Published in the October 2016 issue of Today’s Hospitalist
MANY HOSPITALISTS struggle daily with interhospital transfers. But a new study of several dozen tertiary care facilities in the U.S. suggests that the risks to patients of poorly orchestrated transfers are a much bigger issue than the hassle for doctors.
Led by researchers from New Jersey’s Rutgers-Robert Wood Johnson (RWJ) Medical School, the study found that transfer practices and requirements varied so widely that “there appear to be no standards,” says lead author and hospitalist Dana Herrigel, MD. At the time she was involved with the research, which was published in the June 2016 Journal of Hospital Medicine, Dr. Herrigel was associate director of the RWJ internal medicine residency program.
“We were expecting more consistency and a more regimented process, especially in critical care transfers,” says Dr. Herrigel, who is now a senior associate consultant in hospital medicine at Mayo Clinic Jacksonville in Florida. “But it was truly all over the map.”
“There appear to be no standards.”
One example: Hospitals’ acceptable timeline of clinical status updates on prospective transfer patients ranged from every two to four hours (in 13% of centers studied) to every 24 hours (38%) to—in 19% of cases— none at all.
Most institutions (81%) did require a three-way recorded discussion between transfer-center staff and referring and accepting physicians. Yet key clinical data—current labs, imaging, H&Ps and progress notes—were available in only 29% of hospitals, while 77% didn’t extend that three-way conversation requirement to include bedside nurses.
And in many cases, the quality and timeliness of the information varied widely as well. Dr. Herrigel cites one critically ill transfer patient whose accompanying record stated, “Patient was treated with strong antibiotics for resistant infection,” without detailing the agent or the infection. In some cases, imaging reports were supplied without any actual images, and some receiving facilities were not provided the most recent vitals or key status changes.
Further, only 32% of hospitals used their EHR to document a transfer and share incoming clinical information. And on the back end, only 58% of receiving facilities tracked the outcomes of transfer patients they accepted.
On the plus side, the research did uncover some innovations that, if widely adopted, could substantially improve transfers. Today’s Hospitalist spoke with Dr. Herrigel about her results and how hospitalists could focus their efforts to standardize transfer practices.
This is a very common transition that isn’t often studied. What do you think is the single biggest factor in improving transfers?
The first step is to standardize overall transfer communication, and EHR interoperability is the key thing that has to happen for that to improve. It’s amazing that we have such incredible technology, but we’re still largely communicating by fax with transfers, and some of these faxes run 300 pages.
A big problem is that there’s a lot of status-quo attitude. People want to make this better, but there hasn’t been enough impetus to address EHR discordance and to move away from just having providers speaking over the phone.
What are key transfer barriers, and how can those be removed?
The distance between facilities and uncertain timing are typical barriers. But there are also incongruent treatment goals, disparate information sources and, in some cases, numerous distractions.
One way around some of these is to designate a physician patient flow officer, essentially a “quarterback” physician who is often a hospitalist.
But you have to give that person the time and resources to do the job. Unfortunately, this responsibility frequently falls on whoever is “doc of the day,” and that person usually doesn’t have the time to delve into these cases.
We also need to establish more of a partnership among transferring hospitals so we can set expectations on both ends and standardize transfer requirements. Too often, we see referring hospitals choose a facility that doesn’t require much documentation or “accepts everybody,” instead of the one that requires an H&P, recent labs and frequent status updates. That’s the easy way out, but it might not be better for the patient. It shouldn’t be an us-vs.-them situation, but a collaborative effort.
And it’s very important to provide feedback on transfers. Was the transferred patient different than as presented? Did the receiving team have the information it needed to make an appropriate decision? That must all be conveyed back to referring facilities, while receiving ones should get feedback as well.
What’s in place where you work now?
Here at Mayo, we now have a designated physician who first determines whether the transfer is appropriate and then decides what information is required before the transfer can occur. It’s a rotating hospitalist position, and it helps ensure that the receiving hospital has the updated information it needs to make a decision—like whether an abnormal lab from the night before got repeated—or to prepare to receive the patient. This also helps avoid unnecessary testing, another big problem that hospitalists should work to prevent.
What are “must haves” in terms of information a receiving center should require before agreeing to accept a patient?
To some extent, that depends on the patient, but generally the top five factors would be recent vitals and any recent status change, any critical labs on admission, durable IV access, any oxygen or ventilator requirements, and an accurate medication reconciliation. This last critical piece sometimes gets lost in translation.
There also needs to be context for the receiving hospitalist who doesn’t necessarily need to rely only on absolute lab values, but also the trend. For instance, was the patient who is now ventilated on two liters of oxygen in the morning? That would be a huge change in status, and that’s something that should be communicated quickly. Required status updates should also be standardized, and should ideally be more, not less, frequent, especially with critical care patients.
What interventions did you encounter that should be used more broadly?
One university hospital has set up a “mini-ICU” for incoming critical care patients of any type, and the physician who oversees that unit decides what should happen with each patient. It’s an alternative to delaying critical care transfers due to a lack of bed availability.
We also saw examples of very good communication with potential receiving institutions: clinical updates every two to four hours, alerts to accepting physicians of any clinical status change, and scribed physician handoff notes imported into the EHR.
And some institutions provide monthly reports back to referring hospitals with information on outcomes, how long the transfer took and whether the patient was appropriate for the bed assigned. Others were making the patient’s EMR record available to referring physicians to view transferred patients’ tests, labs and notes, and to receive the discharge summary.
Bonnie Darves is a freelance health care writer based in Seattle.