INTRA and INTERhospital Transfers

Admitting a Patient from Clinic or the Emergency Department to Inpatient

The inpatient unit at YKHC in Bethel is referred to as “North Wing (NW).” If you are seeing an adult or uncomplicated non-CPP patient you feel needs to be admitted, Tiger Connect the North Wing ward doctor for that village. The clinic, ER, or inpatient (x6330) clerk can help you determine which provider you should page.

Chronic Pediatric Patients (designated with CPP in the alert section) and complicated non-chronic pediatric patients are admitted to the pediatric service. If you are admitting to Pediatric Service contact the pediatric provider on call and follow the same flow as below. You can call the Pediatric Hospitalist if you have a question about whether you should admit the patient or not or if the patient is appropriate for the family medicine or pediatric inpatient service. Once the decision has been made for admission, the inpatient pediatric provider assumes the responsibility of disposition; if they feel on reviewing the case that the patient is not ill enough to warrant admission they are responsible for discharging the patient from the emergency room.

The ward doctor will need to write the admitting orders once your Clerk has called registration and gotten an admission FIN (account number). There are different FINs for each encounter, so the Admission encounter FIN will be different from the ED or Ambulatory encounter FIN. The admitting provider may come to clinic or ED immediately to see the patient, but more likely they will ask you about the patient and then the doctor will see the patient on the floor.

If not already started or given, consult with the ward doctor about which antibiotics to start, fluids etc., so those can be started in the outpatient side and get the admission process initiated more quickly. Our hospital admissions are mainly large abscesses and/or cellulitises that have failed outpatient treatment, large lower extremity cellulitis/abscesses that have not yet had outpatient treatment, pneumonia, bronchiolitis, suicidal ideation, COPD exacerbation, fever in a neonate, and labor.

Patient Admission Flow from Clinic or Emergency Department:

• Outpatient/ED Provider to contact Northwing provider for admission. Providers are divided into 2 sections: Yukon and Kusko depending on which village the patient is from will determine which provider you page or Chronic Peds. The clinic clerk can help assist you. Bethel admissions will go to the least busy family physician, so you can contact either one and might be bounced to the other physician.
• Determine if admitting provider will be seeing the patient in clinic/ED or if patient may be transferred to inpatient unit.
• Alert the office assistant and Charge nurse of your plan for admission so they can obtain a preadmission FIN # (outpatient nurse to call ER registration x6905, usually 3-5 minutes for them to call back)
• Outpatient/ED nurse or office assistant to Tiger text the admitting provider with FIN # so orders can be written.
• Clinic/ED charge nurse will contact charge nurse on NW for a “heads up”
• Complete your clinic documentation and interventions as needed. Please keep patient and family updates on status of transfer.
• Once bed has been assigned, provider on NW completes admission orders; clinic/ED nurse will provide sign out to admitting nurse on Northwing (include recent vitals, Hx, diagnosis, etc).
• Patient transferred to assigned room on inpatient unit after report given.

Transferring a patient from Clinic to Emergency Dept

1. Activate Rapid Response or Code Blue if necessary
2. Outpatient Provider must call ED physician to obtain an accepting physician. Inform clinic charge nurse and ED charge nurse of transfer to ER.
3. Complete clinic documentation with important transfer information.
4. Clinic Nurse will give report to ER nurse and transfer patient to ER when room available.
5. Always keep parent/patient informed of status of situation
6. IF you have an emergent patient, call a Rapid Response
7. IF you have an unstable, unresponsive patient in clinic have the clerk call a code blue.

Critical Care Transfers between the Inpatient Ward and the ED

• This occurs on a case-by-case basis and must be discussed with the ward provider, ED provider, ward charge nurse, and ED charge nurse.

1. Anticipate 5-6 minute transport time IF everything goes smoothly. Appreciate risk of unanticipated obstacles/obstructions (such as long elevator wait, maintenance working in the hall, etc).
2. Secure ET tube with a tube holder. If reasonable, place OG tube prior to the tube holder.
3. Establish two working IV's.
4. Either sedate with long acting meds (versed, fentanyl, etc) or use an infusion pump for propofol. Bolusing propofol in route is discouraged.
5. Transfer on a gurney rather than a hospital bed (the large size of a hospital bed is problematic in the elevator and more difficult to navigate past equipment in the hallway).
6. Place ventilator, O2 tank, monitor, etc. ON THE GURNEY (at the foot). Minimize the amount of equipment pushed alongside the gurney.
7. Secure the patients' wrists (to prevent them pulling out the ET tube in route).
8. Transport with an AMBU bag, mask, and oral airway even if the patient is inbutated and on a ventilator. Be prepared to ventilate the patient in the case of ventilator failure and/or unintended extubation in route.

Transferring a Patient from clinic/inpatient/Emergency Department to Anchorage via Commercial Flight or Medevac

1. Contact accepting facility. ANMC/Providence contact appropriate on call service. (e.g.: the surgeons take all trauma patients, the intensivists take all intubated patients, etc.) Once you have obtained an accepting physician initiate transport. Remember if you are transferring a native patient to a non-native facility you will need to obtain approval from contract health at ANMC.
2. All patients who require medevac to ANMC go by LifeMed, the air ambulance service that is 50% owned by YKHC and 50% by Providence Hospital in Anchorage. You have to activate this service as soon as you have an accepting doc at ANMC. ANMC uses Guardian for their air ambulance service, but you must use LifeMed, unless the LifeMed service is busy and you believe that delaying the transport until a LifeMed flight is available would be unsafe for the patient.
3. If patient is stable, contact our travel office and complete a patient transport order form. Have parent sign a consent to transfer patient and discuss risk/benefit. If commercial flights are full and no charter available for a few days, the decision might be made to transfer by Medevac.
4. If patient is unstable, activate Rapid Response or Code Blue as appropriate and initiate transfer via Medevac. Patient will need to be transferred to ER until transport arrives. See transfer to ER section.
5. Complete Raven note / transfer summary with pertinent details.
6. Obtain all radiological images on disk from radiology department.
7. Complete Patient Transfer form (PTOS) with all appropriate signatures.
8. Complete a paper consent for transfer if sending by medevac, signed by you and the patient.
9. Remind clerk to print out all Raven documents and labs and place in transfer packet.
10. If the patient’s condition changes, call and update the accepting doc (for example if you have to intubate the patient, let them know because this affects where the patient can go.)
11. For patients who are traveling via commercial flight to Anchorage, the provider can authorize this travel if the patient does not have Medicaid or a means to pay for travel. See Preauthorized Travel
12. Always keep patient/caregiver informed of status of situation.

Category:Outpatient
Category:Pediatrics
Emergency Department