Background: The availability of beds within healthcare systems has been stressed during each wave of the COVID-19 pandemic. Healthcare systems with tertiary hospitals have had increasing patient volumes and face limitations of specialized urgent (e.g., ECMO) and routine (e.g., Percutaneous Coronary Intervention) functions during critical inpatient surge volumes. Reserving the limited capacity at a tertiary hospital for those patients most in need maximizes the quality of care for the sickest patients. Our quality improvement intervention aimed to implement an interhospital patient transfer protocol for Emergency Department (ED) admissions during critical surge volumes from the tertiary hospital to local community hospitals and preserve critical functions for patient care at the tertiary care hospital, all within the same healthcare system.

Methods: The setting included Intermountain Healthcare, a large non-profit healthcare system in the Intermountain West, with one adult tertiary care hospital with 22 community and rural hospitals. Each day during the intervention period from August 2020 to May 2021, medically stable patients requiring hospital admission were identified by their attending emergency physician at the tertiary care hospital as eligible for transfer within the healthcare system to a community hospital and were approached for patient consent before initiating a transfer request. ED physicians then contacted the on-call Tele-Hospitalist to evaluate the individual case for transfer. Tele-Hospitalists considered a range of factors, including the acute diagnosis, chronic conditions, receiving hospitals with beds and staffing, and the availability of ancillary services, such as hemodialysis, at hospitals capable of receiving a transfer. While ten community hospitals received transfer patients, the three hospitals receiving 95% of transfers were provided with increased Hospitalist support. A local ambulance company was contracted with a fixed cost for medical transfers paid by the healthcare system at no cost to the patient.

Results: Seven-hundred and two patients were transferred from the tertiary hospital ED, and 53.6 % were known or suspected COVID-19. The mean age for transfer was 58 (SD 17.6), ranging from 18 to 98 years old. The median hospital length of stay for transfers was 3.6 days, and a total of 3,405 inpatient days were diverted from the tertiary hospital. Of those transferred, 4.7% required an ICU admission, with all being able to stay at the receiving hospital. Total charges deferred from the tertiary hospital was $8,610,191, with the median charge per admission being $8,634.

Conclusions: The implementation of a tertiary hospital offloading protocol demonstrated effectiveness in preventing the disruption of important medical procedures and maintaining care with appropriate staffing during a time of critical surge. A complex and multidisciplinary effort was effectively coordinated to achieve this goal while maintaining the most appropriate patient care, at the appropriate facility, and at the appropriate time. The maintenance of routine and urgent procedures during winter 2020/2021 likely mitigated significant revenue losses for the tertiary hospital and overall health system while ensuring patient access to necessary procedures. Although initiated during surge volumes spurred by the COVID-19 pandemic, a playbook and protocol continues to be used after the study intervention.

IMAGE 1: Table 1: Patient Characteristics of Those Transferred

IMAGE 2: Inpatient Daily Census at Sending and Receiving Hospitals with Overlay of Off-Loads