March 10, 2008

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Paving the Way for the Transferred Patient

Graham Ramsay Nicole Martin

“We’re going to be getting an outside hospital transfer.”

For an admitting resident or intern, this sentence often creates a sense of dread. Like every tertiary referral center, Massachusetts General Hospital accepts numerous transfers from area hospitals, and every member of the medical house staff has a great deal of experience in treating such patients.

Sometimes, the reason for transfer is quite clear: the need for cardiac catheterization or highly specialized surgical consultation, for example. In other instances, our hospital doesn’t have a specific test or procedure to offer, but we do have expert consultant physicians who can offer fresh perspectives on difficult cases. No matter what the situation, the transfer process is arduous for both transferring and accepting physicians and potentially dangerous for the patient.

Seeing the Clinical Picture

At MGH, medical transfers from outside hospitals (popularly called OSHs) must be approved by the senior resident on call for the house. If a patient is to be transferred to an ICU, the ICU attending physician must also approve. A transferring clinician must speak directly to the on-call senior to provide a brief history and enumerate the reasons for transfer. If the patient is accepted, he or she is added to a master list that is shared by all the seniors who are taking call.

Often, transferred patients wait more than a day for a bed to become available. Consequently, when they roll through our doors, the clinical picture may be substantially different than what the senior was told. The admitting resident or intern, who could be receiving the patient at any time of day or night, may not be able to reach the OSH clinician for an update, either because the hospital doesn’t have 24-hour physician staffing or because the responsible clinician isn’t there and hasn’t given his or her colleagues a detailed pass-off.

The house officer is then left to slog through the written record. Ideally, this contains a typed discharge summary, but often it’s a stack of barely legible, photocopied notes. This phenomenon is so frustrating—and widespread, apparently—that a group of residents at the University of Pennsylvania parodied it in “Outside Hospital,” a YouTube short: “At Outside Hospital, we’re used to working with tertiary care centers. We know how to make these transfers run smoothly. We’re not going to overburden the doctors there with meaningless copies of cath reports, echoes, a transfer summary. We send only what’s important—a big stack of nursing notes.” At least the nursing notes are usually decipherable; the doctors’ notes are another story.

What’s the Problem?

In certain respects, information transfer is easier when a patient comes from a hospital within the Partners HealthCare network, which has a shared electronic record. We can view radiology reports, look up and trend the patient’s lab values, and read ER and admission notes (and, if we’re lucky, the discharge summary—provided it was dictated immediately).

But for the overnight resident, the devil’s in the elusive details. When I’m admitting a patient with renal failure, I don’t care about her thyroid function five years ago—I just want to know when she stopped making urine. Unfortunately, such observations do not always find their way into the record, despite their importance to decision-making.

On a more general note, no written or electronic material can tell me how sick a patient really is. Because of the way in which we’re trained, or simply because we’re human beings, we process clinical histories better when they’re told to us as stories. When I speak to an outside clinician on the phone, I pick up on subtle cues—tone of voice, rate of speech, and hesitations or pauses—that tell me how well the physician knows the patient and how worried he or she is. Certain phrases, most of which aren’t appropriate for the written record, also color my thinking. If I’m told that a patient is “perking up,” then I’m encouraged. Conversely, if a patient is “tanking” or “crumping,” I start to wonder if she will survive the ambulance ride.

Laws and Logistics

Legally speaking, a transferring physician is not obligated to give a thorough, verbal pass-off to an accepting physician. Under the federal Emergency Medical Treatment and Labor Act (EMTALA) of 1986, a transferring clinician in the emergency room must contact the accepting facility to ensure that they can provide the appropriate level of care. This law also states that copies of all relevant written records must accompany the patient.

The key tenets of EMTALA, also called the “anti-dumping law,” are patient stabilization prior to transfer and acquisition of written, informed consent from the patient. A 2003 amendment extended EMTALA to all patients on the hospital campus who request emergency services or who would appear to a “reasonably prudent” person to need medical attention.

The journal Critical Care Medicine published a set of guidelines for the transport of critically ill patients in 2004. With regard to pretransport communication, the document states, “The referring physician will identify and contact an admitting physician at the receiving hospital to accept the patient in transfer and confirm before the transfer occurs that appropriate higher level resources are available. The receiving physician is given a full description of the patient’s condition.”

In a literal sense, these requirements could be satisfied by one phone call to the on-call medical senior to discuss the patient’s condition, then a second call to the ICU to confirm that a bed is available. Usually, bed availability is assessed by the triage nursing supervisor, so we aren’t directly involved in the second part.

Bad Call

As the admitting junior in the medical ICU two months ago, I received a puzzling call from an outside physician.

“Are you going to be admitting Mr. H?” he asked.

“Yes, I am. May I ask who’s calling?”

“This is Dr. Jones from Outside Hospital.”

I was delighted that he had taken the trouble to call me. “Oh, yes, thank you so much for calling. You’ve been taking care of him?”

“Yes, I have. May I have your name?”

“It’s Dr. Martin. Will he be coming to us soon?”

“Do you have a bed?”

“As far as I understand, we do.”

“OK, Dr. Martin. Thank you,” he said with finality.

I realized that he had called just so he could get my name to write on the transfer papers. He could have just asked the secretary for that. “Wait … could you, uh, tell me a little about the patient?” I asked. He did give me some history, but I had to coax it out of him.

I don’t mean to say that every OSH pass-off is this difficult. Quite the opposite—on the same call night around 10 p.m., I received a call from another OSH physician who knew every detail of the case and, fortuitously, had cared for the patient on a previous admission. When I asked him to describe the big picture—“So what do you think is going on with her?”—I got an incredibly useful response. Consequently, when the patient arrived, I had a precise plan in mind, and I was able to accomplish certain diagnostic and therapeutic goals before morning rounds.

I believe that as a medical community, we should work to improve the transfer process, for both patient safety and our own peace of mind. I would like to see our hospital adopt a policy that the transferring clinician talk at length with the admitting resident or intern—not the on-call senior, but the house officer who will actually be examining and writing orders on the patient—no more than two hours prior to transfer. Yes, there are situations in which this is not possible. But if we made it clear that this is our expectation, I think that most outside clinicians would be willing to work with us. If a 10-minute phone call could spare a patient unnecessary procedures, extra days in the ICU, or medication errors, it would be well worth the effort.

—Nicole Martin, HMS ’06, is a resident in internal medicine at Massachusetts General Hospital.

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Copyright 2008 by the President and Fellows of Harvard College