Published in the September 2018 issue of Today’s Hospitalist
WHEN HOSPITALISTS PROPOSE transferring their patients to another hospital, they assume their patients will do better once they receive the kind of specialty expertise or procedures their own facility can’t provide.
But several recent studies from a hospitalist-led research team at Boston’s Brigham and Women’s Hospital suggests that those assumptions warrant a second look. One study published in the June issue of the Journal of Hospital Medicine (JHM) found that nationally, “between 32.4% and 89.1% of patients did not receive any associated specialty procedure at the receiving hospital,” the Brigham authors wrote.
Another study that was presented as an abstract at this year’s Society of Hospital Medicine (SHM) annual conference showed that the risks of transfer can outweigh the benefits. For patients with some diagnoses, the authors noted, inter-hospital transfer is associated with “higher costs, longer length of stay and lower odds of discharge home” compared to similar patients who weren’t transferred.
“The trickle-down information from the accepting provider to the admitting one is not reliable.”
~ Stephanie K. Mueller, MD, MPH
Brigham and Women’s Hospital
Still another of the team’s studies, one published online in June by the Journal of Patient Safety, documents how nearly everyone—including the doctors and patients on both the transferring and accepting ends—report dissatisfaction and frustration with aspects of the frequent but rarely standardized transfer process.
As lead author Stephanie K. Mueller, MD, MPH, a hospitalist and clinical researcher at Brigham and at Harvard Medical School, explains, “there is a lot more research needed in this area. But I think our research highlights that there are specific problems with the transfer process that might put particular patients at risk.”
Data, including those published in the June JHM study, indicate that “patients may be transferred for many reasons other than needing a procedure,” Dr. Mueller points out. Although some alternate reasons for transfer may be valid, such as the need for nonprocedural specialty care, it is worthwhile thinking through which patients may benefit from transfer and which ones may not.
“There are other things we could provide that might serve a patient better besides a physical transfer, which costs a lot of money, introduces risk and interrupts continuity of care,” she notes. One option could be telemedicine for specialty consults, a growing area in health care. “Many innovative things we could do might potentially save unnecessary transfer.”
The need for standardization
Obviously, many inter-hospital transfers are necessary; think of patients who need cardiac catheterization, dialysis or a colonoscopy that isn’t offered at the first facility.
But Dr. Mueller’s research suggests that patient outcomes could improve if transfer processes were more broadly standardized so they resulted in fewer communication breakdowns when complex handoffs occur.
Her hospital, for instance, has started working on a standardized intake form. It will include the questions that the nurses who staff Brigham and Women’s access center will ask all providers who call with a transfer request.
Examples of questions include, “Do you think this patient needs a procedure? Is that why he or she is being transferred?” If the answer is “yes,” Dr. Mueller says, the access center will initiate a call to that particular proceduralist. The goal is to “try to engage these specialists, in addition to the primary team, right at the time of the request,” she says, “so when the patient arrives, the specialist can expedite what needs to get done.”
Another Brigham project aims to address the problem of poor communication, which providers nearly universally complain about. Because many—if not most— hospitals can’t easily share electronic medical records, very sick patients often arrive without charts and with only the scant amount of information that fits on a transfer summary sheet.
That deficiency will require a bigger fix than the hospitalists at Brigham can engineer on their own, Dr. Mueller says. But addressing a related problem of poor verbal communication between transferring and accepting hospitalists is within their reach.
Here’s one issue that crops up at her large academic center: “The accepting provider is not necessarily the person who admits the patient when he or she physically arrives at the hospital,” Dr. Mueller points out. “The trickle-down information from the accepting provider to the admitting one is not reliable. It’s like a game of telephone where things get lost.” Her research team is now working to come up with a more reliable system of communicating between accepting and admitting providers.
Another project is reworking the roles and responsibilities of the people staffing the access center. One goal is to make sure that, for patients accepted for transfer, a message is sent immediately to bed control. In addition to assigning a bed, bed control will “send a templated page to the admitting responding clinician,” she says.
Because the hospitalists are regionalized, the bed control staff—once a bed is assigned—will be able to get the necessary information to the responding physician.
Another study done by Dr. Mueller and her research team has looked at the outcomes of transferred patients. Their conclusion, as stated in an abstract presented at this spring’s Society of Hospital Medicine meeting: Some patients clearly benefit from being transferred to bigger hospitals. Transferring patients who have a primary diagnosis of acute MI or sepsis, for instance, is associated with lower odds of both three- and 30-day mortality compared to similar patients who aren’t transferred.
But transferring patients with esophageal/GI disease, she says, is “associated with greater odds of both three- and 30-day mortality.” Further, the outcomes of transferred patients with other diseases are more variable.
Transferred patients with renal failure, chronic heart failure, metabolic disease, pneumonia, hip fracture, chronic obstructive pulmonary disease or urinary tract infection showed “no difference” in their chance of dying within three days. However, those transfers were associated with greater odds of 30-day mortality.
“Is greater mortality due to risk of transfer or to something else?” Dr. Mueller asks. “If it is due to transfer risks, what are they? And should we modify our transfer practices to try to make transfers safer for patient groups in which we see worse outcomes?”
To start to figure that out, Dr. Mueller’s group is doing research using site-specific data on patients transferred to Brigham from another acute care hospital. One study using these data, which was also presented as an abstract at SHM’s 2018 annual meeting, found that patients who arrived overnight (between 10 p.m. and 7 a.m.) had both a greater chance of needing to be transferred to the ICU as well as greater odds of 30-day mortality than if they arrived during the day or evening.
“It is going to take a lot more work to figure out what aspects of transfer are the riskiest and how we mitigate those risks,” Dr. Mueller says. Moreover, she says that nearly all the research on inter-hospital transfers to date has focused on what happens at the receiving hospital. Less is known about what happens at the community hospital before or during the transfer process itself.
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.