Case Presentation: The patient is a 45 year old female with a PMH of Ischemic Cardiomyopathy (LVEF 25-30%), CKD3b, recent BKA in 7/2025 with poor wound healing and subsequent MRSA bacteremia who presented to an outside hospital for shortness of breath and chest pain. She was diagnosed with an acute heart failure exacerbation and began on diuretic therapy. Over the course of the hospitalization, her creatinine worsened. Due to this, Telehealth at our referral center was consulted. In addition, a blood culture from her initial presentation grew gram positive cocci in clusters. The patient was started on Vancomycin and a work up for acute kidney injury was initiated. The culture was reported as methicillin resistant. Her creatinine continued worsening, and the decision was made to transfer her to our facility. On arrival, she was restarted on Vancomycin for presumed MRSA bacteremia. Nephrology was consulted. She underwent a TEE for further evaluation of infective endocarditis. Subsequently, access was obtained to the first hospital’s electronic medical records. It was noted that she grew Methicillin-resistant Staphylococcus epidermidis in a total of one out of four bottles. The speciation occurred on day of transfer, but the information was not relayed to the accepting facility. Vancomycin was discontinued. Nephrology determined that she had acute tubular necrosis (ATN) complicated by cardiorenal syndrome, and creatinine improved with IV Lasix and holding her antibiotics. Ultimately the patient was able to be discharged with outpatient follow up.
Discussion: Interhospital transfer is an option for complex patient cases, particularly in rural or underserved settings. Despite wider resource availability at accepting hospitals, interfacility transfer is associated with a longer average length of stay, a higher proportion of time spent in the intensive care unit, higher costs per hospital day, lower frequency of discharges home, and higher inpatient mortality (1). After adjusting for patient characteristics, patients who underwent interhospital transfer also had a higher risk of in-hospital death (1). These trends shed light on the risks of interhospital transfer.Advances in technology have also encouraged many rural hospitals to outsource inpatient specialty care to telehealth consultants. Despite increased convenience and cost savings, our case demonstrates some of the potential pitfalls of employing telehealth (4). Virtual providers are confronted with physical limitations and may be unable to perform essential physical exam maneuvers (1,2). Visual assessment of patients may also be limited by the virtual obscuration of visual cues of health, which might otherwise be obvious in person (1,2). These practical limitations could increase the probability of diagnostic errors.
Conclusions: This case highlights some of the potential pitfalls that can accompany interfacility transfer and telehealth. These tools have proven useful in-patient care, yet they should be used judiciously. When faced with complicated cases, hospitals should consider their facility’s capacity to manage patients in-house before requesting interfacility transfers given the accompanying risks to patient outcomes. Future research is needed to develop best practices and interventions to protect patients during these vulnerable times.