Protocol for management of inter-hospital transfers

Protocol number: QH-HSDPTL-025-2:2021

Effective date: 1 October 2021

Review date: 1 October 2024

Supersedes: Nil

On this page:

  1. Purpose
  2. Scope
  3. Management of inter-hospital transfers
  4. Supporting and related documents
  5. Definitions of terms
  6. Approval and implementation
  7. Version control

1. Purpose

This Protocol outlines the mandatory processes for management of inter-hospital transfers of patients.

2. Scope

This Protocol applies to all Department of Health and other employees working in or for HHSs. This Protocol also applies to all organisations and individuals acting as an agent for HHSs (including Visiting Medical Officers and other partners, contractors, consultants, and volunteers).

3. Management of inter-hospital transfers

Inter-Hospital Transfers (IHTs) may operate within or between HHSs based on the clinical needs of the patient, access to specialised services, and capacity constraints.

Each hospital has a nominated staff member responsible for bed management at all times and a generic email address for bed management.

A senior clinician is available for each facility 24/7 as a single point of contact to address access issues related to critically ill patient transfers.

3.1. Pre-transfer requirements

  1. Before transferring a patient, it is essential that adequate communication occurs between the referring and accepting facilities, and Queensland Ambulance Service.
  2. The accepting HHS will prioritise in-patient bed availability for patients received via planned inter-hospital transfer. The accepting hospital is to advise of the entry point to the hospital for the patient, e.g. the in-patient bed location for a direct ward admission, the Emergency Department, or entry via the Transit Lounge.
  3. The transfers of critically ill patients will not be delayed due to bed availability.

3.2. Pre-transfer agreement is made under the following circumstances:

  1. There must be a consultant (or delegate) to consultant (or delegate) agreement on the planned transfer.
  2. For all transfers, the accepting Medical Officer will obtain approval from the Consultant/SMO/delegate of the appropriate accepting team (ED or inpatient consultant) at the accepting facility, before the patient’s departure from the referring hospital.


  1. As determined by Retrieval Services Queensland when urgent critical transfer is required as per the Retrieval Services Queensland Use of Health Service Directive QH-HSD-005:2014.
  2. All decisions to transfer a patient must be based on an appropriate clinical risk assessment.
  3. The initial referring hospital is required to receive the patient back once the services at the accepting hospital are no longer required or indicated.

3.3. Process for transfer of patients into, out of, and between hospitals

  1. Patient transfers are to be scheduled at times which take account of clinical risk and emergency demand.
  2. Where patients are being transferred to another hospital by QAS, appropriate escorts are to be arranged by the referring hospital as clinically indicated.
  3. For all patients being transported out of any hospital the following will have been undertaken by the referring clinician:
    • Notification of the receiving Medical Officer and Bed Management/Patient Flow Unit;
    • The receiving hospital has accepted the patient.
  4. The accepting hospital will minimise delays to QAS when the patient arrives at the hospital.

3.4. Transferring patients will be transported directly to an available inpatient bed unless:

They have an agreed clinical requirement for Emergency Department treatment as decided by the receiving hospital ED Consultant (or delegate) prior to the patient’s departure from the referring hospital.


They have an undifferentiated condition requiring further specific investigations prior to placement in an inpatient bed.


They have deteriorated in transit, necessitating Emergency Department treatment.


A system is in place for the rapid transfer of a critically ill or multisystem trauma patient.

3.5. Communication and handover

  1. Decisions made regarding patient transfer(s) will be made taking clinical priorities into account.
  2. Bed Management/Patient Flow Unit will be notified of all planned inter-hospital transfers prior to movement to prioritise bed availability.
  3. The referring clinician will complete the electronic IHT application form.
  4. In the event of any disagreement surrounding the transfer, consultation must occur between the referring and accepting Consultants or most senior Medical Officers available and the accepting Bed Manager. If the disagreement remains unresolved, this shall be escalated to the Director of Medical Services (DMS) or equivalent at both facilities.

3.6. Post transfer requirements

  1. Healthcare professionals providing the escort during the road transfer of patients are responsible for reporting critical incidents and/or adverse events, which occur during a road transfer, utilising a risk management system.
  2. The receiving hospital shall undertake timely clinical assessment of the patient on arrival.

3.7. Transfer of patients back to referring hospital

  1. The treating consultant (or delegate) confirms that the patient is ready to be transferred back to the referring hospital.
  2. This back transfer is expected to have occurred within a maximum of two (2) days of the patient being considered clinically ready for discharge from the initial accepting hospital. The initial referral hospital will be expected to make a bed available within one (1) working day of clinical acceptance to allow one (1) day to facilitate appropriate transport (road or aeromedical).
  3. In the event of a transfer not occurring within 1 day of acceptance, the transfer should be escalated to the facility Executive Director or delegate of the accepting and receiving hospitals to negotiate a plan for the patient to be transferred within the next day.

4. Supporting and related documents

  • Hospitals and Health Boards Act 2011.
  • Relevant local policies or procedures related to demand management and escalation.

Authorising Health Service Directive

Procedures, guidelines, protocols

5. Definitions of terms

Term Definition / explanation / detailsSource
Bed Flow Manager (or equivalent) Accountable for promoting effective and cost-efficient management of hospital resources and associated patient flow resources and services within a facility. Role description from Metro North HHS
Adverse event Incidents in which harm resulted to a person receiving health care Australian Institute of Health and Welfare 
Inter Hospital Transfer Refers to any patient transported directly from one hospital to another on the advice of clinical staff, whether admitted to either hospital or not. This includes those patients defined under the National Health Data Definitions Dictionary as “Inter Hospital Transfer” and “Inter Hospital Referral". The National Health Data Definitions Dictionary

6. Approval and implementation

Protocol Custodian: Healthcare Improvement Unit, Clinical Excellence Queensland

Approving Officer: Deputy Director-General, Clinical Excellence Queensland

Approval date: 23 September 2021

Effective from: 01 October 2021

7. Version control

VersionDate Prepared byComments
1.0 23/09/2021 Healthcare Improvement Unit Protocol for Management of Inter-Hospital Transfers developed in consultation with key stakeholders.

Last updated: 1 October 2021