POLICY TITLE HIGHER LEVEL OF CARE (HLC) AND/OR LIFE, LIMB AND THREATENED ORGAN (LLTO)

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1 Page 1 of 10 POLICY TITLE 1.0 PURPOSE Patients requiring higher level of care and/or life, limb and threatened organ care will be guaranteed access without exception to an acute care facility that has the programs and services necessary to care for the patient. Referral Centres Higher Level of Care Required 1 Major burns, inhalation injuries, traumatic amputations for replantation, spinal injuries with deficits Referral Centre VGH 2 Major Trauma See Section 3 3 Neurosurgery (If associated with major trauma refer to trauma physician on-call as per Section 3) 4 Cardiac Surgery 5 Cardiac Intervention/Catheter Lab See Section 4 6 Critical Care See Section 5 7 Vascular Surgery, 8 Thoracic Surgery 9 Acute Dialysis,, 10 Mental Health and Substance Use (Patients from nondesignated sites medically cleared and certified under the Mental Health Act) See Section 6 11 Perinatal patients See Section 7 12 Paediatric patients See Section 8 13 Other higher level of care (i.e. cases that cannot be dealt with on site) to no refusal site not covered above CGH, MMH, FCH QPCC (If no bed at original referring site)

2 Page 2 of GENERAL PROCEDURE 2.1 Higher Level of Care and/or Life, Limb and Threatened Organ: Transferring physician contacts BC Bedline at: Press 1 All conversations with BC Bedline are recorded 2.2 The transferring physician identifies priority of transfer for Higher Level of Care transfers using BC Bedline categories. For example: Priority 1: Priority 2: Priority 3: Within 2 hours Within 8 hours Within 8-72 hours 2.3 The BC Bedline Patient Transfer Co-ordinator facilitates a call with the physician from the sending site and specialist. It is a requirement that physicians participate in the conference call initiated by BC Bedline. The BC Bedline Clerk arranges BCAS (B.C. Ambulance Service) transport and informs the receiving site of the incoming patient. 2.4 The receiving site specialist accepts the patient and notifies the Emergency Room if no in-patient bed is available. 2.5 The nurse sending the patient calls the charge nurse at the receiving site to provide a report on the patient and the Bed Booking Department to inform them of the incoming patient. 2.6 If the sending physician declares the patient as a Priority 3 transfer (within 8-72 hours), BC Bedline will contact CGH, LMH, PAH, RMH for capacity in addition to the no refusal sites if required services are available at those sites to care for the patient in the interim. If the patient has not been transferred within the identified timeframe, the patient is sent to the designated no refusal site. 2.7 In the case of a LLTO transfer the patient will be received in the Emergency Room unless arrangements have been made for transfer directly to ICU.

3 Page 3 of 10 Other HLC transfers from FCH and MMH will be transferred to the no refusal site Emergency Room. The receiving Emergency Room Physician will contact the appropriate consultant after the patient has been assessed. Other HLC transfers will be made to the receiving ward at the no refusal site unless no bed is available in a no refusal site. In that case transfer may be made to the Emergency Room and the sending Emergency Room Physician must discuss the case with the receiving Emergency Room Physician prior to transfer. The receiving Emergency Room will notify the consultant when the patient arrives. 3.0 MAJOR TRAUMA PATIENTS 3.1 Major trauma patients are referred via BC Bedline to. 3.2 The referral should be made to the on-call trauma physician at irrespective of which organ systems are involved in the trauma. 4.0 INTERVENTIONAL CARDIOLOGY 4.1 Acute Myocardial requiring emergency cardiac intervention - referral should be made directly to the on-call Cardiac Interventionalist. 4.2 Patients awaiting cardiac surgery with cardiogenic shock or cardiac instability - referral should be made directly to the on-call Clinical Cardiologist. 4.3 All other cardiac patients are referred via BC Bedline. 5.0 CRITICAL CARE (Intensive Care Unit or High Acuity Unit) 5.1 Transfers of critically ill patients due to lack of capacity should be to the closest site that can provide the level of care required. 5.2 All critically ill patients requiring transfer for HLC/ LLTO should be transferred within 2 hours. 5.3 HLC/LLTO patients should be transferred to facilities that can provide the required level of care. Where there is more than one option, the decision should be based on both proximity and bed availability.

4 Page 4 of 10 Neurosurgical consultation/support Interventional Cardiology or Cardiac Surgeon consultation/support Severe ARDS requiring ECMO Severe ARDS requiring alternative ventilation strategies (e.g. Oscillation) Severe GI Bleed, hypovolemic shock requiring potential urgent Interventional Radiologist and/or Endoscopist consultation/support Multiple Trauma Patients Thoracic Surgery consultation/support Urgent hemodialysis (within 12 hours) requiring high levels of vasopressor support need for continuous renal replacement therapy Acute hemodialysis not requiring high levels of vasopressor support,,,, 5.4 For critically ill patients not included in 5.3: Designated NO REFUSAL sites for critical care patients are: CGH, FCH, MMH Referral Site BH Receiving Site HLOC/LLTO preferred sites (Call alternate site or if no beds) RMH LMH, PAH Referral Site Receiving Site

5 Page 5 of MENTAL HEALTH AND SUBSTANCE USE PATIENTS 6.1 In the case of a Mental Health and Substance Use (MHSU) patient (medically cleared and certified under the Mental Health Act) 16 years and older located at non-designated sites (,, FCH, MMH) BC Bedline phones their partner designated hospitals. 6.2 Patients under 16 years presenting in acute psychiatric crisis are not appropriate for admission to an adult inpatient unit. However, any patient under the age of 16 years who presents to the ER of non-designated acute care site (,, FCH, MMH) and requires inpatient psychiatric care should be transferred to the no-refusal site under the care of the attending psychiatrist. Referrals will be made as usual to the Adolescent Crisis Response/Youth Crisis Response Program ACRP/YCRP. After Hours MHSU Access on-call is also available to assist. 6.3 If no appropriate bed is available at the no-refusal site the patient will be received in the Emergency Room under the care of the receiving Psychiatrist. Non Designated MHSU Sites MMH FCH Designated MHSU No-Refusal Site CGH PAH except patients under 16 years old to be transferred to 7.0 PERINATAL PATIENTS 7.1 Refer to Fraser Health Clinical Protocol: Appropriate Level/Location of Care for Perinatal Patients Requiring High Risk and Critical Care. 7.2 Women with deteriorating maternal or fetal condition meeting severity criteria will be guaranteed access without exception to an acute care facility that has the programs and services necessary to care for the patient and avoid preventable adverse outcomes.

6 Page 6 of When arranging for antepartum perinatal transfers it must be coordinated with the Neonatal Intensive Care Unit and arranged through BC Bedline and the provincial Neonatal Bed Coordinator. 7.4 Facilities in which the appropriate resources are available for the care of women with complex perinatal conditions: Maternal fetal medicine Cardiac care Bariatric care (BMI > 40) Renal dialysis Neurosciences Interventional radiology Trauma care Level III neonatal ICU Level IIB neonatal ICU Level IIA neonatal ICU,,, BCWH,, BH 7.5 The following situations may require urgent maternal inter-hospital transport to maximize patient safety and resource allocation: At birth, the fetus is expected to require a higher level of care than offered at the assessing hospital (see Neonatal Levels of Service Classification [BCPHP, 2009]). Assessing hospital staff is unable to provide the required level of surveillance or expertise for severe maternal condition (e.g. severe preeclampsia, unstable Type I diabetes, higher order multiples). Major trauma, neurologic or cardiac complications requiring immediate intervention. Uncontrolled bleeding requiring interventional radiology. Other: Umbilical cord prolapse Obstructed labour Maternal cardiac arrhythmias in labour Multiple gestation requiring emergency obstetric / paediatric management Amniotic fluid embolism Anticipated severe shoulder dystocia Neonatal condition requiring urgent paediatric management

7 Page 7 of Designated Fraser Health No Refusal Sites for Perinatal patients: Sending Sites All sites, quaternary care BH RMH MMH FCH CGH PAH LMH Designated No-Refusal Sites BCWH 8.0 PAEDIATRIC PATIENTS 8.1 Please refer to Fraser Health Clinical Protocol: Pediatric Higher Level of Care and/or Life, Limb and Threatened Organ (May 27, 2010). 8.2 Designated Fraser Health No Refusal Sites for Pediatrics: Sending Sites All sites, quaternary care All sites, trauma care BH RMH CGH FCH MMH LMH PAH Designated No-Refusal Sites (Non Tertiary) BCCH

8 Page 8 of ACCOUNTABILITY 9.1 Obligations of the Receiving Site and Specialist: The receiving hospital must accept the referral of a Higher Level of Care and/or Life, Limb and Threatened Organ care patient when the services needed for a patient do not exist at the sending site. The Most Responsible Physician will be the receiving specialist as defined in the Most Responsible Physician policy. Patients must be assessed at a receiving site by a specialist. They may be sent back to the sending site if no intervention is required. If the sending site is CGH,,, FCH, MMH or QPCC and the patient requires services beyond those available at these sites, then the designated No-Refusal site must accept the patient. The receiving site may send a lower acuity patient (in-patient or emergency patient) to the sending site in order to free up a bed to accommodate the incoming patient. Principles for selection of a lower acuity patient to be sent out: In preparation of needing to send a lower acuity patient out, Access and/or the Charge Nurse and the Attending Physician must identify a patient each day. Ensure that the patient needs match the site services/capabilities. Choose a patient that has an address closest to the hospital that the patient is being sent to. Choose a patient that does not have a predicted long length of stay. If a physician from the receiving site has questions/concerns about a patient sent to their site through the Higher Level of Care and/or Life, Limb and Threatened Organ process, that physician must treat the patient first and then notify his/her Program Medical Director.

9 Page 9 of Obligations of the Sending Site The Sending Site must accept a lower acuity patient immediately from the receiving hospital if the receiving hospital needs to free up a bed. The sending site must: Agree to take the patient back if the specialist at the receiving site deems that higher level of care management is not necessary. Agree to repatriate the patient within 24 hours of transfer orders written. If a patient transfer is delayed beyond a clinically acceptable timeframe then the escalation process needs to be activated. 9.3 Regional Access The Manager of Acute Access will conduct monthly audits of the Higher Level of Care and/or LLTO process and will submit results of the audit to the Executive Directors and Program Medical Directors. 9.4 Regional Programs The Program Medical Directors and Executive Directors will review monthly audits produced by the Manager of Acute Access. 9.5 Unresolved Issues If there are any unresolved issues with the transfer, the physician may contact the Fraser Health Access On-Call and the Medical Director on-call. If unable to finalize transfer within the clinically required time frame, please contact Fraser Health Access On-Call through the Centralized Contact Centre by dialing The Medical Director on call will be responsible for resolving any conflicts/issues that arise from the Higher Level of Care and/or Life, Limb and Threatened Organ policy. Those patients will be reviewed by the Program Medical Directors involved and, if necessary, cases will be sent to the Program Quality Committee to confirm/evaluate complaints/concerns/quality improvement initiatives.

10 Page 10 of ACRONYM DEFINITIONS BCCH BCWH BH CGH FCH MMH PAH QPCC RMH VGH Abbotsford Regional Hospital B.C. Children s Hospital B.C. Women s Hospital Burnaby Hospital Chilliwack General Hospital Delta Hospital Eagle Ridge Hospital Fraser Canyon Hospital Mission Memorial Hospital Peace Arch Hospital Queen s Park Care Centre Royal Columbian Hospital Ridge Meadows Hospital Surrey Memorial Hospital Vancouver General Hospital

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