Department of Health- RO VI

Violence and injury Prevention Alliance

(VIPA)

Violence and injury Prevention Program (VIPP)

  Administrative Order 2014-0007
NATIONAL POLICY ON THE ESTABLISHMENT OF PREHOSPITAL EMERGENCY
MEDICAL SERVICES 

Inter-facility Referral
and Transport
GENERAL OBJECTIVE:

Institutionalize a comprehensive, accessible and integrated system of emergency medical

services from a health care facility to another health care facility or between a health care facility
to a specialty hospital.

SPECIFIC OBJECTIVES:

 Establish a guide for interfacility transfer useful to promote consistent high quality patient
care.
 Determine the level of the patient acuity in order to provide safe and effective care.
 Identify facilities that are capable of care management for patients in need of:
o Emergent Care
o Continuity of Care
o Tertiary Care
 Train and equip personnel with knowledge, skills and abilities required during interfacility
transfer to match patient needs.
 Create a Memorandum of Understanding (MOU) between health facilities.
 Establish a directory and inventory of health facilities including trauma-capable facilities
so as to strengthen networking and linkages.

LEGAL BASIS

ADMINISTRATIVE ORDER No. 2014-0007.

NATIONAL POLICY ON THE ESTABLISHMENT OF PRE-HOSPITAL EMERGENCY MEDICAL

SERVICE SYSTEM.

D. Inter-Facility Referral and Transport: involves the transport of patient with medical escorts,
from one facility to another, as the patient requires services that are not available in the referring
facility.

SECTION VI. A. 4. OF ADMINISTRATIVE ORDER NO. 2010-0003

NATIONAL POLICY ON AMBULANCE USE AND SERVICES

Department of Health (DOH) Bureau of Health Facilities and Services shall establish licensing
standards for ambulance services and ensures their implementation through regulation. The
license of hospital-based ambulance service shall be part of the hospital license. All other
ambulance services shall require a separate license.

REPUBLIC ACT 8344.

AN ACT PENALIZING THE REFUSAL OF HOSPITALS AND MEDICAL CLINICS TO

ADMINISTER APPROPRIATE INITIAL MEDICAL TREATMENT AND SUPPORT IN
EMERGENCY OR SERIOUS CASES, amending for the purpose Batas Pambansa bilang 702,
otherwise known as "an act prohibiting the demand of deposits or advance payments for the
confinement or treatment of patients in hospitals and medical clinics in certain cases"

"SECTION 4. Any official, medical practitioner or employee of the hospital or medical clinic who
violates the provisions of this Act shall, upon conviction by final judgment, be punished by
imprisonment of not less than six (6) months and one (1) day but not more than two (2) years
and four (4) months, or a fine of not less than Twenty thousand pesos (P20,000.00), but not
more than One hundred thousand pesos (P100,000.00) or both, at the discretion of the court:
Provided, however, That if such violation was committed pursuant to an established policy of the
hospital or clinic or upon instruction of its management, the director or officer of such hospital or
clinic responsible for the formulation and implementation of such policy shall, upon conviction by
final judgment, suffer imprisonment of four (4) to six (6) years, or a fine of not less than One
hundred thousand pesos (P100,000.00), but not more than Five hundred thousand pesos
(P500,000.00) or both, at the discretion of the court."

DEFINITION OF TERMS

Interfacility Referral and Transport - involves the transport of patient with medical
escorts, if necessary, from one facility to another, as the patient requires services
that are not available in the referring facility.

Transfer – the comprehensive infrastructure and process involved before, during and
after moving a patient from one location to another.

Transport – the physical process of moving a patient from one location to another.

Health Facility – licensed health care entity (e.g. hospital, clinic, rehabilitation, nursing home,
or Rural Health Unit (RHU)

Emergent care – patients needing access to technological such as computerized

tomography, angiography for evaluation and stabilization of the
critical patient.

Continuity of care – patient receiving initial emergent care to a nearby facility and then
be transferred to a care of a personal physician usually motivated
by patient preference.

Tertiary care – patients needing definitive care at a tertiary care facility.

Ambulance/Transport Vehicle - refers to the mode of vehicular transportation used to

carry and transfer emergency service equipment,
emergency service providers, and patient/s requiring
urgent or emergency care. Vehicles may refer to
motorboats, helicopters, jets, motorcycles, or vans.
INTERFACILITY REFERRAL AND TRANSPORT SERVICES shall observe the following
protocol:

 The attending physician of the referring health facility shall:

o Determine the need for transfer.
o Appraise the patient/folks of the need for transfer.
 Patient/ folks shall sign consent for transfer
 Patient/folks shall sign waiver if refuse to transfer
o Respect patient’s/folk’s health facility preference for transfer
o Guide the patient/folks if health facility preference has not been
identified
o Write transfer orders
o Contact the receiving facility for acceptance and bed availability.
 The mode of transport shall be identified basing on the levels of acuity of
the patient:
o Stable with no risk for deterioration
 Oxygen, monitoring of vital signs, saline lock, basic
emergency medical care.
o Stable with low risk of deterioration
 Running IV, some IV medications including pain
medications, pulse oximetry, increased need for
assessment and interpretation skills (advanced care).
o Stable with medium risk of deterioration
 3-lead ECG monitoring, basic cardiac medications, e.g.,
heparin or nitroglycerine
o Stable with high risk of deterioration – Patients requiring
advanced airway but secured, intubated, on ventilator, patients on
multiple vasoactive medication drips, patients whose condition has
been initially stabilized, but has likelihood of deterioration, based
on assessment or knowledge of provider regarding specific
illness/injury.
o Unstable — any patient who cannot be stabilized at the
transferring facility, who is deteriorating or likely to deteriorate,
such as patients who require invasive monitoring, who are post-
resuscitation, or who have sustained multiple trauma (critical care
or available crew with time considerations).
 The patient for referral shall be required to avail of health facility -owned
transport during transfer.
 The necessary personnel to accompany the patient shall be qualified to
handle potential complications during transport
 The necessary life support equipment shall be made available.
 The medical treatment and drug orders for the duration of the transfer
shall cover any untoward complication during transfer.
 The Back Referral Form shall be filled up by the receiving facility and
shall be sent back to the referring facility.
 (Name of Health Facility)

Sample REFERRAL FORM

Name of Patient___________________________________ Age_________ Sex _____

Address_______________________________________________________________
Date___________________________________________ Time__________________
Referred to ____________________________________________________________
Referred from __________________________________________________________
Reason for referral_______________________________________________________
Vital signs: BP___________ Temp ____________ RR ___________ HR ___________
PE findings: ____________________________________________________________
____________________________________________________________
____________________________________________________________
Impression/Diagnosis: ___________________________________________________
____________________________________________________
Laboratory findings: _____________________________________________________
_____________________________________________________
_____________________________________________________
Medication: ____________________________________________________________
____________________________________________________________
Others: _______________________________________________________________
_______________________________________________________________
_______________________________________________________________

______________________________________
Name and signature of Referring Physician

---------------------------------------- --------- --------------

BACK REFERRAL SLIP

Name of Patient_________________________ Date ____________ Time __________

Referred by:____________________________________________________________
Received by:___________________________________________________________
Disposition:____________________________________________________________

________________________________________
Name and Signature of Receiving Physician/Nurse
 FLOW CHART FOR INTERFACILITY REFERRAL

Attending Physician (AP) determines need for referral/transfer

Appraisal of patient/folks of need for referral/transfer

Patient/folks sign consent for

Refuse to transfer
NO Yes
transfer

Patient/folks decide preferred

Sign refusal
facility or
waiver
AP guides patient/folks if
unable to identify health facility

AP writes transfer order

AP communicates with
receiving facility for admission
and bed availability

Mode of transport identified

(Land/Sea/Air ambulance)

Personnel accompanying the

patient are qualified to handle
possible complications during
transport

Necessary life support

equipment made available
during transfer

Medical treatment and drugs

orders available to cover
complications during transfer

Back Referral Form to

be filled up by
receiving facility and
send back to referring
facility
REFERENCES:

ADMINISTRATIVE ORDER No. 2014-0007. National Policy on the Establishment of Pre-

hospital Emergency Medical Service System.

DEPARTMENT ORDER No. 2014. Guidelines for the Establishment and Operationalization of
Pre-hospital Emergency Medical Service System at the local level.

ADMINISTRATIVE ORDER No. 2016 – 0029. Rules and Regulations Governing the Licensure
of Ambulances and Ambulance Services Providers

REPUBLIC ACT 8344. An act penalizing the refusal of hospitals and medical clinics to administer
appropriate initial medical treatment and support in emergency or serious cases.

GUIDE FOR INTERFACILITY PATIENT TRANSFER. EMS National Highway Traffic and
Safety Administration. DOT HS 810 599 April 2006.

Violence and Injury Prevention Program (VIPP) module on Inter-facility Referral and Transport.

VIPA AUTHORS:

SUSAN MONTILLA ARANETA, M.D., E. M. T.

Medical Officer IV
Don Jose S. Monfort Medical Center Extension Hospital
Barotac Nuevo, Iloilo

NORMA LOSBAṄES LOSAṄES, R.N., M.N.

Director, Nursing Service
Iloilo Mission Hospital
Iloilo City

MA. ELOISA SORONGON PENADO, R.N. M.A.N.

Chief Nurse V
Western Visayas Sanitarium
Sta. Barbara, Iloilo

JULIE LIM GAMUYAO, R.N., M.N., E.M.T.

Nurse III
Corazon Locsin Montelibano Memorial Regional Hospital
Bacolod City