What a Three-Hour Transfer Process With a Decompensating Patient Taught Me
Written by Darin Vercillo, MD, Chief Medical Officer, Central Logic
Medical Economics — January, 2020 — If you have ever been on call for your local hospital, or have received calls about hospitalized patients in the middle of the night, you will likely relate to an experience I had one evening while working as a hospitalist in a suburban community hospital in the West.
At 7 p.m., the day hospitalist handed off 20 patients for night coverage. At about 9 p.m., a woman in her mid-40s, admitted at the end of the day shift for dizziness and facial numbness, began to decompensate, reporting worsening visual changes and headaches. About the same time, radiology reported that CT angiography demonstrated a dissecting carotid aneurysm. I concluded that she would need vascular or neurosurgery consultation, neither of which were available at our hospital. A transfer to a tertiary care facility was required, so I called the transfer center for another local health system.
Eventually, the patient was flown to a hospital for an intervention, and had a successful outcome (actually, obtaining those results was another ordeal later on), but the experience left me concerned: What if she hadn’t had a successful outcome? The case cemented in my mind how crucial well-run, efficient transfer centers are for safe, high-quality patient care. In the age of consolidation and an increasing trend towards Centers of Excellence for specialized service lines, transfers between facilities are becoming more common. Interfacility transfers can seriously affect your patients and your practice.
Knowledgeable, experienced staff
Looking through the “retrospectoscope”, a red flag I should have spotted immediately was that after I explained the patient’s situation, the transfer center staff asked me, “Who do you think we should call?” Nurses and other medical professionals working in a transfer center should not simply function as phone operators connecting calls between physicians. They should act as consultants who can recommend and facilitate efficient and accurate interactions and quick referrals. With their guidance, a high-quality process unfolds and confusion is averted. Without it, providers become frustrated, delays occur, and patient care degrades.
In my case, we cycled through neurosurgery, neurology, vascular surgery, an ER doc, the hospitalist, and two different transfer centers in the network before the health system I was referring to got things right. That part of the process took more than two hours. During this time, the patient had changes in vision, mental status, and ultimately, had a seizure. Poor organization had wasted precious hours when time-to-treat was important. The experience left me unwilling to call that transfer center again for years.
Along with knowing which service lines and providers to contact, transfer center staff should also be certain of the on-call status of the health system’s physicians. For example, the first neurosurgeon we contacted was actually not on call (the sheet was wrong), but did call back and advise us who was. The delay? About 25 minutes. This insight should have come from the transfer center staff—which would have saved time for everyone, including the patient, while not forcing a physician to answer the phone at night when it was not necessary.
I had to explain the patient history to five different physicians, and there still did not seem to be a consensus among them about which specialty should treat her. In the end, the hospitalist agreed to admit, but only if the transfer center confirmed that vascular surgery was on board and would see the patient. That caveat is commonly called “conditional acceptance”—and it caused more delays in transferring the patient.
From a business perspective, when delays and disjointed management occur (especially beyond the 30 minute mark), leakage and lost opportunities occur as physicians seek their own routes to make the transfer happen. They may call previous colleagues, and old classmates and residency-mates practicing in the area. They may even “shotgun call” multiple transfer centers simultaneously, and the first to respond gets the patient. The result can be significant revenue loss for a hospital.
Perhaps most frustrating, after having my call transferred to a second transfer center, we determined that the first transfer center and hospital I called could have accepted the patient after all. The first transfer center staff should have had well-designed workflows and protocols established, clear visibility to facility resources, and a comprehensive overview of physician schedules so they could know who was available to facilitate the transfer. I felt that the patient had been done a tremendous disservice.
Streamlined processes eliminate care delays
Many physicians have had patients in their offices who ultimately required urgent medical or surgical intervention. Rather than making the patient wait in the ED, physicians likely wanted to admit their patient directly, but were unsure who to call. The main health system number? The hospital where the procedure would be performed? A colleague they know in the area?
A hallmark of a well-run transfer center is that referring physicians only need to remember one number to call. From there, the transfer center staff should be able to quickly enlist the appropriate physicians they need to consult. Highly effective transfer centers must have strong relationships with their accepting physicians built on transparency, accountability, and trust, so responsiveness is optimal.
Additionally, for transfer center staff to be most effective, they need information and tools to support their workflows, and even automate steps. For example, effective communication with transport vendors is essential to ensure the fastest response and best continuity of care while moving between facilities. Transfer center staff should be able to create and monitor transportation requests electronically, effectively eliminating the need for multiple phone calls.
Another best practice example is to establish an “arrival zone” for patients where a team is ready to bypass the ED and ICU and route the patient straight to a prepared operating or interventional suite. Streamlined transfer center communication, coordination and scheduling can reduce time to treatment by up to 45 minutes for conditions such as stroke, STEMI, and others.
More than emergencies
Traditionally, transfer centers are utilized to manage the needs of acute and critical care cases. Recently, however, a growing trend is to leverage the transfer center as a hub to create accessibility to scheduled procedures, subspecialist follow-up, and other situations in which referring physicians need to arrange care for their patients. In these non-emergent situations, the expertise of the transfer center staff and their tools are of paramount importance for prompt answers and information. When front office staff are with the patient, they do not want to call numerous phone numbers or get transferred across multiple departments to secure a date and time for arranging follow-up care.
A well-run transfer center can provide access to care more efficiently and with greater satisfaction for physicians, staff and patients. I have transferred patients on numerous occasions, and most went very well—but it only takes one bad experience to burn brightly in your mind for a long time to come.
Healthcare systems and hospitals need to ensure that if they are going to attract and accept transfers, they build an access center operation—the evolution of the transfer center–that makes referring physicians’ jobs easier, not harder.