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Healthy Debate (Nov 26 2015): In Limbo: Why patient transfers between hospitals needs improving

By Wendy Glauser, Debra Bournes and Michael Nolan

A few weeks ago, a patient came into the emergency department in Renfrew, Ontario, after a family member witnessed him collapse and performed CPR. Kristian Davis, medical director of emergency at Royal Victoria Hospital in Renfrew, ordered an electrocardiogram. It suggested a heart attack but the changes could have resulted from the CPR. Plus, the patient was coughing up blood, which meant he could be having another issue.

Davis called a central switchboard, CritiCall, which facilitates discussions between doctors at smaller hospitals with doctors at hospitals that can provide a higher level of care. But both the cardiologist and internal medicine specialists who were contacted thought the patient should be transferred to each other’s department. The back and forth phone calls took four hours, during which Davis’s patient waited.

Across Canada, patients can only be transferred when a physician who will take care of the patient – whether an emergency room physician or surgeon – agrees to take them. Davis says it makes sense that doctors in larger centres are gatekeepers regarding what patients they allow to be sent to them. “There can be some horrible referrals that take up the paramedic’s time, the ambulance resources, the nurses, and then you find out they didn’t need to be sent,” he says. And in many cases, the doctor who answers the phone simply needs to provide advice to the doctor who thinks a patient might need to be transferred.

The delays aren’t likely to result in death. Many provinces have special systems and policies to ensure that when patients are in life-threatening situations, they’re transferred immediately. The hold ups tend to occur for patients who are stable but should be transferred within a day or two, explains Jim Worthington, executive vice-president of medical affairs at The Ottawa Hospital and former medical director of CritiCall Eastern Ontario.

When these transfers don’t occur in a timely manner, patients spend hours, even days, in limbo – waiting to be moved to a hospital that can provide the surgical care, tests or medical expertise they need.

Call lines help speed up transfers, but are limited

Over the last decade, many provinces have vastly expanded call lines that help facilitate transfers of patients. In Ontario, doctors can call CritiCall. A similar system, called RAAPID, is in place in Alberta. When doctors call either service, they explain a patient’s situation, and the nurses on the line call various specialists until they find someone who is able to take the patient. As Bruce Macleod, medical director of RAAPID South for Alberta Health Services explains, “Doctors have to be looking after the patient. We don’t want them wasting time on the telephone.”

Both the Ontario and Alberta programs have computer systems to monitor bed availability so they know which departments in which hospitals have more capacity than others. “We don’t call a hospital that is at 98% occupancy when there’s a hospital at 82%,” explains Donna Thomson, executive director of CritiCall.

The average time between a doctor’s first call to a specialist’s acceptance of a patient transfer takes 30 minutes for CritiCall, according to Thomson. For RAAPID, the monthly averages have ranged from 18 minutes to 36 minutes in 2014-2015, according to the organization’s director, John Montpetit. (As mentioned, if a patient is identified as having a health issue that needs to be responded to immediately, faster systems are activated.)

But the call systems are limited in the services they provide. Both CritiCall and RAAPID tend to only coordinate transfers when the doctor who wants to transfer the patient determines the patient must receive higher-level care within 24 hours.

Mental health transfers, for instance, are notoriously challenging. RAAPID North only began to coordinate the transfer of mental health patients in the last year. CritiCall, meanwhile, is launching the coordination of mental health services province-wide in December, based on feedback from doctors across the province. As Thomson explains, “Many doctors tell us that even when they ‘Form 1’ a patient, meaning the patient can be held for 72 hours until they get a psychiatric consult [even against the patient’s will for the patient’s safety], they can’t get them to a psychiatrist so patients end up getting discharged.”

Need for doctor to accept patient and bed unavailability can be a major hurdle

Jason Malinowski, an emergency physician in Barry’s Bay, Ontario, says that the requirement for a doctor to agree to accept a patient can lead to dramatic delays in some cases. “Doctors are sometimes in the operating room and can’t get back to us quickly,” he says. “But I’ve assessed the person and it’s very clear they need to be treated somewhere else.”

Worthington thinks hospital leaders and Local Health Integration Network officials can work together to establish a central triage to avoid such situations. For areas like orthopedics and mental health transfers, he set up a rotational system with four hospitals in the city. When a hospital is on the top of the list in the rotation (hospitals with more capacity come up more often), they automatically take on patients that need their care. (In rare cases, when the hospital at the top of the list is extremely over capacity, hospital leaders will have an emergency meeting and another hospital will volunteer to take patients for a certain length of time.)

“I think all of the transfers [to specific departments] can be organized and resolved if the hospitals in the region get together and say ‘How can we resolve it collectively, how can we ensure appropriate distribution of patients and rapid access?’” says Worthington. To him, the key to setting up such a system is deciding on “the principles that would guide a transfer,” including the time frames in which patients with given conditions must be transferred under the system, and in which situations patients should be transferred to centres that have highly specialized capabilities.

The reality, however, is that you can have the best coordination system possible, but transfers will still be stalled if all tertiary hospitals are at capacity. “Everyone is doing the best they can but it’s a resource issue,” says Grisdale. “If we had more beds available things would flow better.” When it comes to hospital beds per capita, Canada ranks 30 out of the 34 OECD countries.

Esther Tailfeathers, a doctor in Fort Chipewyan, a fly-in community in Alberta, says that when they are trying to transfer psychiatric patients to Fort McMurray, for example, “often we don’t get an acceptance from the other end because of the bed situation.” Last December, a 14-year-old took her own life and Tailfeathers says suicide attempts are frighteningly frequent in the community of 1,200. The doctors can send patients to Edmonton, but it’s a huge cost to the system, and patients have to pay for their flight back, which is more than $300.

Responsibility of referring hospitals

The responsibility of improving the transfers of patients from one hospital to another doesn’t simply rest with the receiving hospitals. If small community hospitals transfer patients who can be cared for closer to home – or don’t take back the patients they send when they no longer need high-level care – tertiary hospitals quickly become too full to accept new patients.

Avery Nathens, chief of surgery at Sunnybrook Health Sciences Centre, notes that some doctors in community hospitals have the resources and skills to take care of certain patients, but choose to transfer them because they might impact their other patient care responsibilities or due to a lack of comfort as a result of limited exposure to certain types of patients. As an example, says Nathens, “a minor head injury with some blood in the brain does not necessarily need to be transferred to a neurosurgery centre, yet a physician at a community hospital might still push for a transfer or call a second hospital. The doctors may only see patients in this situation two or three times a year so they prefer to transfer them to someone who cares for hundreds of such patients a year,” he says. Nathens suggests it’s the responsibility of smaller hospitals to keep patients closer to home when that’s an option, even if it may require more of a doctors’ time in consulting experts and developing treatment protocols.

Meanwhile, says Nathens, there’s limited accountability when transfers to tertiary centres are unnecessary, nor any opportunity for learning or feedback that would allow more patients to be cared for closer to home. That’s changing, however. Within the next month, Sick Kids Hospital, St. Michael’s Hospital and Sunnybrook Health Sciences Centre through the University of Toronto Trauma Program will start sending reports to referring hospitals that outline the outcomes of their patients and the full extent of their injuries. “If they’re transporting patients out of their community who they believe are severely injured and we send them home from the emergency department, there’s a disconnect there and a learning opportunity,” says Nathens. The reports aren’t meant to shame or punish doctors, says Nathens “but to allow a dialogue to begin” and to reach a shared understanding of how and when tertiary centres can help, and what patients might be cared for safely closer to home.

Another way smaller hospitals can improve transfers is by taking patients that have been treated to the extent necessary in a larger centre – thereby freeing up beds for patients they need to send. “If a hospital has been good enough to accept the patient, then once the patient is stable, the patient should go back within 24 hours,” says Worthington. “In some cases we have 25 to 30 people waiting in our emergency room and they’re still not taking the patients back.”

CritiCall and RAAPID both work to do the calling and coordination to help specialists send patients back – even to nearby hospitals if the original referring hospital isn’t able to accept them. But Worthington argues hospital leaders within a region and Local Health Integration Networks need to establish expectations around “repatriations,” as transfers back to community hospitals are called. In Ottawa, for example, Worthington set up agreements with periphery hospitals that they accept patients back within 48 hours. If a hospital doesn’t meet this deadline, he says, “We call the LHIN and say can you please step in here and remind them of their obligation.”

In Davis’s view, improving transfer times means improving collaborative relationships between hospitals. This requires hospital leaders to work together to create guidelines of when patients should be sent, what tests and treatments should be done at the local hospital before a transfer is initiated, and how quickly patients should be accepted back to the community hospital. Davis has made it clear to referral hospitals, for example, that if he sends a patient for assessment who isn’t admitted, the hospital can send the patient back without needing approval. “If you do a CT scan, that patient is still ours,” Davis explains.

“It’s more difficult to facilitate transfers if you don’t have a relationship,” says Davis.

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