Patient Safety Tip of the Week

October 30, 2018   Interhospital Transfers



We’ve done many columns on problems associated with intrahospital transfers (see list at the end of today’s column). But what about interhospital transfers. There have been several recent publications drawing attention to problems with interhospital transfers.


In our September 2018 What's New in the Patient Safety World column “ECRI Institute Partnership: Closing the Loop” we noted a recent study from University of Minnesota researchers (Usher  2018) which looked at adult patients transferred between 473 acute care hospitals from 5 states from 2011 to 2013. The researchers found that discordance in diagnoses occurred in 85.5% of all patients. 73% of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Moreover, diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11).


But when both involved hospitals shared data via health information exchange (HIE) there was a reduced diagnostic discordance index (3.69 vs. 1.87%) and decreased inpatient mortality (OR 0.88).


In the editorial accompanying the Usher study, Tierney (Tierney 2018) appropriately points out that association does not mean causation. He gives several reasons why there was diagnostic discordance, and more diagnoses and longer lengths of stay at the receiving hospitals. He concludes that the patients who died were sicker, had more adverse events, and hence more recorded diagnoses and comorbidities. But he takes heart in the fact that, when both transferring and receiving hospitals participated in HIEs, mortality was significantly lower, even after adjusting for diagnostic discordance.


Another recent study of Medicare beneficiaries (Mueller 2018) also showed that, across 15 top disease categories, interhospital transfer was associated with significantly higher costs, longer LOS and lower odds of discharge home. But the picture was more complicated when it came to mortality. The odds of 3-day and/or 30- day mortality were lower for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher for others (esophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructive pulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease). Mortality and resource utilization were also higher among children who underwent interhospital transfer to intensive care after initial hospitalization, compared with those transferred directly from emergency to intensive care.(Odetola 2009).


There is little question that patients requiring transfer between hospitals are usually sicker and some studies have attributed higher mortality rates in such patients as being primarily due to patient characteristics. Chu et al. (Chu 2016) found higher mortality rates after lower limb bypass surgery in transferred patients but found that infected wounds, contaminated wounds, and need for emergency surgery were factors most impacting tht mortality. Lucas et al. (Lucas 2014), using the American College of Surgeons NSQIP database, also concluded that worse outcomes seen in transferred patients are largely due to confounding by patient characteristics rather than any true harm from transfer. They cautioned that pay-for-performance schemes should adjust for transfer status to avoid unfairly penalizing hospitals that frequently accept transfers. Patel et al. (Patel  2018) analyzed variables associated with 24-h mortality after interhospital transfer to a tertiary medical ICU. They did not find distance traveled to be a predictor of 24-h mortality after interhospital transfer. They did identify air transportation to be a univariate predictor of 24-h and in-hospital mortality after interhospital ICU transfer, but found evidence suggesting sicker patients may be more likely to be air transported.


But other studies have found that interhospital transfer is independently associated with inpatient mortality. Yelverton et al. (Yelverton 2018) focused on interhospital transfers related to emergency general surgery (EGS). Looking at a large database of patients aged ≥18 years with an EGS admission, they found interhospital transfers comprised 2% of EGS admissions. Interhospital transfers were more likely to be white, male, Medicare insured, and had higher rates of comorbidities. Interhospital transfers underwent more procedures/surgeries and had a higher mortality rate. Mortality remained elevated after controlling for patient characteristics.


Sokol‐Hessner and colleagues (Sokol‐Hessner 2016) analyzed a database of almost 900,000 hospital inpatient admissions. They found that, compared with ED admissions, patients transferred from another hospital had a longer average length of stay, higher proportion of time spent in the intensive care unit, higher costs per hospital day, lower frequency of discharges home, and higher inpatient mortality (4.1% vs 1.8%). After adjusting for patient characteristics and risk of mortality measures, transferred patients had a higher risk of in‐hospital death (odds ratio: 1.36).


It’s a given that patients transferred from one hospital to another are, in general, sicker than those that do not need to be transferred. Patients are also transferred for procedures or a certain level of expertise that are not available at the hospital of origin. So, it’s no surprise that mortality would be higher in patients undergoing interhospital transport.


But what else might contribute to that higher mortality? Here are some potential factors related to interhospital transfer that might contribute:



Delays in transfer certainly contribute to higher mortality. Often, hospitals wait for imaging studies to be performed even though receiving hospitals often repeat those studies (whether appropriate or not!) or when the result of that study would not alter the decision to transfer.


In several of our columns on issues with helicopter or air ambulance transport, we’ve discussed a scenario we’ve seen over and over: miscalculation of transport time. The patient presents to a small, rural hospital with acute coronary syndrome and gets transferred to a tertiary center for a percutaneous angioplasty/stenting. But the hospital of origin never looks at its statistics and fails to recognize that almost none of their transported patients actually arrive at the receiving hospital within the ideal 90-minute window for a coronary intervention. The hospital of origin, assuming the patient would be getting a coronary intervention, withheld thrombolytic therapy. Hence, the patient missed an opportunity for thrombolytic therapy that might have saved significant myocardium.


Poor communication between facilities

Sometimes the communication is emergency physician to emergency physician. While that may be appropriate in many cases, there are others where the communication should be with the physician who will ultimately be caring for the patient. For example, in the acute coronary syndrome example above, an interventional cardiologist might tell the sending hospital that thrombolytic therapy should be given because the patient will likely arrive outside the ideal window for a coronary artery procedure.


Mode of transport

Choosing the optimal mode of transport for the patient may not be as simple as it sounds. In most cases the decision is BLS- vs. ALS- vs. MICU-ambulance or helicopter vs. fixed-wing air transport. In our numerous columns on issues related to helicopters and medial air transport, we’ve pointed out that air transport is not necessarily faster than ground ambulance transport in many cases. So you must be familiar with the total time it takes for a helicopter to arrive in addition to the transit time from your hospital to the receiving hospital. You also need to be aware of weather conditions that may have implications for a flight (or for ground transport).


But there are other considerations as well. You may need a helicopter or medical air transport plane for the more sophisticated medical equipment on board or for the personnel to accompany the patient (eg. a receiving hospital may send a medical team to accompany the patient).


And, as pointed out by Kulshrestha and Singh (Kulshrestha 2016), there are patient-related considerations to the choice of transport mode. For example, you need to take into account what effect vibration in a helicopter would have on a patient with a spinal or cranial injury. They also note that high altitude flights may be associated with expansion of gas in body spaces and in medical equipment, so high altitude flights may be contraindicated in patients with trapped gas in body cavities such as untreated pneumothorax, pneumocephalus, recent abdominal surgery and gas gangrene.


Lastly, you may need to take into account the issue of cost for the patient and his/her family. We’ve seen cases where patients received $10,000+ bills for air transports. Probably the most difficult situation is when the patient’s family, for financial/insurance purposes, wants to drive the patient to the other hospital. Fortunately, there would be very few interhospital transfers in which a patient would be stable enough to allow this and most hospitals would not take on the legal liabilities associated with that. But, in a case where a family insisted upon that, you’d still have to do your best to ensure as safe a transport as possible.



Problems in transit

In one study (Gray 2003), 15% of interhospital transports involved a critical incident. Ligtenberg et al. (Ligtenberg 2005) did a prospective audit of the quality of 100 consecutive interhospital transports of critically ill patients to a university hospital-based medical ICU. Adverse events occurred in 34% of transfers. In 50% of these transports, pretransport recommendations given by the intensivist at the receiving ICU were ignored. Approximately 30% of events might be attributed to technical problems. Examples of things that went wrong in transit:


The authors conclude that further improvement must be achieved by better communication between referring and receiving hospitals, and by strict adherence to checklists and to published protocols.


Monitoring during a transport should include all the parameters you’d be monitoring if the patient were in a hospital room/bed. Dunn and colleagues (Dunn 2007) stress an important point about monitoring in-transit: audible alarm systems from monitors and electrical equipment become obsolete in noisy environments and thus visible alarms should be used.


Another problem, which we’ve discussed in our columns on intrahospital transport, is the potential for interruption of therapy. Dunn et al. (Dunn 2007) recommend that syringe or infusion pumps should be used to enable the delivery of all intravenous fluids and drugs, because gravity‐fed drips may be unreliable when moving. But careful planning is also needed to decide whether insulin pumps or other infusion should be continued or suspended during a transport.


And 2 other problems, which we would not have considered, relate to the atmospheric environment of the transport vehicle. Kulshrestha and Singh (Kulshrestha 2016) point out that the environment inside ambulances is usually kept at lower temperature by use of air conditioning. That can cause hypothermia in susceptible patients, especially neonates, so these patients should be covered with warming blankets during transfer. They also note that humidity decreases with altitude in air transport can lead to drying of secretions of respiratory tract and mucous membranes, so use of humidified oxygen and lubrication of eyes by use of artificial tears or drops should be considered.



Poor preparation for transport

So that gets us to perhaps the most critical contributing factor: poor preparation for transport. Just as we’ve emphasized in our many columns on intrahospital transports, running out of oxygen is a significant factor that is almost 100% preventable. That was the original problem that led to development of “Ticket to Ride” checklists for intrahospital transports. There should be a similar checklist in every interhospital transport. Also, because many such transferred patients are intubated and receiving mechanical ventilation, one must be aware of the status of any battery-operated equipment.


Ligtenberg et al. (Ligtenberg 2005) observed a lack of preparation before transfer of patients. Although they consistently advised that a skilled physician accompany the patient, a number of patients arrived without a doctor. They noted that adherence to existing ambulance checklists would have avoided a few events, for example equipment failures, incomplete supplies, shortage of oxygen or batteries, and drug administration errors. They speculated about the role a special retrieval team using a mobile ICU might improve the quality of transports.




So, it’s clear that safe interhospital transfer of patients is an incredibly complex process. It involves good bidirectional communication and careful planning. The only way anyone can possibly remember to do everything correctly is to use a checklist. Fortunately, there are some good checklists available (Whiteley 2011). The American College of Critical Care Medicine guideline for the inter-and intrahospital transport of critically ill patients (Warren 2004), though from 2004, has a comprehensive list of the minimum equipment and medication supplies that are necessary for transport of critically ill patients.


We’ve also put together our own Checklist for Interhospital Transfers. However, you’ll recall from some of our prior columns on optimizing checklists that ideal checklists are fairly short. So you may find it preferable to have a series of individual checklists for interhospital transfer, such as deciding whether transfer is necessary, meeting EMTALA requirements, deciding on mode of transport, preparing the patient for transport, communicating with receiving hospital, preparing staff for transport, preparation for departure, actual transport, delivering the patient, post-transport actions, and followup and quality improvement activities. We’ve included those “mini” checklists along with the more comprehensive checklist noted above.



Incomplete medical information

In some ways, the transition to electronic medical records has created a problem for interhospital transfers. Today, in most hospitals, the emergency physician dictates his/her note and it is then transcribed by a transcriptionist (or converted to text by a voice recognition program). The emergency physician then needs to review the notes for completeness and accuracy. So, the notes may not be ready to send with the patient. That puts the onus on the emergency physician to do a comprehensive verbal handoff to a physician at the receiving hospital and to handwrite at least some salient information to accompany the patient. But the receiving hospital needs access to the much more complete medical records of the transferred patient. The Usher study mentioned earlier (Usher  2018) showed that, when both transferring and receiving hospitals participated in HIEs, mortality was significantly lower.


Another study (Herrigel 2016), which looked at practices at 32 tertiary care centers, found some less frequent transfer practices included: electronic medical record (EMR) cross‐talk availability and utilization (23%), real‐time transfer center documentation accessibility in the EMR (32%), and referring center clinical documentation available prior to transport (29%).



Failure to close the feedback loop

Most regional trauma programs have a mechanism by which they provide feedback to all referring hospitals. But they do not cover interhospital transfers that involve non-trauma patients. In our experience, most tertiary care hospitals seldom provide feedback to the sending hospitals. In the acute coronary syndrome example given above, the rural hospitals had no idea their patients were arriving outside the optimal time window for intervention.




Your interhospital transport plan should also have a discussion of contingencies. For example, who should the transfer team call when there is an in-transit problem? What should be done if there is an unforeseen barrier to transport (eg. motor vehicle accident closing a route, vehicle breakdown, etc.). Ironicallly, on the day we had begun writing this column, a friend described an ambulance trip in which her ambulance broke down, resulting in a 40-minute delay in transport.




For those hospitals looking for topics for a FMEA (Failure Mode and Effects Analysis), both intrahospital transport and interhospital transfer are prime candidates. You don’t have to wait for a serious incident to trigger your analysis of all the steps and potential vulnerabilities associated with these processes. Transport plans (for both intrahospital transport and interhospital transfer) should be developed by a multidisciplinary team and should be evaluated and refined regularly using a standard quality improvement process (Warren 2004).




Some of our prior columns on the “Ticket to Ride” concept:



Our prior columns dealing with medical helicopter issues:


July 8, 2008                Medical Helicopter Crashes

October 2008              More Medical Helicopter Crashes

February 3, 2009      NTSB Medical Helicopter Crash Reports: Missing the Big Picture

September 1, 2009      The Real Root Causes of Medical Helicopter Crashes

November 2010          FAA Safety Guidelines for Medical Helicopters Short-Sighted

March 2012                  Helicopter Transport and Stroke

April 16, 2013             Distracted While Texting

August 20, 2013         Lessons from Canadian Analysis of Medical Air Transport Cases

December 29, 2015     More Medical Helicopter Hazards







Usher M, Sahni N, Herrigel D, et al. Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study. J Gen Intern Med 2018; 33(9): 1447-1453



Tierney, W.M. Breakdowns on the information highway during inter-hospital patient transfers. J Gen Intern Med 2018; 33: 1415

(Tierney 2018)



Mueller S, Zheng J, Orav EJ, Schnipper JL. Inter-hospital transfer and patient outcomes: a retrospective cohort study. BMJ Quality & Safety 2018



Odetola FO, Davis MM, Cohn LM, Clark SJ, Interhospital Transfer of Children. J. Hosp. Med 2009; 3; 164-170



Chu Y, Aziz F, Lehman E. Transfer from Another Hospital is Associated with Increased Morbidity and Mortality after Lower Extremity Bypass Surgery. Journal of the American College of Surgeons 2016; 223(4): e64



Lucas DJ, Ejaz A, Haut ER, et al. Interhospital Transfer and Adverse Outcomes after General Surgery: Implications for Pay for Performance. Journal of the American College of Surgeons 2014; 218(3): 393-400



Patel JJ, Kurman J, Al-Ghandour E, et al. Predictors of 24-h mortality after inter-hospital transfer to a tertiary medical intensive care unit. Journal of the Intensive Care Society 2018; First Published March 22, 2018



Yelverton S, Rozario N, Matthews BD, Reinke CE. Interhospital transfer for emergency general surgery: An independent predictor of mortality. Amer J Surg 2018; 216(4): 787-792



Sokol‐Hessner L, White AA, Davis KF, et al. Interhospital Transfer Patients. J. Hosp. Med 2016; 4; 245-250



Kulshrestha A, Singh J. Inter-hospital and intra-hospital patient transfer: Recent concepts. Indian J Anaesth 2016; 60(7): 451-457

(Kulshrestha 2016)



Gray A, Gill S, Airey M. et al The descriptive epidemiology of adult critical care transfers from the emergency department. Emerg Med J 2003; 20(3): 242-246



Ligtenberg JJ, Arnold LG, Stienstra Y, et al. Quality of interhospital transport of critically ill patients: a prospective audit. Crit Care 2005; 9: R446–R451



Dunn MJ, Gwinnutt CL, Gray AJ. Critical care in the emergency department: Patient transfer. Emerg Med J 2007; 24:4 0-44



Whiteley S, Macartney I, Mark J, et al. Guidelines for the transport of the critically ill adult (3rd Edition 2011). The Intensive Care Society (UK) 2011



Warren J, Fromm RE, Jr, Orr RA, Rotello LC, Horst HM. American College of Critical Care Medicine. Guidelines for the inter-and intrahospital transport of critically ill patients. Crit Care Med. 2004; 32: 256-262|ExpireAbsolute;source|Journals;ttl|1539445293691;payload|mY8D3u1TCCsNvP5E421JYK6N6XICDamxByyYpaNzk7FKjTaa1Yz22MivkHZqjGP4kdS2v0J76WGAnHACH69s21Csk0OpQi3YbjEMdSoz2UhVybFqQxA7lKwSUlA502zQZr96TQRwhVlocEp/sJ586aVbcBFlltKNKo+tbuMfL73hiPqJliudqs17cHeLcLbV/CqjlP3IO0jGHlHQtJWcICDdAyGJMnpi6RlbEJaRheGeh5z5uvqz3FLHgPKVXJzd9ia1/MJJUFmWp1b9urv13N8B7u/5P6D/BN/e6CYcAKc=;hash|coiQyfdQM/TnXzIdybMHYA==



Checklist for Interhospital Transfers



Herrigel DJ, Carroll M, Fanning C, Steinberg MB, Parikh A, Usher M, Interhospital Transfer Handoff Practices. J Hosp Med 2016;11(6); 413-417






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