Background: Interhospital transfer is a necessary part of patient care in an increasingly complex healthcare environment. However, it is an ill-defined process that has been associated with increased mortality, cost, and length of stay, even after disease severity adjustment.
Purpose: We aim to describe the triage process for interhospital transfer requests at a large, urban academic center and to identify potential missteps that can lead to poor outcomes, including patient instability on arrival.
Description: The project institution is a large academic medical center that handles roughly 550 outside hospital transfer requests per month. There is a dedicated transfer center staffed by registered nurses (RN) trained in emergency or critical care medicine. Calls are screened by the transfer center and discussed with the appropriate service provider. Decision to accept or deny the transfer request is made by an attending or fellow physician based on information collected by transfer center RNs. After observing and interviewing the transfer center RNs, a process map was created detailing the interhospital transfer process from receipt of transfer request to patient arrival (Figure 1). The process was reviewed by multiple providers and others involved in the transfer process, including hospital administrators and quality leads. We identified 3 key junctures where communication errors or failures can lead to missed screening of unstable patients (Figure 1). These steps include 1) the initial intake call, 2) call for clinical updates, and 3) the RN-to-RN report. The transfer center’s initial intake call and clinical update call, were identified as two processes where the use of standardized documentations may improve critical data collection and dissemination. To assist in the standardization of documentation, a transfer note template within the electronic health record (EHR) was created with input from all key stakeholders. Ongoing data collection is planned to assess the utilization of the note template, in addition to the frequency of reported triage and communication errors for all interhospital transfer patients.
Conclusions: Interhospital transfers have multiple transitions of care junctures that may contribute to worse outcomes for this unique patient population. Communication errors or failures can lead to inappropriate triage of unstable patients. Standardized EHR note templates for transfer RN use may be a way to improve communication.