Keep your body in a straight line, with a straight back and bent knees. Your head and chest should be up and straight. Keep your feet a little wider than your shoulder width. Keep the person's head, torso, and legs in line during the transfer.

1. Safe transfer of unstable patient
from hospital
Dr. Anjalatchi Muthukumaran
Vice Principal
Era college of Nursing

2. Equipment for transfer the patients

3. Introduction
• One of the critical task that hospitals have to
frequently undertake is to transfer a critically ill or
unstable patient from one hospital to another.
• Transfer of such patient are likely to induce various
physiological changes, which may adversely affect
the health of patient even leading up-to death.
• Hence, such transfers shall be undertaken with great
care and as per evidenced-based guidelines.
• Following are the key elements and guidelines for
safely executing transfer for an unstable patient.

4. Criteria for identifying unstable
patients
• A patient whose physiological status is in
fluctuation and for whom emergent treatment
and/or surgical intervention are anticipated, is
considered as an unstable patient.
• Hospital should use clinical criteria to identify
an unstable patient.
• Following criteria can be used as reference for
developing hospital’s own criteria

5. Patients with one or more of below
condition shall be considered as unstable
patient
• Glasgow coma scale <= 14
• Pulse < 60 or > 120 beats per minute
• Systolic blood pressure > 190 mmhg
• Respiratory rate < 12 or > 24 breaths per minute
• Poor gas exchange, with oxygen saturation < 90%
• Temperature < 92°f (< 33°c)
• Paralysis
• Hoarseness or inability to talk
• Laboured respirations
• Severe pain
• External haemorrhage
• Combative
• Severe deformity involving spine, neck, chest or extremities
• Penetrating wound from head to popliteal fossa

6. Following co-morbid condition if present
increases the risk of un-stability
• Age > 55 years
• History of coronary artery disease
• History of COPD
• History of liver disease
• History of coagulation disorder
• History of mental illness
• Current insulin-dependent diabetes mellitus
• Current anticoagulation therapy
• Current pregnancy
• Neonates

7. Decision to transfer:
• The decision to transfer the patient shall be
taken by a senior consultant level doctor after
discussing with patient's relatives about the
benefits and risks involved.
• The decision of transfer shall only be taken if
benefits of transferring the patient outweigh the
risks involved in transferring.
• A written informed consent shall be taken
from patient/family before the transfer

8. Communication with receiving
facility:
• The facility where the patient is being transferred
shall be informed prior to shifting.
• It is always preferable that the consultant doctor of
the transferring facility speaks to the consultant
doctor of the receiving facility.
• Complete information on patient's clinical
condition, treatment being given, reasons for
transfer, mode of transfer and timeline of transfer,
shall be shared with the receiving facility in a
written document.

10. Pre-transfer stabilisation and
preparation:
• Patients should be properly stabilized and
prepared before transferring to prevent any
adverse event or deterioration in patient’s
clinical condition during transfer. The patient
should be adequately resuscitated and stabilised
to the maximum extent possible.
•

12. Following points can be used as a
checklist for pre-transfer stabilization
• 1. Airway – If compromise in airway is suspected during transfer of
patient, endotracheal tube intubation shall be done.
• 2. Breathing – Arterial blood gas values should be optimized and
breathing should be adequately controlled. In patients suspected of
pneumothorax, chest drain shall be inserted.
• 3. Circulation – Control for external haemorrhage. Ensure that
cross matched blood is available during transport, if required.
Haemorrhagic shock shall be adequately treated
• 4. Neurological status – In case of patients with head injury their
Glasgow coma scale should be adequately monitored and
documented.
• Patient shall also be protected from cold by provision of blankets
during transfer.

13. Mode of transfer
• Mode of transferring the patient shall be selected as per
the clinical condition of the patient.
• Following guidelines shall be taken into consideration.
• 1. Patients with non-life threatening condition can be
transported in a Basic Life-Support Ambulance.
2. Patients with life-threatening conditions or patients
who may endotracheal intubation, cardiac monitoring,
defibrillation, administration of intravenous fluids or
vasopressors, during transfer, shall be transported using
Advances Life-Support Ambulance

14. Continued
• 3. Patients on life support system, i.e. ventilator can
be transported in a mobile ICU ambulance, if
available
4. In some extreme cases, where patients clinical
condition is critical and time is a big factor, use of
air ambulance shall be considered, if available.
• However, feasibility of air transfer shall be
ascertained with respect to environment, and
patient’s condition. If the patient, due to his/her
condition can undergo sudden decompensation
during air transfer, the same shall be avoided

15. checklist of emergency department
• Ambulance plays a vital role in emergency
medical care. In-order to be able to provide best
ambulance services to emergency cases, NABH
has specified certain requirements to be met. As
functionally ambulance is related to emergency
care, it is suggested that this checklist be used in
combination with checklist of emergency
department.

17. Continued
• Ambulance should be identified as ALS equipped or BLS
equipped. ALS equipped ambulance should be used
for transferring critically ill or unstable patients. For
other patients BLS equipped ambulance can be used.
• ALS ambulance must be equipped with necessary resources
such as transport ventilator, portable suction apparatus,
portable oxygen equipment, ambu resuscitation kit (for adult
and paediatric), multi-para monitors, intubation equipment,
AED, syringe pumps, IV lines, immobilization devices,
emergency medicines etc.
• BLS equipment should be equipped with basic things like
stretchers, emergency medicines, portable oxygen, suction
devices, first aid kit and ambu bags.
• The staff in ambulance (driver and technician) should be
trained in BLS skills.

18. Bed to wheel chair

19. Continued
• Ambulance should be identified as ALS equipped or BLS
equipped. ALS equipped ambulance should be used
for transferring critically ill or unstable patients. For
other patients BLS equipped ambulance can be used.
• ALS ambulance must be equipped with necessary resources
such as transport ventilator, portable suction apparatus,
portable oxygen equipment, ambu resuscitation kit (for adult
and paediatric), multi-para monitors, intubation equipment,
AED, syringe pumps, IV lines, immobilization devices,
emergency medicines etc.
• BLS equipment should be equipped with basic things like
stretchers, emergency medicines, portable oxygen, suction
devices, first aid kit and ambu bags.
• The staff in ambulance (driver and technician) should be
trained in BLS skills.

21. Continued
• Specific points that needs to be taken care of for ambulance
are
• The vehicle should be registered as an ambulance (for each
vehicle being used as ambulance)
• Necessary legal documents should be available and within
validity period. This includes vehicle registration, driver’s
license, PUC and Vehicle Insurance. (Check this post on 'all
legal documents required by a hospital')
• The vehicle should comply with ‘Minimum standards and
guidelines for ambulances, National Ambulance code issued
by Ministry of Road and transport and Highways’
• There should be an un-obstructed way for ambulance to reach
till emergency entrance and take a U-turn
• An identified parking spot near to emergency department
should be used for parking ambulances

23. • The staff in ambulance must have devices (mobile
phone, wireless walkie talkie etc.) to communicate
with hospital. If mobile phones are used, it must be
ensured that the phones are functional all the time
(i.e. battery is charged and adequate balance
available)
• Staff in ambulance must be aware basic emergency
management skills like immobilization technique,
safe transfer of patient, use of oxygen, medication
administration etc.
•

24. Accompanying the patient
• It is recommended that two competent
personnel accompany the unstable patient
during transfer. The accompanying person shall
be suitably trained in patient transfer, advanced
cardiac life support, airway management and
critical care. It is also recommended that a
physician shall accompany the patient, however,
if this is not possible then provision for
contacting the concerned physician shall be
there. For deciding who should accompany, the
patient can be categorized into 4 levels

25. Level of patient condition
• Level 0 – Patients who can be managed at the level of ward, usually
do not require any specially trained person to accompany
• Level 1 – These are patients who are at risk of deterioration during
transfer, but can be managed in acute care setting. Such patient
shall be accompanied by a paramedic or a nurse
• Level 2 – These patients require observation or intervention for
failure of single organ system and must be accompanied by trained
and competent personnel
• Level 3 – These are patients with advanced respiratory care
requirement during transfer with support of at-least two failing
organs. These patients shall be accompanied by a competent doctor
along-with nurse or paramedic

26. Equipment and Drug
• The ambulance transporting the patient shall be
equipped with necessary equipment, monitoring
devices, medicines and consumables.
• All the monitoring needs to be established before
the commencement of transfer along with the
starting of infusion drugs.
• There should be one person responsible for
patient transfer, who shall ensure availability of
all these.

27. Documentation and record
• In all stages of transfer, documentation shall be clearly
done.
• Patient's condition, reason to transfer, names and
designation of referring and receiving clinicians, details
and status of vital signs before the transfer, clinical
events during the transfer and the treatment given, shall
be recorded in patients’ medical files.
• Handing over shall also be documented and things
handed over along with the patient, such as medical files,
clinical reports, films etc. shall also be recorded.

28. Quality improvement
• Any untoward incident happening during
transfer shall be recorded and reported to
appropriate authority.
• Each such incident shall be investigated and
proper corrective and preventive actions shall be
taken.
• Periodic audit of transfer process shall be done
and the transfer records shall be reviewed.

29. Reference
• Kulshrestha A, Singh J. Inter-hospital and intra-
hospital patient transfer: Recent concepts.
Indian journal of anaesthesia. 2016
Jul;60(7):451.