EIIC: Emergency Medical Services for Children | Innovation and Improvement Center

Interfacility Transfer Toolbox

To ensure the best possible health outcomes, critically ill and injured children should be treated at the facilities most prepared to address their needs. Often, however, children are treated at local community emergency departments where pediatric specialty services are not available – i.e. pediatric burn care. Therefore, healthcare facilities should have available written arrangements to formalize their procedures for transferring pediatric patients to specialized centers for optimal care.

Such arrangements include both interfacility transfer agreements and interfacility transfer guidelines. As defined by the EMSC NRC’s State Partnership Implementation Guide:

  1. Interfacility transfer agreements are written contracts between a referring facility (such as a community hospital) and a specialized pediatric center or a facility with a higher level of care and/or appropriate resources for the child. These agreements must formalize arrangements for consultation and transport of a pediatric patient to the higher level of care facility.
  2. Interfacility transfer guidelines are arranged between hospitals – including out of state/Territory facilities – and serve to outline procedural and administrative policies for transferring critically ill pediatric patients to facilities providing specialized pediatric care.

Note: For those interested in the designation of healthcare facilities as pediatric care centers, the NRC’s Facility Categorization Toolbox may provide additional useful information and resources. Similarly, the Pediatric Equipment Guidelines Toolbox contains additional resources for outfitting ambulances appropriately for pediatric patients.

Healthcare Provider Resources

EMSC Program Materials

Inter Facility Transfer Tool Kit
To assist hospitals in developing preplanned processes for inter facility transfer of children, the EMSC Program Materials, the Emergency Nurses Association, and the Society of Trauma Nurses have collaborated in the development of an Inter Facility Transfer Tool Kit. The resource includes an interactive algorithm for developing inter facility transfer processes, sample patient transfer agreements and guidelines, sample transfer checklists, and more. (2013)
EMSC Performance Measures 76 and 77: Making Transfers Work for Critically Ill and Injured Children
This resource provides additional, more specific information on State Partnership performance measures 76 and 77. Performance measure 76 addresses the percentage of hospitals in the state/territory that have written interfacility transfer guidelines that cover pediatric patients and include pre-defined components of transfers. Performance measure 77 addresses the percent of hospitals in the state/territory that have written interfacility transfer agreements that cover pediatric patients. (2009)
Best Practices: A Guide for State Partnership Grantees on the Implementation of EMSC Performance Measures
This document contains information regarding the EMSC State Partnership performance measures, and includes best practices from state activities related to interfacility transfer agreements, in addition to facility categorization. (June 2009)
Webcast: Introduction to Interfacility Transfer Agreements and Guidelines
Developed by the NRC and presented online through the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB), this webcast covers such topics as:
  • the need for interfacility transfer agreements;
  • the basic components of interfacility transfer guidelines; and
  • the implications of transfer guidelines for pediatric outcomes. (February 2008)
Issue Brief June 2009
This fact sheet focuses on transfer agreements and guidelines through a discussion 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. (2009)
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. (2010)

American Academy of Pediatrics

Joint Policy Statement for Guidelines for Care of Children in the Emergency Department
Endorsed by the American Academy of Pediatrics' (AAP) Committee on Pediatric Emergency Medicine, the American College of Emergency Physicians' (ACEP) Pediatric Committee, and the Emergency Nurses Association’s (ENA) Pediatric Committee, these guidelines outline 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, and are also available online through the ACEP website. (Approved April 2009, published in Pediatrics September 2009)
AAP News: Policy Offers Blueprint for Care of Children in the ED
This AAP commentary piece provides background information and a concise summary of the key recommendations contained in the 2009 Guidelines for Care of Children in the ED endorsed by the AAP, ACEP, and the ENA. (November 2009)
Guidelines Checklist
In accordance with the AAP, ACEP, and ENA 2009 Guidelines for Care of Children in the ED, this checklist allows healthcare facilities to assess their own preparedness to manage pediatric emergencies. (Accessed February 2010)
The State of Pediatric Interfacility Transport: Consensus of the Second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference
The American Academy of Pediatrics’ (AAP) Section on Trauma Medicine held the second National Pediatric and Neonatal Transport Leadership conference in June 2000. Ninety-nine total participants representing 25 states and 5 international locations debated and discussed issues relevant to developing the specialty of pediatric transport medicine. Insights and conclusions from this meeting of transport leaders are presented in this consensus statement. (February 2002)
Policy Statements

The AAP website includes a number of policy statements that relate directly or indirectly to interfacility transfer agreements. These include:

American College of Emergency Physicians

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. (February 2009)
Interfacility Transportation of the Critical Care Patient and Its Medical Direction
Outlining the American College of Emergency Physicians’ (ACEP) position on transporting critically ill and injured patients, this document articulates the importance of ensuring that both transport teams and receiving facilities are capable of providing appropriate levels of care. (September 2005)

American College of Surgeons

Regional Trauma Systems: Optional Elements, Integration, and Assessment
Focusing on trauma – the most extensively regionalized emergency care system in the United States – this resource from the American College of Surgeon’s Committee on Trauma includes sections on system coordination and patient flow that highlight that importance of interfacility transfer agreements and guidelines within regionally coordinated care systems. (Accessed October 2014)

Emergency Nurses Association

Care of the Pediatric Patient during Inter Facility Transfer
This position statement supports the use of transfer agreements to facilitate rapid, safe transfer. (2010)

National Association of EMS Physicians

Medical Direction of Interfacility Transports
Designed to serve as a tool to encourage optimal transport of patients between health care facilities, this position statement reviews the roles and responsibilities of those involved in the medical direction of an interfacility transport, and how regulations and accreditation affect them. (2000)

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. (April 2006)
Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances
These guidelines provide national, state, and local emergency medical services organizations with clear guidance on best practices for properly restraining children traveling by ambulance from the scene of a traffic crash or medical emergency to a hospital or medical facility. If widely adopted, the guidelines could serve as a tool for standardizing national child restraint protocols in ground ambulances across the United States. (September 2012)

Example Practices

New Jersey EMSC

The New Jersey EMSC Program, in partnership with the Burlington County College, is conducting “Emergency Department Evaluations through Simulation” at New Jersey hospitals. The goal of the simulation project is to evaluate and improve pediatric readiness and responsiveness. The evaluation includes observation of treatment(s) provided by staff as well as transfer processes that would be followed for pediatric patients when appropriate resources are unavailable.

The use of clinical scenarios and simulation mannequins allows the EMSC Advisory Board members, Burlington County College faculty, and state EMSC staff opportunities to:

  • observe policies and procedures essential to care of the pediatric patient;
  • identify quality improvement opportunities;
  • ensure pediatric equipment availability;
  • identify potential staff training needs; and
  • evaluate pediatric EMS registry documentation processes.

Positive outcomes that have already resulted from the simulation project include:

  • The development of an evaluation tool that accurately assesses current transfer processes and treatments while facilitating improvement conversations with staff.
  • The participation of staff in identifying potential gaps in the emergent transfer of patients.
  • The opportunity for evaluators and EMSC leadership to work with staff on strategies to improve the quality of care rendered during transfer.

For more information about this process, see Best Practices: A Guide for State Partnership Grantees on the Implementation of EMSC Performance Measures. (June 2006)

Vermont EMSC

In March 1999, the Vermont State Hospital Association created the state’s master interfacility patient transfer agreement and guidelines to be followed by all Vermont hospitals. At that time, each of these facilities agreed to (1) accept transferred patients from one another, and (2) utilize the guidelines outlined in the master document. Indicating their support and commitment to the process, all 17 hospital administrators signed the document.

When the federal EMSC program announced the creation of EMSC performance measures, the Vermont EMSC program and EMS director investigated state processes to assure timely and safe interfacility patient transfers. The following information was gleaned from the investigation:

  • The master agreement and guidelines had not been updated since development.
  • Signatories were not necessarily still with the hospitals.
  • The master agreement and guidelines did not specifically identify pediatric patients.
  • Though hospitals leaders were not always aware that the master agreement and guidelines existed, they agreed that the standard procedures as outlined in that document should be kept, utilized, and updated.

Developing a collaborative partnership with the Hospital Preparedness Program (HPP) administered through the U.S. Department of Health and Human Services proved to be a critical step in updating the master document with the integration of pediatric concerns. The state’s health department had previously identified transfers to be of vital importance during mass casualty incidents and pandemic flu outbreaks. Other partners in championing updates to the master agreement and guidelines included Vermont’s Office of Rural Health and the Vermont Hospital Association.

For more information about this process, see Best Practices: A Guide for State Partnership Grantees on the Implementation of EMSC Performance Measures. (June 2006)

Washington State EMSC

In 2006, Washington EMSC conducted a survey to determine the number of hospitals with pediatric interfacility transfer agreements and guidelines. Survey results indicated a need to develop comprehensive state-wide guidelines. Draft pediatric interfacility guidelines were then developed by the EMSC manager with guidance and feedback from the EMSC Advisory Committee, the State Trauma Nurse Coordinators, and the EMSC National Resource Center.

As the guidelines were developed, each draft was distributed to various groups for review, and finally presented to the state’s EMSC Advisory Council for approval. To assure clear understanding among all groups involved, the EMSC program manager participated in numerous statewide meetings to explain the need for the guidelines. The proposed document was introduced as a template that individual hospitals could adapt to accommodate specific situations and facilities in the development of their own pediatric transfer guidelines.

Another strategy utilized to garner support for interfacility transfer agreements and guidelines was to invite several state EMSC Advisory Committee members to watch the 2009 EMSC webcast on interfacility transfers. The webcast provided additional education and enhanced understanding of the relevant performance measures. The site reviewers for state trauma center verification also began checking and verifying the existence and use of interfacility transfer guidelines and agreements.

For more information on this project, see Best Practices: A Guide for State Partnership Grantees on the Implementation of EMSC Performance Measures. (June 2006)

Additional Examples — EMSC State Partnership Program

Many additional states and territories receiving funding through the federal EMSC State Partnership Grant program have also been successful in creating model pediatric transfer agreements and/or guidelines. Examples of these include:

Pediatric/Neonatal Transport Teams

A number of US healthcare facilities have implemented transport team programs designed to improve outcomes for critically ill or injured pediatric and/or neonatal pediatric patients who require transport to greater resources. Focusing on improving patient morbidity and mortality, these teams usually follow well defined agreements, protocols, and guidelines facilitating expeditious transfers.Through its Section on Transport Medicine, the American Academy of Pediatrics (AAP) has developed a comprehensive Pediatric/Neonatal Transport Team Database highlighting each of those US hospitals participating in dedicated pediatric and/or neonatal transfer programs. (Accessed May 2013).

Family and Caregiver Resources

EMSC Improvement Center

Getting Started, Staying Involved: An EMSC Toolkit for Family Representatives
Developed specifically for EMSC family representatives, this document contains advice for families on how to work with state EMSC advisory committees and program managers to ensure all hospitals in the state have interfacility agreements and guidelines in place. (2008)

American Academy of Pediatrics

When Your Child Needs Emergency Medical Services
This tip sheet for families and caregivers provides information on how to react to pediatric healthcare emergencies, when to call an ambulance, and how to communicate with emergency care providers. (Accessed February 2010)
What is a Pediatric/Neonatal Critical Care Transport Team? Developed by the AAP’s Section on Transportation Medicine, this document provides explanation on the need for and composition of pediatric-specific transport teams. (2008)

American College of Emergency Physicians

Emergency Care of Children
This fact sheet answers questions that parents may have about emergency care for children, such as:
  • Which local emergency department is best for your child?
  • Where will your child be taken for treatment in the event of an emergency?
  • What role do pediatric emergency specialists play in the care of your child?
  • What are emergency physicians doing to improve the care of children?
  • How do you make sure your child gets appropriate treatment in an emergency? (Accessed February 2010)

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 Adherence. 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 medical inter facility transport
by Macnab 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.
Should parents accompany pediatric inter facility ground ambulance transports? Results of a national survey of pediatric transport team managers.
by Woodward, et al. Pediatric Emergency Care. 2001 Feb;17(1):22-7. This paper 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 period of time of family unit high stress.