Sample Pediatric Transfer Policy

I. GUIDELINES FOR INTERFACILITY CONSULTATION AND/OR TRANSFER FOR EVALUATION OF PEDIATRIC MEDICAL PATIENTS (NONTRAUMA)

A. Physiologic Criteria

1. Depressed or deteriorating neurologic status

2. Severe respiratory distress responding inadequately to treatment and accompanied by any one of the following:

a. Cyanosis

b. Retractions (moderate to severe)

c. Apnea

d. Stridor (moderate to severe)

e. Grunting or gasping respirations

f. Status asthmaticus

g. Respiratory failure

3. Children requiring endotracheal intubation and/or ventilatory support

4. Serious cardiac rhythm disturbances

5. Status post cardiopulmonary arrest

6. Heart failure

7. Shock responding inadequately to treatment

8. Children requiring any one of the following:

a. Arterial pressure monitoring

b. Central venous pressure or pulmonary artery monitoring

c. Intracranial pressure monitoring

d. Vasoactive medications

9. Severe hypothermia or hyperthermia

10. Hepatic failure

11. Renal failure, acute or chronic requiring immediate dialysis

B. Other Criteria

1. Near drowning with any history of loss of consciousness, unstable vital signs or respiratory problems

2. Status epilepticus

3. Potentially dangerous envenomation

4. Potentially life-threatening ingestion of, or exposure to, a toxic substance

5. Severe electrolyte imbalances

6. Severe metabolic disturbances

7. Severe dehydration

8. Potentially life-threatening infections, including sepsis

9. Children requiring intensive care

10. Any child who may benefit from consultation with, or transfer to, a Pediatric Critical Care Center

II. GUIDELINES FOR INTERFACILITY CONSULTATION AND/OR TRANSFER FOR EVALUATION OF PEDIATRIC TRAUMA PATIENTS

A. Physiologic Criteria

1. Depressed or deteriorating neurologic status

2. Respiratory distress or failure

3. Children requiring endotracheal intubation and/or ventilatory support

4. Shock, compensated or uncompensated

5. Injuries requiring any blood transfusion

6. Children requiring any one of the following:

a. Arterial pressure monitoring

b. Central venous pressure or pulmonary artery monitoring

c. Intracranial pressure monitoring

d. Vasoactive medications

B. Anatomic Criteria

1. Fractures and deep penetrating wounds to an extremity complicated by neurovascular or compartment injury

2. Fracture of two or more major long bones (i.e., femur, humerus)

3. Fracture of the axial skeleton

4. Spinal cord or column injuries

5. Traumatic amputation of an extremity with potential for replantation

6. Head injury when accompanied by any of the following:

a. Cerebrospinal fluid leaks

b. Open head injuries (excluding simple scalp injuries)

c. Depressed skull fractures

d. Decreased level of consciousness

7. Significant penetrating wounds to the head, neck, thorax, abdomen or pelvis

8. Major pelvic fractures

9. Significant blunt injury to the chest or abdomen

C. Other Criteria

1. Children requiring intensive care

2. Any child who may benefit from consultation with, or transfer to, a trauma center or a pediatric critical care center

D. Burn Criteria (Thermal or Chemical) — Contact should be made with a Burn Center for children who meet any one of the following criteria:

1. Second- and third-degree burns of more than 10% of the body surface area for children younger than 10 years of age

2. Second- and third-degree burns of greater than 20% of the body surface area for children over 10 years of age

3. Third-degree burns of greater than 5% of the body surface area for any age group

4. Burns involving:

a. Signs or symptoms of inhalation injury

b. Respiratory distress

c. The face

d. The ears (serious full-thickness burns or burns involving the ear canal or drums)

e. The mouth and throat

f. Deep or excessive burns of the hands, feet, genitalia, major joints or perineum

5. Electrical injury or burns (including lightning)

6. Burns associated with trauma or complicating medical conditions

Source: Illinois Emergency Medical Services for Children, Springfield.