized capabilities medical treatment within its capacity, which
are obligated to accept transfers if they have the minimizes the risk to the individual's health.
capabilities to treat them. Medical care cannot n The receiving facility must accept the transfer
be delayed by questions about methods of and must have space available and qualified
payment or insurance coverage. personnel to treat the individual.
n The transferring hospital must send copies of
No further EMTALA obligations exist if an
appropriate medical screening examination all medical records related to the emergency
identifies no emergency medical condition. No medical condition. If the physician on call
further EMTALA obligations exist if an identified refuses or fails to assist in the patient's care,
emergency medical condition is stabilized. the physician's name and address must be
Additionally, the latest regulations now recognize documented on the medical records provided to
the receiving facility.

n Qualified personnel, with the appropriate medi- As the scope of EMTALA has widened in an effort
cal equipment, must accompany the patient to make the law more effective, existing weaknesses
during transfer. The transferring physician, by in the delivery of care have created new problems:
law, has the responsibility of selecting the most In the binding regulations published in 1994, the
appropriate means of transport to include quali- requirements for basic screening and stabilization
fied personnel and transport equipment. pertained to patients anywhere on hospital prop-
erty, including ambulances owned and operated by
Under EMTALA, patient care during transport is the hospital.
the responsibility of the transferring physician/
hospital, until the patient arrives at the receiving Since EMTALA was enacted, the national ED
facility. The transferring physician is also respon- patient volume has increased and during the same
sible for the order to transfer and for the treatment time period, the number of hospital EDs has de-
orders to be followed during the transport. This clined. As a result, fewer resources are available to
may conflict with State statutes, which in some meet an increasing legal obligation.
instances, allow only authorized medical direc-
tion physicians to give orders to EMS personnel. The discussion in the interpretive guidelines and
EMTALA does not reference the transport service case law obligated a hospital to accept an unstable
and its medical director, leaving ultimate medical patient if it has the capacity and has any equip-
responsibility and its transition during transport ment that the patient’s condition requires that the
open for interpretation. referring hospital lacks. This disproportionately
expands the obligations of EDs with more sophis-
The legislation poses several additional complexi- ticated capabilities, and increases the obligations
ties for individual hospitals and for an integrated placed on on-call physicians. Although EMTALA
EMS system in which transfers can play a consid- obligates hospitals to have a roster of on-call physi-
erable role: cians who can complete medical screening exami-
n First the level of service required before a pa- nations and provide stabilization for the services
tient transferred may not be clear; for hospitals the hospital offers to its community, many hospi-
with comparatively minimal emergency depart- tals are not able to fill their on-call rosters.
ments or with extremely overcrowded EDs,
pressures for staffing and equipment may be A recent decision by a Federal appeals court con-
intense. cluded that a patient coming to the ED triggers
EMTALA obligations not only when the patient
n Second, acceptable grounds for transfer need to is on hospital property, but also while traveling
be clearly defined. In some cases, the primary toward the hospital. So, even when the decision to
reason for transfer is explicitly defined, but divert ambulance patients is reasonable, the ED
many other cases may be less conclusive. may still be liable for EMTALA violation.
n Third, who makes the assessment to determine
that a patient is stable (and able to be trans- As providers grapple with new burdens, they
ferred) or unstable may be a critical factor. confront difficult challenges that are a logical
Decisions may differ depending on the level of consequence of those new responsibilities. The net
the practitioner, or between practitioners of the impact of these changes has resulted in a decrease
same level, or between the responsible practitio- in the availability of the services that the law was
ner at the transferring facility and the interfacil- intended to promote.
ity transfer team or its medical director.

Appendix E:
Certificate of Transfer
Certification of necessity for transfer is a re- The Centers for Medicare and Medicaid Services
quirement for reimbursement by the Centers for has issued regulations pertaining to the enforce-
Medicare and Medicaid Services. The CMS defini- ment of this law. Regulations go into much greater
tion of medical necessity is as follows: detail than the statute. Proposed rules published in
“Medical necessity is established when the patient’s 1988 can be found in the Federal Register, June 16,
condition is such that use of any other method of 1988 (53FR22513). Interim final rules can be found
transportation is contraindicated. In any case, in in the Federal Register, June 22, 1994 (59FR32086).
which some means of transportation other than an The authority supporting the statute is the tax-
ambulance could be utilized without endangering ing and spending clause of the Constitution. In
the individual’s health, whether or not such other essence, Congress has the right to demand certain
transportation is actually available, no payment services from vendors receiving Federal tax dollars.
may be made for ambulance service.” In the EMTALA statute, obligations are tied to
hospitals’ participation in Medicare. In fact, a hos-
It is possible (but not likely) that a patient may pital could relieve itself of EMTALA obligations by
require transfer and not meet the CMS definition dropping out of the Medicare program, although
of medical necessity. this certainly would not be financially beneficial
for the hospital.

Appendix F:
HIPAA
Health Insurance Portability and Accountability Pharmacies, health plans and other covered
Act of 1996 is a law enacted to combat fraud, entities must first obtain an individual’s specific
waste, and abuse in health insurance and the de- authorization before disclosing their patient
livery of healthcare services; to improve access to information for marketing.
long-term care services and coverage, and simplify n Stronger State Laws. The new Federal privacy
the administration of health insurance. The pro- standards do not affect State laws that provide
gram sets standards for the use and disclosure of additional privacy protections for patients. The
protected health information along with measures confidentiality protections are cumulative; the
to ensure the secure transmission and storage of privacy rule will set a national “floor” of privacy
medical records and other individually identifiable standards that protect all Americans, and any
or demographic information. The regulations pro- State law providing additional protections would
tect medical records and other individually identi- continue to apply. When a State law requires
fiable health information, whether it is on paper, in a certain disclosure — such as reporting an
computers or communicated orally. Key provisions infectious disease outbreak to the public health
of these new standards include: authorities — the Federal privacy regulations
n Access to Medical Records. Patients generally would not preempt the State law.
should be able to see and obtain copies of their n Confidential communications. Under the pri-
medical records and request corrections if they vacy rule, patients can request that their doctors,
identify errors and mistakes. health plans, and other covered entities take
n Notice of Privacy Practices. Covered health reasonable steps to ensure that their communi-
plans, doctors, and other health care provid- cations with the patient are confidential.
ers must provide a notice to their patients how n Complaints. Consumers may file a formal
they may use personal medical information and complaint regarding the privacy practices of a
their rights under the new privacy regulation. covered health plan or provider.
Patients also may ask covered entities to re-
strict the use or disclosure of their information HIPAA for Health Plans and Providers
beyond the practices included in the notice, but
The privacy rule requires health plans, pharma-
the covered entities would not have to agree to
cies, doctors, and other covered entities to establish
the changes.
policies and procedures to protect the confidential-
n Limits on Use of Personal Medical
ity of protected health information about their pa-
Information. The privacy rule sets limits on tients. These requirements are flexible and scalable
how health plans and covered providers may to allow different covered entities to implement
use individually identifiable health informa- them as appropriate for their businesses or prac-
tion. In addition, patients would have to sign tices. Covered entities must provide all the protec-
a specific authorization before a covered entity tions for patients cited above, such as providing a
could release their medical information to a life notice of their privacy practices and limiting the
insurer, a bank, a marketing firm or another use and disclosure of information as required un-
outside business for purposes not related to der the rule. In addition, covered entities must take
their health care. some additional steps to protect patient privacy:
n Prohibition on Marketing. The final privacy n Written Privacy Procedures. The rule requires
rule sets new restrictions and limits on the use covered entities to have written privacy proce-
of patient information for marketing purposes.

dures, including a description of staff that has is protected and communicated to others
access to protected information, how it will be strictly on a “need-to-know basis” — or as
used and when it may be disclosed. Covered defined in the HIPAA standards, “Minimum
entities generally must take steps to ensure that Necessary.” The regulation does not specifically
any business associates who have access to pro- state the mode of disclosure/transmission,
tected information agree to the same limitations so it is acceptable to pass on information in a
on the use and disclosure of that information. written form, oral communication — discretion
n Employee Training and Privacy Officer. and a low voice is always advised when
Covered entities must train their employees in communicating orally and in a public setting, or
their privacy procedures and must designate via radio for the purposes of providing a radio
an individual to be responsible for ensuring the “patch” to the receiving medical facility. In order
procedures are followed. If covered entities learn to protect protected health information during
an employee failed to follow these procedures, a radio patch, information should be limited to
they must take appropriate disciplinary action. what the receiving facility needs to know about
n Public Responsibilities. In limited circum-
the patient to prepare for the patent’s arrival
and treatment.
stances, the final rule permits — but does not
require — covered entities to continue certain n Exchanging Protected Health Information
existing disclosures of health information for with Medical Facilities
specific public responsibilities. These permitted As required under the Ryan White Act, prehos-
disclosures include: emergency circumstances; pital care providers are mandated to provide a
identification of the body of a deceased per- copy of their patient care report to the receiving
son, or the cause of death; public health needs; medical facility upon arrival. This practice is
research that involves limited data or has been permitted under HIPAA and does not violate
independently approved by an institutional the standards established in the privacy rule.
review board or privacy board; oversight of the Additionally, the HIPAA standards published
health care system; judicial and administrative in the final rule permit covered entities to share
proceedings; limited law enforcement activities; and exchange information with each other
and activities related to national defense and for the purposes of providing care/treatment,
security. The privacy rule generally establishes obtaining information for payment, and using
new safeguards and limits on these disclosures. the information for health care operations (i.e.,
Where no other law requires disclosures in these quality assessment/quality improvement, educa-
situations, covered entities may continue to use tion, etc.) without the consent or authorization
their professional judgment to decide whether of the patient or the patient’s personal repre-
to make such disclosures based on their own sentative. Thus medical facilities may provide
policies and ethical principles. prehospital care providers with face sheets and
other records for these purposes without patient
HIPAA Considerations for Prehospital consent or authorization.
Care Providers n Safeguarding Patient Information
n Communications As a standard practice, all covered entities must
Anyone involved in prehospital emergency have systems in place that assures the secure
medical service must take precautions to ensure handling and safe storage of patient’s records
that a patient’s protected health information containing protected health information.

DOT HS 810 599
April 2006

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