Patient Evaluation And Transfer

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When it comes to addressing patient transport needs, whether it be a patient who needs evaluative or upgraded care or a patient in palliative care with a routine appointment, the details and decisions matter.

Resources and individual needs may vary, so the standard Medical Priority Dispatch System^™ (MPDS^®) provides two main options for handling these interfacility patient transports—Protocols 33: Transfer/Interfacility/Palliative Care and 37: Interfacility Evaluation/Transfer.

Darren Judd, Priority Dispatch Corp.^™ Implementations Medical Transfer Protocol Suite^™ (MTPS^™) Protocol Expert, explains the purpose and background of these protocols: “Both are specifically designed to streamline communication with medical professionals while gathering needed information to maintain or enhance the current level of care being provided while answering each request.”

The 2025 IAED™ Data Center statistics show that both protocols represent few of the IAED’s collective reported calls, with Protocol 37 comprising about 1.6% and Protocol 33 totaling 2.5%. However, some agencies routinely process a disproportionate number of interfacility calls, primarily from non-emergency numbers, and use these protocols on a regular basis.

“Depending on administration, some agencies choose to use either Protocol 33 or 37, but ProQA^® does allow both Protocols to be enabled together,” said Bryon Schultz, IAED Medical Academics & Standards Expert. “The main thing is each agency needs a clear directive and procedure on using these protocols to avoid under- or overtriaging.”

So, what is the difference between these similar options, and how do they impact the Emergency Medical Dispatcher’s role of addressing the patient’s needs and sending an informed response?

Protocol 33 interrogation 

Protocol 33 was initially seen as a simplified “Sick Person Protocol” for communicating with a medical professional regarding the patient’s transportation needs, according to Jan Althoff, a Quality Assurance Specialist at North Memorial Health Ambulance (Minnesota, USA) who originally assisted in the development of these protocols. “We’ve used 33 as a streamlined calltaking process for communicating with medical facilities that had a nurse or doctor who had already evaluated the patient and was requesting a transfer.”

Protocol 33 is a full interrogation pathway that focuses on identifying any priority symptoms or patient transport needs, which is an advantage for EMDs who may not come from a medical background. It then categorizes transport based on any conditions with urgent needs versus various acuity levels that may be locally defined based on response time standards or conditions common to patient transport requests.

“Some agencies prefer the simplicity of Protocol 33,” said Brett Patterson, IAED Medical Council of Standards Chair. “Often, 33 is used for home health patients where an on-scene nurse is requesting transport for further evaluation, treatment, or relocation. However, some agencies restrict the use of this protocol to specific types of facilities by internal policy from local medical control, which is perfectly appropriate.”

However, data showed Protocol 33 was being utilized to address two different types of requests: transport for evaluation and transport for scheduled treatment or simple relocation. These distinctions prompted the assembly of an Academy Standards Council task force to design another protocol with separate pathways.

Protocol 37 decision-making 

The creation of Protocol 37: Interfacility Evaluation/Transfer allowed “more leeway for trained EMDs to discuss and select the new response options with clinician callers and incorporate their decision-making,” Patterson said. If desired, agencies could still choose to retain possible preferences for Protocol 33.

Protocol 37 (available only in ProQA) has a streamlined approach for interrogation, beginning with a “blue for you” prompt for the EMD to choose the type of incident. You can select either of the defined paths of EVALUATION (patient is being transported to a higher level of care for evaluation or stabilization of an acute or chronic problem) or TRANSFER (patient is being transported to or from a medically supervised environment for the purpose of routine treatment, procedure, checkup, palliative care, or relocation).

Among its distinctions, Protocol 37 includes local definitions for NURSE and DOCTOR (previously undefined in Protocol 33), and it restricts a primary Key Question to an evaluation by a NURSE or DOCTOR within the past two hours to ensure a recent assessment of the patient’s current condition.

EVALUATION 
Based on information obtained during Case Entry and the reason for the patient’s evaluation, you must address another blue operator question to select whether the patient has experienced any conditions consistent with suspected STROKE, hemorrhage, heart attack, acute onset of difficulty breathing, or sudden change in level of consciousness.

"With the multitude of calls processed daily in our busy comm. center, sometimes it can be challenging for EMDs to mentally process what kind of patient they are working with, even after asking all the right questions and data capturing all the right answers,” Althoff said. “Because of the Key Question design differences with Protocol 37, the EMD must be engaged as an extremely good listener and cautious to capture everything that could affect the resources and response mode sent."

These response options are significantly expanded in Protocol 37 depending on varied resources and patient needs, which introduces a significant responsibility for the EMD. Rules and Axioms help illustrate the types of resources assigned to each Determinant Descriptor to competently join into decision-making with the clinician caller.

For instance, “If unsure of the response level requirement after interrogation, [you] should ask the caller what type of response is needed” and you should “obtain and relay any special directions needed to locate the patient in a medical complex.” EMDs should also keep in mind that “a NURSE or DOCTOR with the patient is likely to give an accurate assessment of the patient’s condition.” However, “it is not necessary to seek permission from the NURSE or DOCTOR to upgrade the response level.”

The EMD’s active listening and communication skills are essential to handle these situations appropriately, and the IAED recommends including these calls in the random selection for audit review. A robust auditing process is necessary to determine whether EMDs are skillfully obtaining all relevant information and triaging calls with accuracy and consistency.

TRANSFER 
Obviously, a case involving TRANSFER requires you to participate in scheduling resources the patient needs rather than determining exactly what happened for EVALUATION. As indicated in the Rules on Protocol 37, “When a request for TRANSFER (not EVALUATION) is obvious, replace the Case Entry Question 3 with: ‘What is the reason for transport?’” In these cases, you may also augment the Case Entry Question to “Is there anything else we need to know about her/his condition?”

The expanded response options allow enhanced assignment based on evaluation levels at each Determinant Code level, which differs from the three acuity levels on Protocol 33. Protocol 37 provides these options in both the BLS (ALPHA) and ALS (CHARLIE) levels.

Closing patient transport cases 
Additional Key Questions for both EVALUATION and TRANSFER cases help you address specific needs during the transport including administering and monitoring medication and utilizing special equipment such as ventilators or aortic balloon pumps, some of which may require enlisting additional specially trained personnel. TRANSFERS may involve all types of patient conditions, and codes may be defined with higher or lower levels of care and transport capabilities depending on available resources. These resources range from minimally trained personnel utilizing wheelchair or stretcher vans to EMTs, Advanced EMTs, or paramedics in more conventional ambulances, to Critical Care Transport units or obstetric units staffed with highly trained clinicians. EMDs must record applicable information while also assigning the appropriate suffix to cater the appropriate response. Logistical questions are also available, when appropriate, to obtain agency-specific or jurisdictionally required information such as the referring clinician and/or patient name.

While handling multiple simultaneous facets (concurrent dispatching, waiting calls, and repeating scenarios), it’s easy to become complacent or rely on ProQA software to lead the way, but reviewing the Summary tab can help remind you of important considerations while assigning resources and closing out the call.

Both Protocols 33 and 37 have an option to provide applicable PDIs, including a fill-in-the-blank statement informing the caller of the type of transport on its way: “We will be sending a ______response.” This specification is agency defined, often determined as “routine” or “emergent” or “ALS” or “BLS.” However, this description can sometimes invite discussion from the medical professional.

“The moment you say ‘emergent’ response, our callers often say, ‘They don’t need to come emergent,’” Althoff said. “In our initial implementation of Protocol 33, we allowed downgrading, but it was so subjective amongst medical professionals. Our later analysis determined that to be the wrong decision. After reviewing the data, we found staying firm and following the protocol recommendation we jointly determined is best practice.”

Conclusion 
The purpose of these interfacility protocols is to offer a response mode and level based on a joint medical professional and EMD evaluation of the patient’s medical condition and transport needs. Ensuring effective communication with the reporting nurse or doctor is imperative to facilitate cooperation and appropriate patient care.

Patient transfers can be challenging calls for responders; therefore, your use of Protocols 33 and 37 to collect essential information enables responders to prepare to handle specific requests in the right way without delay. Your service can extend to patients who should never feel overlooked, even if considered routine.

For agencies who need more robust options for patient transports, the Medical Transfer Protocol Suite (MTPS), available as a stand-alone product as well as an adjunct to the MPDS, offers the following Protocols: 

• Protocol 45: Specialized Unscheduled Up-Care Transport
• Protocol 46: Scheduled Interfacility Transfer (Routine)
• Protocol 47: Mental Health Transfer

These Protocols are an excellent alternative to Protocols 33 and 37 that provide many more logic-driven and customizable options to meet the needs of agencies that deal with these types of transports on a regular basis. More information on the MTPS is available at prioritydispatch.net/en/medical-transfer-protocol.