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HomeMy WebLinkAboutpediatric-inter-facility-tool-kitInter Facility Transfer Tool Kit for the Pediatric Patient 2 3 Acknowledgements A special thank you to members of the Emergency Nurse Association (ENA) Pediatric Committee and members of the Pediatric Special Interest Group of the Society of Trauma Nurses (STN) for participating in the building of this inter facility transfer tool kit. ENA members contributing to this product include: STN members contributing to this product include: EMS for Children (EMSC) National Resource Center staff members contributing to this product include: Additional contributors include: Anne Blevins, RN, MSN, CEN Pediatric Trauma Clinician Tampa General Hospital, Florida Lisa Gray, RN, BSN, CPN Director, Trauma Services St. Mary’s Level II Adult and Pediatric Trauma Centers, Indiana Diana Ropele, MSN, RN Trauma Manager Helen DeVos Children’s Hospital, Michigan Nathan Selstad RN, BSN, CCRN, CPEN Program Manager EMS/Trauma Education Children’s Hospitals and Clinics of Minnesota, Minnesota Sally Snow, RN, BSN, CPEN, FAEN Trauma Program Director Cook Children’s Medical Center, Texas Deena Brecher, MSN, RN, APRN, ACNS-BC, CEN, CPEN Sue Cadwell, MSN, RN, NE-BC Director ED Initiative, Clinical Services Hospital Corporation of America Kathy Szumanski, MSN, RN, NE-BC Director, Institute for Quality, Safety and Injury Prevention, Emergency Nurses Association Dale Wallerich, MBA, BSN, RN, CEN Senior Associate Institute for Quality, Safety and Injury Prevention Emergency Nurses Association Michael Vicioso, MSN, RN, CPEN, CCRN Chair, Pediatric Special Interest Group Emergency Nurses Association Diana Fendya, MSN (R), RN, Trauma/Acute Care Specialist EMSC National Resource Center Jaclynn Haymon, MPA, RN Director Planning and Communications EMSC National Resource Center Suzanne Sellman, MA Senior Communication Specialist/Designer EMSC National Resource Center Shari Herrin, MSN, RN, MBA, CEN Clinical Manager, Pediatric ED Cardon Children’s Medical Center Banner Health System Sheila Giles RN,CPN Burn Program Coordinator Nationwide Children’s Hospital Dear Healthcare Partners: Scarcity of pediatric medical specialists for critically ill and injured children often requires today’s providers and medical systems to plan for the inter facility transport of pediatric and neonatal patients. In 2012, more than 10,500 severely injured children were transferred to access higher levels of care and specialty services.1 Moving a very sick or critically injured infant or child from one facility to another facility is both complex and stressful to the child, family and staff. Preplanned processes can reduce the strain of unfolding events, ensure that the handoff of the pediatric patient’s care is smooth, and increase the safety of the transfer. The Emergency Nurses Association (ENA), the Society of Trauma Nurses (STN), and the EMS for Children (EMSC) National Resource Center have collaborated to ensure that hospitals and providers can better ad- dress these important processes. Resources included in this tool kit support efforts in establishing agree- ments or memorandums of understanding to facilitate transfer of children to specialty resources when needed. Additionally, the tool kit will aid in the development of pediatric transfer guidelines to assist staff as they work to ensure safe and timely inter facility transfer. Contents are reflective of both current litera- ture and the best practices of hospitals around the country. Background and Significance: Consider the following: • Approximately 27% of all emergency department visits consist of children younger than age 18;2 and rural or remote facilities care for approximately 89% of all pediatric emergencies.3 • Though research has shown outcomes for critically ill and injured children are optimized at hospitals with specific pediatric resources and expertise,4, 5 pediatric specific critical care areas are only avail- able in 10% of all hospitals.6 • Therefore, transfer of critically ill and injured children from receiving emergency departments to pediatric specialty facilities is an essential component of pediatric emergency care.7 • Additionally, the 2009 Joint Policy Statement of Guidelines for Care of Children in the Emergency Department, issued by the American College of Emergency Physicians, the American Academy of Pediatrics, and the Emergency Nurses Association states that hospitals lacking higher levels of pediatric care should have transfer guidelines and agreements for transfer of children to pediatric specialty facilities.8 Overview of Toolkit Materials The tool kit consists of 10 sections, each of which provides guidance on specific components associated with inter facility transfer. Users may find all sections helpful or may prefer to focus on individual sections depending on one’s unique situation. Though designed as a kit to aid in developing organized transfer processes for the pediatric patient, all of the information in the kit has applicability for all patients requiring transfer for specialty resources. Introduction Section One 4 5 Examples or templates may be utilized as is or revised to meet the requirements of individual facilities. A case study section includes two real life scenarios that involve pediatric transfer and the complexities that ultimately impacted patient/family outcomes. Toolkit Sections We are thankful for the efforts and work of the collaborative group in developing this tool kit. Addition- ally, we thank you, the user, for accessing this tool and helping to ensure both timely and safe transfer of children when specialty care is needed. Sincerely, • Section 1 – Introduction to the Tool Kit • Section 2 – An Algorithm for Developing Inter Facility Transfer Processes – the algorithm will serve as a guide to facilitate tool kit use in the development of inter facility transfer agreements and guidelines. • Section 3 – Standards and Regulation Con- siderations Associated with Inter Facility Transfer – includes important often complex concerns the provider may have in regards to the Emergency Medical Treatment and Labor Act (EMTALA), the Health Insurance Portabil- ity and Accountability Act (HIPAA), as well as Joint Commission considerations. Addition- ally the user will find a table listing states with regulations requiring hospitals to have transfer processes in place for services that they cannot provide. • Section 4 – Talking Points for Establishing Inter Facility Transfer Agreements– identi- fies important points for addressing the need for inter facility transfer agreement and guidelines as discussions occur with hospital leadership. • Section 5 – Inter Facility Transfer Agree- ments – contains examples of several types of agreements and a memorandum of un- derstanding that the user can download and adapt for institutional use. • Section 6 – Inter Facility Transfer Guidelines – includes examples of hospital transfer guidelines, including: pediatric triage con- siderations, i.e. patients to be considered for possible transfer; preparation for transfer, i.e. consent to be signed; and a transfer checklist. • Section 7 – Family Considerations – provides numerous resources addressing cultural con- siderations and family-centered care. • Section 8 – Follow-up Communications and Quality Improvement Planning – addresses opportunities to improve and build upon organized transfer processes. • Section 9 – Inter Facility Case Presentations – presents two pediatric case scenarios reflec- tive of the complexities associated with inter facility transfer. • Section 10 – Inter Facility Transfer Library – contains manuscripts and documents sup- porting organized transfer processes, as well as a glossary. Janet Houston, MHA EMS for Children Manager Dartmouth Hitchcock Med. Ctr. New Hampshire Joan Eberhardt, RN, MA, FAEN Administer, Time Critical Diagnois System and Chief Nurse, Disaster Medical Assistance Team State of Missouri Trauma/ED Educator Marla Vanore, RN, MHA Clinical Director Trauma and Injury Prevention Programs Children’s Hospital of Philadelphia Footnotes 1American College of Surgeons, Committee on Trauma, Pediatric National Trauma Data Base Report, 2012. http://www.facs. org/trauma/ntdb/pdf/ntdb-pediatric-annual-report-2012.pdf 2Institute of Medicine. Emergency Care for Children. Growing Pains. Washington, DC: The National Academies Press; 2007. Committee on the Future of Emergency Care in the United States Health System. 3Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: a 2003 survey. Pediatrics. 2007;120 4Kanter RK. Regional variation in child mortality at hospitals lacking a pediatric intensive care unit. Critical Care Medicine 2002;30:94Y99. 5Pracht EE, Tepas JJ 3rd, Langland-Orban B, et al. Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? Journal of Pediatric Surgery. 2008;43:212Y221.Joint policy statement guidelines for care of children in the emergency department. Pediatrics. 2009;124:1233Y1243 6Kimberly Middleton. Advance Data. (2006) Availability of Pediatric Services and Equipment in Emergency Departments: United States, 2002-03. US Department of Health and Human Services. 7Woodward GA, Insoft RM, Pearson-Shaver AL, et al. The state of pediatric interfacility transport: consensus of the sec- ond National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference. Pediatric Emergency Care. 2002;18:38Y43. 8Joint policy statement guidelines for care of children in the emergency department. Pediatrics. 2009;124:1233Y1243. The Inter Facility Transfer Tool Kit for the Pediatric Patient is funded by a grant through the Health Resources and Services Administration, Maternal and Child Health Bureau, EMS for Children (EMSC) Program. Cooperative agreement number # U07MC09174-05-02: EMSC National Resource Center at Children’s National Medical Center, Washington, D.C. 6 7 Evidence based practice suggests rapid triage and transfer of critically ill and injured pediatric patients is crucial to reducing the overall mortality and morbidity of this patient population. Organized processes may also be paramount when mass casualty incidents quickly overwhelm existing standard operating procedures. The overarching goal of the pediatric inter facility transfer toolkit is to help facilities establish agreements and develop guidelines for ensuring safe and expeditious transfer of the pediatric patient when higher level(s) of care and resources are required and when mass casualty necessitates patient movement outside of traditional local or regional patient flows. This section provides a mapping algorithm that a facility or an individual within a facility may find use- ful as they work to establish inter facility transfer processes. The Agreement and Guideline Algorithm provides a step-by-step process for the establishment of agreements and guidelines while referencing examples and information from other toolkit sections. The algorithm has been constructed to be used by any facility regardless of size or scope of service. Click for more information Algorithm for Developing Inter Facility Transfer Processes Section Two YES NOAgreements exist for one patient population Are agreements current and are staff educated on their existence? Do peds trauma agreements exist? Enlist/develop stakeholder support for establishing transfer agreements Present to executive leadership Develop formal agreements Moniter use for process improvement Develop guidelines and policy to functionally deploy agreements in clinical setting As formal transfer agreements and guidelines are established review with staff at referring and recieving institutions. Establish a follow up and quality improve- ment process (section 8) Are pediatric inter facility transfer agreements and guidelines available at your organization? Click for more information Collect validation information for established transfer agreements Click for more information Click for more information Click for more information 8 9 Appropriate transfer of pediatric patients from one facility to another requires thoughtful design, thor- ough planning, and ongoing monitoring. Inter facility transfer programs are subject to review related to compliance with key laws, elements of performance defined in accreditation programs, and prevailing professional standards and guidelines. Variability in state laws makes it necessary for inter facility transfer design teams to have a knowledge base of the legal requirements of their state. Licensed health care professionals participating in care responsibilities during transfer events also have personal accountability for assuring that they are practicing within the boundaries of their scope of prac- tice and license. A primary starting point for any inter facility transfer program for pediatric patients is an awareness of the policies and procedures currently in existence with the facility. While all laws, regulations, and standards are subject to ongoing revisions over time, the following list provides identified areas of importance related to rules and regulations. 1. Emergency Medical Services for Children Performance Measures 76 and 77. The EMS for Children Program has identified two performance measures in the establishment of inter facility transfer agree- ments and guidelines. 2. The Emergency Medical Treatment and Labor Act (EMTALA). This act became a federal law in 1986 and was designed to prevent hospitals from refusing to treat patients or transferring them to public hospitals when they were unable to pay. For more information, read a Legal Issues in Inter Facility Transfer: EMTALA Issue Brief is available. 3. Certificate of Transfer. Under EMTALA, a hospital may not transfer an individual with an unstabilized emergency medical condition unless a physician signs a certification stating that the benefit to the individual of receiving treatment at another medical facility outweighs the risk of being transferred. Certificates of transfer are re- quired by the Centers for Medicare and Med- icaid Services in order for reimbursement to occur. Rules and Standards and Inter Facility Transfer Section Three 4. The Health Insurance Portability and Accountability Act. This act set standards for the use and disclo- sure of protected health information as well as measures to ensure proper storage and transmission of medical records. 5. Federal Aviation Administration. Federal regulations related to air medical transport are available un- der the Federal Code of Regulations and apply to patients being transported by air. 6. State and Territorial Regulation (see the EMS for Children National Resource Center’s State and Ter- ritorial Regulations Authorizing Pediatric Interfacility Transfer Guidelines or Agreements). Wide varia- tions of state laws and regulations exist related to the provision of emergency care. In some instances, the interfacility transport process is specified in state regulations. In addition, when referral crosses state lines there may be specification in state regulation that apply. 7. Standards of Practice. Defined standards of emergency care, including transfer needs for adult and pediatric nurses, have been identified by the Emergency Nurse Association. 8. The American Nurses Association, the Joint Commission Accreditation of Hospitals, and the Centers for Medicare and Medicaid Services also have standards addressing transfer of patients (see Standards Addressing Organized Inter Facility Transfer Processes.) 9. The following professional organizations address the need for organized transfer processes through a variety of educational offerings. • Trauma Nurse Core Course • Emergency Nurse Pediatric Course • Transport Nurse Advanced Trauma Course • Advanced Trauma Care for Nurses • Rural Trauma Team Development Course, Chapter 7, Transfer to Definitive Care • Advanced Trauma Life Support, Chapter 13, Transport: 10. Emergency Nurses Association’s 2010 Inter Facility Position Statement 10 11 Fact The documents provided in this section are designed to provide support for the establishment of inter facility transfer agreements to streamline the transfer of critically ill children from general emergency departments to facilities offering more specialized pediatric care. Some particular points of interest include: • Establishing a relationship between facilities via transfer agreements and guidelines may help to mitigate unnecessary transfers of children. • Emergency Medical Treatment and Active Labor Act (EMTALA) implications associated with transfers may be avoided by establishing transfer agreements. While the Centers for Medicare and Medicaid Services (CMS) clearly articulates the duty of specialty hospitals to accept patients from more gen- eral facilities, the courts have been more ambiguous – sometimes articulating the failures of trans- ferring facilities to adequately stabilize patients. • An organized inter facility transfer process with clearly articulated steps and roles may improve out- comes in critically ill or injured children. • Inter facility transfer agreements and guidelines may assist the physician ahead of time in the selection of an ap- propriate destination and mode of transport for critically ill and injured chil- dren. • The Emergency Nurses Associa- tion (ENA) and the Society of Trauma Nurses support the use of transfer agreements and guidelines to fa- cilitate rapid and safe transfer of all patients. Talking Points for Establishing Interfacility Transfer Agreements Section Four Published Documents Supporting the Need for Inter Facility Transfer Processes • EMS for Children Face Sheet on Performance Measures 76 and 77 (EMS for Children National Re- source Center) – Provides an overview of the advantages of having transfer agreements in place, as well as the requirements for transfer guidelines. • Inter Facility Transports (Blackwell, TH) – The transfer process, including stabilization of the patient and transfer of the unstable patient, is covered in this manuscript. Supports coordination of the process, communication, and review of transfers for appropriateness. Outlines considerations for selection of mode of transport. • Position Statement Care of the Patient During Inter Facility Transfer (ENA) – Supports the use of transfer agreements to facilitate rapid, safe transfer. • Organized Inter Facility Transfer Process (Fendya, et al) – Calls for a closer look at the effect of trans- fer agreements and guidelines on timely pediatric transfers. • Inter Facility Transfers of Non-critically Ill Children (Li, et al) – Speaks to the number of transfers that were either discharged from the tertiary center emergency department or within 24 hours of the transfer. Points out the importance for transfer criteria and addressing the readiness of emergency departments to care for children. • Transfer Agreements Help Hospitals Comply With Antidumping Laws (Kingsolver, JC) – Provides a legal overview of the value of transfer agreements. • Issue Brief June 2009 (EMS for Children National Resource Center) – Supports transfer agreements and guidelines through discussion of EMTALA implications when transferring both inpatients and unstable emergeny department patients in the context of uncertainty with court rulings vs. CMS interpretations. • Issue Brief May 2010 (EMS for Children National Resource Center) – Discusses EMTALA liability issues that can arise in the case of an inter facility transfer. Supports transfer guidelines and agree- ments and their importance in establishing the terms of the transfer to clarify respective duties and methods for assuring the proper execution of those duties. 12 13 Specialty care for children, i.e., pediatric neurosurgeons and pediatric specific critical care units, is often limited in availability. Many hospitals do not have the specialty resources needed to care for critically ill and injured children. It is essential that hospitals lacking pediatric specialty care proactively identify partnering facilities capable of providing the needed resources while identifying and streamlining effective transfer processes. An inter facility hospital agreement and memorandum of understanding (MOU) may be defined as a writ- ten document of understanding between a referring facility (e.g., community hospital) and another hospi- tal. The agreement identifies collaborative roles in the provision of additional needed care resources and specific duties as they relate to the inter facility transfer of patients. Often they include guidelines that outline procedural and administrative policies for transferring critically ill patients to facilities that provide specialized care or services not available at the referring facility. A pediatric specific agreement or MOU formalizes arrangements for consultation and the timely transport of the pediatric patient to additional care resources. Having established hospital transfer agreements or MOUs can also provide opportunities to craft transfer guidelines to expedite the safe movement of pa- tients to the essential resources when time may be critical. This section contains several blank examples of hospital agreements as well as MOUs that have been uti- lized to ensure that arrangements and access to specialty resources are available to pediatric patients. Example agreements in this section include: • Generic Patient Transfer Agreement #1 • Generic Patient Transfer Agreement #2 • Specific Service Pediatric Transfer Agreement (Trau- ma and Non-Trauma Pedi- atric Patient) • Hospital Inter-System/Net- work Transfer Agreement • Pediatric Inter Facility Transfer Memoradum of Agreement Inter Facility Transfer Agreements and Memorandums of Understanding Section Five Generic Patient Transfer Agreement #1 This type of agreement is common between smaller community hospitals and larger facilities or medical centers where additional care resources may be available. The agreement is not restrictive to a specific patient population (i.e., pediatric) or diagnosis (i.e., burns). The collaborative relationship covers all pa- tients needing additional resources not readily available at the receiving institution. Click here to download “Generic Patient Transfer Agreemnt #1” to your desktop. 14 15 Specific Service Pediatric Transfer Agreement (Trauma and Non-Trauma Pediatric Patient) This type of agreement would be made between a facility with minimal pediatric resources and a chil- dren’s hospital or a hospital with extensive pediatric resources. The transferring facility desires a collab- orative working relationship between themselves and a hospital with specific pediatric resources. Click here to download “Specific Service Pediatric Transfer Agreement” to your desktop. Generic Patient Transfer Agreement #2 This type of agreement is common between smaller community hospitals and larger facilities or medical centers where additional care resources may be available. The agreement is not restrictive to a specific patient population (i.e., pediatric) or diagnosis (i.e., burns). The collaborative relationship covers all pa- tients needing additional resources not readily available at the receiving institution. Click here to download “Generic Patient Transfer Agreemnt #2” to your desktop. 16 17 Pediatric Inter Facility Transfer Memoradum of Agreement A Memorandum of Understanding (MOU) may more easily be established between two institutions as op- posed to a formal transfer agreement. MOUs or Memorandum of Agreements are developed when two facilities want to work together on a common goal or action but do not want to enter into a formal agree- ment, i.e., ensuring access to pediatric specialty care when needed. Click here to download “Pediatric Inter Facility Transfer Memoradum of Agreement ” to your desktop. Hospital Inter-System/Network Transfer Agreement This type of agreement might be used by members of a multi-hospital system in which two or more hospi- tals are owned, leased, sponsored, or contract managed by a central organization. A network agreement may be in place when a group of hospitals, physicians, other providers, insurers and/or community agen- cies work together to coordinate and deliver a broad spectrum of services to their community. Click here to download “Hospital Inter-System/ Network Transfer Agreement” to your desktop. 18 19 As defined by the EMS for Children Program (see EMS for Children performance measure 76), safe and timely transfers to a specialty care center are better coordinated through the presence of inter facility transfer guidelines. These guidelines should include the following components: • Defined process for initiation of transfer, including the roles and responsibilities of the referring facility and referral center (including responsibilities for requesting transfer and communications). • Process for selecting the appropriate care facility. • Process for selecting the appropriately staffed transport service to match the patient’s acuity level (level of care required by patient, equipment needed in transport, etc.). • Process for patient transfer (including obtaining informed consent). • Plan for transfer of patient medical record. • Plan for transfer of copy of signed transport consent. • Plan for transfer of personal belongings of the patient. • Plan for provision of directions and referral institution information to the family. Effective stabilization and timely transport of a critically ill and/or injured child is very important in the reduction of further harm and negative outcomes. Severely ill and injured children have the potential to deteriorate quickly, making initial stabilization and identification or triage of those requiring additional resources important in developing transfer processes. This section includes the following resources: 1. Examples of pediatric triage criteria/considerations for children often benefitting from transfer for additional medical care and resources. • Pediatric Critical Care • Pediatric Surgery • Pediatric Burns 2. Example transfer checklists for referral, care considerations dur- ing actual transfer, and essential patient information to accom- pany the patient: • Patient medical record and testing informa- tion • Care giver information, both refer- ring and receiving information • Transport information • Parent information includ- ing consents and direc- tions Inter Facility Guidelines for Pediatric Transfer Section Six Pediatric Critical Care: Example Considerations for Transfer The following criteria are to serve as guidelines for directing the transfer of critically ill or injured patients to a higher level of care. Exceptions can be made upon consideration of the individual patient’s needs, and after consultation with nursing, subspecialists, and attending physicians involved. Availability of ap- propriate support services, including radiology and laboratory/pathology services, in a timely fashion may determine necessity of transfer. The parent(s), primary care physician, physician of record, and consultants have the final say in the loca- tion of the care of the patient, taking in to account the following criteria: The following patients should be considered for transfer to a higher level of care: 1. Patient with multi-organ system failure 2. Patient requiring constant bedside attendance for six hours or more 3. Patient requiring ongoing input from a subspecialist or the subspecialist requests transfer to an- other facility 4. Patient requiring cardiovascular surgical input or attention 5. Patient with renal failure requiring dialysis 6. Transplant recipient patient with transplant-related clinical issues 7. Patient with specific infectious diseases (e.g. HIV) that require pediatric ID input 8. If for any reason it is in the patient’s best interest to be transferred to another facility (e.g. social, insurance, equipment only available at another facility, etc) In addition, the following factors may also impact determination of the appropriate location for the care of a patient: 1. Pediatric Intensive Care Unit divert status 2. Admissions and transfers from emergency departments 3. Trauma patients’ disposition is at the discretion of the Trauma Service 4. Nursing or support personnel feel patient’s status or needs exceeds their comfort level This list of guidelines will be under constant review, and criteria can be added or removed, depending on further evolution of the patients’ needs. 20 21 Pediatric Surgery: Example Considerations for Transfer The following criteria are intended to serve as guidelines for directing the transfer of pediatric surgical patients to a higher level of care. Exceptions can be made upon consideration of the individual patient’s needs, and after consultation with nursing, subspecialists, and attending physicians involved. Availability of operating room time and appropriate support services, including radiology and laboratory/pathology services, in a timely fashion may determine necessity of transfer. The pediatric surgeons have the final say in the location of the care of their patients, taking in to account the following criteria: Neonates 1. Patients with known cardiac defects in utero should be delivered at the tertiary care center 2. The following conditions should be sent to ter- tiary care center after delivery due to the issues of complex surgery, multiple surgical proce- dures, and the need for multiple consultants • Omphalocele • Gastroschisis • Trachoesophageal Fistula • Congenital Diaphragmatic Hernia • Spinal defects • Bowel obstructions 3. Patients having the following surgical condi- tions may be appropriate to stay at a general pediatric care facility, depending upon pa- tient condition and facility capabilities. • Patent ductus arteriosis • Hernia repair • Lumps and bumps • Perforated necrotized bowel (This is on a case-by-case basis. Stable babies with a perforation may be operated on at the surgeon’s discretion. Sicker babies will be transferred. A neonatologists must agree to be in house for six hours or longer if these cases are to be done.) 4. Surgeon will schedule anesthesia if not same day admission. Infants, Toddlers, Children 1. Patients presenting to the emergency depart- ment will be stabilized and treated. 2. Patients requiring the following surgery will be admitted to ________________ unless ap- propriate clinical support is not available. • Hernia repair • Abscesses • Empyema (This is on a cases-by-case basis. Sicker children requiring ventilator support pre-op or with significant signs of sepsis should be considered for transfer to ________. More stable patients may be operated on at _________ at the sur- geons discretion but an intensivist must be present in house post-op for at least six hours to address any respiratory is- sues, unless mutually agreed upon by the surgeon and intensivist.) • Appendectomy • Foreign bodies of the airway and esopha- gus (assuming adequate endoscopy carts are maintained • Intussusception (assuming an attempt at a therapeutic barium enema can be obtained by a trained pediatric radiologist prior to surgery.) 3. Those surgical patients needing the following conditions should be considered for transfer to _____________ for PICU placement: • Multi-organ system issues (two or more systems or oncology) • Ventilator support expected to be needed for greater than 48 hours • Need for bedside physician presence for six hours or longer 4. Trauma patients will be managed by the trau- ma surgeons and managed by the pediatric intensivist. Pediatric surgery may be consulted and will treat or transfer based on collabora- tion with the trauma surgeon and intensivist. 5. The surgeons of _____________agree to make in-house consults on all requested pa- tients unless it is clear that the patient meets transfer criteria and waiting for the consult would only delay appropriate medical care. Pediatric Burns: Example Considerations for Transfer to Burn Center The following criteria are to serve as guidelines for directing the transfer of pediatric burn patients to a burn center. Exceptions can be made upon consideration of the individual patient’s needs, and after consultation with nursing, subspecialists, and attending physicians involved. Availability of appropriate support services, including social service, pediatric nurtritionist, and rehabilitation, may also determine necessity of transfer. The following patients should be considered for transfer to a burn center: 1. Partial thickness burns greater than 10% total body surface area (TBSA) 2. Burns that involve the face, hands, feet, genitalia, perineum or major joints 3. Third degree burns in any age. 4. Electrical burns, including lightning 5. Chemical burns 6. Inhalation injury 7. Burn injury with preexisting medical disorder 8. Burn injury with associated trauma 9. Burn injury in patients that require special social, emotional, and/or long-term rehabilitative inter- vention Click here to download “Pediatric Burn Center Referral Criteria/Guide- lines for Stabilization” to your desktop. 22 23 Pediatric Inter Facility Consultation and Transfer Guidelines In 2005, the EMS for Children Program established 10 performance measures to guide the activities of state EMS for Children grantees. Performance measures 76 and 77 address the need for hospitals to have inter facility transfer guidelines and agreements in place for the pediatric patient. The goal of the mea- sures is to ensure that all children have access to pediatric specialty care that is not available at every hospital. The following states and their EMS for Children Advisory Committees developed inter facility transfer guidelines to provide assistance to hospitals as they develop their own transfer processes. • California EMS for Children: Interfacility Pediatric Trauma and Critical Care: Consultation and/or Transfer Guidelines • Maryland EMS for Children: Maryland EMS Inter-hospital Transfer Resource Manual • South Dakota EMS for Children and Sanford, University of South Dakota Medical Center: Pediatric Consultation and Transfer Guidelines • Washington State De- partment of EMS and Trauma Systems: Pedi- atric Consultation and Transfer Guidelines In addition, the Pennsylvania Trauma Systems Foundation shared its Required Inter Facil- ity Transfer and Consulation guidelines. The Trauma Center Association of America (TCAA) also shared its Pediatric Trauma Inter Facility Transfer Guidelines. The TCAA guidelines define physiologic and anatomic criteria for transfer of pediatric patients. The guidelines also include details on how to recognize the patient needing transfer, the responsibilities of the transferring facility, collaboration with receiv- ing trauma surgeon, expeditious transfer modes, and recommen- dations regarding limiting diag- nostic testing, especially imaging diagnostics. Example Inter Facility Transfer Guideline Checklists Click here to download “Transfer Checklist” to your desktop. Click here to download “Pediatric Interfacility Transfer Form” to your desktop. 24 25 Example Inter Facility Authorization for Transfer Click here to download “Authorization for Transfer” to your desktop. Family-centered healthcare is an approach to patient care characterized by mutually beneficial collabora- tion between patient, family, and health professionals. Children rarely enter an emergency department or health care setting alone. A family member/caretaker or an entire family may accompany them. There- fore, family-centered care is paramount when caring for the pediatric patient. Families have the greatest influence over the health of their children and should be considered essential partners in both the planning and implementation of health plans. Numerous professional organizations have developed position statements supporting family-centered care for the pediatric patient. During high stress situations, illness or injury necessitating emergency care, family-centered care can be both comforting to patient and family while helpful to providers delivering care. Local community emergency departments and hospitals are often the first destination for many ill or injured children – most pediatric emergency visits occur in community or local emergency departments. Community hospitals are often close to home and perceived as comforting when care is provided by neighbors and trusted friends who are known in the community. Transfer of the pediatric patient for additional specialty services can cause additional concern and stress- ors on both the child and family unit. As community providers discuss the need for transfer and the pro- cess that will unfold, it is important that this discussion be on a level that family and child, if appropriate, can understand while being culturally sensitive. The links below may be helpful in accessing information on family-centered care, health literacy, and cultural competency to aid in development of your facility’s transfer guidelines and family transfer information sheets. Addi- tionally, a separate list of published resources sharing information on family considerations and concerns as they relate to facility transfer is provided. • Family-Centered Care in the Emergency Department: A Self- Assessment Inventory. Developed by the Emergency Nurses Association, this tool addresses Family Participation in Care; Family Support; Information and Decision Making; Service Coordination and Continuity; Personnal Practices and Training; Environment and Design, among other important components of family-centered care. • Family Presence During Invasive Procedures and Resuscita- tion in the Emergency Department. Developed by the Emergency Nurses Association in 1995 and reapproved in 2010. Cultural and Family Considerations in Inter Facility Transfer Section Seven 26 27 • MCH Definition of Family-centered Care. Posted to the Family Voices website, this Maternal and Child Health Bureau document defines family-centered care and lists the principles of family-cen- tered care for children. • Family Self-Assessment Tool Kit – Provider Guide. Developed by Family Voices, this tool is designed to increase outpatient health care settings’ and families’ awareness about the implementation of family-centered care and to provide an organized way for health care settings to assess current ar- eas of strength and identify areas for growth, plan future efforts, and to track progress. • Health Literacy and Cultural Competency. Maintained by the Agency for Healthcare Research and Quality, this website contains patient guides to encourage more patient/family involvment in self healthcare, as well as fact sheets, podcasts, and video presentations. • Health Literacy Interventions and Outcomes, by Berkman et al. This article provides a systematic review of health care service use and health outcomes of individuals with low health literacy and the interventions designed to improve outcomes. • Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy, by Wu HW et al. This document shares recommendations to guide health care organizations striving to meet the requirement for an effective informed consent process. • Clear Communication: A NIH Health Literacy Initiative. Maintained by the National Institutes of Health, this website provides an overview of health literacy, a 2010 Healthy People Objective, and includes numerous resources and tools to assist in developing communication strategies for a range of diverse audiences. • Health Literacy Online. Developed by the Department of Health and Human Services’ Office of Disease Prevention and Health Promotion, this online guide provides tools for developing health websites and includes a downloadable guide to writing and designing easy-to-use health websites. Documents Addressing Family Considerations as Related to Inter Facility Transfer • Safety Threats and Opportunities to Improve Interfacility Care Transitions; Insights from Patients and Family Members, by Jeffs L., et al. Patient Prefer Ad- herence. 2012;6:711-8. doi: 10.2147/PPA.S36797. Epub 2012 Oct 5. This paper explores family members detected safety threats across care transitions and strategies that may improve care transitions from acute care hospitals to complex continuing care and rehabilitation health care organizations. • The cost of family-oriented communication before air medi- cal inter facility transport, by Macnab et al. Air Med Journal. 2001 Jul-Aug;20(4):20-2. Com- munication with parents by transport teams can ease stress associated with transferring children to tertiary care. This paper reports on a study conducted to determine the duration of family-oriented visits prior to transfer and potential additional costs and benefits. • Should parents accompany pediatric inter facility ground ambulance transports? Results of a na- tional survey of pediatric transport team managers, by Woodward, et al. Pediatric Emergency Care. 2001 Feb;17(1):22-7. Reports results of a survey of parents and specialty transport team members regarding value of parents accompanying the pediatric patient during inter facility transport, a pe- riod of time of family unit high stress. 28 29 Inherent safety risks and costs are associated with the transfer of patients. When a pediatric patient is transferred to access specialty care, the team providing care for child and family has been extended beyond the referring facility to include transfer providers, EMS, and potentially a specialty team, as well as the care providers at the receiving facility. Monitoring transfer processes for opportunities of improve- ment while providing follow-up communications on patient outcome and condition are important com- ponents for the collaborative team of both referring and receiving institutions. Additionally, each trans- fer should be reviewed to assure that it was appropriate. Inappropriate patient transfers can tax scarce resources and can be inconvenient to families. Quality improvement or performance improvement has many definitions. Below are some of the more common descriptions of the process. Mosby’s Medical Dictionary, 8th edition. © 2009, Elsevier Continuous Quality Improvement (CQI) seeks to improve the provision of services with an emphasis on future results. Like total quality management, CQI uses a set of statistical tools to understand subsystems and uncover problems, but its emphasis is on maintaining quality in the future, not just controlling a process. Once a process that needs improvement is identified, a team of knowledgeable individuals is gathered to research and docu- ment each step of that process. Once specific expectations and the means to measure them have been established, implementation aims at preventing future failures and involves the setting of goals, education, and the measure- ment of results. If necessary, the plan may be revised on the basis of the results, so that the improvement is ongoing. Centers for Disease Control and Prevention Quality improvement in public health is the use of a deliberate and defined pro- cess, such as Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort Quality Improvement and Follow up Considerations Surrounding Inter Facility Transfer Section Eight to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, out- comes, and other indicators of quality services or processes which achieve equity and improve the health of the community. (Source: Riley et al, “Defining Quality Improvement in Public Health”, JPHMP, 2010, 16(10), 5-7.) Systems performance improvement is defined as positive changes in capacity, process and outcomes of public health as practiced in government, private and voluntary sector organizations. Performance improvement can occur system-wide as well as with individual organizations that are part of the public health system. It involves strategic changes to address public health system (or organizational) weak- nesses and the use of evidence to inform decision making. (Source: National Public Health Performance Standards Program) Performance management is the practice of actively using performance data to improve the public’s health. This involves the strategic use of performance standards, measures, progress reports, and ongoing quality improvement efforts to ensure an agency achieves desired results. Ideally, these practices should be integrated into core operations, and can occur at multiple levels, including the program, organization or system level. (Source: Turning Point Performance Management Collaborative, 2003.) Health Resources Services Administration Quality improvement includes regular measurement of care processes and outcomes to analyze the performance of the system of care. It involves the implementation of solutions to improve care and the monitoring of their effectiveness, with the goal of achieving optimal health outcomes for patients. Ongo- ing cycles of change and re-measurement are implemented to test and try different ideas to determine which practices result in improved care. Quality improvement activities in clinics can range from a single team focusing on improving one aspect of care to a comprehensive quality improvement program with many teams working on a wide variety of improvement projects, with a well-established plan and an oversight committee. The methods of quality improvement are based on core principles that are readily translated into a practi- cal approach and integrated into the clinical care delivery system. Joint Commission on Accreditation Performance Improvement is the systematic process of detecting and analyzing performance problems, designing and developing interventions to address the problems, implementing the interventions, evalu- ating the results, and sustaining improvement. Quality Improvement Tools This section contains the following tools for guiding quality improvement activities around patient transfer: • System Performance Improvement Committee Transfer Follow-up Guidelines • Routine Follow-up Communication Form between a Trauma Center and a Referring Facility • Routine Follow-up Letter between a Trauma Center and a Referring Facility 30 31 System Performance Improvement Committee Transfer Follow-up Guidelines Click here to download “System Performance Improvement Committee Transfer Follow-up Guide- lines” to your desktop. Routine Follow- up Communication Form between A Trauma Center and a Referring Facility Click here to download “Routine Follow- up Communication Form be- tween a Referring Facility and a Trauma Center” to your desktop. 32 33 Routine Follow- up Letter between a Trauma Center and a Referring Facility Click here to download “Routine Follow- up Letter between a Trauma Center and a Referring Facility” to your desktop. This section of the tool kit features two actual situations in which inter facility transfer was required to access pediatric specialty resources. Both cases provide a vehicle to envision the complexities of inter fa- cility transfer and support the necessity for comprehensive transfer plans at all facilities that include inter facility transfer agreements and guidelines. Case Study One: 8-month-old with Abdominal Injury The first case is one in which a mother shares the story of her toddler’s injury, the local emergency department providing care, the early iden- tification of the need for pediatric specialty services, and the difficul- ties encountered while trying to transfer the child, which may have been eliminated if an organized transfer processes had been in place. As an educated mother of two children, Melanie Jarreau, MBA, never fathomed that her local hospital would not be equipped to provide her child with the appropriate life sustaining treatment necessary for her to overcome injuries sustained in an accident. Her local regional hospital lacked the resources her child needed, necessitating her transfer to a larger facility. However, it was a lack of planning and preparation that ultimately cost her daughter her life. In September of 2003 her 8-month-old child, Skylar Grayce, sustained an abdominal injury as a result of an adult tripping and falling on her. Shortly after the accident Skylar began demonstrating signs of short- ness of breath. Melanie immediately took her to her pediatrician. He examined her briefly and requested she be directly admitted to the local hospital for observation and x-rays. After an almost two hour wait for x-rays, Melanie learned that Skylar sustained an internal abdominal injury requiring surgical repair. The local hospital did not have pediatric surgeons on staff nor a pediatric intensive care unit (PICU), which physicians believed Skylar would need for aftercare. Therefore, it was decided that it would be in Skylar’s best interest to transfer her to a hospital with resources that could better accommodate her unique pedi- atric needs. Upon learning the extent of Skylar’s injuries and being informed that she would have to be transferred, Melanie was a little uneasy to say the least. However, after speaking to friends and loved ones, she was reminded they were less than an hour away from two of the best pediatric hospitals in the state. Melanie was a little relieved and confident that Skylar would now receive the best possible care. Melanie was not prepared for the time and effort it would take for a hospital to accept and take care of her baby. The first hospital was contacted. After an hour the hospital responded that it was not in a position to ac- cept Skylar because of a full PICU and two other babies were awaiting admission. A second hospital was contacted and they agreed to accept Skylar. Melanie quickly learned that the accepting hospital would be sending their own transport team to pick her up because they were better equipped to care for Skylar Pediatric Case Presentations and Inter Facility Transfer Section Nine 34 35 in the event something went wrong during the transport. That sounded okay in theory but the roundtrip would take two hours. Two additional hours of critical time would pass. Three hours after receiving word from the accepting hospital the transport team arrived. They began examining Skylar and preparing her for transport. Once Skylar arrived at the accepting hospital she was prepped and went into surgery approximately ten hours after the initial examination by medical person- nel. It took surgeons two hours to repair her internal injuries. She fought a strong battle over the next few days and the hospital provided extensive resources to help her recovery, including extra corporeal membrane oxygenation, a heart-lung bypass procedure. In spite of these extreme efforts, her body could not fight any longer. Due to complications, Skylar’s life support was terminated on a Sunday afternoon at 3:10 p.m. Skylar’s death did not result from the accident. It was the result of precious time lost in her treatment. She died of heart failure caused by the extra stress placed on her heart when her body went into sep- tic shock during the 10 hour wait for treatment. This loss of life could have been prevented had Skylar received the proper medical care in a timely fashion. Since her death, Skylar’s family has spent countless hours on raising public awareness on the importance of hospital interf acility pediatric transfer agree- ments and how not having those in place impacted Skylar’s short life. “It is imperative that our children receive the proper medical attention in a timely man- ner to better improve their chances of survival. I urge you to get involved now before you too fall victim to a lack of system organization as my family did. We lost our pre- cious daughter, but we have vowed to do everything possible to prevent any further loss of life, especially the lives of children. Your advocacy can help save a child’s life!” – Melanie Jarreau (Skylar’s mom) Case Study Two: 16-month-old with Popcorn Aspiration The second case identifies the value of triage criteria being included as part of facility transfer guidelines while also emphasizing the need for follow up communications with referring facilities. Loop closure and identification of opportunities to improve care are important benefits and elements of the transfer process. A 16-month-old toddler presents to the multigenerational emergency department at 4:00 pm following a choking episode after eating pop- corn at a Halloween Party at his church around 1:00 pm. He is alert, speaking clearly at his baseline, shows no respiratory distress, no cya- nosis, and no drooling. He is able to drink apple juice without difficulty. For more information about this case study, download the slide set “Looked Who Popped Into Your ED... A Pediatric Transfer Case Scene- rio.” Care of the critically ill or injured child can present a challenge for all providers on the emergency care team. This is especially true in community hospitals where the opportunity to care for critically ill or injured children is infrequently. The anxiety provoking event can be compounded tenfold when suddenly the team realizes they don’t have the resources necessary to provide definitive care and they have no plan in place to facilitate moving the patient to another care facility where the resources of personnel, equipment, and services are available. Anticipation and preparation can play a huge role in helping facilities prepare, in advance, so that transfer of the patient can be done in an organized and seamless manner. Having pre-arranged transfer agree- ments and pre-established criteria detailing which patients may need to be transferred can decrease the anxiety in the heat of battle. The library section of the Inter Facility Transfer Tool Kit is a rich resource for the development of a robust plan for interfacility transfer of pediatric patients. Transferring and receiving facilities alike can find applicable resources. In this section, the following resources can be found: • Supporting manuscripts related to inter facility transfer • Transfer criteria established by states and regions to guide providers in making decisions regarding what patients may need to be considered for transfer. • Links to courses that help personnel become pre- pared to care for children in a variety of clinical set- tings. • Resources that reference the need for organized inter facility transfer processes. Resource Tools American College of Emergency Physicians Policy, Appropriate Interhospital Patient Transfer. This policy statement outlines the characteristics of an appropriate interfacility transfer, highlighting the legal requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA). It specifically focuses on the medical screening exam and the patient stabilization requirement within the capabilities of each healthcare facility. Guide For Interfacility Patient Transfer. Developed by the National Highway Traffic Safety Admistration, this document can be used to provide general guidance, references, and ideas for conducting a systematic assessment of the processes and personnel supporting inter facility transfer and how they can be enhanced to provide optimal delivery of care. Section TenInter Facility Transfer Library Resources 36 37 Clear Communication: A NIH Health Literacy Initiative. This website provides an overview of health litera- cy, a 2010 Healthy People Objective. It also provides numerous resources and tools to assist in develop- ment of communication strategies for a range of diverse audiences. Emergency Medical Treatment and Labor Act (EMTALA). This act became a federal law in 1986 and was designed to prevent hospitals from refusing to treat patients or transferring them to public hospitals when they were unable to pay. Emergency Nurses Association, 2010 Position Statement on Inter Facility Transfer. This statement supports the use of organized transfer processes including establishment of agreements. Emergency Nurse Standards of Practice. Defined standards of emergency care, including transfer needs, for adult and pediatric nurses have been identified by the Emergency Nurse Association. EMS for Children Fact Sheet on Performance Measures 76 and 77. The EMS for Children Program has identified two performance measures in the establishment of inter facility transfer agreements and guide- lines. This fact sheet provides an overview of the advantages of having transfer agreements in place as well as the components that should be included in transfer guidelines. Family-Centered Care in the Emergency Department: A Self-Assessment Inventory Family Presence During Invasive Procedures and Resuscitation in the Emergency Department Family Self-Assessment Tool Kit – Provider Guide Federal Aviation Administration. Federal regulations related to air medical transport are available under the Federal Code of Regulations and apply to patients being transported by air. Health Insurance Portability and Accountability Act (HIPAA). This act set standards for the use and disclo- sure of protected health information as well as measures to ensure proper storage and transmission of medical records. Health Literacy and Cultural Competency. This Agency for Healthcare and Research-supported website provides tools for providers to improve patient communications. The site also contains patient guides to encourage more patient/family involvement in self-healthcare. The website includes fact sheets, podcasts and video presentations. Health Literacy Online. This site provides tools for developing health websites and includes a download- able guide to writing and designing easy-to-use health web sites. Issue Brief June 2009. This fact sheet focuses on transfer agreements and guidelines through a discus- sion of Emergency Medical Treatment and Active Labor Act (EMTALA) implications when transferring both inpatients and unstable emergency department patients in the context of uncertainty with court rulings vs. CMS interpretations. Issue Brief May 2010. This fact sheet discusses EMTALA liability issues that can arise in the case of an inter facility transfer. Supports transfer guidelines and agreements and their importance in establishing the terms of the transfer in order to clarify respective duties and methods for assuring the proper execution of those duties. MCH Definition of Family Centered Care National Highway Traffic Safety Administration Guide for Interfacility Patient Transfer. This document is intended for EMS agencies providing interfacility transfers at the local, state, and regional levels, as well as those involved in transfer planning. It can be used to provide general guidance, references, and ideas for conducting a systematic assessment of the processes and personnel supporting interfacility transfers, and how they can be enhanced to provide optimal patient care. Pediatric National Trauma Data Base (NTDB) Report, 2012. This report provides recent data collected from NTDB contributing trauma centers inclusive of major mechanisms of injury, injury severity scores, discharge status including transfer to pediatric trauma centers etc. Standards Addressing Organized Inter Facility Transfer Processes. This resource identifies those states hav- ing regulatory standards in place requiring hospitals to have agreements/guidelines in place which may help validate the need for organized processes when approaching hospital administrators. Advanced Trauma Care for Nurses (ATCN). This course is designed for the registered nurse interested in increasing his/her knowledge in the management and care of the multiple trauma patient. Advanced Trauma Life Support (ATLS). This course teaches a systematic, concise approach to the early care of the trauma patient. It is helpful in guiding care for the injured patient in emergency departments. Emergency Nursing Pediatric Course (ENPC). This national standardized 16-hour course is designed to provide the learner with pediatric emergency nursing knowledge and psychomotor skill experience. The content is presented through lecture material, accompanying slide presentations, and dedicated time for learning and practicing six psychomotor skill stations. Rural Trauma Team Development Course (RTTDC). This course focuses on rural receiving facilities and the fundamental elements of injury resuscitation. Course content includes key concepts relative to organiza- tion of the trauma receiving area, utilization of available resources and regional system relationships in a way that is straightforward and easy to understand. Trauma Outcomes and Performance Improvement Course (TOPICS). This course is designed for all mem- bers of the trauma team who participate in the on-going assessment, evaluation and improvement of trauma care. TOPIC focuses on the on-going assessment of the continuum of trauma care with a struc- tured review of process and discussions of strategies to monitor trauma patient outcomes. Trauma Nurse Core Course (TNCC). This course is a standardized, 16-20 hour course integrating the trau- ma nursing process into the content while providing the learner with core-level trauma knowledge and psychomotor skill experience. Transport Nurse Advanced Trauma Course (TNATC). This three-day educational experience focuses on care of the trauma patient during initial resuscitation and transport. Course content includes: transport physiology, safety, neurological trauma, shock, thoracic and abdominal trauma, trauma in pregnancy, pediatric trauma, legal aspects of transport, burn trauma, airway and ventilator management and crisis management. American Academy of Pediatrics Manual, 3rd, Guidelines for Air & Ground Transport of Neonatal & Pe- diatric Patients. This manual provides guidelines for health care professionals who make decisions about the emergency inter facility transport of children. Though focused on pediatric specialty teams this text 38 39 The Cost of Family-oriented Communication before Air Medical Inter Facility Transport, by Macnab AJ, et al. Air Med Journal. 2001 Jul-Aug;20(4):20-2. Communication with parents by transport teams can ease stress associated with transferring children to tertiary care. This paper reports on a study conducted to determine the duration of family-oriented visits prior to transfer and potential additional costs and benefits. Golden Hour, The Handbook of Advanced Pediatric Life Support, 3rd edition, Nichols D. et al, Pennsylva- nia, Pa: Elsevier, Inc.;2011. Contains a nice section on transfer of the pediatric patient including guidelines to assist staff in both administrative components and patient care considerations. Policy Statement Guidelines for Care of Children in the Emergency Department. This policy statement focuses on the essential resources (medications, equipment, policies, and education) and staff to ensure that hospital emergency departments are prepared to care for and – when necessary -- transfer children of all ages, from neonates to adolescents. The guidelines are consistent with the recommendations of the Institute of Medicine’s (IOM) 2006 report Future of Emergency Care in the United States Health System. The state of pediatric interfacility transport: Consensus of the second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference, by Woodward GA, Insoft RM, Pearson-Shaver AL, et al. Pediatric Emergency Care. 2002;18:38Y43. Should parents accompany pediatric inter facility ground ambulance transports?, by Woodward GA, et al. Pediatric Emergency Care. 2001 Feb;17(1):22-7. Reports results of a survey of parents and specialty trans- port team members regarding value of parents accompanying the pediatric patient during inter facility transport, a period of time of family unit high stress. Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy, by Wu HW, et al. National Quality Forum; 2005. This document shares recommendations to guide health care organi- zations striving to meet the requirement for an effective informed consent process. also includes valuable information on legal considerations of transfer/transport and quality improvement as well as family centered care. EMSC Performance Measure Manual. This manual contains information on all 2006 EMSC Performance Measures. Performance Measure 76 and 77 address the need for all hospitals to have inter facility trans- fer agreement available for pediatric patients as well as guidelines that include specific components to facilitate safe, timely and family centered transfer. Health Literacy Interventions and Outcomes, by Berkman et al. This resource provides a systematic review of health care service use and health outcomes of individuals with low health literacy and the interven- tions designed to improve outcomes. Disparities in health outcomes and effectiveness of interventions among different sociodemographic groups were also examined. Institute of Medicine. Emergency Care for Children. Growing Pains. Convened in 2003, the Institute of Medicine examined the emergency care system in the United States to create a vision for the future while making recommendations for improvements. Findings and recommendations were presented in three reports. The pediatric report describes the challenges of emergency care for children and their impact on the outcomes of critically ill and injured children. Inter facility Transports, Seminars in Respiratory and Critical Care Medicine, by Blackwell TH. 2002 Feb. 21;(1)11-8. The transfer process, including stabilization of the patient and transfer of unstable patients is covered in this manuscript. Importance of communication coordination and the review of transfers for appropriateness is also stressed. Organized Inter facility Transfer Processes, by Fendya DG, et al. Pediatric Emergency Care 2011:27;900- 6. doi: 10.1097/PEC.0b013e318230277e. While providing national information on availability of hospital transfer agreements and guidelines this manuscript calls for a closer look at the effect of transfer agree- ments and guidelines on timeliness of pediatric inter facility transfers. Regional Variation in Child Mortality at Hospitals Lacking A Pediatric Intensive Care Unit, by Kanter RK. Critical Care Medicine 2002;30:94Y99. This paper explores regional variation in failure to utilize existing regional pediatric intensive care units (PICUs) and impact on pediatric mortality. Inter facility Transfers of Non-critically Ill Children to Academic Medical Centers, by Li J, et al. Pediatrics 2012 July 130 ;(1);83-92. doi: 10.1542/peds.2011-1819. Epub 2012 Jun 4. This paper addresses the num- ber of transfers that were either discharged from the tertiary center ED or within 24 hours of the transfer and thus emphasizes the importance for transfer criteria and addressing the readiness of EDs to care for children. Safety Threats and Opportunities to Improve Interfacility Care Transitions; Insights from Patients and Family Members, by Jeffs L., et al. Patient Prefer Adherence. 2012;6:711-8. doi: 10.2147/PPA.S36797. Epub 2012 Oct 5. This paper explores family members perceived safety threats across care transitions and strategies that may improve care transitions from acute care hospitals to complex continuing care and rehabilitation health care organizations. Transfer Agreements Help Hospitals Comply With Antidumping Laws, by Kingsolver JC. Kentucky Hospital Magazine, 1990 Summer;7(3):22-3. Provides a legal overview of the value of transfer agreements. 40 41 Glossary Certificate of Transfer - Under the Emergency Medical Treatment and Labor Act (EMTALA), a hospital may not transfer an individual with an unstabilized emergency medical condition unless a physician signs a certification stating that the benefit to the individual of receiving treatment at another medical facil- ity outweighs the risk of being transferred. Note that a hospital’s EMTALA obligations apply to individuals who present at a hospital seeking emergency care and are subsequently diagnosed with an emergency medical condition; they do not, however, apply to hospital inpatients, whether such patients are admitted after being diagnosed with an emergency medical condition or are admitted for elective (non-emergency) diagnosis or treatment. Family-centered Care – An approach to patient care characterized by mutually beneficial collaboration between patient, family, and health professionals. Inter Facility – The movement of a patient from one facility to another, such as from one hospital to an- other hospital; from an urgent care center to a hospital; or from a hospital to a rehabilitation center. Inter Facility Agreement – A recorded document of understanding and intention between two or more parties with respect to the effect upon their relative rights and duties as they relate to inter facility trans- fer of patients. Inter Facility Guideline – Defines the process/steps and responsibilities that should be addressed by care- takers when planning to transfer a patient to another facility for additional care resources. These process- es ensure both organized and safe transfer of the patient. Injury Severity Score (ISS) – An established medical score to assess trauma severity. It correlates with mortality, morbidity, and hospitalization time after trauma. It is used to define the term major trauma. Memorandum of Agreement (MOA) or Memorandum Cooperative Agreement (MCA) – A document written between parties who agree to cooperate on a project or meet an agreed upon objective. Memorandum of Understanding (MOU) – A document describing a mutual agreement between two or more parties. It expresses a union of parties for an intended common line of action. Pediatric Patient – Generally defined as a newborn to less than 18 years. Note that the definition of the pediatric patient may be state and/or hospital specific. The following classifications are commonly used for the pediatric patient. • Neonate is defined as a newborn to 3 months of age. • Infant is defined as a 3 - 18 month old baby. • Child is defined as 18 months to 12 years of age. • Adolescent is defined as 13 years through 17 years of age. Performance Improvement – The systematic process of detecting and analyzing system performance problems, designing and developing interventions to address the problems, implementing the interven- tions, evaluating the results, and sustaining improvement. Quality Improvement – A recognized method for the analysis of performance and disciplined efforts to improve it. Quality improvement includes regular measurement of care processes and outcomes to ana- lyze performance. Regional Quality Improvement – Quality improvement initiatives within a service area, geographic area, state, or municipality that involves multiple facilities or care service organizations. Regulation – A rule put forth by a government or a non-government, administrative entity that mandates a certain enforceable code of practice; a regulating principle. Standard – An authoritative statement by which the quality of practice, service, or education can be evaluated. Tertiary Pediatric Care Facility – Pediatric tertiary care facilities provide highly specialized pediatric equip- ment, pediatric critical care capabilities, and pediatric medical subspecialists. Tertiary pediatric care facili- ties are often affiliated with medical schools and serve as teaching centers for pediatric subspecialists. Children will often be referred from smaller hospitals to a tertiary pediatric hospital for major operations, consultations with sub-specialists and, when required, sophisticated intensive care. Transfer Triage Criteria – A process for quickly identifying or sorting injured or ill patients who may re- quire additional resources and thus would benefit from transfer to another facility.