Transfer Guidance: Skilled Nursing Facility to ED

Transfer Guidance: Skilled Nursing Facility to ED

March 19, 2020

Dear partners in the post-acute and long term care community,
To support our patients and residents in the community, avoid overwhelming our Emergency Departments, and prioritize the care for those who need inpatient support, we are proposing the following protocol, summarized below with further detail at the end of this letter:

  • Mild Risk: manage all patients/residents at home/facility
  • Moderate Risk: manage all patients residents at home/facility if able to perform close monitoring.
  • High risk: transfer the patients/residents to the hospital

MedStar requires the facility physician/medical director to contact the corresponding MedStar ER (provider to provider), and have the standard ED transfer form filled out, indicating that this is a potential COVID 19 patient.

Thank you for your support and cooperation during this challenging time.


George Hennawi, MD

Interim Executive Director, MedStar Geriatrics

Criteria for Management of a Potential COVID-19 Resident or Transfer to an Acute Care Unit or Emergency Department

  1. It is recommended to Isolate the Resident in his/her room once COVID-19 is suspected or confirmed.
  2. Personal Protective Equipment (PPE) should be used at all time by the staff who would care for this resident with other precautions as described by CDC at
  3. Once a resident is identified with COVID-19, he/ she should be assessed and treated regularly (2 to 4 hours depending on the severity) with Vitals, Pulse Oximetry and Over all symptoms.
  4. Resident should undergo Risk Stratification based on the Risk Factors present.
    • Mild Risk: Mild or no symptoms, Age <65. Not residing in a nursing facility.
    • Moderate Risk:
      • Mild to moderate symptoms like myalgia, fever, cough, occasional shortness of breath
      • Age >65 years III.
      • Chronic Illnesses and Co-Morbidities like Heart Failure, COPD, Diabetes, Renal failure with or without Dialysis
      • Immunocompromised status or taking Steroids or Immunomodulator therapies
    • High Risk:
      • Risk factors as of above (Moderate risks)
      • Uncontrolled symptoms
      • Unstable Vitals not responding to in-house treatments
      • Acute change in cognition
      • Persistent low pulse ox not responding to oxygen
      • Acutely developing pneumonia which is not being controlled at the facility despite of the current therapy VII. Other signs or symptoms which may cause severe morbidity and mortality
  5. To prevent the spread of COVID-19 it is best recommended to identify and treat residents at the origin location of residence (Homes, Independent Living, Assisted Living or Long-Term Care facilities). Transfer to the hospital is recommended only if the resident symptoms and condition becomes uncontrolled and life threatening.
  6. It is suggested to continue ongoing Advance Care Planning discussion including but not limited to life sustaining treatments like CPR, Intubation, Bi-Pap, C-Pap, Acute of Chronic Dialysis, Artificial Nutrition and hydration and Transfer to the Hospital while carrying Goals of Care discussion with the Residents and their families.
  7. It is recommended to visit CDC website and contact with your Local State Health Department if you have suspected or diagnosed resident / patient/ Staff with COVID-19 for further treatment and management. Key is to prevent the spread of the virus as much as possible.

More details can be viewed on