Imagine the following scenario: a hospitalist on the previous shift accepted a patient from another hospital and received a verbal sign-out at the time of acceptance. Now, 14 hours later, a bed at your hospital is finally available. You were advised that the patient was hemodynamically stable, but that was 8 hours ago. The patient arrives in respiratory distress with a blood pressure of 75/40, and phenylephrine running through a 20g IV in the forearm.
A 400-page printout of the patient’s electronic chart arrives – but no discharge summary is found. You are now responsible for stabilizing the patient and getting to the bottom of why your patient decompensated.
The above vignette is the “worst-case” scenario, yet it highlights how treacherous interhospital transfer can be. A recent study, published in the Journal of Hospital Medicine ( doi: 10.1002/jhm.2515 ), found increased in-hospital mortality (adjusted odds ratio 1.36 [1.29-1.43]) for medical interhospital transfer patients as compared with those admitted from the ED. When care is transferred between hospitals, additional hurdles such as lack of face-to-face sign-out, delays in transport and bed availability, and lack of electronic medical record (EMR) interoperability all contribute to miscommunication and may lead to errors in diagnosis and delay of definitive care.
Diametrically opposed to our many victories in providing technologically advanced medical care, our inability to coordinate even the most basic care across hospitals is an unfortunate reality of our fragmented health care system, and must be promptly addressed.
There currently exists no widely accepted standard of care for communication between hospitals regarding transferred patients. Commonalities include a mandatory three-way recorded physician verbal handoff and a transmission of an insurance face sheet. However, real-time concurrent EMR connectivity and clinical status updates as frequently as every 2 hours in critically ill patients are uncommon, as our own study found ( doi: 10.1002/jhm.2577 ).
The lack of a standard of care for interhospital handoffs is, in part, why every transfer is potentially problematic. Many tertiary referral centers receive patients from more than 100 different hospitals and networks, amplifying the need for universal expectations. With differences in expectations among sending and receiving hospitals, there is ample room for variable outcomes, ranging from smooth transfers to the worst-case scenario described above. Enhanced shared decision making between providers at both hospitals, facilitated via communication tools and transfer centers, could lead to more fluid care of the transferred patient.
In order to establish standardized interhospital handoffs, a multicenter study is needed to examine outcomes of various transfer practices. A standard of communication and transfer handoff practices, based on those that lead to better outcomes, could potentially be established. Until this is studied, it is imperative that hospital systems and the government work to adopt broader EMR interoperability and radiology networks; comprehensive health information exchanges can minimize redundancy and provide real-time clinical data to make transfers safer.
Ideally, interhospital transfer should provide no more risk to a patient than a routine shift change of care providers.
Dr. Dana Herrigel is associate program director, internal medicine residency at Robert Wood Johnson Medical School, New Brunswick, N.J. Dr. Madeline Carroll is PGY-3 internal medicine at Robert Wood Johnson Medical School.