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Inter-hospital Transfer/Direct Admissions to UW Health (2.1.10)

Inter-hospital Transfer/Direct Admissions to UW Health (2.1.10) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.10


UW HEALTH CLINICAL POLICY 1
Policy Title: Inter-hospital Transfer/Direct Admissions to UW Health
Policy Number: 2.1.10
Category: UW Health
Type: Inpatient
Effective Date: December 28, 2017

I. PURPOSE

To facilitate safe and expedited admission to UW Health in compliance with state and federal law, including
the Emergency Medical Treatment and Labor Act (“EMTALA”), and assure appropriate communication
between referring physicians and accepting physicians. Our emphasis should always be patient-centered.

II. POLICY ELEMENTS

All calls for inter-hospital transfers are coordinated through the Access Center. Accepting physicians are
responsible for obtaining a thorough assessment from the referring physician in order to determine medical
necessity and appropriateness of transfer, and the patient's clinical needs upon arrival.

As outlined in this Policy, UW Health will not refuse to accept an appropriate transfer from another hospital
of an individual with an unstabilized emergency medical condition who is protected under EMTALA and
requires specialized capabilities or facilities available at UW Health if UW Health has capacity to treat the
individual.

III. PROCEDURE

A. Initiation of Inter-hospital Transfer Request.
i. All calls for inter-hospital transfer begin and end with the Access Center. All transfer requests to
UW Health should be forwarded to the Access Center.
ii. Access Center staff obtains demographic and clinical information, determines the nature of the
referring physician's request (consult or transfer); and determines patient's current location and
status (ED, ICU or general care).
iii. Access center staff determines the most appropriate service to triage the call, and connects the
referring physician to the appropriate UW Health physician. When the appropriate UW Health
service to accept the call is not clear, the Hospitalist service will be available to triage cases as
needed.
iv. The UW Health physician accepting the call should obtain a complete assessment of the patient
from the referring physician to determine whether patient transfer is appropriate. That assessment
should include, but is not limited to, the following:
a. Clinical information, especially an assessment of patient’s acuity and stability (e.g., vital
signs, level of consciousness, potential for deterioration during transfer, appropriateness
for general service or intensive care unit).
b. Indication for University Hospital/AFCH transfer, including which services (procedures,
consultations) will need to be coordinated and the level of care needed for patient
placement.
c. Relevant patient care plans (e.g., code status, end-of-life expectations if relevant).
B. Decision to Accept or Decline Transfer.
i. For patients in emergency departments, observation status, and urgent care centers:
a. The UW Health physician must accept a requested transfer if:
1. The referring physician has determined that (i) the patient has an emergency
medical condition, (ii) the emergency medical condition is not resolved or
stabilized, and (iii) the patient requires specialized capabilities of UW Health, and
2. UW Health has capacity to provide the specialized services required.
b. The Nursing Coordinator determines whether UW Health has capacity to accept the
transfer.
c. See UWHCA Access Center Standards of Practice titled “Handling Transfer Requests by
Outside Hospitals for Patients in Emergency Departments, Observation Status, and
Urgent Care Centers.”
ii. For patients in inpatient units, outpatient departments, and non-hospital settings, and patients who
do not meet the parameters outlined in Section III.B.i.:
a. The UW Health physician may accept or decline the transfer as appropriate based upon



UW HEALTH CLINICAL POLICY 2
Policy Title: Inter-hospital Transfer/Direct Admissions to UW Health
Policy Number: 2.1.10

medical necessity and appropriateness of transfer, UW Health capacity/bed availability,
and administrative approval.
b. The Nursing Coordinator determines whether UW Health has capacity to accept the
transfer.
c. See UWHCA Access Center Standards of Practice titled “Handling Transfer Requests by
Outside Hospitals for Patients Admitted As Inpatients.”
iii. It is ultimately the responsibility of the accepting physician to determine patient's clinical needs
upon arrival at the University Hospital/AFCH. Where diagnostic or acuity uncertainty exists, patients
will be accepted through the Emergency Department as outlined in Section D.
iv. Once the patient has been accepted, the accepting service becomes the service of record.
v. The Access Center informs the referring facility of the patient’s bed assignment. Referring hospital
is instructed by the Access Center to inform transport team of inpatient unit/bed number with
directions to take patient to the assigned unit. Staff should encourage medical transport teams to
divert to the closest ED when there is a change in patient condition mandating more emergent
evaluation.
vi. The patient will be placed electronically in a bed to facilitate the accepting physician's ability to write
admission orders (based upon clinical assessment and discussion with referring physician) prior to
the patient's arrival.
vii. The Inpatient Unit staff will notify the accepting physician or designee of patient's arrival.
C. Role of Hospitalists. Hospitalists will assess and triage patients for the Department of Medicine. Additionally,
they will be involved in the initial triage process when the admitting service is not clearly identified.
D. Role of Accepting Physician. If after thorough screening by an accepting physician, s/he feels there is
diagnostic or acuity uncertainty that affects patient care, the accepting physician should contact the
Emergency Department Administrative physician (or Pediatric Emergency Physician as appropriate) through
the Access Center to explain the need for transfer of the patient to the ED. No transferred patient is to be
sent to the ED for evaluation without a direct conversation taking place between an accepting physician and
Emergency Physician. If patient is sent to the ED, s/he will receive a full evaluation by Emergency care
team, similar to that for any other ED patient. If needed, the patient will be admitted to the service of the
accepting physician unless an alternate service is deemed more appropriate by the Emergency Physician.
With only rare exceptions should inpatients at other facilities be transferred for evaluation in the ED.
E. Role of Emergency Physicians. The ED Administrative Physician will make electronic notes in patient's
record regarding clinical background and need for ED evaluation. The ED Administrative Physician may or
may not be the Emergency Physician to see the patient upon his/her arrival to the ED. The Emergency
Physician who does evaluate the patient will initiate appropriate ED diagnostics and interventions. Specialty
services will be consulted as deemed appropriate and necessary. Level of care assignment (floor, IMC, ICU)
will be determined by the attending Emergency Physician. When there is disagreement as to service
assignment, the admitting service defaults to the accepting service. When there is disagreement as to level
of care assignment, the team that is first contacted will be responsible for evaluating the patient in the ED in
a timely manner and arranging for admission to alternate team.

IV. COORDINATION

Author(s): Manager, Access Center; Director, Access Services
Senior Management Sponsor: SVP, Medical Affairs
Reviewers: Director, ED Quality; Director, Quality and Patient Safety
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: July 20, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer



UW HEALTH CLINICAL POLICY 3
Policy Title: Inter-hospital Transfer/Direct Admissions to UW Health
Policy Number: 2.1.10


J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

UWHCA Access Center Standards of Practice: Handling Transfer Requests by Outside Hospitals for
Patients in Emergency Departments, Observation Status, and Urgent Care Centers
UWHCA Access Center Standards of Practice: Handling Transfer Requests by Outside Hospitals for
Patients Admitted As Inpatients

VII. REVIEW DETAILS

Version: Revision
Last Full Review: December 2017
Next Revision Due: December 2020
Formerly Known as: Hospital Administrative Policy #7.04, Inter-hospital Transfer/Direct Admissions Policy