Home Handoffs/Transfers A dedicated service ensures more appropriate transfers

A dedicated service ensures more appropriate transfers

Tracking metrics and declining transfers

January 2024

See Part 1 of this article here: How hospitalists can better manage transfers

HOW SUCCESSFUL has Oregon Health & Science University’s intake hospitalist service program been?

To measure its success, the group has tracked several metrics including the number of RRT activations and transfers to an ICU within 24 hours of a transfer patient arriving at one of the system’s hospitals, to measure how many of them are unstable when they arrive. (Post-intake hospitalist, that percentage fell from more than 5% to less than 1%.) Michael Hendricks, MD, assistant medical director of hospital medicine at OSHU in Portland, Ore., and his team also track the number of transfers that arrive with incomplete (or missing) medical records, which dropped from more than 17% to just over 1%.

Another metric followed for patients being transferred for a procedure: arrival-to-procedure time. That time decreased from 51.3 hours to 35.3 hours.

“Maybe making an immediate transfer decision isn’t the best thing.”


Michael Hendricks, MD
Oregon Health & Science University

Then there are unnecessary transfers, defined as transfer patients who ultimately don’t receive the procedure, consult or study they were ostensibly transferred to receive. That percentage fell from 15.3% to 2.6%.

Outreach to referring hospitals
Importantly, Dr. Hendricks points out that OHSU’s percentage of transfers deemed inappropriate dropped from 15% to only 3%.

“But that statistic might sound different when you’re trying to explain it to a hospital that isn’t sure it can care for a particular patient, and the referring clinicians are scared,” he adds, noting that OHSU is the sole academic center in a state where 40% of all hospitals are critical access. When launching the intake service, he did a lot of outreach through regional transfer meetings and talked to a lot of CMOs from hospitals around the state.

What helped reassure referring hospitals was the amount of time the intake hospitalists, when declining a transfer, put into arranging rapid outpatient follow-up and consults or a procedure-only alternative. (See “A procedure-only pathway,” below.) In addition, they help referring hospitals continue to treat patients locally.

“We also allow hospitals to send pathology and scans even if patients aren’t being transferred, so they feel well-supported,” he says.

The pandemic and its chronic bed shortages also brought about another change in the thinking around transfers.

“We realized that at the time of the transfer request, we really don’t know what trajectory a patient may take,” he explains. “Because we had such long waitlists, we began to understand that many patients who couldn’t be immediately transferred were able to improve just staying where they were.”

That reasoning has remained in place post-pandemic. “Maybe making an immediate transfer decision isn’t the best thing,” says Dr. Hendricks. Now, when a referring hospital requests a transfer, “it’s a frequent opportunity for the intake hospitalist to say, ‘First, try these three things.’ ”

As a result of tighter transfer oversight, OHSU saw its case mix index increase by one-third, corresponding to about a 60% jump in reimbursement.

Building a program
If your hospital is considering ways to improve the transfers it accepts, Dr. Hendricks says to first assess your needs. How many transfer calls does your department receive, and does the doctor taking those calls have a safe workload to triage those requests?

Certainly, not all hospitals will have the volume needed to actually dedicate physicians. But some interventions can still improve the safety and appropriateness of transfers, even if an intake hospitalist isn’t the answer.

“For the person fielding transfer calls,” he points out, “make sure they have some protected time by, say, giving them a lower census that day. You also need to acknowledge that transfer medicine is important, it has a significant impact on a patient’s care, and it takes time to do safely and well.”

Also, work with specialists to standardize the templates used to determine inclusionary and exclusionary criteria for transfers, as well as preop guidelines for procedures. Standardizing documentation is also key, allowing clinicians to understand a transfer patient’s relevant history and reason for being transferred.

Read how the hospitalist medical department at OHSU sold the concept of an intake hospitalist service to administration by maximizing patient safety and improving bed utilization and physician satisfaction.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

A procedure-only pathway

One of the transfer alternatives that Oregon Health & Science University (OHSU) in Portland, Ore., now offers some patients from outlying hospitals who need certain procedures is a “procedure-only” pathway. Those patients—who can’t be too medically complex—come to OHSU’s academic center for a procedure without being formally transferred. Once the procedure is finished, they return to their referring facility.

“We’re trying to grow that program, and we’re getting to the point where we’re doing one or two a week,” says Michael Hendricks, MD, medical director of OHSU’s intake hospitalist service, which manages all transfer requests. “We hope to get to the point where we actually start budgeting time in proceduralists’ schedules for procedure-only transfers, particularly in cardiology and GI.”

Dr. Hendricks and his team decided to develop the option after seeing how long transferred patients often stayed in the hospital post-procedure.

“Their average length of stay was about eight days,” he points out—days when those beds can now go to other patients. At the same time, because these patients don’t need an inpatient bed, they can get the procedure they need in about half the time it would otherwise take.

But “the biggest impediment to growth is the types of infrastructure—transportation, billing and legal contracts—you need behind the scenes,” Dr. Hendricks says. Unfortunately, hospitals don’t have any single legal document that they can create and use with different hospitals for procedure-only transfers.

“Instead,” he adds, “you have to create an agreement with every hospital that refers patients for procedures only—and that’s been a huge barrier to expansion, not only for us but for hospitals around the country.”

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