Background: Interhospital transfers (IHT) for additional care are a necessary, if high-risk, part of the healthcare system. Return transfers, in which the patient is returned to the referring hospital once higher-level care is no longer needed, are also a part of the healthcare system but are even more varied and less systematized and studied within the IHT landscape. Over the last decade, our department has implemented a standardized IHT process with accompanying templated acceptance transfer note to drive patient care improvement.Since the closure of a large safety-net hospital in Philadelphia in summer 2019, the remaining three large referral centers have strained with capacity constraints. We have responded by attempting to better load manage to better match patient complexity with hospital capabilities. In this study, we seek to determine if sequential interventions – first, a prompt to discuss and document return transfer discussion and agreement in the templated IHT accept note (Phase 1; live 1/1/2023) and, second, a banner in our electronic health record (EHR) making the presence of a return agreement more visible to clinicians (Phase 2; live 2/1/2024) – increased IHT return transfers.
Methods: EHR, transfer center log, and Vizient data availability provided bounds for analysis. Phase 0 (no intervention – return agreements completed unsystematized, ad hoc) included all IHTs to Department of Medicine (DOM; other departments do not use the templated note) from 7/1/2022-12/31/2022. Phase 1 (templated note nudge) included DOM IHTs from 1/1/2023-1/31/2024. Phase 2 (EHR banner) included DOM IHTs from 2/1/2024-8/5/2024. Transfer center logs were used to identify IHTs. Matched Vizient data was used to identify discharge date. Discharge date was used to find a match in outbound transfer center logs. A return transfer was confirmed if the patient returned to a hospital with the same name as the original IHT inbound transfer. “N-1” Chi-squared test was used for proportion comparison. Analysis was completed in Excel.
Results: During Phase 0, 0% (0/247) patients completed a return transfer. In Phase 1, 4.2% (25/601) patients completed a return transfer, a significant increase from Phase 0 (p=0.0011). In Phase 2, 5.2% (16/305) patients completed a return transfer, a significant increase from Phase 0 (p=0.0003), and a non-significant 24% relative increase from Phase 1 (p=0.49).
Conclusions: The inclusion in a templated IHT acceptance note of a prompt to ask for a return transfer agreement is associated with a 4.2% increase in return transfers. The addition of an EHR banner to improve return agreement visibility is associated with a non-significant 24% further increase in return transfers. Though there is a paucity of literature characterizing rates of IHT return transfers, these rates seem low. There are potential benefits to return transfers including proximity of family, friends and support networks, better insurance/service matching across states, and, as above, better matching of healthcare resources to health care needs so further exploration and iterative improvement is necessary. Our next step is to explore process adherence (e.g., was templated note used; if so, was return transfer discussed) to determine potential areas of iterative impact. Future research should also explore the potential deleterious impact of return transfers; just as communication breakdowns can make IHT upgrades high risk, further characterization of return transfers to ensure safety is needed.