Background: As hospitals organize into larger regional systems anchored by tertiary care facilities, delivering appropriate care at the best-suited institution presents a growing challenge. Interfacility transfer can offer increased access to equipment, services, and expertise; however, managing patients across long distances can put undue burdens on health systems, patients and families, especially when negotiating end of life decisions. Tertiary care centers must balance patient inflow from community hospitals while working to maintain outcomes-based reimbursement through reduced readmission and mortality rates. Identifying patients least likely to benefit from increased level of care (i.e. futile transfers) may result in better allocation of resources and patient experiences.
Methods: We performed an observational study at Regions Hospital, a large tertiary care hospital in St. Paul, MN that serves as a referral center to four community hospitals in western Wisconsin, to identify common characteristics among western Wisconsin transfers. Population was narrowed to transferred patients that subsequently died within that hospitalization. A futile transfer was defined as death, de-escalation, or transition to comfort cares without surgical, radiologic, or endoscopic intervention within 48 hours of transfer.
Results: Over a 12 month period, 28 patients who transferred from western Wisconsin community hospitals to Regions Hospital expired during that admission. Of these, 3 patients died in the receiving ED. An additional 12 died within 48 hours of transfer. Nine patients expired without receiving procedural intervention. Among the patients who survived the first 48 hours, 3 transitioned to comfort cares within the same interval. Eight patients were transferred for traumatic brain bleeds, though none received neurosurgical intervention, and 3 of these patients were deemed to have non-survivable injury on initial imaging. Six patients were transferred for intensive care following cardiac arrest. Only 9 of the 28 patients had advanced care planning documented in their chart. Overall, 14 of 28 transfers were considered futile.
Conclusions: Among western Wisconsin transfers that died, half could be considered futile transfers. Individual case review revealed several instances where patients had unsurvivable injuries based on imaging alone. Others were transitioned to comfort cares as soon as family arrived. Considering the emotional and financial investment required to transfer critically ill patients, there may exist opportunities to improve the delivery of compassionate and appropriate care by keeping patients closer to home and family without necessitating transfer. Possible interventions include facilitating pre-transfer neurosurgery consultation, obtaining family consent prior to transfer, and expanding palliative care training to ED physicians in western Wisconsin.