Background: The transfer of patients between hospitals, known as inter-hospital transfer (IHT), is associated with higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Despite these poor patient outcomes, best practices to guide IHTs are lacking. To characterize the IHT process and identify key challenges and solutions to IHT care, we examined the experiences of hospital medicine physicians and advanced practice providers (APPs) who care for IHT patients.
Methods: Qualitative descriptive study using semi-structured interviews from 09/2021-12/2021 with hospital medicine physicians and APPs from an academic acute care hospital that accepts ~5,000 IHT patients annually. A combined inductive and deductive coding approach guided by thematic analysis was used until thematic saturation was achieved. The Agency for Healthcare Research and Quality’s Care Coordination Measurement Framework was used for interview guide development and analysis.
Results: We interviewed 30 hospitalists with 1-18 years of experience (mean 5.7 years). 17 (57%) of interviewees were physicians and 13 (43%) were APPs. Participants reported a wide variety of practices for IHT care. They described IHTs as challenging when 1) information exchange was incomplete and inaccurate, 2) communication structures were inaccessible, unidirectional, and fragmented, 3) healthcare team members had differing care expectations, and 4) cognitive load and workload pressures were high. Due to the lack of process standardization and unreliable timing of information exchange and physical transfer of the patient, some hospitalists described patient safety issues including delays in care and inappropriate triage of patients to the floor after clinical status changes. Participants also expressed professional dissatisfaction related to the pressure continuing patient care seamlessly and the challenges with piecing together the patient’s clinical course that occurred prior to transfer due to the barriers described above. “Even when [IHT’s are] not haphazard, even when it happens exactly the way it’s supposed to, there are a lot of transfers of … information. Each one of those creates the opportunity for information attrition or error… and, even if all the communication has been perfect, sometimes patient status changes, and it really creates a lot of risk to patients when they are transferred to floor status, and then immediately require escalation of care.” Recommended solutions include: 1) standardization of handoff report and clinical documentation content, 2) bi-directional, transparent, and accessible communication structures to facilitate real-time information exchange, 3) clarity about roles and responsibilities amongst healthcare team members involved in IHT care, and 4) providers dedicated to coordinating the care of IHT patients separate from other clinical duties.
Conclusions: We found wide variability in how participants care for IHT patients. This variability stemmed from issues with information transfer, fragmented communication structures, unclear accountability, and cognitive overload. In turn, hospitalists perceived a negative impact on IHT patient care and safety. To streamline care for IHT patients, IHT best practices should include highly reliable and timely information transfer, clear interdisciplinary communication about IHT cases, and restructuring of personnel for IHT management to reduce the cognitive load on providers.