Background: The inter-hospital transfer process is complex even under ideal circumstances, susceptible to logistical errors, inefficiencies, and patient harm. Clinical hospitalists have historically been responsible for triage of all Medicine transfers at Oregon Health and Science University (OHSU), fielding 10-20 calls daily alongside clinical and educational responsibilities. In part due to time constraints during triage, transfer patients sometimes arrived unprepared for procedures, lacking crucial records, or even in unstable condition. Other patients were transferred unnecessarily. The effects of mis-triage have been magnified during the pandemic, amidst dire capacity and staffing challenges. We were compelled to decline 258 transfers due to bed constraints during the first year of the pandemic.
Purpose: In response to unprecedented capacity issues and growing inefficiencies within the transfer process, we created the Intake Hospitalist role. The role was designed with a number of objectives in mind: to establish a standardized and safer transfer process, to augment hospital bed capacity both by reducing transfer patient door-to-procedure time as well as decreasing unnecessary transfers through creative alternatives to transfer, and to provide clinical hospitalists with more time for direct patient care and resident education.
Description: The Intake Hospitalist role was implemented on January 1, 2021 at OHSU, an academic medical center that provides quaternary care, and Hillsboro Medical Center (HMC), a community hospital within the OHSU system. The Intake Hospitalist is responsible for triage of all external consults, intra- and inter-hospital transfers, and direct admissions to medicine services at both OHSU and HMC. The Intake Hospitalist group is comprised of 16 hospitalists with 3+ years of experience, each prepared for the role through extensive systems, EMTALA and triage training. Transfer documentation was standardized, and workflows for our most common and complex transfer indications were designed with assistance from subspecialists. Importantly, the role is independent of clinical and educational responsibilities. This allots ample time to ensure that transferred patients arrive medically optimized with all pertinent documentation and imaging in place, or, in cases we decline, time to provide ongoing recommendations to the referring provider, and to organize expedited outpatient follow-up for the patient.
Conclusions: To address safety and capacity concerns, we implemented the Intake Hospitalist role. The goal of the innovation was to reach a state wherein we transfer only those who truly need our services, with great effort to ensure they arrive safely, to the right hospital and ward within our system, at precisely the right time. With training, standardization, and undivided time, the Intake Hospitalist led to marked improvements among our measured metrics—which includes door-to-procedure time, transfer patient safety, number of unnecessary transfers, transfers avoided through creative solutions, and hospitalist quality of life. Of those patients we did not accept in transfer, we performed chart review to ensure there were no unintended harms, and that outpatient follow-up occurred as planned. We believe our innovation increased transfer safety and markedly decreased potentially unnecessary transfers, freeing up beds in a time of critically low access. Because of this success, and using the same model, a triage physician position for our ICUs is under development.