Transferring patients between hospitals is a common occurrence at community hospitals and tertiary care facilities. Although not enough is known about the burden this puts on our healthcare system, it has been estimated that 1.6 million inpatients originated at another facility,1 including 1.5% of all admitted Medicare patients.2 Despite the high volume of patient transfers, there is no structured way to ensure that the patients medical records arrive along with them to the receiving institution. This has posed significant, and even life threatening outcomes, but is there a solution?
Interhospital transfers often occur when the initial hospital facility lacks the specialty care required for the admitted patient. Transferring hospitals seek out another facility that they feel can provide better care. However, transferring hospitals often have to convince the accepting hospital that the transfer is necessary and not just convenient. This requires the transmittal of detailed clinical information in advance. Unfortunately, this is most often done by telephone, is not well recorded and therefore may not be available for anyone other than the physician on the other end of the phone. It often is a subjective view of the transferring physician him or herself in an attempt to convince the receiving physician on the other end of the telephone connection. A set of objective information would be more appropriate.
Many of these transfer patients are some of the more critical cases that a facility encounters, subjecting very sick patients to less than systematic transfers and putting their already compromised health at additional risk.
Potential Medical Errors
Transitions of care are major sources of preventable medical errors. Incomplete or inaccurate communication during these handoffs is the root cause of many adverse events.3
Below is a case description reprinted from an article4 published by Dr. Stephanie Mueller that illustrates just how impactful a poor transfer can become.
A 63-year-old man with a history of hypertension, coronary artery disease, and diabetes was evaluated by his primary care physician for a rash. The physician noted the presence of high fevers and headache, and so he sent the patient to the emergency department (ED) for further evaluation and possible admission. Repeat vital signs in the ED were notable for a slightly low blood pressure and elevated respiratory rate. His rash was worsening, with sloughing of his skin. Laboratory test results showed an elevated lactate and white blood cell count, both concerning for possible sepsis. Fluids and antibiotics were administered. The patient was started on IV norepinephrine through a peripheral IV to maintain his blood pressure, but no central line was placed.
The admitting physician was concerned that the patient might require subspecialty care, including dermatology consultation and critical care interventions not available at the local hospital. The physician arranged to have the patient transferred to a large academic medical center that could provide these services, but he was not familiar with any formal process to do so. He called a colleague at the receiving hospital to make the request for transfer. The colleague secured a bed through the bed control department and suggested he send the patient over.
The details of the patient's current clinical condition and clinical data were not formally transmitted to the receiving hospital. Not knowing that the patient required pressors to maintain his blood pressure and that he was likely developing worsening shock, the accepting physician booked a general ward bed for the patient rather than an intensive care unit (ICU) bed. He did not inform the hospital's transfer center.
Four hours later, the patient arrived at the academic medical center and was placed on a telemetry floor. His mentation was altered, and he was breathing rapidly. The bedside nurse realized that norepinephrine was infusing through a peripheral IV. He called the rapid response team and ICU fellow to arrange for transfer to the ICU. Unfortunately, in the interim, the patient went into cardiac arrest and was pronounced dead about an hour after transfer.
Results like that which occurred in this case need not happen. There are ways to improve communication and the exchange of clinical information amongst referring and receiving hospitals.
Exchanging Patient Medical Records
Legislation known as the Emergency Medical Treatment and Labor Act (EMTALA) provides a protocol for the transfer of a patient who needs specialty care unavailable at the transferring institution. However, it is often hard to determine which patients actually need to be transferred and which do not. The law provides some guidelines, however the actual process of selecting which patients require transfer remains somewhat arbitrary.
In many of these cases, speed is of the essence. That starts with a quick determination of whether a patient can be adequately (better) treated at the receiving hospital. Making the patient’s current health records and test results available to the potential receiving hospital to supplement physician to physician conversations can go a long way toward enabling the receiving hospital to appreciate the actual situation.
All the information compiled by the sending hospital, including objective clinical information, current labs, radiology images, and physician notes need to be rapidly transmitted along with the patient. Unfortunately, the lack of interoperability amongst electronic medical records systems, means that this communication is dependent upon photocopying documents and physical transport of CDs; processes which are prone to mistakes in an urgent high-tension situation. Recent studies indicate that transferred patient information like this accompanies the patient less than a third of the time.5 Overall, high quality communication both prior to the transfer as well recording this information for subsequent physician consults are essential for avoiding issues that might arise from the discontinuity of care.
What is needed is a way to present these patient records electronically and efficiently in order to ensure that the transfer is both necessary and appropriate. Hospitals can’t count on compatible EHR systems for this task and require a system that operates in a heterogeneous environment. Once the patient is transferred, these records need to be immediately available to the receiving team. Delays caused by awkward and time-consuming uptake into the receiving system can compromise the patient’s treatment outcome.
There is a better way
Purview has developed a solution that enables hospitals with incompatible electronic health records systems to seamlessly communicate and present records to the receiving hospital. Any hospital with the appropriate technology can present, share and transfer complete sets of patient records (including medical images, test results, labs and physicians comments) immediately to a receiving hospital to prepare the hospital in advance of the critical patient’s arrival.
1 HCUP National Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP) 2012 Agency for Healthcare Research and Quality, Rockville, MD www.hcup-us.shrq.gov/nisoverview
2 Cases and Commentaries, February 2019 AHRQ, PSNET www.psnet.ahrq.gov
3 Raduma-Thomas MA, Flin R, Yule S, Williams D. Doctors’ handovers in hospitals: a literature review. BMJ Qual Saf. 2011: 128-133
4 Cases and Commentaries, February 2019 AHRQ, PSNET www.psnet.ahrq.gov
5 J. Hosp. Med 2016 June; 11(6) 413-417110.10021 jhm.2577, p.414