6. Hospital administrations from both facilities endorse transfer agreement. 7. Transferring and receiving facilities establish a rigorous protocol for rapid transfer of patients, including the proper personnel with appropriate experience. 8. A transport provider is available to begin transport within 20 min of the request and provide vehicle/helicopter with necessary life-sustaining equipment, including IABP and monitoring capability. 9. Transferring physician obtains consent for surgery from patient or appropriate surrogate. 10. Initial informed consent for PCI discloses that the procedure is being done without on-site surgical backup and acknowledges the possibility of risks related to transfer. The consent process should include the risk of urgent surgery (approximately 0.3%) and state that a written plan for transfer exists. 11. As part of the local continuous quality improvement program, a regular review of all patients transferred for emergency surgery with the outcome of surgery and identification of any improvement opportunities. IABP indicates intra-aortic balloon pump; PCI, percutaneous coronary interven- tion; and SCAI, Society for Cardiovascular Angiography and Interventions. Adapted with permission from Dehmer et al.352 Table 7. 