Streamlining patient transfers

First-rate communication is key.

Inherently high-risk, inter-hospital patient transfers involve sick patients who are likely getting sicker. It's an important time for clear communication, but information exchange during transfers doesn't follow any set patterns in quality or quantity, experts say.

“It can vary from very little, ‘We would like this patient transferred because of x,’ or it may be more detailed,” said Genevieve Folse Maronge, MD, ACP Member, hematologist/oncologist at the Hematology Oncology Clinic of Baton Rouge in Louisiana. As a resident, Dr. Maronge co-authored a study on patient transfers. “Up front, even the reason for the transfer could be where the information exchange becomes challenging,” she said.

To remedy this gap, some hospitalists are finding ways to streamline these care transitions. “It's making sure we're thorough and having quality communications at the time of the decision to transfer the patient,” said Jennifer Borofsky, MD, ACP Member, attending physician in hospital medicine at Fletcher Allen Health Care and assistant professor at the University of Vermont College of Medicine in Burlington.

What goes wrong?

It's difficult to pinpoint any one place where transfers typically break down, but experts have identified areas where issues tend to arise. “The first place that comes to mind is the initial communication between hospitals,” explained Dr. Borofsky, who was lead author of a study on inter-hospital transfers presented at the Hospital Medicine 2013 conference.

Communication is certainly a hot spot for failures, especially lack of standardization in communication, said Andrew White, MD, FACP, assistant professor of medicine and director of the hospital medicine group at University of Washington Medical Center in Seattle. The lack of a widespread standard for approaching inter-hospital patient transfers means each organization creates (or doesn't create) its own protocols.

Whatever their protocols, sending and receiving hospitals must share some basic information so patient care doesn't suffer during the transfer. For example, it's important the receiving hospitalist knows whom to call at the sending hospital for patient details, said Lauge Sokol-Hessner, MD, ACP Member, a hospitalist and associate director of inpatient quality at Beth Israel Deaconess Medical Center in Boston who has also studied transfers.

“We essentially do a mini-evaluation over the phone,” he explained. “We talk about the presentation of the patient when they arrived, what has happened to them, what the current plan of care is, what the current reason for transfer is, as well as their medical history, their medications, and their allergies.” Understanding the patient's current status allows the receiving hospitalist to more quickly determine who should care for the patient and what setting of care will be most appropriate.

Augmenting this information with a discharge summary is recommended, and Dr. Borofsky offered some additional questions that may also be useful to formulate the right plan for care. “Are they suitable for a general medical floor or do they need an ICU?” she asked. “Is their clinical status changing? What interventions have been carried out at the other hospital?”

Dr. Borofsky investigated communication on such issues in her research. “None of the physicians in any of the calls we looked at were talking about code status or goals of care,” she reported. These topics are important to cover to ensure that transfer is appropriate and compatible with the patient's goals of care.

The absence of electronic medical record (EMR) interoperability contributes to the challenges of transfer communication. “There is no electronic medical record integration, so up-to-date information is almost never available,” said Michael G. Usher, MD, PhD, ACP Member, assistant professor of medicine at the University of Minnesota in Minneapolis.

Dr. Usher has also studied transfers, and he found that conversations weren't sufficient for an effective transfer. “A lot of the signout process and clinical decision-making that happens around the time of transfer is based on word-of-mouth. Just one physician talking to another and very little objective, verifiable information actually gets transferred during that process,” he said.

One solution, which the University of Washington Medical Center uses, is a checklist for capturing the information needed to transfer the patient and arrange for his or her care.

“That checklist is in our EMR, so it immediately documents all the variables we want to know about to discern if this is going to be a safe transfer or not,” Dr. White said. Another advantage of this system is that if the hospitalist who accepts the patient isn't the one who admits him or her, all the important data are in the chart and accessible as needed.

The checklist protocol wasn't implemented without some early challenges. “The barrier we found was that we had to develop systems to create electronic records for these patients before they even arrive. We had to work with our IT infrastructure to do that,” Dr. White said.

The team approach

Because specialists and other physicians are often involved in caring for transferred patients, coordinating details and activities across multiple clinicians can be tricky. Hospitalists are typically able to receive incoming transfers, but in some cases it's the services offered by a specialist that predicate the transfer in the first place.

“If you don't talk to that physician—not just the hospitalist, but also the specialist—you may not know if they're even going to be able to perform a needed procedure,” said Dr. Maronge.

For example, a patient being transferred for a complicated stroke that may need neurosurgical intervention may be “being taken care of by a general internist and a critical care physician, and so there are 3 or 4 doctors at the receiving hospital who may be coordinating care,” said Dr. Usher.

That can cause problems. “If you talk about how bad transitions of care happen, the more people that are involved in coordinating care, and the greater number of conversations that have to happen, the more potential there is for breakdowns in communication,” Dr. Usher said.

Though decision-making involves one or more specialists and other physicians, the accepting hospitalist is usually the one orchestrating much of the care and holding responsibility for coordinating communication.

Triage centers

To center transfer communication in a single place, some hospitals that regularly receive transferring patients have established a dedicated call center. Typically staffed by senior-level nurses, these teams coordinate communications between accepting and receiving physicians.

Dr. Usher said his organization recently concluded a survey of about 30 tertiary referral facilities, and it appears the functionality and effectiveness of these call centers is highly variable. “We found there is no common practice of these individual transfer centers. Some do a great job of getting regular updates and getting objective information at the very beginning of the process, and with others it's more laissez-faire,” he explained.

When hospitalists are busy, going through a triage nurse or call center may help to ensure that critical data are properly communicated, according to Dr. Maronge. However, she added, “Even with really well-trained RNs taking the information, there are still pieces of information that hospitalists will know is important to them specifically.” Oftentimes, the physician who will be caring for the patient will want to be involved early in the process to ensure her particular questions are answered.

Dr. Maronge previously worked at a hospital that had a nurse call center, and she said it did help streamline the process. “I think the surrounding hospitals appreciated it, because they had a direct line to someone they could speak to immediately rather than wait to talk with a physician who may be busy with patients,” she said. The facilities using the process were able to understand how it worked very quickly, and transfers increased once the system was put into place, Dr. Maronge said.

Planning ahead for how transfers will be handled before they're needed is an important step in improving the process at both sending and receiving hospitals, experts said. “Our hospital and hospital medicine leadership have proactively had conversations with some of our most common referring providers. Out of those conversations came an agreement around the process,” said Dr. Sokol-Hessner.

Referring clinicians now follow a standardized template designed to systematically share information about each patient prior to any transfer. “That, I think, has really helped a lot in streamlining the process,” Dr. Sokol-Hessner said.