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We’ve done many columns on the dangers of intrahospital transports and the need to do careful planning to avoid those dangers. But we’ve focused primarily on temporary transports to areas such as radiology or the OR. But there is a different sort of intrahospital transfer that is also problematic – the transfer of patients from beds on one unit to beds on another unit.
A recent study from the UK (Boncea 2021) found that intrahospital transfers are associated with increased odds of developing a healthcare-associated infection (HAI). The authors suggest that strategies for minimizing intrahospital transfers should be considered, and further research is needed to identify unnecessary transfers. Their reduction may diminish spread of contagious pathogens in the hospital environment.
The frequency of such intrahospital transfers should probably not surprise you. Only 27.8% of patients did not undergo any intrahospital transfers. 44.2% of patients underwent one intrahospital transfer, 17.1% underwent two transfers, and 11.0% underwent three or more transfers. Overall, 11.9% of patients developed an HAI. C. difficile infection accounted for almost a third of the HAI’s, but many other pathogens were implicated as well.
The multivariable logistic regression modelling showed that each additional intrahospital transfer was associated with a 9% increase in the odds of developing an HAI (OR=1.09).
The accompanying editorial (Escobar 2021) notes that cases and controls were well matched, and the statistical modelling provided very compelling results. But it notes the study did not adjust for the indication for transfer (eg, transfer to or from the intensive care unit based on patient acuity, transfer for isolation precautions or transfer due to bed capacity or staffing issues) to determine if the patient care needs, isolation status or hospital strain modify the observed risk. It therefore recommends, as do Boncea et al., that prospective studies are needed to better identify the clinical, administrative and systems factors that contribute to more frequent intrahospital transfers.
Boncea et al. note several factors that could underlie a possible association between HAIs and intrahospital transfers:
Especially in the COVID-19 era, where hospital bed shortages are rampant, we often move patients from one site to another, The Boncea study suggests we not simply act reflexly in such intrahospital transfers, but rather carefully consider the implications before carrying out such transfers. The 9% increased risk of an HAI associated with each transfer is a substantial consideration. There are, of course, other unwanted consequences of intrahospital transfers. For example, one study (Goldberg 2015) found that room transfers amongst hospitalized elderly medical patients substantially increased the risk of development of delirium (OR 9.69).
But one has to weigh the benefits of transfer against the risks. There are risks of keeping a patient on a unit not used to caring for such patients. We cohort patients on floors with special expertise in care for patients with certain conditions. A patient being followed by one service (eg. neurology) who is temporarily housed on a non-neurology floor gets less attention from the neurology staff than he would were he housed on the neurology floor. In addition, the nursing care on the specialty unit is much more attuned to the problems that neurology patient is likely to have. So, decisions about transferring patients from one location in the hospital to another can’t simply be based on the risk of HAI. Nevertheless, the substantial risk of HAI pointed out in the Boncea study should make us recognize that decisions about transfer of patients should not be made rashly.
Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:
Boncea E, Expert P, Honeyford K. Association between intrahospital transfer and hospital-acquired infection in the elderly: a retrospective case-control study in one urban UK Hospital network. BMJ Qual Saf 2021; Published Online First: 25 January 2021
Escobar D, Pegues D. Healthcare-associated infections: where we came from and where we are headed. BMJ Quality & Safety 2021; Published Online First: 08 January 2021
Goldberg A, Straus SE, Hamid JS, Wong CL. Room transfers and the risk of delirium incidence amongst hospitalized elderly medical patients: a case-control study. BMC Geriatr 2015; 15: 69. Published 2015 Jun 25
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