Five Problems with Transferring Critical Patients From A Rural Hospital

[stattransfers]

1) It is a phone based system.

I have to call the admitting department. The admissions person makes phone calls to find a receiving doctor. The admissions person has to call to find a nurse and a bed. There is no integrity of the patient report with so many phone calls.

2) I have to call hospitals one at a time.

I never buy anything without comparing 10 website and reading tons of customer reviews. I should be able to screen multiple hospitals at once.

3) Each receiving hospital has a different admissions process.

Sometimes I talk to another nurse. Sometimes I talk to a secretary. Sometimes they want a face sheet and other times they want a sheave of paperwork.

4) I can't call the transport company until a bed is secured.

In Sept 2011, the AHA Journal Circulation published a study "Causes of Delay and Associated Mortality in Patients Transferred With ST-Segment-Elevation Myocardial Infarction" that showed 26.4% of all transfer delays were caused by "awaiting transportation"

5) EMTALA has no time restrictions.

It has been common knowledge that transferring patients take a long time. Two studies last year proved that it takes way too long. One study showed that mortality doubles in heart attack patients that wait longer than 30 minutes to be transferred - less than 12% of transfers met this goal. A stroke study found a median transfer time of 104 minutes in spite of a median distance of 14.7 miles!!

[Altra, BSN, RN]

I'd like to ask your profession - nurse, provider, or other lay profession, so that I can better understand your position.

You mention EMTALA in your post, so I know that you are aware that it governs inter-facility transfers. Specifically, it requires the transferring hospital staff to verify that the accepting hospital has available space and resources to appropriately treat the patient.

Secondly, hospitals do not initiate the admission of patients -- physicians admit patients to hospitals where they have privileges. The semantics are important.

Thirdly ... if a truly emergent situation occurs and there is still an undue delay in EMS transport ... this to me would represent an unusual failure in EMS mutual-aid agreements. When I worked at a hospital without a cath lab, for example, an EMS crew bringing in a patient who they believed was likely having a STEMI or CVA usually hung around for the 5-10 minutes that it took the ER to complete the patient's EKG & examination and confirm that yes, they were having a STEMI or CVA. That same crew often transported the patient to one of a couple of hospitals in the area with interventional cardiology capabilities or neuro/neurosurgery. In truly rural areas the problem is simply the time it takes to get from point A to point B ... and that is a very real risk that comes with living in a rural area. You can advocate for increased funding, staff, and equipped vehicles & equipment for EMS for better coverage, but surely you're not avocating taking EMS units out of service any longer than absolutely necessary, as would be the case if they were called for transportation prior to completing every other detail necessary for the patient's transfer.

I have not seen a hospital without specialty services who does not have some prior arrangement with one or more physicians larger hospitals which have more extensive specialty & subspecialty capabilities. In other words, if a rural hospital is presented with a patient with a burn, a cardiac issue requiring intervention, a neuro event requiring intervention, other specialty surgery, etc. ... they should already know what physician(s) at which facilities are likely to accept the patient.

For these reasons, I do not think that arranging continued care for a patient can be compared to comparison shopping for an appliance.

[CanuckNurse1]

Wow! It's much different up here. I work in British Columbia (BC), Canada. For the past two summers, I've worked in an extremely rural area, and had several patients medevaced by plane to a larger city due to critical illness/injury. The way it works in this province is that the physician caring for the patient calls BC Bedline, which is a program/organization that co-ordinates transfers between hospitals in BC. BC Bedline calls us back when they find a hospital with a bed in the appropriate hospital and ward (e.g. a Children's hospital, or a major trauma centre, or ...). Then BC Bedline co-ordinates a physician-to-physician report, so the information isn't diluted or mixed up, as you mentioned happens with your patients. BC Bedline also co-ordinates the transportation, getting the appropriate paramedics (even physicians if needed) on the appropriate medevac plane, and sends them up to us to collect the patient.

[CanuckNurse1]

BTW, here's the BC Bedline website if you want more info: https://www.bcbedline.ca/

[bagladyrn, RN]

Transfer time of 104 minutes may be long for suburban or East Coast rural areas but I've worked in really rural locations where the "best case" scenario was 4 hours for air transport to arrive - if the weather and all other circumstances were perfect.

I don't think this time frame recommendation is realistic for true rural locations.

[TopazLover, BSN, RN]

When my late H was ill and transfer was considered it was "who has a bed?" We were told it could be in city X or city Y depending on bed availability when a decision was made. That was horrible for family trying to get flights to see him. Tickets for X, Y, or A, the original place? When the decision was made it took hours to get a chopper there for him. Did it matter? I don't know. I do know that as a family member waiting, it was like dropping in a rabbit hole. Focus is changed for all the staff around him. They now just want him out. Before they were involved, invested, even. After the decision it seemed like they had given up and just wanted him gone.

In our case it was a 35 min. flight preceded by at least 2 hours of exactly what the OP said. There was an extra wait time for the chopper so lag time was at least 3 hours.

Family did not know until he landed where he would be. I did not call them at 3 am, I waited until 5 am to let them know where he was. The plane tickets cost double what they would have if we had known sooner. I don't blame anyone for this. I tell it only to let nurses know that while they are dealing with the move, others are effected. Some they will never see or know how their work impacted others.

Oh, Canada. How I wish we had a system like yours.

[Spidey's mom, ADN, BSN, RN]

I live in a rural area. It is up to the physician to call down the mountain and find another physician to accept and when he/she does then it is up to that hospital's nursing supervisor to find a bed within an very short time period before we can call the helicopter/plane.

It is the physician's responsibility.

How odd to think of a service that does his/her job.

[stattransfers]

Thank you for the information about the BC Bedline. A universal system to arrange transfers and transports would be awesome. I just wrote down some of my frustrations after reading some recent studies that provided some empirical evidence behind my angry musings!!

Strokes - from this study "The median distance from the transferring hospital was 14.7 miles, and 91% of the patients were transported by ambulance. The median transfer time was 104 minutes, and the median time from symptom onset to arrival was 296 minutes"

Cardiac - "found that only 11 percent of patients left the referral hospital within the recommended 30 minutes. In fact, more than one-third of patients waited more than 90 minutes."