UR Medicine Acute Shock Program

UR Medicine

Transfer Checklist

  • Transport/Transfer Consent
    • Physician Certification Statement (PCS) for EMS
  • Copy of Patient Records
    • Discharge Summary, H&P, MOLST FORM/HCP
    • Imaging on Disc: CT Scans, ECHO, Cardiac Cath
    • Imaging Report: paper copy of ECHO, Cardiac Cath
    • Operative Notes: especially any cardiac procedures
    • Lab Data including micro studies and/or Blood transfusion record
    • ECMO: Copy of flow sheets for 24 hours pre-ECMO placement
    • CARDIOHELP: Request MD or Surgical PA for splicing circuit

Patient Stability Guidelines:

Device flows > 2L/min or pump Index > 2.0
Bleeding < 300 cc/hr
Neurological Function
pa02 > 60 on < 100% FiO2
RR 8-30 with SpO2 >90
HR 50-130 with adequate perfusion
MAP > 60 without max drug support
Normal pH
Lactate < 8
Potassium 2-7 mmol/L
Temp > 36C
Minimum 2 PIV
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