guidelines for the inter- and intrahospital transport of critically ill patients

Special Articles

Guidelines for the inter- and intrahospital transport of critically illpatients*

Jonathan Warren, MD, FCCM, FCCP; Robert E. Fromm Jr, MD, MPH, MS; Richard A. Orr, MD;Leo C. Rotello, MD, FCCM, FCCP, FACP; H. Mathilda Horst, MD, FCCM; American College of Critical CareMedicine

T he decision to transport a crit-ically ill patient, either withina hospital or to another facil-ity, is based on an assessment

of the potential benefits of transportweighed against the potential risks. Crit-ically ill patients are transported to alter-nate locations to obtain additional care,whether technical, cognitive, or proce-dural, that is not available at the existinglocation. Provision of this additional caremay require patient transport to a diag-nostic department, operating room, orspecialized care unit within a hospital, or

it may require transfer to another hospi-tal. If a diagnostic test or procedural in-tervention under consideration is un-likely to alter the management oroutcome of that patient, then the needfor transport must be questioned. Whenfeasible and safe, diagnostic testing orsimple procedures in unstable or poten-tially unstable patients often can be per-formed at the bedside in the intensivecare unit (1, 2). Financial considerationsare not a factor when contemplatingmoving a critically ill patient.

Critically ill patients are at increasedrisk of morbidity and mortality duringtransport (3–17). Risk can be minimizedand outcomes improved with carefulplanning, the use of appropriately quali-fied personnel, and selection and avail-ability of appropriate equipment (16–37).During transport, there is no hiatus inthe monitoring or maintenance of a pa-tient’s vital functions. Furthermore, theaccompanying personnel and equipmentare selected by training to provide for anyongoing or anticipated acute care needsof the patient.

Ideally, all critical care transports, bothinter- and intrahospital, are performed by

specially trained individuals. Since therewill almost certainly be situations when aspecialized team is not available for inter-hospital transport, each referring and ter-tiary institution must develop contingencyplans using locally available resources forthose instances when the referring facilitycannot perform the transport. A compre-hensive and effective interhospital transferplan can be developed using a systematicapproach comprised of four critical ele-ments: a) A multidisciplinary team of phy-sicians, nurses, respiratory therapists, hos-pital administration, and the localemergency medical service is formed toplan and coordinate the process; b) theteam conducts a needs assessment of thefacility that focuses on patient demograph-ics, transfer volume, transfer patterns, andavailable resources (personnel, equipment,emergency medical service, communica-tion); c) with this data, a written standard-ized transfer plan is developed and imple-mented; and d) the transfer plan isevaluated and refined regularly using astandard quality improvement process.

This document outlines the minimumrecommendations for transport of thecritically ill patient. Detailed guidelines

*See also p. 305.From Northwest Community Hospital, Arlington

Heights, IL (JW); Baylor College of Medicine, Houston, TX(REF); Children’s Hospital of Pittsburgh, University of Pitts-burgh School of Medicine, Pittsburgh, PA (RAO); Subur-ban Hospital, Bethesda, MD (LCR); Henry Ford Hospital,Detroit, MI (HMH).

These guidelines have been developed by the Amer-ican College of Critical Care Medicine and the Society ofCritical Care Medicine. These guidelines reflect the officialopinion of the Society of Critical Care Medicine and do notnecessarily reflect, and should not be construed to reflect,the views of certification bodies, regulatory agencies, orother medical review organizations.

Copyright © 2004 by Lippincott Williams & Wilkins

DOI: 10.1097/01.CCM.0000104917.39204.0A

Objective: The development of practice guidelines for the con-duct of intra- and interhospital transport of the critically ill pa-tient.

Data Source: Expert opinion and a search of Index Medicusfrom January 1986 through October 2001 provided the basis forthese guidelines. A task force of experts in the field of patienttransport provided personal experience and expert opinion.

Study Selection and Data Extraction: Several prospective andclinical outcome studies were found. However, much of the pub-lished data comes from retrospective reviews and anecdotalreports. Experience and consensus opinion form the basis ofmuch of these guidelines.

Results of Data Synthesis: Each hospital should have a for-malized plan for intra- and interhospital transport that addresses

a) pretransport coordination and communication; b) transportpersonnel; c) transport equipment; d) monitoring during transport;and e) documentation. The transport plan should be developed bya multidisciplinary team and should be evaluated and refinedregularly using a standard quality improvement process.

Conclusion: The transport of critically ill patients carries in-herent risks. These guidelines promote measures to ensure safepatient transport. Although both intra- and interhospital transportmust comply with regulations, we believe that patient safety isenhanced during transport by establishing an organized, efficientprocess supported by appropriate equipment and personnel. (CritCare Med 2004; 32:256–262)

KEY WORDS: intrahospital transport; interhospital transport; crit-ical care; health planning; policy making; monitoring; standards

256 Crit Care Med 2004 Vol. 32, No. 1

targeted to the transport of infants andchildren have been published by theAmerican Academy of Pediatrics (23). In-stitutions performing commercial or or-ganized interhospital transports are re-quired to function at and meet a higherstandard, as the requirements for orga-nized transport services are considerablymore rigorous than the recommenda-tions in this guideline (24, 38–41).

The references for this guideline wereobtained from a review of Index Medicus(see key words) from January 1986through October 2001 and are catego-rized according to the degree of evidence-based data employed. The specific cate-gory assigned to each reference is notedin the References at the end of this arti-cle. The letter a denotes a randomized,prospective controlled investigation; bdenotes a nonrandomized, concurrent, orhistorical cohort investigation; c denotesa peer-reviewed “state-of-the-art” article,review article, editorial, or substantialcase series; and d denotes a non-peer-reviewed opinion such as a textbookstatement or official organizational pub-lication. The asterisk symbol will follow astatement of practice standards. This in-dicates a recommendation by the Ameri-can College of Critical Care Medicine thatis based on expert opinion and is used incircumstances where published support-ing data are unavailable.

INTRAHOSPITAL TRANSPORT

Because the transport of critically illpatients to procedures or tests outsidethe intensive care unit is potentially haz-ardous, the transport process must beorganized and efficient. To provide forthis, at least four concerns need to beaddressed through written intensive careunit policies and procedures: communi-cation, personnel, equipment, and moni-toring.

Pretransport Coordination and Com-munication. When an alternate team at areceiving location will assume manage-ment responsibility for the patient afterarrival, continuity of patient care will beensured by physician-to-physician and/ornurse-to-nurse communication to reviewpatient condition and the treatment planin operation. This communication occurseach time patient care responsibility istransferred. Before transport, the receiv-ing location confirms that it is ready toreceive the patient for immediate proce-dure or testing. Other members of thehealthcare team (e.g., respiratory ther-

apy, hospital security) then are notified asto the timing of the transport and theequipment support that will be needed.The responsible physician is made awareof the transport. Documentation in themedical record includes the indicationsfor transport and patient status through-out the time away from the unit of origin.

Accompanying Personnel. It isstrongly recommended that a minimum oftwo people accompany a critically ill pa-tient.* One of the accompanying personnelis usually a nurse who has completed acompetency-based orientation and has metpreviously described standards for criticalcare nurses (42, 43). Additional personnelmay include a respiratory therapist, regis-tered nurse, or critical care technician asneeded. It is strongly recommended that aphysician with training in airway manage-ment and advanced cardiac life support,and critical care training or equivalent, ac-company unstable patients.* When the pro-cedure is anticipated to be lengthy and thereceiving location is staffed by appropri-ately trained personnel, patient care may betransferred to those individuals if accept-able to both parties. This allows for maxi-mum utilization of staff and resources. Ifcare is not transferred, the transport per-sonnel will remain with the patient untilreturned to the intensive care unit.

Accompanying Equipment. A bloodpressure monitor (or standard bloodpressure cuff), pulse oximeter, and car-diac monitor/defibrillator accompany ev-ery patient without exception.* Whenavailable, a memory-capable monitorwith the capacity for storing and repro-ducing patient bedside data will allow re-view of data collected during the proce-dure and transport. Equipment for airwaymanagement, sized appropriately foreach patient, is also transported witheach patient, as is an oxygen source ofample supply to provide for projectedneeds plus a 30-min reserve.

Basic resuscitation drugs, includingepinephrine and antiarrhythmic agents,are transported with each patient in theevent of sudden cardiac arrest or arrhyth-mia. A more complete array of pharma-cologic agents either accompanies the ba-sic agents or is available from supplies(“crash carts”) located along the trans-port route and at the receiving location.Supplemental medications, such as seda-tives and narcotic analgesics, are consid-ered in each specific case. An ample sup-ply of appropriate intravenous fluids andcontinuous drip medications (regulatedby battery-operated infusion pumps) is

ensured. All battery-operated equipmentis fully charged and capable of function-ing for the duration of the transport. If aphysician will not be accompanying thepatient during transport, protocols mustbe in place to permit the administrationof these medications and fluids by appro-priately trained personnel under emer-gency circumstances.

In many hospitals, pediatric patientsshare diagnostic and procedural facilitieswith adult patients. Under these circum-stances, a complete set of pediatric resus-citation equipment and medications willaccompany infants and children duringtransport and also will be available in thediagnostic or procedure area.

For practical reasons, bag-valve venti-lation is most commonly employed dur-ing intrahospital transports. Portable me-chanical ventilators are gainingincreasing popularity in this arena, asthey more reliably administer prescribedminute ventilation and desired oxygenconcentrations. In adults and children, adefault oxygen concentration of 100%generally is used. However, oxygen con-centration must be precisely regulatedfor neonates and for those patients withcongenital heart disease who have singleventricle physiology or are dependent ona right-to-left shunt to maintain systemicblood flow. For patients requiring me-chanical ventilation, equipment is opti-mally available at the receiving locationcapable of delivering ventilatory supportequivalent to that being delivered at thepatient’s origin. In mechanically venti-lated patients, endotracheal tube positionis noted and secured before transport,and the adequacy of oxygenation and ven-tilation is reconfirmed. Occasionally pa-tients may require modes of ventilationor ventilator settings not reproducible atthe receiving location or during transpor-tation. Under these circumstances, theorigin location must trial alternatemodes of mechanical ventilation beforetransport to ensure acceptability and pa-tient stability with this therapy. If thepatient is incapable of being maintainedsafely with alternate therapy, the risksand benefits of transport are cautiouslyreexamined. If a transport ventilator is tobe employed, it must have alarms to in-dicate disconnection and excessively highairway pressures and must have a backupbattery power supply.*

Monitoring During Transport. All crit-ically ill patients undergoing transportreceive the same level of basic physiologicmonitoring during transport as they had

257Crit Care Med 2004 Vol. 32, No. 1

in the intensive care unit. This includes,at a minimum, continuous electrocardio-graphic monitoring, continuous pulseoximetry (44), and periodic measurementof blood pressure, pulse rate, and respi-ratory rate. In addition, selected patientsmay benefit from capnography, continu-ous intra-arterial blood pressure, pulmo-nary artery pressure, or intracranial pres-sure monitoring. There may be specialcircumstances that warrant intermittentcardiac output or pulmonary artery oc-clusion pressure measurements.

INTERHOSPITAL TRANSPORT

Patient outcomes depend to a largedegree on the technology and expertise ofpersonnel available within each health-care facility. When services are neededthat exceed available resources, a patientideally will be transferred to a facility thathas the required resources (45). Interho-spital patient transfers occur when thebenefits to the patient exceed the risks ofthe transfer. A decision to transfer a pa-tient is the responsibility of the attendingphysician at the referring institution.Once this decision has been made, thetransfer is effected as soon as possible.When needed, resuscitation and stabiliza-tion will begin before the transfer (46,47), realizing that complete stabilizationmay be possible only at the receiving fa-cility.

In the United States, it is essential forpractitioners to be aware of federal andstate laws regarding interhospital patienttransfers. The Emergency Medical Treat-ment and Active Labor Act (EMTALA)laws and regulations (updated at intervalsfrom the 1986 COBRA laws and the 1990OBRA amendment) define in detail thelegal responsibilities of the transferringand receiving facilities and practitioners.The American College of Emergency Phy-sicians has published a book (48) thatreviews the legal responsibilities of refer-ring institutions as well as the ramifica-tions of noncompliance with the COBRA/EMTALA regulations, and it is anexcellent resource for any facility in-volved in patient transfers. In general,under COBRA/EMTALA, financially moti-vated transfers are illegal and put boththe referring institution and the individ-ual practitioner at risk for serious penalty(49, 50).

Current regulations and good medicalpractice require that a competent patient,guardian, or the legally authorized repre-sentative of an incompetent patient give

informed consent before interhospitaltransfer. The informed consent processincludes a discussion of the risks andbenefits of transfer. These discussions aredocumented in the medical record beforetransfer. A signed consent should be ob-tained, if possible. If circumstance do notallow for the informed consent process(e.g., life-threatening emergency), thenboth the indications for transfer and thereason for not obtaining consent are doc-umented in the medical record. The re-

ferring physician always writes an orderfor transfer in the medical record.

Several elements are included in theprocess of interhospital transfer, and allfall within minimum guidelines, as de-scribed subsequently. It is important torecognize that these process elementsmay frequently, and out of necessity, beimplemented simultaneously, espe-cially when stabilization and treatmentare needed before transfer. An algo-rithm has been developed to guide prac-

Figure 1. Interfacility transfer algorithm.


titioners through the transfer process(Fig. 1).

Pretransport Coordination and Com-munication. The referring physician willidentify and contact an admitting physi-cian at the receiving hospital to acceptthe patient in transfer and confirm beforethe transfer occurs that appropriatehigher level resources are available. Thereceiving physician is given a full descrip-tion of the patient’s condition. At thattime, advice can be requested concerningtreatment and stabilization before trans-port. The appropriateness of transferringa patient from an inpatient setting (crit-ical care unit) to an outpatient setting(e.g., emergency department) at a receiv-ing institution must be cautiously exam-ined. If a physician will not be accompa-nying the patient during transport (34),the referring and accepting physicianswill ensure there is a command physicianfor the transport team who will assumeresponsibility for medical treatment dur-ing the transport. It may be appropriatefor this individual to receive a medicalreport before the team departs.

In some instances (e.g., when a receiv-ing institution provides the transportteam), the receiving physician may deter-mine the mode of transport. However,the mode of transportation (ground orair) usually is determined by the trans-ferring physician, in consultation withthe receiving physician, based on the ur-gency of the medical condition (stabilityof the patient), time savings anticipatedwith air transport, weather conditions,medical interventions necessary for on-going life support during transfer, andthe availability of personnel and re-sources (51, 52). The transport servicethen will be contacted to confirm itsavailability, to prepare for anticipated pa-tient needs during transport, and to co-ordinate the timing of the transport.

A nurse-to-nurse report is given by thereferring facility to the appropriate nurs-ing unit at the receiving hospital. Alter-natively, the report can be given by atransport team member at the time ofarrival. A copy of the medical record, in-cluding a patient care summary and allrelevant laboratory and radiographicstudies, will accompany the patient. Thepreparation of records should not delaypatient transport, however, as theserecords can be forwarded separately (byfacsimile or courier) if and when the ur-gency of transfer precludes their assem-blage beforehand. Under these circum-stances, the most critical information is

Table 1. Recommended minimum transport equipment

Airway management/oxygenation—adult and pediatricAdult and pediatric bag-valve systems with oxygen reservoirAdult and pediatric masks for bag-valve system (multiple sizes as appropriate)Flexible adaptors to connect bag-valve system to endotracheal/tracheostomytubeEnd-tidal carbon dioxide monitors (pediatric and adult)Infant medium- and high-concentration masks with tubingMacIntosh laryngoscope blades (#1, #2, #3, #4)Miller laryngoscope blades (#0, #1, #2)Endotracheal tube stylets (adult and pediatric)Magil forceps (adult and pediatric)Booted hemostatCuffed endotracheal tubes (5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0)Uncuffed endotracheal tubes (2.5, 3.0, 3.5, 4.0, 4.5, 5.0)Laryngoscope handles (adult and pediatric)Extra laryngoscope batteries and light bulbsNasopharyngeal airways (#26, #30)Oral airways (#0, #1, #2, #3, #4)Scalpel with blade for cricothyroidotomyNeedle cricothyroidotomy kitWater-soluble lubricantNasal cannulas (adult and pediatric)Oxygen tubingPEEP valve (adjustable)

Adhesive tapeAerosol medication delivery system (nebulizer)Alcohol swabsArm boards (adult and pediatric)Arterial line tubingBone marrow needle (for pediatric infusion)Blood pressure cuffs (neonatal, infant, child, adult large and small)Butterfly needles (23-gauge, 25-gauge)Communications backup (e.g., cellular telephone)Defibrillator electrolyte pads or jellyDextrostixECG monitor/defibrillator (preferably with pressure transducer capabilities)ECG electrodes (infant, pediatric, adult)Flashlights with extra batteriesHeimlich valveInfusion pumpsIntravenous fluid administration tubing (adult and pediatric)Y-blood administration tubingExtension tubingThree-way stopcocksIntravenous catheters, sizes 14- to 24-gaugeIntravenous solutions (plastic bags)

1000 mL, 500 mL of normal saline1000 mL of Ringers lactate250 mL of 5% dextrose

Irrigating syringe (60 mL), catheter tipKelley clampHypodermic needles, assorted sizesHypodermic syringes, assorted sizesNormal saline for irrigationPressure bags for fluid administrationPulse oximeter with multiple site adhesive or reusable sensorsSalem sump nasogastric tubes, assorted sizesSoft restraints for upper and lower extremitiesStethoscopeSuction apparatusSuction catheters (#5, #8, #10, #14, tonsil)Surgical dressings (sponges, Kling, Kerlix)Tourniquets for venipuncture/IV accessTrauma scissorsThe following are considered as needed

Transcutaneous pacemakerNeonatal/pediatric isoletteSpinal immobilization deviceTransport ventilator

PEEP, positive end-expiratory pressure; ECG, electrocardiogram; IV, intravenous.


communicated verbally. It is stronglysuggested that policies be establishedwithin each institution regarding thecontent of documentation and communi-cation between personnel involved in thetransfer.

Accompanying Personnel. It is recom-mended that a minimum of two people,in addition to the vehicle operators, ac-company a critically ill patient duringinterhospital transport.* When trans-porting unstable patients, the transportteam leader should be a physician ornurse (41, 53, 54), preferably with addi-tional training in transport medicine. Forcritical but stable patients, the teamleader may be a paramedic (41). Theseindividuals provide the essential capabil-

ities of advanced airway management, in-travenous therapy, dysrhythmia interpre-tation and treatment, and basic andadvanced cardiac life support. In the ab-sence of a physician team member, therewill be a mechanism by which the trans-port team can communicate with a com-mand physician. If communication ofthis type becomes impossible, the teamwill have preauthorization by standingorders to perform acute lifesaving inter-ventions. In the absence of a readily avail-able external transport team, a transportteam and vehicle may need to be assem-bled locally. The development of policiesand procedures for such emergencies isstrongly recommended.

Minimum Equipment Required. Ta-

bles 1 and 2 provide a detailed list of theminimum recommended equipment andpharmaceuticals needed for safe interho-spital transport. Emphasis is placed onairway and oxygenation, vital signs mon-itoring, and the pharmaceutical agentsnecessary for emergency resuscitationand stabilization as well as maintenanceof vital functions. Very short or very longtransports may necessitate deviationsfrom the listed items, depending on theseverity and nature of illness or injury.Furthermore, advances in knowledgeover time will result in periodic reviewand modification of these lists. All itemsare checked regularly for expiration ofsterility and/or potency, especially whentransports are infrequent. Equipmentfunction is verified on a scheduled basis,not at the time of transport when theremay be insufficient time to find replace-ments.

Monitoring During Transport. All crit-ically ill patients undergoing interhospi-tal transport must have, at a minimum,continuous pulse oximetry, electrocar-diographic monitoring, and regular mea-surement of blood pressure and respira-tory rate.* Selected patients, based onclinical status, may benefit from themonitoring of intra-arterial blood pres-sure (55), central venous pressure, pul-monary artery pressure, intracranialpressure, and/or capnography (56). Withmechanically ventilated patients, endo-tracheal tube position is noted and se-cured before transport, and the adequacyof oxygenation and ventilation is recon-firmed.

Occasionally, patients may requirespecialized modes of ventilation not re-

A lthough both in-

tra- and interhos-

pital transport

must comply with regula-

tions, we believe patient

safety is enhanced during

transport by establishing an

organized efficient process

supported by appropriate

equipment and personnel.

Table 2. Recommended minimum transport medications

Adenosine, 6 mg/2 mLAlbuterol, 2.5 mg/2 mLAmiodarone, 150 mg/3 mLAtropine, 1 mg/10 mLCalcium chloride, 1 g/10 mLCetacaine/Hurricaine sprayDextrose 25%, 10 mLDextrose 50%, 50 mLDigoxin, 0.5 mg/2 mLDiltiazem, 25 mg/5 mLDiphenhydramine, 50 mg/1 mLDopamine, 200 mg/5 mLEpinephrine, 1 mg/10 mL (1:10,000)Epinephrine, 1 mg/1 mL (1:1000) multiple-dose vialFosphenytoin, 750 mg/10 mL (500 PE mg/10 mL)Furosemide, 100 mg/10 mLGlucagon, 1 mg vial (powder)Heparin, 1000 units/1 mLIsoproterenol, 1 mg/5 mLLabetalol, 40 mg/8 mLLidocaine, 100 mg/10 mLLidocaine, 2 g/10 mLMannitol, 50 g/50 mLMagnesium sulfate, 1 g/2 mLMethylprednisolone, 125 mg/2 mLMetoprolol, 5 mg/5 mLNaloxone, 2 mg/2 mLNitroglycerin injection, 50 mg/10 mLNitroglycerin tablets, 0.4 mg (bottle)Nitroprusside, 50 mg/2 mLNormal saline, 30 mL for injectionPhenobarbital, 65 mg/mL or 130 mg/mLPotassium chloride, 20 mEq/10 mLProcainamide, 1000 mg/10 mLSodium bicarbonate, 5 mEq/10 mLSodium bicarbonate, 50 mEq/50 mLSterile water, 30 mL for injectionTerbutaline, 1 mg/1 mLVerapamil, 5 mg/2 mL

The following specialized/controlled medications are added immediately before transport asindicated

Narcotic analgesics (e.g., morphine, fentanyl) (59)Sedatives/hypnotics (e.g., lorazepam, midazolam, propofol, etomidate, ketamine) (59)Neuromuscular blocking agents (e.g. succinylcholine, pancuronium, atracurium, rocuronium)

(60)Prostaglandin E1Pulmonary surfactant


producible in the transport setting. Un-der these circumstances, alternate modesof mechanical ventilation are evaluatedbefore transport to ensure acceptabilityand patient stability with this therapy. Ifthe patient is incapable of being main-tained safely with alternate ventilatortherapy, the risks and benefits of trans-port are cautiously reexamined.

Patient status and management dur-ing transport are recorded and filed in thepatient medical record at the referringfacility. Copies are provided to the receiv-ing institution.

Preparing a Patient for InterhospitalTransport There is no evidence to sup-port a “scoop and run” approach to theinterhospital transport of critically ill pa-tients. Therefore, referring facilities will,before transport, begin appropriate eval-uation and stabilization to the degreepossible to ensure patient safety duringtransport. Unnecessary delays may be ex-perienced if the transport team must per-form lengthy or complex procedures tostabilize the patient before the transfer(57). Nonessential testing and procedureswill delay transfer and should be avoided.Information and recommendations aboutthis aspect of patient care generally canbe requested from the accepting physi-cian at the time of initial contact with thereceiving facility.

All critically ill patients need secureintravenous access before transport. Ifperipheral venous access is unavailable,central venous access is established. Ifneeded, fluid resuscitation and inotropicsupport are initiated, with all intravenousfluids and medications maintained inplastic (not glass) containers. A patientshould not be transported before airwaystabilization if it is judged likely that air-way intervention will be needed en route(a process made more difficult in a mov-ing vehicle). The airway must be evalu-ated before transport and secured as in-dicated by endotracheal tube (ortracheostomy).* Laryngeal mask airwaysare not an acceptable method of airwaymanagement for critically ill patients un-dergoing transport. For trauma victims,spinal immobilization is maintained dur-ing transport unless the absence of sig-nificant spinal injury has been reliablyverified. A nasogastric tube is inserted inpatients with an ileus or intestinal ob-struction and in those requiring mechan-ical ventilation. A Foley catheter is in-serted in patients requiring strict fluidmanagement, for transports of extendedduration, and for patients receiving di-

uretics. If indicated, chest decompressionwith a chest tube is accomplished beforetransport. A Heimlich valve or vacuumchest drainage system is employed tomaintain decompression. Soft wristand/or leg restraints are applied whenagitation could compromise the safety ofthe patient or transport crew, especiallywith air transport. If the patient is com-bative or uncooperative, the use of seda-tive and/or neuromuscular blockingagents may be indicated. A neuromuscu-lar blocking agent should not be usedwithout sedation and analgesia.

Finally, the patient medical record andrelevant laboratory and radiographicstudies are copied for the receiving facil-ity. In the United States, a COBRA/EMTALA checklist is strongly suggestedto ensure compliance with all federal reg-ulations regarding interhospital patienttransfers. Items on this checklist will in-clude documentation of initial medicalevaluation and stabilization (to the de-gree possible), informed consent disclos-ing benefits and risks of transfer, medicalindications for the transfer, and physi-cian-to-physician communication withthe names of the accepting physician andthe receiving hospital.

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guidelines for the inter- and intrahospital transport of critically ill patients

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