Protected patient transfer and clinical escalation protocol

Prevention & Management of Complications

KEIT DAY HOSPITAL

Protected patient transfer and clinical escalation protocol

Official Manual of Clinical, Care and Organizational Protocols

1. Document Control Information

2. Scope of Application

Applicable to patients requiring diagnostic or therapeutic escalation that cannot be fully managed within the facility.

3. Responsibilities

• Responsible physician: decision to transfer, patient stabilization and clinical communication.
• Nurse: preparation of documentation, medications and materials required for transport.
• Coordination Team: activation of logistical arrangements and communication with the receiving facility.

4. Operating Procedure

• Stabilize the patient as far as reasonably possible before transfer.
• Identify the appropriate receiving facility and provide advance notification with a concise clinical summary.
• Prepare complete documentation, including the medical record, reports, current treatment, recent clinical events and the reason for transfer.
• Ensure that transport is provided with a level of clinical support appropriate to the patient’s condition.
• Conduct a structured clinical handoff to the receiving facility and record the times and names of all personnel involved.
• Review every urgent transfer through an internal audit.

5. KEIT Operational Standards

• Clinical escalation is considered a patient safety measure rather than a failure; protection of the patient is the primary priority.
• Communication with the receiving facility must be clear, complete and documented.

6. Records and Documentation

• Transfer form.
• Clinical documentation transmitted to the receiving facility.
• Handoff record.

7. Review and Updates

Review after every urgent transfer and regular updating of referral network contact details.

8. Related Attachments and Forms

• Operational checklists, recording forms, audit sheets and maintenance registers applicable to this protocol.
• Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.

9. Final Approval