Compliance with the law and appropriate medical standards during interhospital transfers

Interhospital transfer patients constitute a significant proportion of medical center emergency department (ED) patients in Taiwan. Many such transfers are poorly planned and put the patient at risk. We wished to evaluate the safety and compliance with the Taiwan Medical Law among patients transferred to the Linkou Chang Gung Memorial Hospital ED from other health care centers. We performed a prospective, cross-sectional, observational study on 1,056 patients transferred from August 15 to September 30, 1997. Of these patients, 357 were critically ill or injured and only 160 received adequate pretransfer stabilization. The major omissions included: 1) failure to intubate in 121 (55%) of the 220 patients in severe respiratory distress or unprotected patent airways; 2) no intravenous line in 74 (20.7%) of the 357; and 3) inadequate IV lines in 36 (63.2%) of the 57 severely hypotensive patients. Overall, 894 patients were sent with transfer notes, but few indicated whether the referral was to the ED or outpatient department. This added an unnecessary burden for patients with stable longstanding problems who claimed they had been referred to the ED. While the majority of patients (49.4%) were transferred at the request of physicians for further treatment, 28% of the critically ill patients were transferred because of family requests. Physicians accompanied these patients only on seven occasions and nurses on 84 occasions. Despite the 1993 Department of Health policy of pretransfer phone contact with the receiving hospital for critically ill patients, such contact occurred only 10.6% of the time. While the Taiwan emergency medical system, Emergency Medicine, and Critical Care Medicine are all in their developmental stages, a medical and legal noncompliance rate of above 55% for critically ill transfer patients is unacceptably high. The appropriate medical societies and the Department of Health should work in concert to upgrade existing transfer practices.