IN WESTERN PENNSYLVANIA, hospitalist Allison Walton, MD, is trying to manage an ongoing crisis that started with the pandemic and still persists: long delays in transferring patients out.
While she works across several community hospitals, Dr. Walton—who is regional quality and education director for her company—says her primary hospital has 90 beds. It has no neurosurgery, cardiothoracic surgery, surgical subspecialties or interventional radiology.
While patients at that hospital wait, often days, for a bed at a larger facility, “the ED is begging us to admit these patients, who are clogging up the ED.” Dr. Walton is very aware of research findings indicating that patients boarded in the ED, without the nursing care they need, have worse outcomes. But when hospitalists do admit patients awaiting transfers, “I’ve run into patients completely losing their spot at a tertiary center, and then it takes us even longer to get them a bed than if they still had ED status.”
“The ED is begging us to admit these patients, who are clogging up the ED.”
Allison Walton, MD
Other complications of admitting those patients include the fact that EMTALA no longer applies, and patients can decompensate. And “insurers can deny stays if all we’re doing is trying to keep patients stable.” That doesn’t include the hassles around patients who aren’t accepted for transfer at a particular center because that receiving hospital won’t take that patient’s insurance.
“It’s beyond frustrating,” says Dr. Walton, who covers days with one other hospitalist and two advanced practice providers. “At the end of the day, the people who really suffer are our patients.”
It may be hospital medicine’s version of the supply chain problem. Covid surges drove too many nurses out of hospitals, and staffing shortages have now made transfers more problematic at both ends of the process. While community hospitals short on nurses may need to send more transfers, larger hospitals are staffing fewer beds and can’t accept them.
That’s in addition to the problems that plagued transfers before the pandemic. Doctors on the receiving end say that all too often, they don’t get quality information about a prospective patient and have to wade through a lot of variability in why transfers are being sought. For patients, transfers remain a risky time when a lot can go wrong.
Even without current delays and bottlenecks, “transfers are a huge area that needs improvement,” says Christopher Whinney, MD, hospital medicine department chair at Cleveland Clinic. “We need a greater understanding of best practices at both ends.”
According to Dr. Walton, long transfer delays happened before the pandemic, but only rarely. Then covid hit, and “nurses quit, and I don’t blame them,” she says. “But now the rest of us who are still working have an even worse struggle.”
“Coming here, patients pass many hospitals equipped with all the services they need.”
Jeremy Jaskunas, MD
UnityPoint Health-Meriter Hospital
Jeremy Jaskunas, MD, is a hospitalist with UnityPoint Health-Meriter Hospital, a community teaching hospital in Madison, Wis. While his hospital is located in southern Wisconsin, it’s taking transfers from as far away as Michigan’s Upper Peninsula.
“Coming here, patients pass many hospitals equipped with all the services they need,” Dr. Jaskunas says. “They’re bypassing those hospitals because they are all full—but they’re probably not really full. They probably don’t have available beds because they lack nurses to staff them.”
At Cleveland Clinic, Dr. Whinney says that staffing shortages have seriously cut into bed capacity.
During the height of the omicron surge into April of this year, “we had as many as 10% of our 3,000 beds closed because of staffing challenges.” As a result, the number of transfers that Cleveland Clinic accepted decreased. But that has improved, Dr. Whinny says, with more aggressive recruitment and hiring, as well as with agency and travel nursing support.
The rise of large health systems
While staffing shortages are very real, Jessica Dekhtyar, MD, director of medicine at the Moses campus of the Montefiore Medical Center in the Bronx and medical director of the transfer center there, points to another factor driving more transfers now: “The day of the stand-alone hospital is fading.” As more hospitals are folded into large health systems, specialty services have been consolidated and distributed across separate hospitals. That can limit access to specialty services—and increase the number of transfers that need to take place.
“More and more transfer volume is this movement within the system.”
Jessica Dekhtyar, MD
Montefiore Medical Center
Dr. Dekhtyar’s system, which used to encompass only four hospitals in the Bronx, is a case in point. Now, the health system includes seven additional hospitals throughout New York state and one acute rehab facility. With the health system growing, the number of transfers within the system has shot up. “More and more transfer volume,” she says, “is this movement within the system.”
At her tertiary center, Dr. Dekhtyar says the biggest challenge with transfers is that sending and receiving hospitals don’t have the same EHR. “You really have to rely on what’s said over the phone, and you can miss critical information,” she points out. “You may not fully understand the needs of patients until after they arrive, and by then, you’ve lost substantial time.”
Information shared over the phone isn’t standardized, and “some sending hospitals don’t share anything,” she adds. “They just want to give you the patient’s name and birth date and find out when the transport is coming, so it can be hard getting on the same page.”
Not being able to share images between hospitals leads to repeat imaging when patients arrive—a waste of resources that also “really delays care.” And it can be a challenge to get physicians on the receiving end engaged. “If they have worked only at major academic centers where every support system is at their fingertips,” says Dr. Dekhtyar, “they don’t understand how difficult it is for sending hospitals to get some resources and labs.”
Issues for community hospitals
Hospitalist Ifedolapo Olanrewaju, MD, is now in Texas, providing post-acute telemedicine for Sound Physicians, a national physician organization. But until the end of June 2022, he was the medical director of a hospitalist group, also with Sound Physicians, at CHRISTUS Highland Medical Center in Shreveport, La.
“To dedicate one doctor to triage during the day in a community hospital would shift too much work to the other rounding FTEs.”
Ifedolapo Olanrewaju, MD
That community hospital, Dr. Olanrewaju explains, transferred more patients in from outlying critical access hospitals than were transferred out to tertiary institutions. But he and his colleagues didn’t have the luxury of dedicated transfer triage—a fact of life at many community hospitals that take transfers. One rounding physician every day became the triage doctor on call, fielding all transfer requests by phone while still rounding on patients and trying to meet performance metrics.
“To dedicate one doctor to triage during the day in a community hospital would shift too much work to the other rounding FTEs,” he points out. “Your standard clinical workflow is now infused with this additional layer of complexity.” While the group spares that physician any admissions to lighten his or her workload, working triage is still “hugely disruptive.”
Another big complication: In a community hospital, it can be a challenge to get consultants on the initial call to help decide if a transfer should be accepted. “Hospitalists often have to field subspecialty-related transfer requests,” Dr. Olanrewaju says—and they may not always get those right for many reasons, including incomplete information from the requesting hospital and their own limited subspecialty know-how.
Experienced community hospitalists have come to identify those cases where the triage doctor “must insist that a specialist talk to a referring hospital” before a transfer is agreed to. While large systems can mandate that consultants weigh in immediately, community hospitals may struggle to do so.
“In many cases, they’re not dealing with employed specialists but with those in private practice,” says Dr. Olanrewaju. Over his three years as hospitalist medical director, he and his colleagues worked closely with hospital leadership and the transfer center director “to get commitments from consultants, especially in surgical cases, to be more involved in the transfer process early on.”
One advantage of partnering with a larger hospital system is being able to dedicate time to that triage function. In Madison, Dr. Jaskunas says his hospital recently entered into a partnership with UW Health, which has a large university hospital and several community hospitals. As a result, his hospital’s transfer activity dramatically increased.
“Triage officers need good communication skills, emotional intelligence and situational awareness.”
Christopher Whinney, MD
Just this year, the system adopted a centralized triage process where one hospitalist works as triage officer, fielding transfer and admission calls from all over the region, then assigning those patients to one of several hospitals in the system, including his own.
“Any of the UW or Meriter hospitalists could fill that role, but you need special training,” Dr. Jaskunas says. “Only a small cohort of people have volunteered.” Before the UW partnership, Dr. Jaskunas and his colleagues, like in Dr. Olanrewaju’s former hospital, struggled to manage transfer calls during regular clinical shifts.
“This has been,” he says, “a huge improvement.”
At Cleveland Clinic, a “quarterback” or triage officer—the physician who handles all transfer and admission requests for the general medicine service—has been in place since 2004. (Recently, the center created a regional quarterback role to triage transfer patients among the system’s many hospitals in greater Cleveland.)
“Not everyone can do this, and we have several criteria for those who do,” Dr. Whinney explains. First, they need to be an experienced provider in the system, so they know what resources are available in each service line.
Read why transfers may not produce the care you think patients need: The (many) problems with transfers
And because transfer requests are “sometimes challenging conversations,” he adds, “triage officers have to have good communication skills, as well as emotional intelligence and situational awareness.” Transfer calls are often nuanced conversations around managing patients’ expectations and exploring whether potential transfers could instead be followed up as outpatients. The role rotates among a cadre of about 25 doctors among the 100 in Dr. Whinney’s group.
Part of the triage officer’s job at Cleveland Clinic is to stratify incoming transfers into three tiers of urgency: patients who need to be brought in within four hours, those who should be transferred within four to eight hours, and those who can wait between eight and 24 hours. Given his system’s capacity challenges, Dr. Whinney points out, “those time frames get stretched quite a bit.”
Knowing that a sending hospital has admitted a patient awaiting transfer doesn’t knock that patient off the waiting list, he adds. “But having the patient stabilized may change the level of transfer urgency.” He compares that situation to a transfer request from a freestanding ED that can’t admit patients.
“That comes into play in deciding how urgent a transfer is,” says Dr. Whinney. “If an inpatient facility can deliver care, admitting the patient isn’t a bad idea until the transfer can take place—and that can take days.”
At Montefiore, one recent intervention is designed to better stratify the urgency of waiting transfers.
“We now do clinical updates on transfers we’ve accepted but have to wait on, reconnecting with the sending team to see if anything has changed,” Dr. Dekhtyar says. Different services have different thresholds for when those updates occur; the ICU does them every shift, while the medicine service does an update every 24 hours a transfer is delayed. “Sometimes, the updates change where the patients will be assigned.”
And every transfer phone call is now recorded for review and for quality assurance and improvement, an innovation that has been a “game-changer,” she notes, that helps with physician engagement.
But the most helpful change the medicine service at Montefiore has put in place to improve transfers is standardizing information. Dr. Dekhtyar and her colleagues worked to create a “dot phrase” (SmartPhrase) in Epic that pulls down a list of eight questions.
“That reminds the medical consult attending who is taking the request what questions to ask,” Dr. Dekhtyar says. “Whoever then ends up getting the patient assignment now has a standardized note in the health record.”
At Boston’s Brigham & Women’s Hospital, hospitalist and researcher Stephanie Mueller, MD, MPH, says that she and her team are just finishing a project that does something similar. That project has tried to identify the most pertinent clinical information to include in a standard template that can serve as a transfer accept note in the EHR.
“That accept note is being populated by the nurses in our access center when a transfer request comes in,” Dr. Mueller says. As part of the intervention, nurses from that center now sit in on the call between the requesting and accepting physicians. “Those nurses now have the authority to interject and ask questions so they can complete the template.” The accept note, which is in the iPASS format, has already been implemented among the general medicine, cardiology and oncology services. Potentially, it will be used for all types of transfers within the system.
She and her research colleagues are still analyzing the data to see if that standardization has had an impact on patient outcomes. Still, Dr. Mueller notes, “the feedback from frontline clinicians has thus far been positive.”
In western Pennsylvania, Dr. Walton says that patients waiting for transfer—and the decision of whether to keep them in the ED vs. admitting them—are considered on a case-by-case basis. It all depends on what patients need, how quickly they might get a bed elsewhere, how many nurses are available and what is safest for them.
“If they have a brain bleed and need neurosurgery, there’s no way we’ll admit them,” she says. But for patients with a bowel obstruction from an abdominal tumor, for instance, “the patient can actually wait a few days, so we’re pretty confident admitting them.”
When the crisis with transfer delays first started, the standoff with the ED over whether or not to board patients “felt a little antagonistic,” Dr. Walton says. But the hospitalists began meeting with their ED colleagues.
“We adopted a policy about six months into the pandemic that if a patient is waiting in the ED for transfer longer than four hours, the hospitalists are consulted,” she says. During those consults, the hospitalists see patients in the ED, put in orders for them and “begin managing their care, just as if they were inpatients.”
In practice, Dr. Walton adds, “a lot flows from getting a hospitalist involved, even when patients are still physically located in the ED. We start calling other hospitals to help get those patients out.” While the best thing for patients is to get them to an appropriate facility, “the next best thing for some is to have a hospitalist take care of them.”
Dr. Mueller—who has done extensive research into transfers and the problems that attend them—notes that covid ushered in another major change: what she calls “reverse transfers.” Less acute patients admitted to major centers are transferred to community hospitals to free up beds.
Going forward, Dr. Mueller says, such transfers could relieve capacity problems at larger hospitals and reduce delays. According to Dr. Dekhtyar, Montefiore relied on such bi-directional transfers in covid surges, sometimes regionally or even state-wide. “During covid, it really became a load-leveling system,” she says—one her system hasn’t maintained since its last surge.
But “it’s part of the discussion, and it’s been brought up several times,” says Dr. Dekhtyar. “Smaller hospitals in our system have beds available, so we will likely entertain such transfers soon.”
Interhospital transfers: taking a broader view
Hospitalist Jeremy Jaskunas, MD, with UnityPoint Health-Meriter Hospital in Madison, Wis., knows that transfers can save lives and that it’s important to streamline and strengthen the transfer process. But he believes interhospital transfers need to be viewed through a much broader lens.
“People under-recognize the risks associated with transfers.”
Stephanie Mueller, MD, MPH
Brigham & Women’s Hospital
“We can talk about checklists and how to get all the information we need when we get the call,” Dr. Jaskunas says. “But we can’t just focus on process. We also need to standardize how we decide who is transferred, what transfers we can prevent and what financial decisions impact clinical decisions.” He mentions a local freestanding ED (not in his health system) that, he and his colleagues suspect, sends them mainly uninsured and Medicaid patients who need to be admitted, while transferring insured patients to its own affiliated hospital.
Dr. Jaskunas would also like to see an analysis on what happens to the number of transfers in a region when mergers and acquisitions that are financially motivated lead to a consolidation of specialty resources. And how is the number of transfers affected by insurance status, gender, race and socioeconomics? After all, he points out, research indicates that patients transferred between hospitals have worse outcomes.
And even for diagnoses where transfers have proven benefits, such as in stroke, “research shows that Black patients are transferred less often, and that’s a big problem.”
Much of the research done into the downsides of interhospital transfers over the past decade is thanks to Stephanie Mueller, MD, MPH, a hospitalist and researcher at Boston’s Brigham & Women’s Hospital. Her interest in the problems associated with transfers was sparked as a chief resident, pulling together morbidity and mortality conferences.
“I was struck by how a disproportionate number of those conferences were related to outside hospital transfers,” Dr. Mueller says. “It was clear that it’s a risky time for patients—and very scary for the physicians receiving them. They don’t necessarily have any communication about them or know how to care for them.”
Across their research, Dr. Mueller and her team have challenged the conventional thinking on how effective transfers are. According to their results, the risks of transfers for many patients outweigh the benefits, and many patients transferred for specialty procedures don’t actually receive them. Costs are higher, lengths of stay are longer, and Black and Hispanic patients have lower odds of being transferred.
“People under-recognize the risks associated with transfers and think, ‘It’s better to be safe than sorry,’ ” she says. “If you can’t figure out whether or not patients would benefit from being transferred, the thinking is to just go ahead with it.”
Does she believe her body of research has changed that mindset? “I don’t think we’ve changed that opinion yet, but we’re moving the needle,” Dr. Mueller replies.
While definite subsets of patients benefit from being transferred—she mentions stroke patients and those who need a cardiac procedure—”where my research is leading is trying to define which transfers are necessary and which patients should be offered some other alternative.”
To that end, Dr. Mueller hopes to start research this year with a grant from AHRQ that would look at precisely that: the patient selection process and which patient populations may not benefit from transfers. She’s also received an AHRQ grant to drill down on the “health information exchange piece, making sure people have access to the clinical information they need when they need it.” That’s another “really problematic aspect” of transfers that makes patients more vulnerable.
“Fortunately for me but unfortunately for our field, there’s a lot of work yet to be done,” says Dr. Mueller. “There’s a lot of opportunity for people to get involved in this research.”
Published in the September/October 2022 issue of Today’s Hospitalist.