Background: Inter-hospital transfers are integral to a functioning health care network. Critical access, rural, and community hospitals established in sparsely populated territories are unable to support tertiary care infrastructure and rely on academic centers for consultation and transfer. Transfers comprise an estimated 3.5% of inpatient admissions (1), owing in part to increased procedural specialization concentrated at larger urban facilities. However, critical bed shortages within these tertiary care hospitals, driven by pandemic-related factors like surges, staffing shortages, and gridlock related to restricted discharge options, have caused marked delays for interhospital transfer patients. Some spend upwards of seven days awaiting an open bed, leading to delays in care and placing undue strain on referring hospitals.
Purpose: Many interhospital transfers are initiated exclusively for procedural intervention, without a need for ongoing consultation. Their tertiary care needs are thus time-limited and fully addressed within one to two days of transfer, however, they remain at our hospital until discharge, occupying a desperately needed bed during convalescence while geographically disconnected from their support system. In order to accommodate as many transfers as possible, and apply tighter stewardship to our inpatient beds, we identified an opportunity to make procedural intervention available to patients at referring hospitals without requiring interhospital transfer.
Description: We created a ‘round trip procedure-only’ transfer pathway, through which patients can be transported from rural or community hospitals solely for a specified procedure, after which they are immediately transported back to the referring facility. They remain inpatient status at the referring hospital for the entirety of the process. Candidates for the pathway include patients in need of endoscopic, electrophysiologic, or radiologic procedures, without ongoing tertiary care needs. The workflow is a logistically complex one, and to function safely required us to establish a multi-disciplinary care plan that clearly define each team’s tasks—review of outside imaging, scheduling according to operating room time and proceduralist availability, arrangement of bi-directional medical transport, pre-operative screening and optimization prior to transfer, and contingency planning in the event of intra-operative complications. In addition, our legal and billing departments were required to negotiate separate contracts between all hospitals we partnered with.
Conclusions: The ‘round trip procedure-only’ pathway has been online for six months at the time of submission, and we have completed approximately 25 procedures in this manner. No patients required post-procedural admission at our institution due to medical instability. The most common complication thus far has been transportation delays, some long enough to require procedural unit staff to remain late. We are comparing outcomes between the ‘round-trip’ patients and those transferred via the traditional pathway for like procedures, including the time from initial transfer call to procedure, complications, and average length of stay. We are also tracking the tertiary care inpatient days saved as a result of our intervention.