Accessing the Regional One Number Protocol – User's Guide

ACCESSING THE REGIONAL ONE NUMBER PROTOCOL South West Local Health Integration Network

A USER’S GUIDE

CONTENTS

Introduction ...... 3

Section 1 – Overview ...... 4

Section 2 – Inclusion Criteria ...... 5

Section 3 – Transfer And Repatriation Guidelines ...... 7 A. Transfer Of Critically Ill Patients ...... 7 B. Transfer Of Emergent Patients ...... 9 C. Transfer Of Urgent Care Patients ...... 11 D. Repatriation ...... 13

INTRODUCTION

The User’s Guide has been created to assist clinicians and organizations throughout the South West Local Health Integration Network (LHIN) to understand and effectively fulfill their role in the delivery of timely care to critically ill, emergent and urgent care patients whose immediate clinical needs cannot be met by the hospital in which they are located.

This manual is made up of four (4) sections. 1. Overview 2. Inclusion Criteria 3. Transfer and Repatriation Guidelines 4. Roles and Responsibilities for Patient Transfer

This manual is intended to be a common reference document and it will be updated on an as needed basis.

SECTION 1 – OVERVIEW

Timely access to care is a fundamental objective of healthcare organizations, staff and physicians alike. Unfortunately, for a variety of reasons, this objective is challenging to realize. It may be due to lack of human resources; challenges accessing transportation including ambulance services; lack of adequate resources such as hospital beds; or other complicating factors including not having a standard system-wide approach to the referral or transfer of patients.

It is this last factor that is the focus of this initiative.

The focus of the One Number Protocol is hospital patients who are critically ill or who require emergent or urgent care and whose immediate health care cannot be addressed by the hospital at which the patient is currently located. Operationally these patients have been assessed as: . Life or Limb – requiring in less than four hours, . Emergent – requiring care in four to 24 hours, . Urgent – requiring care in 24-48 hours, and . Non-Urgent – requiring care in over 48 hours.

The reason for separating out the patients in this way is that each scenario requires the system to respond with different degrees of urgency – in some cases the speed of response can mean the difference between life and death, the difference between a full recovery and a life-long disability.

The level of care that is required but not available at the patient’s current location could include consultation services from a specialist or rapid access to and direct intervention by a specialist at a secondary or tertiary care hospital.

The scope of this initiative involves all of the acute care hospitals in the South West LHIN, as well as Bluewater Health and Chatham-Kent Health Alliance (CKHA) in the Erie St. Clair LHIN.

This initiative not only involves connecting with medical specialists at the outset but also the return or repatriation of patients back to the originating hospital or community as soon as it is medically warranted. The transfer of patients is a challenging task given the demands on the use of available beds at each hospital. Some hospitals have admitted patients waiting in the emergency department for an inpatient bed to become available. Being able to admit yet another patient in these circumstances is not a simple matter of saying yes. It can be a significant logistical and operational challenge and as such requires the active involvement of skilled and experienced staff with an understanding of the clinical needs of the patient as well as an understanding of current and pending demands for beds.

Since the One Number Protocol is a systems solution to a systems problem it requires the full involvement and commitment of everyone and every organization to be successful. The One Number Protocol does not address all of the issues associated with ensuring timely access to care but it does make a difference. Knowing that there is a system in place, knowing that the needs of the these patients will be matched with available resources as quickly as necessary means that much of the guesswork around the current patient transfer processes will be reduced, if not eliminated.

SECTION 2 – INCLUSION CRITERIA

The following inclusion criteria are to be used to assess patient eligibility:

CRITICALLY ILL – requiring transfer in less than four hours A patient with a critical medical problem1 is assessed by a physician and clinical staff as completely and thoroughly as possible and as a result of this assessment it is determined that the patient’s medical condition is such that he/she requires immediate transfer to the nearest appropriate secondary or tertiary centre for follow-up assessment, treatment and admission.

Patients who are critically ill would typically include patients with life threatening conditions such as cardiac/respiratory arrest, major trauma especially general trauma, head or neck trauma, shock states or hemodynamically compromised, unconscious patients or altered level of consciousness, severe respiratory distress, head injury, myocardial infarction, overdose and Cerebrovascular accident (CVA).

The province of Ontario has developed referral criteria to assist physicians in identifying patient as being in a Life or Limb situation requiring immediate acceptance and transfer. (Life or Limb Policy Implementation Guide)

Important Note: Cardiac patients with Percutaneous coronary intervention (PCI), stroke patients and dialysis patients in immediate need of transfer to a specialized dialysis centre have their own region- wide bi-pass protocol in which patients are transferred directly to the service they need.

EMERGENT – requiring care in greater than four and less than 24 hours A patient with a serious medical problem is assessed by a physician and clinical staff as completely and thoroughly as possible and as a result of this assessment it is determined that the patient’s medical condition is such that he/she requires transfer to the nearest appropriate secondary or tertiary care centre for follow-up assessment, treatment and admission if appropriate, in the next 4-24 hours.

URGENT CARE – between 24 and 48 hours A patient with a serious medical problem is assessed by a physician and clinical staff as completely and thoroughly as possible and as a result of this assessment it is determined that the patient’s medical condition is such that he/she requires transfer to the nearest appropriate secondary or tertiary care centre for follow-up assessment, treatment and admission if appropriate in the next 24-48 hours.

1 Children and adults with acute psychiatric problems are excluded from this protocol.

REPATRIATION There are a number of circumstances that trigger the need for a patient to be repatriated that is, returned for care at the hospital from which they were sent or return to the community in which he/she lives.

Not all patients need to be repatriated and the first option is to return the patient to his/her home with community services. If a patient does require follow-up hospital services, this could include transfer to a specialized service (for inpatient rehabilitation for example).

The focus here is on patients who need additional acute care, but not at the level that required them being transferred in the first place.

The following four repatriation scenarios have been developed as part of this project.

1. Taking patients back who have been transferred to another hospital for care

2. Taking patients back who were critically ill, emergent or required urgent care when admitted to another hospital but who did not originate from their community or home hospital (e.g. motor vehicle accident and stroke patients)

3. Taking a patient back in exchange for the other hospital accepting a patient who is critically ill, emergent or requires urgent care - happens when all beds are occupied (Swapping Scenario)

4. When a patient cannot be returned to their home community hospital due to all available beds being full and swapping not being possible, but there is capacity at a nearby hospital that might provide an opportunity to return the patient to a comparable, nearby hospital, closer to family etc. This option would only be considered when the ability to serve patients who are critically ill and who require emergent care is being compromised. (Almost Home Scenario)

SECTION 3 – TRANSFER AND REPATRIATION GUIDELINES

The transfer and repatriation guidelines are divided into five sub-sections. A. Transfer of Critically Ill Patients B. Transfer of Emergent Patients C. Transfer of Urgent Care Patients D. Repatriation of Patients E. Roles and Responsibilities for Patient Transfer

A. TRANSFER OF CRITICALLY ILL PATIENTS Patient with a critical medical problem is assessed by a physician and clinical staff as completely and thoroughly as possible and as a result of this assessment it is determined that the patient’s medical condition is such that he/she requires immediate transfer to the nearest appropriate secondary or tertiary centre for follow- up assessment, treatment and admission.

Overview of the Transfer of Critically Ill Patients Process a. Sending Hospital (Primary or Secondary) Physician and staff assess the patient’s needs and determine that patient is critically ill and needs immediate consultation with and then transfer to the nearest appropriate secondary or tertiary care centre for immediate attention.

Sending physician or delegate calls CritiCall [1-800-668-4357] and tells CritiCall that they have a patient that is critically ill and needs immediate transfer to the nearest secondary or tertiary care centre for immediate assessment and treatment for their condition.

Sending physician or delegate is as specific as possible concerning the type of specialist or service that needs to treat the patient.

b. CritiCall and Hospital One Number Based on the information received, CritiCall obtains the call-back number and then calls the designated One Number at the nearest appropriate secondary or tertiary care hospital to where the patient is located.

If the critically ill patient is identified as needing a secondary care hospital specialist, CritiCall will call the nearest secondary care hospital first.

The staff operating the One Number will quickly answer the phone and after hearing the request from CritiCall will contact the receiving physician on call for the service the patient needs. At the same time the staff will assess bed availability. If the physician on call cannot be located immediately, CritiCall will hang up and the One Number staff will call CritiCall back as soon as the receiving specialist comes on the line. Once the receiving specialist, One Number and CritiCall are connected, CritiCall will connect in the originating hospital and get the sending physician at the community hospital on the line.

Once all parties are on the line decisions will be quickly made concerning the necessary next steps to be taken. Any immediate actions recommended by the receiving specialist

will be communicated to stabilize the patient for transfer, accompaniment or medical needs on route etc.

The receiving specialist and receiving hospital will accept the patient, provided the patient is a suitable candidate for the service. If the patient is not, advice will be given and alternatives suggested. In this case, CritiCall will expedite the follow-up call. Bed availability will not be a factor in determining whether to accept a critically ill patient.

If the outcome is to have the patient seen by another service at the same hospital, the One Number staff will take the necessary steps to locate the receiving physician on call for that service as quickly as possible and connect them with both CritiCall and the sending community hospital physician.

Getting Ready to Transfer Critically Ill Patients The sending hospital staff will: . get the standardized Patient Transfer Record completed . put together any other important patient information and put it all in an envelope using the standardized Inter-Hospital Patient Transfer Envelope Cover Sheet . inform family members (if applicable) of the actions being taken . make arrangements for physician and/or nurse accompaniment as required . brief paramedics as required once they arrive at the hospital . ready the patient for transfer and continue with any necessary interventions to maintain patient stability as best as possible under the circumstances . notify the Central Ambulance Communication Centre (CACC) c. CACC and Emergency Medical Services (EMS) – Ambulance Services When the patient is ready to be transferred, and at the request of the sending hospital’s One Number or clinical staff, the CACC will dispatch the EMS service to the sending hospital. Paramedics will be quickly briefed on the situation and transfer the patient to the designated hospital and to the location as directed. A sending physician and/or nurse may accompany paramedics depending on their condition. An estimated time of arrival (ETA) will be given to the specialty hospital – i.e. to the One Number staff. d. Tertiary or Secondary Hospital Preparations will be made, as required, by the clinical staff to receive the patient. The receiving specialist physician (and team as applicable) will meet the patient and paramedics as well as the accompanying sending nurse or physician if present. Vital information will be exchanged verbally and in written form. The Inter-Hospital Patient Transfer Envelope including the Patient Transfer Record will be handed over. The patient will be taken to an appropriate location for immediate assessment and treatment.

The One Number staff at the tertiary or secondary hospital will notify the One Number at the sending community hospital that the patient has arrived and that immediate action has been taken. Other information that may be important to the sending community hospital physician, staff as well as the patient’s family is shared.

B. TRANSFER OF EMERGENT PATIENTS Patients with a critical medical problem is assessed by a physician and clinical staff as completely and thoroughly as possible and as a result of this assessment it is determined that the patient’s medical condition is such that he/she requires immediate transfer to the nearest appropriate secondary or tertiary centre for follow-up assessment, treatment and admission.

Overview of the Transfer of Emergent Patients Process a. Sending Community Hospital (Primary or Secondary) Sending Physician and staff assess the patient’s needs and determine that patient is emergent and that they need immediate consultation with and then possible transfer to the nearest appropriate secondary or tertiary care centre within the next 4-24 hours, the sooner the better.

Sending Physician or delegate calls CritiCall [1-800-668-4357] and tells CritiCall that they have a patient that is emergent and needs immediate consultation with and possible transfer to the nearest secondary or tertiary care centre within the next 4-24 hours for assessment and treatment for their condition.

Sending physician or delegate is as specific as possible concerning the type of specialist or service that needs to treat the patient.

b. CritiCall and Hospital One Number Based on the information received, CritiCall obtains the call-back number and then calls the designed One Number at the nearest appropriate secondary or tertiary care hospital to where the patient is located.

If the emergent patient is identified as needing a secondary care hospital specialist, CritiCall will call the nearest secondary care hospital first.

The staff operating the One Number will quickly answer the phone and after hearing the request from CritiCall will contact the physician on call for the service the patient needs. At the same time the staff will assess bed availability. If the receiving physician on call cannot be located immediately, CritiCall will hang up and the One Number staff will call CritiCall back as soon as the receiving specialist comes on the line. Once the receiving specialist, One Number and CritiCall are connected, CritiCall will connect in the sending hospital and get the sending physician at the community hospital on the line.

Once all parties are on the line decisions will be quickly made concerning the necessary next steps to be taken. Any immediate actions recommended by the receiving specialist will be communicated to stabilize the patient for transfer, accompaniment or medical needs on route etc.

The receiving specialist and hospital will accept the patient, provided the patient is a suitable candidate for the service and an appropriate bed is available. If the patient is not suitable, advice will be given and alternatives suggested. In this case, CritiCall will expedite the follow-up call. Bed availability may be a factor in determining whether to accept an emergent patient.

The patient’s condition will be closely monitored by clinical staff and any changes (i.e. deterioration) will be reported to the receiving hospital’s One Number staff. If the patient becomes critically ill their transfer to the accepting hospital will be expedited, regardless of bed availability.

Getting Ready to Transfer Emergent Patients The sending hospital will: . get the standardized Patient Transfer Record completed . put together any other important patient information and put it all in an envelope using the standardized Inter-Hospital Patient Transfer Envelope Cover Sheet . inform family members (if applicable) of the actions being taken . make arrangements for physician and/or nurse accompaniment as required . brief paramedics as required once they arrive at the hospital . ready the patient for transfer and continue with any necessary interventions to maintain patient stability as best as possible under the circumstances . notify the Central Ambulance Communication Centre (CACC) c. One Number and EMS - Ambulance Services As soon as the patient is ready to be transferred, and at the request of the sending hospital’s One Number or clinical staff, the CACC will dispatch the EMS service to the sending hospital. Paramedics will be quickly briefed on the situation and transfer the patient to the designated hospital and to the location as directed. A sending physician and/or nurse may accompany paramedics depending on their condition. An ETA will be given to the specialty hospital – i.e. to the One Number staff. d. Tertiary or Secondary Hospital Preparations will be made, as required, by the clinical staff to receive the patient. The receiving specialist physician (and team as applicable) will meet the patient and paramedics as well as the accompanying nurse or physician if present. Vital information will be exchanged verbally and in written form. The Inter-Hospital Patient Transfer Envelope including the Patient Transfer Record will be handed over. The patient will be taken to an appropriate location for immediate assessment and treatment.

C. TRANSFER OF URGENT CARE PATIENTS Adult patient with a serious medical problem is assessed by a physician and clinical staff as completely and thoroughly as possible and as a result of this assessment it is determined that the patient’s medical condition is such that he/she requires transfer to the nearest appropriate secondary or tertiary care centre for follow-up assessment, treatment and admission if appropriate, in the next 24-48 hours.

Overview of the Process Transfer of Urgent Care Patients Process a. Sending Community Hospital (Primary Or Secondary) Sending physician and staff assess the patient’s needs and determine that requires urgent care and needs to be assessed and possibly transferred to secondary or tertiary care centre for assessment and treatment within 24-48 hours.

Sending physician or delegate calls One Number at the closest appropriate hospital and tells the One Number staff person that they have a patient that is stable and in need of urgent care and they need a consult with a specialist and possible transfer to their hospital for assessment and treatment for their condition within the next 24-48 hours – the sooner the better.

Sending physician or delegate is as specific as possible concerning the type of specialist or service that needs to assess and treat the patient.

b. One Number The staff operating the One Number at the hospital that is called will quickly connect with the receiving specialist on call for the service that is identified as being needed and at the same time assesses bed availability. Once the receiving specialist and One Number are connected, One Number will connect in the sending hospital and get the sending physician at the community hospital on the line.

Once all parties are on the line decisions will be quickly made concerning the necessary next steps to be taken. Any immediate actions recommended by the specialist will be communicated to treat the patient until they are transferred, assuming that is the recommended course of action.

It is expected that the receiving specialist and hospital will accept the patient, provided the patient is a suitable candidate for the service and an appropriate bed is available. If the patient is not suitable for the service, advice will be given and alternatives suggested. If the outcome is to have the patient seen by another service at the same hospital, the One Number staff will take the necessary steps to locate the physician on call for that service as quickly as possible.

If a bed is not immediately available, the One Number staff will take action to determine if the patient requiring their service can be admitted within 24-48 hours. If this is confirmed, the sending community hospital will alert the One Number if there is any change in the patients’ condition, especially any change that would make them critically ill and therefore suitable for immediate transfer.

If the condition of the patient does deteriorate and they need immediate transfer, the community hospital will notify One Number immediately of the change in the patient’s condition and the patient’s status. At this time every effort will be taken to accept the

patient. If this is not possible CritiCall will be notified and asked to find another specialist and hospital to take the patient.

Getting Ready to Transfer Urgent Care Patients The sending hospital will: . notify the transportation service to be used (EMS or private transfer service) . get the standardized Patient Transfer Record completed . put together any other important patient information and put it all in an envelope using the standardized Inter-Hospital Patient Transfer Envelope Cover Sheet . inform family members (if applicable) of the actions being taken . make arrangements for physician and/or nurse accompaniment as required . brief paramedics or patient transfer staff as required once they arrive at the hospital . Ready the patient for transfer and continue with any necessary interventions to maintain patient stability as best as possible under the circumstances. c. One Number and EMS - Ambulance Services For urgent care patients an ambulance or private patient transfer service may be used.

When the patient is ready to be transferred, and at the request of the sending hospital’s One Number or clinical staff, the CACC will dispatch the EMS service to the sending hospital. Paramedics will be quickly briefed on the situation and transfer the patient to the designated hospital and to the location as directed. An ETA will be given to the specialty hospital – i.e. to the One Number staff.

If a Patient Transfer Service is used, One Number and EMS services will not be contacted. The hospital will contact the Patient Transfer Service and make arrangements for transfer directly. d. Tertiary or Secondary Hospital Preparations are made, as required, to receive the patient by both the One Number and clinical staff. The receiving specialist physician or team as applicable will meet the patient and paramedics. Vital information is exchanged verbally and in written form. The Inter-Hospital Patient Transfer Envelope including the Patient Transfer Record will be handed over. The patient is then taken to an appropriate location for immediate assessment and treatment.

The One Number staff at the tertiary or secondary hospital notifies the One Number at the sending community hospital that the patient has arrived and that immediate actions have been taken. Other information that may be important to the sending community hospital physician, staff as well as the patient’s family is shared.

D. REPATRIATION2 There are a number of circumstances that trigger the need for a patient to be repatriated that is, returned for care at the hospital from which they were sent or return to the community in which they live.

Not all patients need to be repatriated and the first option is to return the patient to their home with community services. If a patient does require follow-up hospital services, this could include transfer to a specialized service (for inpatient rehabilitation for example).

The focus here is on patients who need additional acute care, but not at the level that required them being transferred in the first place.

The following four ‘repatriation’ scenarios have been developed as part of this project although there are essentially two main categories of repatriation; the return of a patient to the originating hospital and the transfer of a patient to a hospital other than the one they came from. In the first case, the same patient is the common reference point. In the second it is a different patient.

1. Taking patients back who have been transferred to another hospital for care

3. Taking a patient back in exchange for the other hospital accepting a patient who is critically ill, emergent or requires urgent care – happens when all beds are occupied and the patient is being transferred to the same bed type as the patient is currently occupying (Swapping Scenario)

4. When a patient cannot be returned to their home community hospital due to all available beds being full and swapping is not possible, but there is capacity at a nearby hospital that might provide an opportunity to return the patient to a comparable, nearby hospital, closer to family etc. This option would only be considered when the ability to serve patients who are critically ill and who require emergent care is being compromised. (Almost Home Scenario)

Overview of the Repatriation Process a. Secondary or Tertiary Care Clinical Team Physician and staff assess the patient’s condition and decide that the patient no longer needs the specialized services of the hospital and that:

Patient can be discharged home with/without in-home services . Patient needs to be transferred to another acute care facility that offers the level of care the patient needs – preferably the hospital from which the patient was transferred or the hospital closest to where the patient lives . Patient needs to be transferred to another acute care facility – but if the patient is in a tertiary care facility and needs secondary level care, then

2 If a patient is transferred to the US through CritiCall, CritiCall will manage the repatriation process of the patient.

steps could be taken to transfer the patient to a secondary level facility, as close to where they live as possible. . Patient needs to be transferred to another type of health care facility – Long Term Care (LTC) home, inpatient Rehabilitation, Complex Continuing Care etc.

Clinical Staff determines the best course of action and depending on the outcome contact: . Family to take the person home . CACC for LTC home placement or in-home services – this should be done as soon as possible since return home with support is the preferred option to having a patient continue to be in hospital, if that is not necessary . One Number at their own hospital to make contact with the One Number staff at the originating hospital to assess ability of the originating hospital to repatriate the patient within 48 hours. . If the patient cannot be returned to the originating hospital within 48 hours, One Number will work with the community hospital’s One Number staff to identify an alternate hospital with the necessary services to which the patient could be transferred b. One Number One Number staff makes the initial contact with the hospital to which the patient might be transferred to assess their ability and capacity to repatriate the patient as per scenarios outlined above. The Patient Repatriation Transfer Request Form is used to guide this conversation. After this initial call, the sending hospital will fax the completed Patient Repatriation Transfer Request Form to the potential accepting hospital. Approximately 30-60 minutes later the sending hospital will follow up with a phone call to ensure the fax was received and to discuss any other relevant details. On this basis the hospital contacted decides whether or not they will be able to manage the patient from a service perspective.

Assuming the hospital is prepared to accept the patient, the One Number staff at the community hospital will then find an accepting physician. If the physician needs more information than provided by the staff before accepting the patient, the physician or One Number staff will link with the sending hospital’s physician to get more information. On this basis a clinical decision will be made. The physicians will not be contacted until after this preparation work has been done and the patient is ready to be transferred. This way the physicians talk on the day the patient will arrive at the receiving hospital. If the answer is yes, the two One Number staff at the sending hospital will take the necessary steps to facilitate the patient’s repatriation. This will include: . Notifying the One Number or patient transfer service as applicable . Faxing the Patient Repatriation Transfer Request Form to the community hospital . Ensuring inpatient staff complete the Patient Transfer Record . Putting together any other important patient information and include it in the Inter-Hospital Patient Transfer Envelope . Informing family members (if applicable) of the actions being taken . Making arrangements for any accompaniment if required . Briefing paramedics or patient transfer staff as required once they arrive at the secondary/tertiary hospital.

Meanwhile the secondary or tertiary care hospital physician and clinical staff will ready the patient for transfer and continue with any necessary interventions.

In most cases, patients who need to be repatriated to another hospital will be transferred by a private patient transfer service rather than by an EMS service.

The secondary or tertiary hospital One Number staff will contact the Patient Transfer Service and they will then be dispatched to the secondary or tertiary hospital. Patient Transfer Service staff are briefed on the situation and transfer the patient to the designated hospital and to the location as directed. A nurse may accompany these staff depending on their condition. An ETA is given to the receiving community hospital – i.e. to the One Number staff. c. Community Hospital Preparations are made, as required, to receive the patient by both the One Number and clinical staff. The most responsible physician (and team as applicable) meets the patient and patient transfer service staff. Vital information is exchanged verbally and the Inter-Hospital Patient Transfer Envelope is handed over. The patient is then taken to an appropriate location for immediate assessment and treatment.

The One Number staff at the community hospital notifies the One Number at the secondary or tertiary hospital that the patient has arrived and the immediate actions that have been taken. Other information that may be important to the secondary or tertiary hospital is shared.

SECTION 4 – ROLES AND RESPONSIBILITIES FOR PATIENT TRANSFER

Physician – Sending Hospital Referring or sending Community Hospital Physician will: . Triage the patient and assess their needs as thoroughly and quickly as possible . Identify the level of care required by the patient – secondary or tertiary . Identify the urgency with which they need to speak with a consulting physician or have the patient transferred . May call or ask another staff member to call either CritiCall or the One Number at another hospital – to initiate contact and communicate key information . If the patient is Critically ill (life or limb) and needs to get to another hospital within four hours call CritiCall and communicate key information . If the patient is emergent – seriously ill and needs to get to another hospital between 4 and 24 hours call CritiCall and communicate key information . If the patient is urgent (need to be transferred between 24-48 hours, call the One Number at the nearest, most appropriate hospital and communicate key information

Once linkage with consulting physician has been established through CritiCall or One Number . Talk with the consulting physician and together with CritiCall and/or One Number staff; determine the most appropriate course of action to take. . Provide medical care to the patient as recommended by the consultant (if applicable) . Provide medical care to the patient until EMS arrives  If physician is to accompany the patient – have staff call in another physician to cover  If nurse is to accompany the patient – brief nurse on actions to take en route  If patient is to be transferred with EMS staff, brief EMS staff on actions to take en route . Be available to accept follow-up call from consulting physician after the patient arrives at the secondary or tertiary care hospital to:  Provide additional information if required  Accept patient back if they have been assessed as not needing the services of the secondary/tertiary hospital and are stable enough to return  Receive follow-up information re the patients’ status . If accompanying patient → Provide medical care en route → Brief the hospital staff upon arrival and share vital information while staff and physician assess the patient → Return to home hospital at the first available opportunity. . If not done by nurse, inform the family of the actions being taken and why and where the patient is being sent and the unit or service they are going to.

Nurse – Sending Hospital Referring or sending Community Hospital Nurse will . Participate in the patient triage and assessment process . Participate in Identifying the level of care required by the patient – secondary or tertiary . Participate in Identifying the urgency with which the patient needs to speak with a consulting physician or be transferred . May call or ask another staff member to call either CritiCall or the One Number at another hospital – to initiate contact and communicate key information

. While the physician is on the phone, continue to provide nursing care to the patient . Provide nursing care to the patient as directed by the physician and consultant (if applicable) . Provide nursing care to the patient until EMS arrives → If nurse is to accompany the patient – get briefing on actions to take en route – and make arrangements for another nurse to be called in (if applicable) . Complete the Patient Transfer Record and fax it to the receiving hospital using the designated fax number. Include contact phone number. . Be available to provide follow-up information to the receiving hospital staff based on the information sent on the Patient Transfer Record and in the Inter-Hospital Patient Transfer Envelope (if not accompanying patient) . If accompanying patient → Provide nursing care en-route → Brief the hospital staff upon arrival and share vital information while staff and physician assess the patient → Hand over and review the information in the Inter-Hospital Patient Transfer Envelope → Return to home hospital at the first available opportunity. → If not done by physician, inform the family of the actions being taken and why and where the patient is being sent and the unit or service they are going to.

One Number Staff – Referring or Sending Hospital One Number staff at the referring or sending hospital will . Connect with CritiCall or One Number as directed . Complete or assist with the completion of the Patient Transfer Record and send it to the receiving hospital . Call One Number and arrange for EMS transportation . Collect any important information about the patient that needs to accompany the patient en route . Fax any information that is needed by the receiving hospital before the patient arrives . If not done by physician or nurse, inform the family of the actions being taken and where the patient is going (location and unit or service)

CritiCall Ontario CritiCall will . Receive the call from the sending physician or delegate. . Talk to the physician and get key information to assist with their decision-making regarding the nature of the service needed . Connect with the One Number staff person at the nearest, most appropriate hospital . Convey nature of the request and service needed . Stay on the line if the consulting physician is immediately available but if not will hang up and wait for a call back from the One Number staff, who will have the consulting physician on the line . CritiCall will put the One Number staff and consultant on hold while they call the original physician back . CritiCall will stay on the line while the physicians and One Number staff decide on the best course of action to take. Once this has been determined the call will end and CritiCall will close the call.

One Number Staff – Receiving Hospital One Number staff at the secondary or tertiary hospital will . Receive the call from CritiCall or One Number at the sending hospital . Use the information provided to identify and connect with the most appropriate service or physician on call . Contact the service and physician on call . Once the physician is on the line connect back with CritiCall and/or the sending hospitals One Number (CritiCall will connect the sending physician on the line) . Note any information that may be important to the decision-making process such as bed and resource availability and bring this information forward . Suggest options if a transfer to another hospital is needed

Central Ambulance Communications Centre Central Ambulance Communications Centre will . The One Number will process the request for ambulance services using their standardized protocol.

Emergency Medical Services Emergency Medical Services (EMS) will . The EMS services will respond to the request for service as directed by CACC . Talk to the sending hospital staff and receive the Inter-Hospital Patient Transfer Envelope if the patient is not accompanied by a nurse and/or physician . Transport the patient to another hospital as directed . Provide paramedic services to the patient on route as needed . Upon arrival at the designated location, talk to the receiving staff and communicate patients current condition and hand over the Inter-Hospital Patient Transfer Envelope . Document the transfer using their standardized call report . Return to service

Physician – Receiving Hospital Receiving Secondary or Tertiary Hospital Physician will . Take call from One Number and together with CritiCall and/or One Number staff, connect with community hospital physician who is needing consult and/or patient transfer . Exchange information with the community physician and together determine the most appropriate course of action – could be consultation only, consultation and follow-up contact if condition does not change or gets worse, or immediate transfer or direction to send to another hospital . If patient is to be transferred, give direction to staff re: steps to be taken to prepare for patient’s arrival . Review information made available through PACS and EPR information if available and applicable. . Meet the patient at the location designated . Assess the patient . Review information that comes with the patient in the Inter-Hospital Patient Transfer Envelope and exchange information with paramedic, nurse or physician, depending on who has come with the patient . Determine the next steps to be taken and both direct and act accordingly

. At a suitable time, inform the referring physician or direct that the referring physician be informed of the actions taken . If the patient is assessed and it is determined that the patient can return to the sending hospital, physician will ask that sending physician be contacted. (One Number will contact the sending hospital and through the One Number at the sending hospital, connect with the sending physician.) . Once the sending physician is on the line, they will share information and sending physician will accept the patient back at the first opportunity. Follow-up medical advice will likely be given to the community physician at this time. One Number staff at both hospitals will be on the line during this time so that can follow-up on the decisions made (for example, calling ambulance or patient transfer service)

Nurse – Receiving Hospital Receiving Secondary or Tertiary Hospital Nurse will . Locate the physician on-call as quickly as possible if they get the call from One Number . Review any information that is available while the patient is en route . Meet the patient along with the consulting physician and other staff as applicable . Participate in the patient assessment process and exchange of information with paramedics, nurse or physician – depending on who accompanied the patient. . Review information provided in the Inter-Hospital Patient Transfer Envelope . Provide nursing care as required . If the patient is to be return to the sending hospital following assessment, contact One Number and initiate steps to have the patient transferred back. . If applicable, complete the Patient Transfer Record to ensure key information is transferred to the community hospital . Fax the Patient Transfer Record to the designated fax number at the sending hospital. . Once the transfer back is underway, contact the nurse at the original sending hospital and transfer any important information that is not on the transfer form that may assist with follow-up nursing care.