Pan American Health Organization · October 2022
Operational procedures for coordinating safe secondary patient transfers during surge capacity events; for EMS, hospitals and coordination desks.
- Issuer
- Pan American Health Organization
- Edition
- October 2022
- Audience
- Decision-makers and professionals in emergency medical services, hospital transfer coordination, dispatchers, ambulance crews, physicians, nurses involved in COVID-19 patient transfers
- Evidence
- Expert consensus from PAHO Community of Practice on prehospital EMS, Regional Emergency Medical Team Secretariat, international EMS specialists; incorporates NFPA, EN, CAAS, GSA ambulance standards
- Reviewed
- 18 Oct 2026 · GMJ
What this guideline says
GMJ summary
This PAHO technical document presents a comprehensive system for managing inter-hospital transfers of COVID-19 patients during epidemic surges. It establishes a centralized Inter-hospital Transfer Coordination Desk (ITCD) model that coordinates between sending facilities, emergency medical services, and receiving hospitals, drawing on mass casualty incident frameworks adapted for prolonged pandemic response.
The guidance addresses the complete transfer pathway: identifying patients requiring transfer (either critically ill needing higher care or redistribution from high-to-low volume areas), calculating oxygen requirements for transport, ensuring appropriate ambulance capabilities (minimum 3000 litres oxygen capacity, 100 L/min flow rate at outlets), standardized communication protocols, proper PPE use during transport, and ambulance decontamination procedures. All COVID-19 patients not on ventilators should wear surgical masks if tolerated; transport crews require full PPE including N95 respirators for aerosol-generating procedures.
The document emphasizes real-time resource tracking (beds, ventilators, ambulances), standardized handoff procedures (SBAR format for nursing, physician-to-physician for critical patients), universal protocols for emergencies en route, and system accountability with agreed operating principles among all stakeholders. Detailed annexes provide oxygen calculation formulas, ambulance specification standards (NFPA, EN, CAAS, GSA), and computerized dispatch system capabilities.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Establish a centralized Inter-hospital Transfer Coordination Desk (ITCD) as single point of contact between hospitals and EMS, using existing mass casualty incident infrastructure where available
- Ambulances must have minimum 3000 litres medical oxygen capacity with outlets delivering ≥100 L/min flow rate; pressure regulators set at 50 ± 5 psi line pressure
- Calculate oxygen needs generously: (Gauge Pressure – 200 psi residual) × Cylinder Factor ÷ Flow Rate = minutes available; add contingency for delays
- All COVID-19 patients not on ventilators/non-invasive ventilation should wear surgical masks during transport if tolerated
- Transport crews require N95/FFP2 respirators, gown, gloves, goggles/face shield when performing aerosol-generating procedures; medical masks acceptable for non-AGP transport with isolated patient compartment
- Medical gas systems must be leak-tested to 200 psi and lose ≤5 psi over 2 hours; cylinders mounted with restraining devices meeting SAE J3043 or AMD 003 standards
- Critically ill patients require physician-to-physician handoff and physician presence for prehospital provider handoff; multidisciplinary transport team with ≥2 advanced providers recommended
- Ambulances require ≥9 square inches open venting in oxygen compartments; decontamination must occur in designated areas before return to service
Personal Protective Equipment for Inter-hospital Transfer of Patients with COVID-19
Table extracted from the guideline
| Level of care | Hand hygiene | Medical mask | Respirator (N95/FFP2) | Gown | Goggle/face shield | Gloves |
|---|---|---|---|---|---|---|
| Transport WITHOUT aerosol-generating procedure | X | X | X | X | X | |
| Driving WITH patient compartment isolated | X | X | ||||
| Driving WITHOUT patient compartment isolated | X | X | ||||
| Transport WITH aerosol-generating procedure | X | X | X | X | X | |
| Cleaning the Ambulance | X | X | X | X | X |
Source: Pan American Health Organization, Management of Inter-Hospital Transfer of Patients with COVID-19. Reproduced in summary form.
From the guideline
Verbatim
“All COVID-19 patients who are not on a ventilator or on non-invasive ventilation equipment (BIPAP/CPAP), should have a surgical mask in place if they are able to tolerate it, this includes patients on other forms of supplemental oxygen.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Georgia continues strengthening emergency preparedness following the COVID-19 pandemic, this PAHO framework offers immediately applicable operational guidance for our EMS system modernization. The centralized coordination desk model addresses a critical gap we observed during surge periods when ad hoc transfer arrangements led to inefficiencies and delays. I would particularly emphasize to Georgian colleagues the oxygen calculation methodology in Annex 2—our mountainous geography means many inter-regional transfers face both prolonged transport times and altitude-related increases in oxygen demand, making generous pre-transport calculation essential. The realistic implementation challenge for Georgia will be achieving the 3000-litre oxygen capacity standard across our ambulance fleet, especially for rural and mountain EMS stations where older vehicles remain in service; a phased approach prioritizing high-volume inter-hospital routes would be prudent while seeking equipment modernization funding.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 18 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia’s emergency medical services system would benefit from adopting this centralized coordination model, particularly as the country continues building surge capacity following COVID-19 experience. The oxygen calculation formulas and ambulance specifications are directly applicable for Georgian EMS fleet modernization and for establishing oxygen capacity standards. Georgian EMS agencies should verify current ambulance oxygen carrying capacity against the 3000-litre minimum standard and 100 L/min outlet flow rate requirements. The ITCD model could be piloted in Tbilisi and regional centres (Kutaisi, Batumi) where multiple hospitals exist within transfer range, using existing emergency coordination infrastructure. The document’s emphasis on real-time bed availability tracking aligns with Georgia’s ongoing health information system digitalization efforts and could integrate with existing hospital information systems. For inter-regional transfers in mountainous terrain, the guidance on calculating increased oxygen needs at altitude is particularly relevant for Georgian geography.
Questions this guideline answers
Quick answers
How much oxygen capacity must an ambulance have for COVID-19 inter-hospital transfers?
Minimum 3000 litres medical oxygen capacity, with outlets delivering ≥100 L/min flow rate. Oxygen piping must be leak-tested to 200 psi and lose ≤5 psi over 2 hours. Calculate patient needs using: (Gauge Pressure – 200 psi residual) × Cylinder Factor ÷ Flow Rate, adding contingency for delays. For example, a full Type E cylinder (2000 psi, factor 0.34) delivers only 10 minutes at 60 L/min high-flow but 122 minutes at 5 L/min conventional cannula.
What PPE is required for ambulance crews transporting COVID-19 patients?
For transport without aerosol-generating procedures: hand hygiene, medical mask, gown, goggles/face shield, and gloves. For aerosol-generating procedures (intubation, CPAP/BiPAP): upgrade to N95/FFP2 respirator. Drivers with isolated patient compartments need only hand hygiene and medical mask; without isolation, full PPE required. Patients not on ventilators should wear surgical masks if tolerated.
What is the role of the Inter-hospital Transfer Coordination Desk (ITCD)?
The ITCD serves as the single point of contact coordinating all stakeholders: receiving patient transfer requests from hospitals, tracking real-time bed/ventilator/ambulance availability across the region, dispatching appropriate EMS resources based on patient acuity and location, and ensuring communication between sending facility, receiving hospital, and transport crew. It operates on agreed principles including timely data sharing, accepting triage decisions, and accountability through regular briefings.
What essential information must be communicated before transferring a patient?
Sending physicians must communicate: isolation requirements and projected duration, symptom onset and testing dates, current symptoms and severity, devices in place (ventilator settings, central lines), medications received and anticipated needs during transport, radiography/laboratory values, and estimated arrival time. Critical patients require verbal physician-to-physician handoff. Documentation must include COVID-19 testing dates, DNR orders, ventilator settings, and medications. Use SBAR format (Situation, Background, Assessment, Recommendations) for nursing handoffs.
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Quality & accreditation
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- October 2022
- Status
- Current
- Published
- 2022-01-01
- Languages
- English
- Scope
- Inter-hospital transfer of COVID-19 patients during outbreaks, epidemics or disasters; secondary transfers between hospitals, emergency medical teams, and alternative medical care sites providing inpatient/critical care
- Audience
- Decision-makers and professionals in emergency medical services, hospital transfer coordination, dispatchers, ambulance crews, physicians, nurses involved in COVID-19 patient transfers
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Expert consensus from PAHO Community of Practice on prehospital EMS, Regional Emergency Medical Team Secretariat, international EMS specialists; incorporates NFPA, EN, CAAS, GSA ambulance standards
- Record history
- Created 18 Oct 2026 · updated 18 Oct 2026 · next check Apr 2027
Pan American Health Organization. Management of Inter-Hospital Transfer of Patients with COVID-19, October 2022. Washington, DC: PAHO; 2022. (PAHO/PHE/IHM/COVID-19/22-0018).GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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