Home On the Wards Not all transfer patients are created equal

Not all transfer patients are created equal

September 2011

Published in the September 2011 issue of Today’s Hospitalist

WHEN CAN’T YOU AVOID A TRANSFER PATIENT? If you’re new to hospital practice, you might think that sounds pessimistic. You’re flattered that the transferring doc thought enough of you to request your help, you’ve decided which consultants to use and the problem sounds challenging. What’s not to like?

Hold your enthusiasm. Just how much do you really know about this patient? When is he or she likely to arrive, and will a med-surg bed be OK? Or would the ICU be more appropriate?

Let’s face it: Every transfer patient is at least partly an unknown entity. Here are a few situations that can ruin the patient’s day “and yours in the process ” with some suggestions on how to avoid them.

From one professional to another
The one person you absolutely must talk to is the physician (or sometimes a PA or NP) who has been providing most of that patient’s care. If the attending doctor has turned things over to a consultant who can summarize the patient’s condition thoroughly, get your information there.

But calls from a hospital administrator who is trying to do a friend a favor, an insurance company representative who knows that hospitalists help control costs, or anyone not directly involved in the patient’s care should not be the basis for accepting a transfer.

While you’re getting your clinical information from someone reliable, take complete notes “and then call your hospital’s admitting office or transfer center to accept the patient. You will avoid accepting someone whom no surgeon in your facility can help, and you will have an ICU bed reserved if necessary. You will also have a good idea of where to start once the patient arrives.

The midnight surprise
You talked to the transferring doctor at 10 a.m. Your consultants are primed for action, and the ICU nurse manager has a room set up with all the right equipment.

But now it’s 5 p.m. and the other hospital still hasn’t even called the ambulance, much less given a report to your nurses on the patient’s condition. Do you (a) hang around the nursing station playing Word Mole on your smartphone; (b) pass on the information to a night doctor who expects to spend the whole evening in the ED; or (c) cancel the transfer?

I suggest (d): Call the other hospital and postpone the transfer until tomorrow.

Several hours have now elapsed between the transferring doctor’s call to you and the patient’s arrival at your end. The patient may have improved enough to go to a regular bed, or the surgery may no longer be appropriate. Or “and yes, this does happen “the patient is so much worse now that he arrives at 2 a.m. with no measurable blood pressure or agonal respiration.

Keeping the patient at Elsewhere General until daylight is often your safest bet. He will stay where the doctors know him. And if he gets worse, either the problem can be handled there or the transfer can be done faster. When you call the doctor to ask to wait until tomorrow, it notifies him that the patient is still his responsibility. Plus, your rapid response team has a peaceful night.

Which transfers do you have to take?
Your hospital’s admissions office will often tell you to wait until they can check a transfer patient’s insurance coverage before accepting him or her.

Federal regulations, particularly the Emergency Medical Transfer and Active Labor Act (EMTALA), dictate when that hospital policy can and should be bypassed. The exceptions are emergencies or elective situations in which the transferring institution cannot provide necessary care. An example would be if the only two ICU beds at that other hospital are full or if there’s no neurosurgeon on that staff.

A patient with infected wounds needing plastic surgery doesn’t have to be loaded into an ambulance right this minute, but the guy who was just intubated by the mini-hospital’s ED doctor does. If a hospital is asked to accept that transfer patient and has the necessary equipment and specialists, it is obligated to accept him “and so are you.

The same goes for a lady who arrives with contractions three minutes apart; she is in active labor and cannot be transferred elsewhere unless she is in some high-risk situation. In that case, she has to go to a tertiary care hospital.

Document, document, document
I am sorry to say that not all transfers are motivated by concern for patient care. The administrators at the other hospital may be pressuring the doctor to "lose" an uninsured patient, or the patient’s family may want a more prestigious tertiary care hospital. Or family members may just want a more convenient location, or an insurer may cover only a few hospitals in your area.

Be sure to state in your own records the reason the transferring doctor gave for the transfer. Did he or she assure you that the patient was stable, which turned out to be untrue? Document that too.

I practiced in one tertiary care hospital where the nurses in the transfer center not only participated in the doctors’ conversations via conference call, they recorded them. When a misleading statement from a transferring doctor led to problems, the recording protected the doctor on the receiving end from having to face a medical board or a jury.

On the plus side
Look at it from the patient’s point of view: Hospital #1 didn’t have the necessary resources, but hospital #2 has this fine hospitalist and everything needed to help. The patient and family arrive believing that you and your consultants are well qualified and will take good care of them. That’s a nice change from some of the ED patients who view you as some hospital flunky who just happened to be on call when they came in.

Accepting transfer patients can build your reputation and expand your practice, as well as make points with administrators, insurers and consultants. Taking precautions to ensure quality handoffs and a good exchange of information will protect patients from both small and large disasters, and avoid big problems for your group.

Stella Fitzgibbons, MD, has been a hospitalist since 2002. She spent six years receiving transfers at a large tertiary care hospital, and is now happy to work in a smaller hospital where more transfers go out than in.