Researchers to hospitals: Only transfer patients if there’s no other path to a good outcome

Analyzing more than 1,500 cases of patients who got sent from an acute-care hospital to an ostensibly more-capable facility, Harvard researchers have found 1 in 4 such transfers could—and probably should—have been avoided. 

The finding is not trivial, as prior research has shown inter-hospital transfer may be associated with unintended consequences. These can include rehospitalization, longer stays, higher costs and other negatives affecting care quality and patient safety.  

For the present study, published Sept. 29 in JAMA Network Open, Stephanie Mueller, MD, MPH, and colleagues concentrated on cases in which the receiving hospital was one of 16 representative academic medical institutions in the U.S. 

Here are summaries of five of the team’s key findings and observations.
 

1. The majority of potentially avoidable transfers in the study set could have been served by alternatives.

Better options might have included teleconsultation, expedited outpatient specialty care or engagement of a known clinician who provided care, Mueller and co-authors note. 

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‘Avoidable transfers tended to be lower acuity, and many patients did not require interhospital transfer (IHT) to obtain more specialized care (ie, it was already available at their initial hospital). Patient and family request and transfer for purposes of care continuity were also associated with avoidable transfer.’

2. Understanding which IHTs may be unnecessary or avoidable is essential to ensure that patients receive appropriate care.

Such understanding also cuts the odds of exposing patients to unnecessary risks related to discontinuity of care, Mueller and co-researchers remark. 

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‘The complexity of medical patient transfers has been shown to be high risk, with suggestion of patient harm among selected patient transfers. This understanding is also critical for developing alternative strategies that deliver optimal care without relying on transfer.’

3. In the present study, many potentially avoidable transfers had a care need that could have been managed at the transferring hospital (66.8%). 

Of note, teleconsultation was the most common alternative to transfer under both current and ideal lenses, the authors report. Other alternatives to transfer were also thought to be appropriate replacements to IHT, they add, citing as examples “expedited outpatient follow-up” and “engagement of a known clinician who provided care.”

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‘More robust processes for screening patients for care needs that require transfer may be necessary to ensure necessity of IHT. Furthermore, teleconsultation with a specialist may be an area to target for preventing avoidable transfers.’

4. Time delays in transfer and lower patient illness severity were associated with potentially avoidable transfers. 

Time delays between patient acceptance and arrival is “often inversely correlated with patient acuity, that is, higher-acuity patients are most often prioritized for rapid transfer, while lower-acuity patients are more likely to have delays in transfer,” Mueller and colleagues write. 

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‘Given the dynamic nature of clinical acuity, reevaluation of the need for transfer every 24 hours could prevent unnecessary IHT of patients who have experienced improvement in their clinical status, thus obviating their need for transfer.’

5. Transfer to a medical specialty service categorized as ‘other’—as opposed to general medicine, cardiology, oncology or ICU service—was associated with potentially avoidable transfers. 

The “other” category covered such service lines as hepatology and kidney care. “It is possible that these services were more likely to accept longitudinal care patients regardless of medical necessity for transfer,” Mueller et al. comment. “It is also possible that specialists were not appropriately involved in the transfer decision-making”—a possibility supported by a telling finding: Less than half of all patient transfers had documented involvement of a consult service prior to transfer. 

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‘Existing literature suggests that specialist involvement in transfer decision-making has been recognized as a persistent challenge and an important opportunity for improvement withing current IHT practices. This approach may serve as another potential area to target to prevent potentially avoidable transfers.’

The study is available in full for free.