Better Care Coordination Needed for Interhospital Transfers
By Melinda Young
EXECUTIVE SUMMARY
Interhospital transfers can be challenging and frustrating for nursing staff — and sometimes dangerous and tragic for patients and their families. Health systems should pay more attention to how these transfers are handled and work to improve communication between sending and receiving hospitals.
- Patient transfers with poor communication and coordination can lead to higher risk-adjusted inpatient mortality.
- The worst outcomes occur with nighttime transfers, especially on Sundays, research shows.
- Care coordinators could ensure everyone knows what is happening and is prepared to take responsibility for the patient.
One of the most challenging — and sometimes tragic — events is patient transfers between hospitals. New research revealed poor communication and coordination during these transfers can harm patient care and lead to stress among nurses.1
Studies also show interhospital transfers can lead to poor outcomes, longer lengths of stay, and higher risk-adjusted inpatient mortality rates. Also, in-hospital adverse events are more common among transfer patients vs. non-transfer patients.2,3
The poor outcomes are especially true for nighttime transfers — particularly on Sunday nights. Researchers found nighttime interhospital transfers can increase the odds of an ICU stay and result in a higher 30-day mortality rate.2
“Interhospital transfers are riddled with poor information exchanges, communication structure, and high variability,” says Amy Yu, MD, lead study author and an assistant professor in the division of hospital medicine at the University of Colorado in Aurora. “There’s no guideline for how to effectively perform an interhospital transfer.”
Typically, hospitals set their own rules, and providers follow their own practices for these transfers, but there are no standardized procedures each hospital would use. “This is the same across the nation, and literature bears that out,” Yu says.
Sometimes, nightmare scenarios occur due to the lack of standardization. For example, Yu recalls a patient who was transferred to a different hospital in the middle of the night. The man died at 6 a.m., and it took hospital staff two days to find the man’s wife because she did not know he had been sent to that hospital.
“She was driving around the state, looking for him in every hospital, and her voicemail was full,” Yu explains. “It also turned out he didn’t need to be transferred because the procedure he was supposed to get did not need to happen. The situation was awful for everyone.”
This is a scenario no nurse or physician wants to experience. It highlights why more attention to interhospital transfers is needed.
Often, patients and their caregivers are unaware of the risks of interhospital transfers. They may assume the transfer occurs seamlessly, with their loved one receiving even better care at the new hospital. But they are unaware of the poor communication and coordination between hospitals, and how that could leave the patient untreated for longer than necessary.
Researchers focused on nurses’ experiences with interhospital transfers because they often are the first point of contact. “They are at the nexus of care coordination and can highlight those key challenges and provide insider solutions,” Yu explains. “There are a lot of people to talk to, and you need to talk to everybody. We started with bedside nurses.”
Researchers studied the steps that involved preparation for arrival, arrival to accepting hospital, and accepting hospital admission. They focused on the experiences of inpatient floor-level bedside nurses at the receiving hospitals. Their perspectives highlighted coordination gaps.1
“This is a huge void,” Yu says. “There is so much research on posthospitalization transitions of care, but we have overlooked this transition between hospitals or facilities.”
Most people assume these transfers run well, but when bedside nurses are asked, they report seeing poor transfer experiences. “The system is broken,” Yu says. “It’s my hope to one day rebuild the system. At the end of the day, we want to make sure our patient is being taken care of, and the system is not set up to do that.”
There are potential solutions, including eliminating unnecessary transfers and involving case managers or care coordinators in the process to ensure better communication and more seamless transfers. (See story in this issue on possible solutions to poor interhospital transfers.)
Key Challenges
Yu and colleagues identified key challenges in these three areas:
• Information exchange and communication. Nurses described how handoffs to other hospitals often included incomplete information. The patient’s care may have changed, but no one updated the changes in the documentation sent to the new hospital.
“Sometimes, they wouldn’t even get reports until a minute or two after the patient arrived,” Yu adds. “When patients actually arrived, nurses had such a difficult time getting ahold of the right provider and getting an understanding of the care plan.”
For example, when patients asked when they would receive pain medication, nurses were unprepared and could not give them an answer. “You were getting morphine at the other hospital, but I’ll give you an ice pack because I don’t know the orders now,” Yu says.
• Environmental information preparedness. Because of the gaps in knowledge, nurses were unable to prepare patients appropriately from an environmental and informational perspective. Patients thought they were going to a big hospital with more expertise, but nurses did not have the information they needed to help patients immediately. For example, nurses may not have prepared the right equipment because they did not receive advance information on what the patient would need.
“No one intentionally forgets to tell people, but it’s hard without a standardized structure,” Yu says. “These are nurses in a bind, not ready for the patients, and it’s not a great atmosphere for the patient and nurse when starting off at a new facility.”
• Determining who takes responsibility for the patient. Nurses know they are responsible when a patient arrives, but providers might not see the patient immediately.
“The providers often rely on nurses to tell them if the patient looks OK. It puts a huge responsibility on nurses to assess patient’s clinical acuity and what their needs are off the bat,” Yu says. “It’s not necessarily in their job description, but it’s what they are able to do, and it’s incredible they can manage all those things. They are advocates for patients.”
Poor communication and a lack of ownership for updating the receiving hospital on the patient’s status can lead to disastrous outcomes. For example, there may be a situation where a patient is accepted into internal medicine because the sending hospital did not believe the patient needed care in an ICU. But something happened during the transport, and no one called the receiving hospital to report the patient’s condition had worsened. The patient arrives, and the nurses can see the patient needs more help than they can provide on the floor.
“They don’t know who to call because patients aren’t assigned to a team until they arrive,” Yu adds.
When a provider team finally arrives, someone has to look through the patient’s documentation and talk with the ICU team to move the patient to the correct level of care. This is more complicated than if the patient had arrived through the ED.
“With interhospital transfers, there is this uncertainty about what happens. If we don’t get that update, we can’t get the patient where it’s needed,” Yu explains. “It creates this moment of chaos, where no one really knows the patient, and we have to make split-second decisions about their care.”
There are the cases when people are transferred hundreds of miles for a procedure, but they are unable to undergo the procedure.
“They’re told, ‘We’re not going to do that procedure,’” Yu says. “Sometimes, they don’t have the pictures or imaging to make a definitive decision.”
These types of risks to interhospital transfers are rarely explained to patients’ families. “Everyone wants to do right by the patient, but it’s so hard when there are so many exchanges of information that things get lost,” Yu says. “This is why a standardized process is really key.”
REFERENCES
- Yu A, Jordan SR, Gilmartin H, et al. “Our hands are tied until your doctor gets here:” Nursing perspectives on inter-hospital transfers. J Gen Intern Med 2022;37:1729-1736.
- Mueller SK, Fiskio J, Schnipper J. Interhospital transfer: Transfer processes and patient outcomes. J Hosp Med 2019;14:486-491.
- Hernandez-Boussard T, Davies S, McDonald K, Wang NE. Interhospital facility transfers in the United States: A nationwide outcomes study. J Patient Saf 2017;13:187-191.
Interhospital transfers can be challenging and frustrating for nursing staff — and sometimes dangerous and tragic for patients and their families. Health systems should pay more attention to how these transfers are handled and work to improve communication between sending and receiving hospitals.
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