TRANSFER MEDICINE is now one of the hottest topics in hospital medicine. That’s due in part to a rapidly growing recognition of just how complex transfers can be—and how much around them can go wrong.
Another driver: Hospital beds, both during and since the pandemic, are at a premium, and hospitals now need to exercise tighter oversight over the number and type of transfers they accept.
“In the past, we’ve had the capacity,” says Michael Hendricks, MD, assistant medical director of hospital medicine at Oregon Health & Science University in Portland, Ore. “But we’re at a point where we’re on divert almost every day, with an extensive waiting list, and if we accept one patient, we literally can’t accept another. If we choose wrong, we may be depriving someone of care who really needs it.”
“We are starting to realize that transfer medicine requires a distinct skill set, quite separate from clinical medicine.”
Michael Hendricks, MD
Oregon Health & Science University
As described in a case study published in the November 2023 NEJM Catalyst, Dr. Hendricks and his colleagues launched what OHSU calls an intake hospitalist service. That service includes a group of dedicated, specially-trained hospitalists who manage all interhospital transfers as well as all direct admissions and intrahospital transfers, including ICU step-down, to both OHSU’s academic center and its two affiliated community hospitals. While working that service, doctors take on no other clinical or educational duties.
“We are starting to realize that transfer medicine requires a distinct skill set, quite separate from clinical medicine,” says Dr. Hendricks, who thinks of transfer medicine as a fledgling specialty. “One of the errors we’ve made in the past is basically treating those two skill sets as interchangeable.”
As medical director of the intake hospitalist service, Dr. Hendricks points out that adopting the service line also ushered in a significant cultural shift.
“Many hospitals have held the philosophy that we should be accepting every transfer request because that’s what’s good for patients and for our relations with outside hospitals,” he points out. “But we’re starting to realize that being transferred isn’t always what patients need. Quite often, it’s the opposite.”
Making the case
A growing body of research—much of it led by hospitalist Stephanie Mueller, MD, MPH, with Boston’s Brigham & Women’s Hospital—has laid out many of the problems related to transfers. Those include higher complication rates, longer lengths of stay and poorer outcomes.
Moreover, the way the hospitalists at OHSU traditionally handled transfer requests was a big job dissatisfier for them. All hospitalists used to take turns managing those requests during their long call shift on the teaching service. Because the group rotated more than 50 doctors through that shift in any given year, it wasn’t feasible to give them all special training in managing transfers.
“Some of them fielded more than 10 transfer requests a day and could spend four or five hours on the phone,” Dr. Hendricks points out. “That prevented them from being able to round or address the learning needs of the residents working with them.”
At the same time, transfer guidelines and criteria weren’t standardized, and transfer management varied widely across specialties in the same hospital and even among doctors within the same specialty group.
The solution: Train a cadre of doctors to focus on all transfer requests, standardize the work (and the documentation) around transfers, and build in checkpoints both before and after every transfer.
Dr. Hendricks and his team sold the concept to administration on being able to maximize patient safety and improve bed utilization and physician satisfaction. In the three years since the service was launched in January 2021, the cost of the program has also been offset by being able to backfill inpatient beds with higher-complexity patients.
Intake hospitalist role
Before the intake hospitalist position was created, OHSU at least had much of the transfer infrastructure it needed: a transfer center set up with a multidisciplinary team that included transfer center RNs, emergency transfer coordinators, an RN bed flow manager and a case manager, in addition to a recorded transfer line.
“But we needed someone with the medical expertise to decide which transfer patients needed to come here, when they needed to arrive and where they needed to go within our system,” Dr. Hendricks says. “That’s where the medical savvy comes in, and it requires being comfortable with uncertainty.” It also requires deep knowledge of an institution and health system.
“We now cover hospitals that have incredibly variable staffing patterns for certain specialties and procedures,” Dr. Hendricks says. “The ability to obtain a specific procedure may be based not only on the day of the week but also on which attending is on call.”
Sixteen hospitalists now rotate through the intake position, each working a 14-hour shift (7 a.m.-9 p.m.). (One of two nocturnists manages transfers overnight.) If their shift time isn’t filled with transfer requests, intake hospitalists also do quality review as well as administrative work, which could include triaging all medical admits as well as screening patients for partner hospitals or for the hospital at home virtual unit.
All intake hospitalists have at least three years’ experience taking transfer calls. They also all complete a five-hour onboarding curriculum, which stresses guidelines for triage and for challenging transfer cases.
The intake hospitalist on duty also takes part in three daily interdisciplinary huddles, the first of which is with transfer center personnel to prioritize the transfer wait list. The second huddle deals with hospital-wide capacity, while the third entails system-wide capacity.
HOW SUCCESSFUL has Oregon Health & Science University’s intake hospitalist service program been? Read how the group has tracked several metrics to determine whether or not it is reaching its goal.
Phyllis Maguire is Executive Editor of Today’s Hospitalist