DEPARTMENT OF CRITICAL CARE

ICU INTERFACILITY TRANSFER CHECKLIST

Patient Name: __________________ Patient Identification No. ______________
Sending Site: FMC RGH PLC Receiving Site: FMC RGH PLC
Date (yy/mm/dd):__________________ Time (24 hour clock): ______________
Responsible physician during transport: ____________________________________
Responsible physician contact phone number: _______________________________
Reason for transfer:
Documentation by Discipline Check Action MD confirmation/
initials
Unit Clerk (Not applicable in Emergency):
Chart Yes No
X-rays (if not on PACS) Yes No

Physician:
Pt reviewed within 2 hours of transfer Yes No
MD to accompany Yes No
RT to accompany Yes No
Family notified of transfer Yes No
Transfer notes from MD Yes No
List of meds (incl. planned stop dates) Yes No

Respiratory Therapy:
ET position confirmed by CXR Yes No Date: ________
or bronchoscopy Yes No Date: ________
Position of tube-gums/teeth Yes No Position in cms:
confirmed within 30 minutes of transport
FiO2 increased by ≥ 0.2 since transfer Yes No Yes Î Notify MD
decision was made
RR>30 Yes No Yes Î Notify MD
Breath sounds present bilaterally Yes No
Saturation at transfer _______
ABG if pt. paralyzed (time frame) Yes No pH:___pC02___

Nursing (when in Emergency, filled out by physician):

Vasopressor increase by ≥ 20% Yes No Yes Î Notify MD
since transfer decision was made
BP at time of transfer
Goal mean BP ________
Altered L.O.C. from baseline Yes No Yes Î Notify MD
Current GCS ________
Sedation orders for transport received Yes No
SCM order summary Yes No
Printed QS Kardex Yes No
Patient’s Nurse or Attending Signature:_____________________________ Date: ________________
Patient’s Nurse or Attending (print name):____________________________ Time: _______________
Please make two copies and send one copy to Dr. George Alvarez and one copy to Dr. Terry Hulme
(see second page of checklist for instructions). July 13, 2007
 DEPARTMENT OF CRITICAL CARE
INSTRUCTIONS SHEET
For ICU to ICU Transfer
1. Bedside nurse to make sure each discipline has reviewed the checklist.
2. For items that require notify MD, please ensure MD initials the item.
3. Bedside nurse to sign off.
4. Original copy to go with patient in their chart.
5. One copy to be sent to Dr. Terry Hulme at RGH site ICU.
6. One copy to be sent to Dr. George Alvarez at RGH site ICU.

For ED to ICU Transfer

1. Attending to make sure each discipline has reviewed the checklist.
2. Atttending to sign off.
3. Original copy to go with patient in their chart.
4. One copy to be sent to Dr. Terry Hulme at RGH site ICU.
5. One copy to be sent to Dr. George Alvarez at RGH site ICU.

July 13, 2007