Background: Advancement of patient care can necessitate inter-hospital transfers to another facility. The inter-hospital transferring process can pose inherent risks to the patient due to the transition of care, as well as increase overall cost for the healthcare system. Reviewing cases of mortality after inter-hospital transfer can identify opportunities to improve patient safety and efficiency of care.

Methods: A retrospective review was conducted on 211 mortalities with dates of death between 9/17/2017 and 6/16/2018. These mortalities occurred after inter-hospital transfers to Mayo Clinic Rochester campus. Each case was reviewed by the triaging physician with a focus on opportunities for improvement in the areas of communication, transfer decision, transfer process, and goals of care.

Results: Of the 211 mortalities reviewed, 152 cases (72%) were indicated to have appropriate transfer and management. Opportunities for improvement in goals of care were identified in 26 cases (12.3%). The second most commonly indicated area for improvement was communication between referring and accepting providers (8 cases; 3.7%).

Conclusions: This retrospective review of inter-hospital transfer mortality cases showed that several transfers may have been avoided by goals of care discussion prior to the decision on transfer. In addition, communication between referring and accepting providers is a potential opportunity for improvement in the inter-hospital transfer process.