I recently cared for a patient with severe burns. His physician refused to approve a transfer from this community hospital to a nearby teaching hospital with a burn unit, and the patient ultimately had a poor outcome. Could a hospital be held liable for harming a patient if the patient got the best care the hospital can deliver-but he could have gotten better care elsewhere?-B.R., CALIF.

If the patient (or the patient's family) could prove hospital administrators knew that the facility couldn't provide safe and reasonable care and that thehospital was negligent in not transferring the patient to a nearby facility with the necessary expertise, the hospital could be held responsible for the patient's "poor outcome." In general, hospitals must rely upon the professional judgment and expertise of their physicians and nurses. But even if the hospital isn't involved in clinical decision making, it usually shares legal responsibility with physicians who use poor judgment or don't provide appropriate care.

If you believe strongly that your patient needs care that he can't get in your facility and another option is available, communicate openly with the treating physicians and your nurse manager. Be prepared to go up the chain of command, if necessary.

Every hospital should have a policy and procedure on transfer criteria for burn victims, based on criteria from the American Burn Association and the American College of Surgeons. If your facility doesn't have such a policy, this incident should spur you and your colleagues to create one.