A physician at a community hospital was trying to transfer one of her patients to Johns Hopkins Hospital for a liver transplant evaluation. Although a hepatologist at the Baltimore-based medical center had already reviewed the patient's labs and determined that an on-site evaluation was not warranted, the community hospital physician—feeling pressure from the patient's family—called the hospital's transfer center anyway.
It was up to the hospitalist on call at Johns Hopkins that day to make the final decision.
“I ended up not accepting the request because our hepatologist felt the patient wouldn't benefit from being moved and would improve with time—which is what ended up happening,” said Carrie Herzke, MD, FACP, clinical director for Johns Hopkins' hospitalist group, which handles all general medicine transfer requests. “We understood the community [hospital] provider's concern, but also [felt] that this patient shouldn't take one of our last remaining beds if a transfer isn't warranted.”
Balancing the interests of transferring and receiving hospitals while optimizing care for patients is a significant challenge. Large hospitals often have established protocols and dedicated staff assigned to handle requests and triage patients to the correct specialty and level of care. In smaller systems, the role might be filled by several on-call specialists, including physicians and advanced practice providers.
Either kind of hospital faces the problem that there are no universal standards or evidence-based guidelines to help clinicians decide which patients are most likely to benefit from being moved.
“Hospital transfers are a necessary resource for connecting patients to appropriate care that isn't available in their local facilities,” said Stephanie Mueller, MD, assistant professor of medicine at Harvard Medical School and a hospitalist at Brigham and Women's Hospital in Boston. “However, transferring often very sick patients between care providers and systems heightens the risk of bad outcomes, and currently we have no clear guidelines on when transfers are necessary and when they are potentially harmful.”
Transferring patients between hospitals is a complex process that presents issues for all involved.
For patients, there can be higher risk of mortality or adverse events and increased length of stay, according to an April 2016 study published in the Journal of Hospital Medicine (JHM) that compared outcomes between patients who were and weren't transferred. After adjustment, patients who were transferred had 36% higher risk of dying in the hospital.
For clinicians on either side of a transfer, lack of standardization is a major obstacle. The transfer process remains highly variable among institutions, according to a study of 32 U.S. tertiary care centers, published in the June 2016 JHM. Less than a quarter of the hospitals had interoperable electronic health records (EHRs) and only a slightly higher fraction (28%) required any kind of clinical documentation to arrive before the patient.
At Cleveland Clinic, a hospitalist serves as transfer specialist or “quarterback” for the general medicine service, said Christopher Whinney, MD, FACP, chair of the department of hospital medicine. When a call comes into the transfer center, the quarterback is conferenced in to speak directly with the referring clinician.
That conversation determines whether or not to transfer, and if so, whether patients can best be accommodated at the main campus or at one of Cleveland Clinic's nine affiliated regional hospitals, said Dr. Whinney.
“Having a hospitalist fill this role is critical so we can quickly clarify the goals of care and determine whether we have the resources available to accept the patient,” he said. “It requires a high level of diagnostic acumen, clinical judgment, and situational awareness.”
Not all hospitalists are suited to the role or want to do it, he added. “We're very careful in who we select as quarterback as it requires exceptional emotional intelligence and communication skills,” he said. “However, it can be a tremendous opportunity for the right person because they get to have an impact on the throughput of the hospital and be the first conduit for getting new patients into our system.”
Those who serve as a transfer point person should be empathetic without sounding condescending or offering false hope, said Dr. Herzke. They must also be helpful and informative while staying mindful of legal concerns.
“I am legally responsible for advice I give on the phone, but I can't see the patient,” she said. “I have to rely on the interpretation of an outside provider who I don't know and who doesn't know me. It can be tempting to offer medical advice, but I have to be measured in how I do that because I am not actually taking care of this patient.”
It's important to remain calm as emotions can run high during transfer calls, she added. For example, the family of a patient with a very serious or terminal condition might push for a transfer even though experts have determined that it won't change the patient's prognosis.
“I really feel for the referring provider in these cases because we usually can't take these patients. . . . It's important for the receiving provider to empathize with the referring physician's situation and compassionately explain their thought process,” said Dr. Herzke. “We don't like to pull a patient far away from their family and support system only to tell them that we don't have anything different or better to offer than what they can get at their local hospital.”
Transfers without benefit
A receiving hospital's inability to offer any additional benefit is a common issue with transfers, according to research.
In his role as executive director for clinical operations with Pittsburgh-based TeleTracking, which develops automated patient flow systems, Scott Newton, DNP, RN, tracks what happens to transferred patients after they arrive at a tertiary center. His analysis has revealed that 20% of patients are discharged within 24 to 48 hours without receiving any procedure or intervention.
“The question of why patients are transferred is difficult to answer because there is no one central place where providers are documenting the underlying reasons,” said Dr. Mueller. “It is still largely a nonstandardized process.”
A study led by Dr. Mueller and published in the June 2018 JHM found that between 32% and 89% of transferred patients did not receive any associated specialty procedure at the receiving hospital. These patients may have been transferred for other reasons, such as comorbidities, hospital location, prior relationship with the hospital, or desire for a second opinion, the authors noted.
However, the explanation for a transfer might sometimes be as simple as first come, first served. A recent analysis of one regional transfer network, published in the January 2018 Joint Commission Journal on Quality and Patient Safety, found that surgeons at the tertiary center automatically accepted all patients referred by the outlying hospitals, regardless of outcome or resource considerations. Transfers were refused only when the hospital ran out of beds.
In such systems, care is not always fairly distributed, said study coauthor Michael Ward, MD, assistant professor of emergency medicine at Vanderbilt University Medical Center in Nashville, Tenn. Referring surgeons, who may be feeling pressure from families, might seek to transfer dying patients in order to exhaust treatment options, even when the benefit is uncertain, he suggested. Meanwhile, beds are denied to patients who have the potential for better outcomes.
The involvement of an appropriate specialist—a hepatologist in the case of a potential liver transplant, for example—in the transfer discussion can help avoid this problem, the experts recommended. This also adds credibility to the transfer decision and reassures transferring clinicians, patients, and families that the right decision is being made.
At Mayo Clinic in Rochester, Minn.—which gets transfer requests from all over the world—admission transfer officers try to get as much information as possible before a patient comes to the hospital, said James Newman, MD, MHA, MACP, a hospitalist and founding medical director of the clinic's Midwest Admission and Transfer Center.
In addition to medical data, details requested before nonurgent transfers include patients' insurance and social support. “It's better to let people know up front whether their insurance covers care at our facility so they aren't surprised by a bill down the road,” he said. “If they are traveling far from home, it's important to know if they will have family or friends around, especially if they have problems with cognition or are not capable of making medical decisions on their own.”
While gathering information is important, physicians handling transfer conversations should also strive for efficiency, recommended Dr. Ward. “Our research has shown that the highest-quality calls are ones where the physician is able to quickly evaluate a case, and are actually shorter. This is a somewhat counterintuitive finding but suggests that the quality of communication doesn't need to be sacrificed for efficiency's sake,” he said.
To speed the process, physicians considering transfer requests also need a handle on their own hospital's situation. “It's important for the receiving physician to understand at the outset of a call if the hospital is at capacity,” said Dr. Newton, who has also worked in Johns Hopkins' Lifeline Critical Care Transport Program. “You might be willing and able to take care of the patient but if you don't have a place for them, it's important to say that up front so the referring provider can start thinking about alternatives.”
He noted, however, that it's not always possible to assess bed availability in real time.
In receiving hospitals that do not have a transfer team or center, even more basic information, such as clear instructions on how to initiate a transfer, may be lacking, said Dr. Mueller. During interviews conducted as part of her research, referring clinicians often report that they have trouble figuring out who or what number to call with a transfer request.
Once a call is received, there can be internal system issues or poor workflow processes that make it difficult to track down the appropriate specialist responsible for accepting the patient, such as a surgeon, she said. Similarly, there may not be a structured way of exchanging essential clinical data.
“Not having efficient workflows can delay transfers or impact decisions,” said Dr. Mueller. Templates and checklists can help ensure that essential information is collected and recorded during the call and communicated to key people in the receiving hospital, she suggested. “Requiring providers to fill out certain fields in a standardized note directs the conversation so that essential pieces don't get left out.”
Another major challenge on calls is developing a “shared mental model” of the patient without the benefit of common EHRs, said Dr. Herzke. “It's much harder to make a decision when I can't see the trajectory of a patient's care and am depending on an outside provider to interpret the data for me.”
In order to improve transfer practices, hospitals need data on how they work out, and that information is problematically rare, according to the study in the June 2016 JHM.
“The most consistent finding of this survey was the lack of common processes to improve outcomes. Simple interventions, such as regular clinical updates, documentation of the handoff process, and obtaining objective information early in the process, were inconsistently adopted,” the authors wrote. “Approximately half of the hospitals surveyed specifically tracked outcomes of transferred patients, and a minority had systems in place to provide feedback to referring centers.”
At Johns Hopkins, Dr. Herzke analyzes outcomes of transfers, such as whether patients were triaged to the correct level of care upon arrival. However, there is no formal process for tracking outcomes of all transfers. “For busy clinicians, it takes a fair amount of effort to follow up on what happened to a patient,” she said. “There's not a lot of feedback either way.”
At Mayo Clinic, a transfer quality committee reviews transfer cases, including all in which the patient died or a clinician flagged a problem, as well as overall transfer volumes and patterns. “Feedback is given to the referring facility or our own providers,” said Dr. Newman.
Cleveland Clinic uses a web-based tracking tool that syncs with its EHR system to track patients' movements after arrival, so they don't get lost in the system, said Dr. Whinney. Calls to the admission and transfer center are recorded and used to provide feedback to quarterbacks on areas for improvement.
Major EHR providers have begun to introduce information-sharing tools so that clinicians can view patient records across facilities, said Dr. Ward. However, such tools are not yet widely available and are only useful in individual cases—the data cannot be extracted for research that might inform best practices and lead to more standardization.
“We're just at the beginning of technological advances in this area—for now, most providers handling transfers are dealing with stacks of paper records, which is incredibly time-consuming,” he said. “Information fragmentation is a real challenge to making the process run more efficiently.”