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By Martin Sellberg, MD, FACEP
Managing medical risk is a constant for physicians, and hospital care teams are used to working together to reduce the potential for medical error. While it may be impossible to completely negate the risk of misstep, research shows that avoidable medical errors remain a major cause of preventable inpatient deaths.
Although dedicated clinicians do their best to avoid adverse events, medical errors are most often enabled by faulty systems, processes, and conditions that elevate the likelihood of mistakes. It’s no surprise that medical errors with serious consequences are most likely to occur in high-pressure areas that handle immensely complex cases, including operating rooms, the ICU, and emergency departments.
More than a decade ago, the Joint Commission estimated that 80% of serious medical errors involved caregiver miscommunication during transfer of care between providers, which led to the development of the Center for Transforming Healthcare’s Hand-Off Communications project in 2009. This pilot program targeted the specific causes of inadequate care transfer processes at 10 hospitals and health systems, which resulted in an average 50% reduction in defective hand-offs.
Clearly, focused mitigation efforts can reduce the risk of avoidable medical errors. Let’s take a look at the interfacility patient transfer process, an area ripe for reform. Typically, sending facilities, receiving facilities, and patient transporters act on their own, with their own insular processes and procedures. By breaking down the silos between emergency departments, specialist offices, and transport providers, healthcare ecosystems can reduce the risk of miscommunication and medical error by giving every stakeholder a common language, platform, and process to follow for interfacility transfers.
The Complexity of Interfacility Patient Transfers
At first glance, the process of transferring from Hospital A to Hospital B seems straightforward. The Emergency Medical Treatment and Active Labor Act directs the expectations for hospitals with specialized capabilities to accept transfers from hospitals that cannot provide for patients who require an advanced level of care.
The decision to transfer a patient to a higher level of care triggers a series of required steps. Referring hospitals must communicate directly with a physician from the receiving facility, and must confirm bed availability and acceptance. If the destination is on diversion or lacks capacity, the process begins again with the next receiving destination. While delays were not uncommon even before the pandemic, the recent healthcare saturation crisis has extended the length of this initial communication process.
Once a receiving physician and facility accepts the patient and the destination and distance is confirmed, the journey to secure transport can begin in earnest. To determine the best option for the patient, care teams must contact local emergency services (EMS) or private ground or air transport vendors to assess their availability, staffing, and estimated arrival times. The patient’s clinical story and condition is now condensed in conversations with transporters, who are evaluating their ability to accept the request.
This period carries a risk of miscommunication, as abridged information is flowing to a variety of other microsystems, including hospital transfer centers and EMS companies. This shortened patient story includes a much lower level of detail than will ultimately be given to the receiving physician and documented within the nursing report. There is no current national standard for this type of condensed patient report.
The heavy workload involved in the transfer process contributes to the complexity and risk of transfers. Care teams must communicate patient status to multiple parties, complete transfer paperwork, update the EHR, share nonclinical information with family members and transporting agencies for logistical purposes, ensure radiology downloads are complete, and obtain final signatures necessary for the transfer. In the meantime, they must also continue to care for other patients.
Communication Flow Matters
In a 2016 analysis, The Doctors Company found that diagnostic-related issues—including oversights related to unordered tests and unaddressed abnormal findings—accounted for 57% of patient allegations in emergency medicine claims. Communication among providers was the third most common factor contributing to medical errors and patient injury. Issues included failure to review the medical record and inadequate documentation of clinical findings and patient history, which resulted in information not being disseminated to other providers.
An organized communication process can help care teams navigate the precise timing of interfacility patient transfers, which is critical for a smooth handoff. While tertiary hospitals expect to receive patients every day, specialty physicians at receiving hospitals do not spend their day waiting for transfers. A specialist’s day is guaranteed to be already full between procedures, inpatient rounds, consults, and clinic.
As a request for transfer acceptance is outside a specialist’s normal workflow, securing an accurate time of arrival for the incoming patient is essential. When receiving physicians have reliable notice of the patient’s arrival time, they can organize the necessary information review and plan accordingly.
Implementing Best Practices for Managing Risk
As medical errors are usually process-related, they are also preventable. By studying the nuances of interfacility transfers and implementing standardized processes and procedures, healthcare systems can mitigate the risk of patient harm. Accurate communication and effective transfer of care hand-offs are a result of collaborative relationships with everyone involved in the patient transfer and transport process.
A unified system to streamline communication between all patient transfer stakeholders is key. A patient movement platform can provide immediate transparency to sending hospitals, receiving hospitals, and EMS and transport agencies. Every constituent can input and view data relating to the patient’s general condition in real time, accessing shared information for all stakeholders about the patient’s current condition, status, and location.
Such a system augments the detailed provider and nursing report, and strengthens the safety net by capturing ongoing patient data. It also provides an information source for details which may not have been passed on during the transition of care. A dedicated patient movement system can also surface new insights about the hospital’s patient transfers by documenting the time-sensitive delivery of definitive care or tracking transport utilization for various levels of care. These insights can be valuable in process oversight and lead to performance improvements.
The downward trend in medical errors is a direct result of healthcare professionals’ continual commitment to process improvement. Given the pace and demands of emergency care, this field in particular will benefit from standardized communication processes to ensure seamless care transitions for interfacility transfer patients.
Dr. Martin Sellberg has spent more than 30 years in emergency medicine, holding director positions at level 1 trauma centers, regional EDs, and emergency medical services. He is the co-founder of Motient, a patient movement technology company that supports safe, efficient interfacility patient transfers.
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