Background: Inter-hospital transfer (IHT) refers to the movement of patients between acute care hospitals and is a routine practice within healthcare systems. The process, however, remains unstandardized, resulting in variability in how patients are identified, managed, and transferred, as well as in patient outcomes, safety, and associated costs. While IHT typically provides specialized care unavailable at the sending hospital, some transfers are not medically necessary. As part of the Identification and Prevention of Potentially Inappropriate Inter-Hospital Transfers (POINT) study (AHRQ R01 HS28621), we explored the incidence of inappropriate IHT, their impact on patient safety, and the effects of a site-specific transfer process.
Methods: A single-site chart review was conducted to examine patients transferred to Department of Medicine specialties between May and June 2023. Data was collected using a REDCap Adjudication Tool for pre-screening and case reviews. Eligible patients were 18+, transferred between acute care hospitals, and admitted to a medical service (e.g., general medicine, medical specialties, or ICU). Standardized reviews assessed transfer details, rationale, appropriateness, patient safety impact, and the use of a site-specific templated IHT note. Transfers were rated from “highly inappropriate” (no clear benefit, high risk) to “highly appropriate” (clear benefits, need for continued hospitalization).
Results: A total of 42 encounters meeting inclusion criteria were reviewed. Transfer communication was documented in 23 charts (54.8%), with 15 charts (35.7%) utilizing a Jefferson-developed templated EHR note and 8 charts (19.1%) utilizing non-templated notes. Three transfers were determined by double adjudication to be inappropriate (7.1%). These cases each had transfer communication documentation and were transferred to the following service lines: Gastroenterology/Hepatology (1 of 22; 4.5%), Pulmonary Medicine (1 of 9; 11%), and Hospital Medicine (1 of 7; 14%), with none to Cardiology (4; 0%). Inappropriate IHT rates by note type were: no note (0 of 19; 0%), non-templated note (2 of 8; 25%), and templated note (1 of 15; 6.7%). ‘Patient/family preference’ was a primary or secondary reason for transfer for all inappropriate transfers. No escalations in care within 24 hours or transfer-related adverse events were noted. Additionally, none of the inappropriate cases involved a medical condition requiring care unavailable at the transferring hospital.
Conclusions: This exploratory analysis suggests an inappropriate IHT rate of about 7%, primarily driven by patient preference. No concerning safety outcomes suggesting disruption in continuity of care were identified, which may be due to power of study or a robust site-specific transfer process. Hospital Medicine had the highest inappropriate IHT rate (14%) and Cardiology had the lowest (0%); warranting further exploration. Unexpectedly, no note correlated with 0% inappropriate IHTs; non-templated note had a 25% rate, and templated note had a 7% rate. This may reflect differences in transfer reason, study power, or lack of specific nudges within notes to ensure necessity of transfer; the templated note was designed for safety. We aim to build on this analysis by further powering the study to better answer questions raised by this data. Insights will inform efforts to optimize transfer practices, reducing disruptive and unnecessary physical transfers and improving overall care delivery.