Background: Advances in technology and life-sustaining interventions afford patients access to a wider network of subspecialized care through inter-facility transfers. Implicit in these transfers are multiple complex steps that leave patients vulnerable to adverse events. The few guidelines that exist regarding the inter-facility transfer process focus on critically-ill or surgical patients, and emphasize pre-transfer communication and safe transportation. Little literature exists on non-emergent transfers and the systems necessary ensure timely and safe care on patient arrival to an accepting facility. As a quaternary referral center, University of Colorado Hospital (UCH) accepts and cares for many patients transferred from other facilities.
Purpose: Our project’s purpose is to improve safety outcomes of non-ICU medical patients transferred non-emergently to UCH from outside facilities. Specifically, we planned to decrease the time between patient arrival and placement of admission orders, as well as decrease the number of rapid response calls in this patient cohort.
Description: Through a systematic survey of current operating procedures for patients who arrive from outside facilities at UCH, we identified substantial heterogeneity in admissions processes. Baseline data collected during 2016 through 2017 found that patients transferred from an outside facility to Internal Medicine services at UCH had an average wait time of 75 minutes before provider evaluation and orders. Further, this population comprised approximately 10% of all rapid responses called in the hospital. Based on collective contribution from physicians, nurses, and administrators, we created a streamlined communication process that ran in parallel instead of in sequence (see attached). This process specifically addressed the delay in timely provider evaluation and appropriate triage of patients at time of arrival. Through several PDSA cycles we achieved a modest reduction in average evaluation time from 75 to 60 minutes, but was compromised by lack of adherence. Our work has led to a hospital-wide effort that includes the in-parallel communication model while incorporating a physical change in workflow to facilitate adherence.
Conclusions: Although transferring patients to other hospitals is often necessary, patients are vulnerable during transitions of care. We identified great variability in the arrival process and found the resultant delays in evaluation and care may contribute to adverse events during this critical period. More streamlined systems that lead to faster clinician evaluation may result in fewer adverse events in patients transferred from outside facilities.