Purpose of the Survey
Thank you for helping to complete this survey.
This survey is part of a national effort to reach performance measures set by the
Emergency Medical Services for Children (EMSC) program that are assessing the
pediatric emergency care infrastructure in this State.
This survey focuses on the availability of inter-facility transfer guidelines and
agreements for the care of PEDIATRIC patients.
When completing the survey, please refer to the “definitions” provided in the
survey. We thank you for your time, cooperation, and participation in this
survey.
Please be assured that the answers you provide to this survey will be kept
confidential and will only be used to report aggregate information on a
national level for our state/territory.
To complete this survey on-line please use the following link:
http://www.nedarc.org/surveys/SD/HOS/
IF YOU NEED TO EXIT THE SURVEY AND RETURN AT A LATER TIME TO
FINISH, SIMPLY CLOSE YOUR BROWSER. WHEN YOU RETURN (YOU MUST
BE USING THE SAME COMPUTER) ALL OF YOUR DATA WILL BE SAVED
AND YOU CAN RESUME WHERE YOU LEFT OFF.
Return completed survey to:
Amy Marsh
SD EMS for Children
1400 West 22nd Street
Sioux Falls, SD 57105-1570
Should you have any questions or concerns about this survey please contact:
Amy Marsh – (605) 328-6668
South Dakota Inter-facility Transfer
Guidelines & Agreements for PEDIATRIC
Patients Survey:
Background Information: (for tracking purposes only)
1) Date of survey completion (mm/dd/yy): ________________
2) Name of your hospital: ____________________________________________
3) Name of person completing survey: _____________________________________
4) Job title of person completing survey: ___________________________________
5) Phone Number: ______________________ [format: (xxx) xxx-xxxx]
Hospital Demographics:
6) Indicate the number of patients seen annually in your emergency department:
(Use numeric e.g., “18000” not “eighteen thousand” or “~18,000”):
____________________
7) Indicate the number of patients 18 years of age or younger seen annually in
your emergency department:
(Use numeric e.g., “18000” not “eighteen thousand” or “~18,000”):
____________________
8) Please list the age range your hospital uses to define a PEDIATRIC patient
(Use numeric e.g., “18” not “eighteen”):
Pediatric patient begins at age (in years): __________________
Pediatric patient ends at age (in years): _______________________
Inter-facility Transfer Guidelines for PEDIATRIC Patients
For this section, please refer to the definition below:

Inter-facility transfer guidelines: written hospital-to-hospital (including
out of state/territory) guidelines that outline procedural and
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administrative policies for transferring PEDIATRIC patients to facilities
that provide specialized pediatric care.
9) Does your hospital or medical facility have written guidelines/protocol(s) that
specify a decision making process for identifying those patients needing transfer
to a specified facility? (select one)
 Yes, we have written guidelines/protocols
 No, but we are currently developing written guidelines/protocols.
When do you anticipate the guidelines/protocol(s) to be ready:
Month/Year (mm/yyyy): _____________________________________
 No, we do not have written guidelines/protocols
If you answered “No” to question 9, please skip to the section labeled “Interfacility Transfer Agreements for PEDIATRIC Patients.”
10) Do these written guidelines/protocol(s) contain language that covers
critically ill and injured PEDIATRIC patient transfers to alternate care sites that
have the capabilities to meet the clinical needs of critically ill and injured
pediatric patients? (e.g., contains language that specifically addresses pediatric
patients OR that states that patients of ALL ages are covered) (select one)
 Yes
 No
If you answered “No” to question 10, please skip to the section labeled “Interfacility Transfer Agreements for PEDIATRIC Patients.”
For this section, please refer to the definitions below:

Referring facility: The hospital or center that refers a pediatric patient
to another, more specialized pediatric center better able to handle
pediatric patients.
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
Referral center: A center with specialized pediatric critical care or
pediatric trauma services to which referring facilities refer patients.
11) Do the written guidelines/protocol(s) include information specifically for the
transfer of PEDIATRIC patients regarding: (check either “yes” or “no” for each of
the items listed below)
a. Defined process for initiation of transfer including the roles and
responsibilities of the referring facility and referral center (including
responsibilities for requesting transfer and communication)
 Yes  No
b. Process for selecting the appropriate care facility
 Yes  No
c. Process for selecting the appropriately staffed transport service to
match the patient’s acuity level (level of care required by patient,
equipment needed in transport, etc.)
 Yes  No
d. Process for patient transfer (including obtaining informed consent)
 Yes  No
e. Plan for transfer of:
1) patient medical record
 Yes  No
2) copy of signed transport consent
 Yes  No
3) personal belongings of the patient
 Yes  No
4) directions and referral center information to family
 Yes  No
f. Process for return transfer of the pediatric patient to the referring
facility as appropriate
 Yes  No
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Inter-facility Transfer Agreements for PEDIATRIC Patients
For this section, please refer to the definition below:

Inter-facility transfer agreements: Written contracts/agreements between
a referring facility (e.g., community hospital) to alternate care sites that
have the capabilities to meet the clinical needs of critically ill and injured
PEDIATRIC patients.
12) Does your hospital or medical facility have written inter-facility transfer
agreement(s) with other specialized medical facilities for patients in need of care
not available at your institution? (select one)
 Yes, we have written agreement(s)
 No, but we are currently developing a written agreement(s).
When do you anticipate the agreement(s) to be ready:
Month/Year (mm/yyyy): _____________________________________
 No, we do not have written agreement(s)
If you answered “No” to question 12, please skip to the section labeled
“Additional Transfer Information.”
13) Do these written agreement(s) contain language that covers critically ill and
injured PEDIATRIC patient transfer to alternate care sites that have the
capabilities to meet the clinical needs of critically ill and injured pediatric
patients? (e.g., contains language that specifically addresses pediatric patients OR
that states that patients of ALL ages are covered) (select one)
 Yes
 No
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Additional Transfer Information
14) If your hospital or medical facility has written guidelines/agreement(s), list
the name of the top five facilities to which you transfer PEDIATRIC patients:
a. Hospital 1: ____________________
b. Hospital 2: ____________________
c. Hospital 3: ____________________
d. Hospital 4: ____________________
e. Hospital 5: ____________________
15) Please provide any additional comments related to PEDIATRIC inter-facility
transfer guidelines/protocols or agreements that may help us better understand
your facility:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
You have now completed our survey.
We appreciate the time you have given to take this survey.
Please return the survey as outlined in the instructions above.
Thank you.
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