Transfers were viewed as a core part of the work at community Emergency Departments and Intensive Care Units. Since transfers were a frequent occurrence, being an effective care provider in a community setting necessitated the ability to quickly identify patients that required more intensive care. Efficiently identifying which patients needed to be transferred enabled physicians and nurses to attend to the patients that their hospital was equipped to treat. Describing this dynamic, one nurse reported: “We always like when we’re transferring people because we’re saving beds for the other 10 patients that are waiting here in the ED. Everybody we transfer out is another bed that we have for an ED patient.”
Our analyses revealed that the transfer process contained four distinct components, as outlined in . These components were common across all sites, both ED and ICU. At all sites, protocolization of certain specific conditions simplified these challenges, but also served as a contrast to highlight the problems faced in the care of the large majority of non-protocolized patients. Patients did not always flow unidrectionally through the processes—most prominently, challenges in negotiating the transfer might force the identification of a new destination hospital.
Key Components and Recurrent Issues in the Transfer Process a.
Identifying Transfer-Eligible Patients
For patients who presented with a select set of conditions, highly protocolized care was in place to rapidly determine whether these patients needed to be transferred, and if so, the transfer destination. Respondents at all three hospitals noted with pride that new protocols designed to identify patients presenting with chest pain had streamlined the process for determining which patients are transfer-eligible, particularly focusing on the rapid identification of ST-elevation acute myocardial infarctions (STEMI). All hospitals reported similar routines, such as one nurse described:
If they walk in the door up front and they’re complaining of chest pain, we immediately take them by wheelchair to [a room]. Usually have 2–3 staff that will come in [to] immediately get them set up for an EKG. Everybody is simultaneously putting them on oxygen, getting aspirin, monitoring [the patient] and getting the EKG in the doctor’s hands within ten minutes. Once the doctor’s seen the EKG, they usually are on the phone to get them transferred straight to the Cath lab [at another hospital].
In contrast, respondents were less able to articulate the way in which patients with a non-protocolized condition are identified as candidates for transfer. Patients were primarily designated for transfer because the hospital did not have the capacity to either treat the condition itself or complications that might arise from treatment. Yet, the identification process could be fraught with ambiguity or disagreements. ED physicians described often being caught between local admitting services’ refusal to accept their patient and the receiving hospital’s belief that the patient should not be transferred. An ED attending described a common situation:
[For MIs] it’s more cut and dried because we don’t have a cath lab, so if somebody’s actively having an MI, we can’t do anything for them, they have to get out of here. Other things are more subtle, because our doctor might think it’s okay for them to be admitted [here] but the admitting doctor [does not] want to take the patient because they think [she] is too complicated [or] there may not be an ICU bed.
There is some evidence that the patient identification process considered non-medical issues in identifying candidates for transfer. At 2 sites, regardless of the nature of their condition, patients with a select insurance plan had to be transferred to the plan’s designated hospital. It was also suggested that a patient’s age was used as a criteria for assessing whether a patient is a candidate for transfer, with less aggressive care for older patients and vigorous transfer efforts for unusually young patients.
Identifying a Destination Hospital
Protocols at 2 of the 3 hospitals dictated the particular hospital to which patients with protocolized conditions would be transferred—direct links to specific cardiac catherization labs for patients with ST-elevation AMIs were an example. For patients who did not fall under such protocols, institutional arrangements routinely dictated the hospital to which a patient transfer would first be attempted, but the nature of those arrangements varied. At Site 1, formal ownership dictated that nearly all transfers were sent to the owning hospital—and there was explicit discussion of “keeping the monies in the family.” A nurse described the selection of a receiving hospital this way: “If it can’t be done here, then we’re a feeder hospital to the hospital” which owns Site 1. In contrast, despite recently-established formal ownership at Site 2, patients were routinely transferred to two proximate tertiary care hospitals without clear preference—but primarily to those two hospitals. At Site 3, a referral center had actively cultivated a relationship as a receiving hospital within a broader quality improvement agenda. While that quality improvement work nominally focused on only a single condition, the relationship extended broadly whenever a transfer for any condition was needed. A nurse described the fidelity to the receiving hospital of choice:
I mean we choose between [Referral Site A] and then [Referral Site B] but really…we’re basically straight to Site A… If it was emergent and Site B could handle this and they could get there quicker for some reason, we would definitely do that if it wouldn’t, you know, hinder care, but 99% of the time, 99.9% of the time, it’s Site A.
In the face of such routinization, we found little evidence that patient-centered factors played a decisive role in the hospital selection process for either protocolized or unprotocolized patients. Patient preferences and pre-existing doctor-patient relationships were offered cursory—if any—discussion. There was no discussion in any interview of the comparative quality of care at different hospitals to which the patient might be referred, despite explicit probing about the role of quality indicators and other hospital characteristics in the choice of transfer destination. As noted above, a patient’s insurance could play a determining role in where the patient was transferred—and insurance was sometimes seen as slowing the process of a necessary transfer or as routing the patient to a more distant, but not necessarily better, hospital.
Of course, not all transfer requests were accepted—although participants asserted that this was for only a small minority of patients.
Negotiating the Transfer
For the patients with indications for transfer that were protocolized, those protocols typically included a simple process for insuring that the patient was accepted in transfer by a designated hospital. In contrast, for transfer indications that were not well protocolized, an important part of the transfer process was negotiating whether or not the patient actually needed to be transferred. This typically occurred between medical staff, and was frustrating and time consuming. An illustrative example is quoted at length as . Frankly put, community hospitals routinely needed to convince the accepting hospitals that the patient was not a “dump” (a transfer of patient who could be appropriately cared for at the community hospital)—with the frequent implication that community hospitals were being lazy or inept.
Report of Challenges of Negotiating a Transfer
Before such a negotiation could occur, however, an accepting physician needed to be identified. Often this task could not be delegated to clerical staff at the community hospital—the clerical staff at the potential receiving hospital required detailed clinical information before they would contact their own medical staff. Staff complained of personally waiting on the telephone, as they were required to speak directly with physicians at the receiving hospital site to ensure acceptance for their patient.
Common to all sites is a discrepancy between bureaucratic and clinical expectations for a “timely” response. A ten or fifteen minute delay between returning phone calls or requests for information may meet standards for being highly responsive in many settings. However, with an acutely unstable patient, such delays were reported to be profoundly challenging for the health care providers. An Emergency Physician described her role in caring for patients in need of transfer as often waiting by the phone to ensure that all the information was given to make the transfer possible—rather than being at the bedside of the patient so sick they needed more intensive care.
Accomplishing the Transfer
After a patient was accepted for transfer, community hospitals still faced at least 3 barriers to actually getting the patient to the receiving hospital.
All sites reported conflict with the Emergency Medical Service (EMS) transfer teams, as well as difficulties with the availability, timeliness and skill level of ground transportation systems. A nurse complained that patients “can sit here for 45 minutes waiting for us to …get the helicopter here, to find the MICU [ambulance].” Basic EMS teams often had policies or practice against the transport of patients with who were perceived to be unstable, despite the fact that such instability might be the thing that required transfer – and providers belief that such transport would be safe. Advanced EMS teams were seemingly in short supply. Aeromedical transfer was sometimes used because the crews were perceived to be more likely to transport the critically ill patient, rather than some specific aeromedical need.
Once a receiving hospital was arranged, patients needed to be converted to dosings and medications acceptable to the receiving hospital. These included not only vasopressors, but antihypertensives, anticoagulants, and antiplatelet agents. Site 3 had protocolized these regimens as part of the acceptance processes for STEMI, and nurses noted that “that really helped, having everything just be laid right out for you,” particularly given the time pressures of many transfers.
Finally, all the information compiled by the sending hospital needed to be rapidly transmitted with the patient—a process made more difficult by a lack of interoperable electronic medical records. At these sites, transfer involved extensive photocopying of documentation. Although usually undertaken by administrative staff, this often took substantial input from nurses and physicians.