Developing a transfer center in a tertiary cancer center: streamlining access and communication to accommodate increasing demand for service.
Hospitals (Emergency service)
Tortorella, Frank R.
Ewer, Michael S.
Douglas-Ntagha, Pamela B.
Ecung, Wenonah B.
|Publication:||Name: Journal of Healthcare Management Publisher: American College of Healthcare Executives Audience: Trade Format: Magazine/Journal Subject: Business; Health care industry Copyright: COPYRIGHT 2011 American College of Healthcare Executives ISSN: 1096-9012|
|Issue:||Date: May-June, 2011 Source Volume: 56 Source Issue: 3|
|Topic:||Event Code: 200 Management dynamics Computer Subject: Company business management|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
|Legal:||Statute: Emergency Medical Treatment and Active Labor Act of 1985|
Hospital-to-hospital transfers in a tertiary cancer centre present an unusual set of problems involving a diverse group of acutely ill patients with highly specialized needs. The level and urgency of care required and the costs of providing optimal management often are exceedingly high. We present the administrative issues involved during a major revamping and streamlining of the Transfer Center at The University of Texas MD Anderson Cancer Center. The impetus for change included overuse of the emergency facility as a triage center for transferred patients, lack of adequate preadmission medical and financial screening of patients in anticipation of a transfer, a suboptimal level of physician-to-physician handoff communication, and insufficient protocols for prioritizing potential admissions and thus optimizing the institution's limited resources. During implementation of these revised policies, additional concerns were identified, including reluctance to modify established protocols and an inability to ensure the arrival of non-emergent transfer patients at our institution during daytime hours. Prioritizing admissions based on the degree of urgency and available resources required ongoing flexibility in accepting new concepts and ideas. The success of the project is documented in this report, as are suggestions for how other centers that experience similar challenging reorganizations can apply the lessons learned from our endeavors.
The University of Texas MD Anderson Cancer Center (MDACC) is considered a tertiary center. Although the definition of tertiary is evasive, the label implies a specialty hospital (a) that provides an advanced level of specific subspecialty care, (b) to which clients are often referred from smaller hospitals for a variety of major interventions and consultations, and (c) where sophisticated intensive and emergency care facilities are required and available. MDACC provides care for all age groups and in all relevant cancer medical subspecialties and offers emergency oncology services.
MDACC has enjoyed an extremely broad referral base and a high demand for services that often has exceeded its capacity to accommodate all potential patients, in part because of its reputation as the preeminent cancer center in the United States and in part because of its location in the Texas Medical Center (Comarow 2009). At times, the center's resources have been stretched to the degree that the facility has had to limit elective admissions and emergency room visits and delay elective surgeries. Within this context, MDACC receives many requests for hospital-to-hospital transfers, which constitute a special subset of direct admissions to the institution. These patients fall into several categories and include those for whom the transferring facility is unable to provide the necessary level of care, those previously treated at our institution who need additional care, and those who want to be transferred here because the patient or patient's family perceives that a tertiary center will provide care not available in the transferring facility. Traditionally, hospital-to-hospital transfer patients were accepted on the basis of bed availability; thus, the timing of their arrival was a matter of chance, and their immediate needs were assessed on arrival at the institution's emergency center. As a group, hospital-to-hospital transfer patients tend to be among the sickest patients, and their immediate needs for stabilization and symptom control thus consume considerable manpower and other resources. These conditions, along with the fact that inpatient bed utilization often exceeded defined capacity, created substantial problems that required the institutional leadership to revisit the processes of hospital-to-hospital transfer and emergency department utilization.
In 2004, a hospital-to-hospital Transfer Center as a component of the admissions department was established. This entity had limited resources and primarily dealt with third-party payment issues and documentation. The assessment of medical need and priority were delegated to the clinical staff and addressed on presentation, which usually occurred in the emergency department. This article reviews the evolution of the Transfer Center and summarizes the operational aspects of this process. We also discuss the successes and opportunities for ongoing improvement following process changes implemented at the center during its first nine months.
The burden these hospital-to-hospital transfers placed on the emergency center became more apparent as resources were increasingly stretched and the demand for services increasingly exceeded our capability to meet them. On realizing that demand was outpacing capabilities, the institution set new goals to address the specific problems identified by internal physicians and patients, which included (1) suboptimal communication from external physicians to internal physicians; (2) compromised triage leading to inappropriate level of care; (3) sporadic arrival of non-emergent transfers during off shifts; and (4) lack of systematic screening and documentation of medical and financial information during the transfer process.
THE ESTABLISHMENT OF THE EXPANDED TRANSFER CENTER
Patients designated as hospital-to-hospital transfer patients come to our facility from all over the world, and air-ambulance transport from other continents is not unusual. As part of the change intended to streamline the transfer process, the Transfer Center would now oversee the hospital-to-hospital transfer patients in a coordinated manner and whenever possible without routing these patients through the facility's emergency center. The Transfer Center, rather than the emergency center, would serve as the focal entry point for all related communication. Centralization of transfer requests to the Transfer Center staff would allow transfers to be managed in an area that had firsthand knowledge of bed capacity and surgical schedules and that could coordinate the needs of these patients with institutional realities such as resource and bed availability.
Team Membership and Considerations
When designing a transfer center, hospitals have created multidisciplinary teams comprising representatives from nursing, finance, the medical staff, marketing, and legal services (Moore 1990). The vice president for clinical support services established our team under his direction; members, all of whom were employees of the MDACC, included, but were not limited to, the associate vice president for clinical programs, the associate vice president for medical operations and informatics, the director of patient resources, and a performance improvement specialist. The team members were selected based on the diversity of their skills and backgrounds: two members are attorneys, one is a physician, and two have a background in nursing.
The team was charged with overseeing the Transfer Center and addressing emergency center overcrowding and revamping physician-to-physician communication for patients admitted through the Transfer Center. Additionally, the team was asked to study and make recommendations regarding the delay in routing patients to preferred nursing stations, treatment areas, or one of the intensive care units with the goal of standardizing and streamlining the processes.
The team had reviewed interhospital transfers over the preceding year to ascertain the number of transfers, the ultimate destination of these patients within MDACC, and the length of time that patients remained within the emergency center prior to being moved to another unit within MDACC. Inefficiencies and strengths around routing all hospital-to-hospital transfers became clear. Alternate mechanisms for managing the admission process of such patients directly through the Transfer Center (thereby bypassing the emergency center) gradually evolved. To ensure that an appropriate physician would be available to accept the patient and coordinate the ongoing care, the team ultimately endorsed a concept of direct admission of patients hospitalized in an outside facility, subject to the availability of beds in specific treatment areas or dedicated hospital floors, and overseen by a newly expanded and focused Transfer Center. Consideration of the relative urgency of the transfer, the most appropriate location among available beds, and, whenever feasible, avoidance of emergency center triage were all critical aspects that contributed to the success of the program. Full compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) was also a paramount consideration (EMTALA 1999).
Initially, a project charter and plan was created to ensure that the team had a clear focus of the project's scope, the measurable goals, and the broader project outcomes as potential benefits to the institution were developed. Through brainstorming, multivoting, prioritization, and process mapping, the team oversaw the evolution of focus areas. To ensure that the team remained focused, an aim statement was developed; the goal was to implement a systematic process to increase the percentage of externally accepted transfer patients routed directly to the appropriate patient care setting (e.g., inpatient unit, intensive care unit, emergency center). Process mapping revealed variation in acceptance between shifts and identified numerous procedures that needed improvement. Two medical codirectors were identified to take on the responsibility for the day-to-day operation of the Transfer Center and to review all the requests for hospital-to-hospital transfers.
Priority areas that required integration with the Transfer Center were identified and focused on systems, people, policies, and process or work flow. Among the weaknesses identified was the inability to share critical clinical information regarding the transfer of patients and the unavailability of an identifiable physician who had both deemed the patient appropriate for transfer and who had accepted the patient for ongoing treatment under her care. Additionally, the team identified varying processes for accepting patients across shifts, multiple and sometimes inconsistent or conflicting institutional policies, lack of understanding as to obligations and responsibilities under EMTALA, and an inability to prioritize those patients for whom transfer would be most beneficial or for whom treatment delay would constitute a significant risk.
Initial discussions highlighted that a major aspect of the Transfer Center and its ultimate success or failure would depend on implementing a systematic process for communication (Dwyer 2003). Communication was deemed to be a common denominator in many of the identified weaknesses.
Systematic Process for Accepting External Transfers: Practical Considerations
An efficient transfer center streamlines the sequence of communications needed to accept and accommodate patients within a healthcare institution. The establishment of a transfer center has been found to improve communication and control on acceptance of transfers (Strickler, Amor, and McLellan 2003). The collaboration between the Transfer Center medical director and the treating physician teams in the interhospital transfer process adds value to the hospital operations by conserving limited bed capacity and ensuring financial equity while caring for non-sponsored patients. When fully implemented, the process optimizes new patient revenues and efficient use of hospital resources (Southard et al. 2005). Ultimately, a three-phase procedural algorithm evolved.
In an attempt to prevent poor communication, which is a common cause of medical errors (Hospital & Health Networks 2006), Phase I involved communication and medical acceptance. A physician at the transferring facility contacted or was placed in contact with the on-call MDACC physician (the accepting physician) for the appropriate service. That physician (the MDACC attending physician for that service) determined whether the transfer was appropriate on medical grounds, and if it was, notified the Transfer Center of that determination. Failure to concur that the transfer was medically justified ended the process, in which case the Transfer Center had no further involvement.
Phase II was initiated by a conference call generated by the Transfer Center, whereby the accepting MDACC physician and the Transfer Center physician addressed the following variables: level of care (emergent, urgent, or routine); preferable location for direct admission (specific floor, specific specialty unit, or, in the event that further assessment on arrival is deemed necessary, admission to the emergency center); and the timing of the physician's initial visit to the patient to ensure a prompt assessment and writing of admission orders. Primary and most critical among these aspects is the delineation of the level of care, but integrating the level of care with bed availability is also of importance to ensure a smooth hospital-to-hospital transfer. Ultimately, during Phase II, the Transfer Center attending physician balances the variables of level of care and bed availability and either approves the transfer, defers the decision pending additional information, or refuses to accept the patient for transfer. The accepting MDACC attending physician immediately is made aware of the decision and of the expected time frame of arrival, the anticipated location, the need for prompt assessment, and the estimated degree of patient stability.
Phase III constitutes the more standard preadmission review. For patients not considered emergency transfers, the review includes financial screening and verification or precertification of third-party coverage. Patients with conditions deemed to be of an emergent nature are not screened as part of the transfer process; in essence, such patients are treated in the same way as are emergency center drop-in patients in that they are evaluated and stabilized prior to financial screening, in compliance with EMTALA requirements.
To overcome subjectivity, we established a policy that included classifications to distinguish emergent, urgent, and routine patients (Health & Medicine Week 2010). The designation of an emergency transfer embraced the nationally accepted criteria; emergent transfers encompassed patients for whom delay is considered either potentially life-threatening or for whom delay could result in the loss of a vital bodily function. Patients who were deemed to meet the criteria of "emergent" often had needs that changed rapidly, and therefore these patients sometimes were directed either to the emergency center for review and triage; directly admitted to an intensive care unit, a surgical area, or procedure area for expedited intervention; or triaged to an observation unit for enhanced monitoring. As noted, financial concerns, preapproval, or screening were not part of the process for emergency transfers to ensure that such issues would not interfere with the prompt transfer of acutely ill patients and would not involve potential violations of EMTALA regulations.
Urgent patient transfers were defined as those not meeting "emergent" criteria but for whom the initial or ongoing care to be administered could offer meaningful therapeutic benefit and for which timing was less critical. Patients falling under the "urgent" umbrella were not sufficiently stable to allow their discharge from the transferring facility to be subsequently seen at our institution on an elective basis. Nevertheless, they could be evaluated for medical appropriateness and financial considerations prior to acceptance. Whenever possible, urgent admissions are directed toward an inpatient unit where prompt evaluation and the writing of initial orders can be facilitated. Flexibility in the location to which the patients are transferred is built into the system so as not to compromise patient care in the event of unusual contingencies. These patients are financially screened and preapproved for transfer.
Patients for whom transfer to our facility was requested and who were deemed not to fit within "emergent" or "urgent" criteria were designated as "routine" transfers and could either be transferred directly to an inpatient bed or, if they were sufficiently stable, discharged from the outside facility and seen electively in one of MDACC's specialty clinics for evaluation and triage. Such patients are seen based on bed availability, medical need, available treatments, available alternate facilities, and financial considerations.
Review and monitoring of metrics demonstrated considerable success in addressing the four issues outlined in the introduction. Baseline data were collected for seven months prior to the intervention. Little difference was found in the number of external accepted transfers prior to the intervention (monthly average: 58 transfers) and post-intervention (monthly average: 53 transfers). However, the monthly average for the type of approved transfers changed. Routine transfers decreased from 15 patients to 2 patients, urgent transfers decreased from 30 patients to 26 patients, and emergent transfers increased from 13 patients to 25 patients. To ensure sustainability of outcomes, data were collected for 17 months postintervention. The data indicated that resources are increasingly being used for emergent patients (Exhibit 1).
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Problem 1: Suboptimal Communication
The required Transfer Center form became part of the electronic medical record, and during the first eight months of operation we achieved 85 percent compliance with regard to documentation of the transfer that included a review of urgency, the diagnosis of the patient, and the name of the Transfer Center attending physician who participated in the review. However, with physician education and active participation of the Transfer Center medical directors, the compliance rate for this metric increased to 100 percent in January 2010 and has been sustained to date (Exhibit 2). Internal physician to external physician communication ensures medical acceptance is based on discussion between the referring and accepting physicians.
Problem 2: Placement of Patients in Appropriate Care Setting
When looking at pre-intervention to post-intervention results, the average monthly external transfers to inpatient beds increased from 9 patients to 25 patients. The monthly average for transfers to ICU remained unchanged at five patients. Transfers to the emergency center decreased from 43 patients to 22 patients, resulting in decreased utilization of the emergency center by external transfers and patients being placed in the appropriate care setting (Exhibit 3).
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Problem 3: Sporadic Arrival of Non-emergent Transfers
The majority of after-hours (between 5 pm and 8 am) transfers were routine and urgent patients; the combined average was nine transfers per month. After the intervention, this number dropped to five transfers per month. After-hours emergent transfers increased from three transfers per month preintervention to ten transfers per month post-intervention. Average monthly transfers during the first shift (8 am to 5 pm) also showed a difference from pre-intervention to post-intervention as follows: routine transfers decreased from 13 transfers to 2 transfers; urgent transfers decreased from 23 transfers to 21 transfers; and emergent transfers increased from 10 transfers to 15 transfers (Exhibit 4). This resulted in predictable arrival times for external transfers and ensured MDACC resources were available to manage the patient in the appropriate care setting.
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Problem 4: Lack of Systematic Screening and Documentation
As we attempted to ensure the most critical patients had access to our limited resources, the Transfer Center form provided a systematic process of documentation to justify the level of transfer. To ensure patients were being assessed at the appropriate level of care, the Transfer Center medical directors, in collaboration with the director of patient resources, conducted retrospective medical record audits on 100 percent of emergent transfers. Since the project implementation, 97 percent of the total number of emergent transfers was confirmed as emergent upon retrospective review (Exhibit 5).
The reasons for the denial of external transfer requests were also measured as demonstrated in Exhibit 6.
MDACC had fostered the paradigm that hospital-to-hospital transfers had to be routed through the emergency center, owing to the nature of the underlying disease that we treat, the severity of illness, the need for timely assessment, and the perceived risk of liability in the event of delay. The expansion of the Transfer Center and its ability to foster direct admission, bypassing the emergency center, ensures that patients are being admitted to the most appropriate level of care. Specific advantages were that the changes resulted in shorter lag times for admissions, more appropriate placement of patients with special problems, and enhanced communication. Some concerns were that the emergency center's role in assessing the patient and writing initial orders would have to be assumed by the physician in many instances. To help overcome these concerns, a number of educational sessions followed by question-and-answer periods were scheduled, and these were largely successful. In one instance, a service specializing in the treatment of very unstable patients whose conditions and needs change very rapidly was deemed an exception, and all nonroutine hospital-to-hospital transfers directed to that service were redirected to the emergency center. No additional concerns have been raised that might have resulted in a further change in policy.
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Establishing and implementing a systematic process for accepting and directing external transfers to the appropriate setting has also been accepted and appreciated by our referring physicians because of the improved communication and the efficiency of a one-call process. Additionally, communication was improved with regard to interdisciplinary team members within our institution.
A major success factor in our process was stakeholder involvement and participation in identification of the problem, development of the plan, and implementation. This led to significant success in achieving institutional goals, especially with regard to improving both patient care and satisfaction. The tracking of specific metrics and ongoing monitoring of success has clearly supported this conclusion.
SUMMARY AND CONCLUSION
This reorganization was begun with the institutional mindset that all hospital-to-hospital transfers must proceed via the emergency center and that triage, admission, and financial clearance could be best undertaken in that area of the facility. Altering that established process was thought to represent a highly disruptive, inappropriate, and counterproductive change. However, through the creation of the Transfer Center, the paradigm shift incorporating bypass of the emergency center has been proven not only to be workable but also to improve efficiency, improve triage to optimize bed utilization, simplify the execution of documentation required for compliance, improve physician-to-physician handoff communications, and enhance patient satisfaction.
Bertazzoni, G., M. Cristofani, A. Ponzanetti, H. Attalla, C. De Vito, and P. Villari. 2008. "Scant Justification for Interhospital Transfer: A Cause of Reduced Efficiency in the Emergency Department." Journal of Emergency Medicine 25: 558-61.
Comarow, A. 2009. "Best Cancer Hospitals--America's Best Hospitals." US News & World Report 146 (7): 84-6, 89-90, 92 passim.
Dwyer, K. 2003. "Lack of Clear Channels of Communication in Patient Transfer Between Care Facilities Leads to Fragmentation in Care." International Journal for Quality in Health Care 15:441.
EMTALA (Emergency Medical Treatment and Active Labor Act), 42 USC 1395dd (1999).
Health and Medicine Week. 2010. "TeleTracking's Transfer Center Conference Draws Major Interest." Health & Medicine Week, May 10, 4215.
Hospital & Health Networks. 2006. "Face-to-Face Handoffs and Better Physician Training Can Improve Patient Transfers." Hospitals & Health Networks 80 (1): 62.
Moore, R. E. 1990. "Transfer Center Can Control, Manage Admissions." Healthcare Financial Management 44 (9): 40-45.
Southard, P., J. R. Hedges, J. G. Hunter, and R. M. Ungerleider. 2005. "Impact of a Transfer Center on Interhospital Referrals and Transfers to a Tertiary Care Center." Academy of Emergency Medicine 12 (7): 653-57.
Strickler, J., J. Amor, and M. McLellan. 2003. "Untangling the Lines: Using a Transfer Center to Assist with Interfacility Transfers." Nursing Economics 21 (2): 94-6.
Jeff Heffelfinger, DMin, FACHE, administrative director, cancer programs, IU Health / IU Simon Cancer Center, Indianapolis, Indiana
We owe our colleagues at MDACC a special note of thanks for creating and sharing their innovative solutions within a complex environment. In addressing issues that were undermining their hospital-to-hospital transfers, Tortorella and colleagues have integrated the use of sound clinical practice with solid administrative principle to achieve the healthcare trifecta of increased patient care/satisfaction, improved referring physician relationships, and preservation of precious resources.
While many healthcare facilities, large and small, find it difficult to navigate and balance clinical practice with administrative policy, MDACC has provided a keen example of how clinicians and administrators (both sides of the healthcare equation) can collaborate to improve clinical outcomes for patients and contribute to the financial performance for the health system without compromising compliance with regulatory standards. Certainly, this is a significant challenge within any healthcare system.
All too often the "reluctance to modify established protocols" immediately pits clinicians and administrators against each other, often resulting in entrenched positions with little progress or chance of success. In this case, MDACC established an interdisciplinary team, with members specifically "selected based on the diversity of their skills and backgrounds," and provided them with a common focus: "to implement a systematic process to increase the percentage of externally accepted patients routed directly to the appropriate patient care setting." Again, this is no small task. Providing the right care, in the right setting, at the right time seems like a straightforward process, but internal politics and external variables get a bit tricky to manage on a routine basis.
As an administrator with a tertiary cancer center, I've experienced firsthand the difficulty of aligning clinical and administrative processes. "Herding cats" is an expression used often when describing the challenge of bringing autonomous and altruistic individuals to the table to review processes and implement change to established policy.
Our health system utilizes two separate transfer centers: one to oversee the patient's hospital-to-hospital transfer and one to get the appropriate clinical specialist to the patient's bedside on arrival. With approximately 70 percent of our patients coming to us from beyond our primary market (a 30-mile radius of our facility), physician-to-physician communication, appropriate triage, and timing of arrivals are all challenges with significant implications. As part of our efforts to improve collaboration between our transfer centers and enhance coordination of patient referrals and transfers, we have engaged our colleagues at other tertiary care facilities to assess best practices.
MDACC's Transfer Center is commonly recognized as among the best in the nation, and it is refreshing to see the center constantly assessing and improving its system. Ultimately, our colleagues at MDACC were successful in their assigned task not only because they focused on the systems, people, policies, and process involved with improving their Transfer Center but also because of their method for approaching change management across the board. By bringing together a diverse group of professionals, providing them the oversight and authority to make necessary changes, engaging key stakeholders in the discovery and implementation phases, and remaining flexible when specific patient conditions warranted an exception to their algorithm, Tortorella and colleagues have provided us a framework from which real patient care and health system improvements can be realized.
Frank R. Tortorella, JD, MBA, FACHE, vice president, Clinical Support Services; Michael S. Ewer, MD, JD, MBA, special assistant to the vice president of medical affairs; Pamela B. Douglas-Ntagha, RN, JD, MBA, MSN, director, Patient Resources; Gaffe Harper, MSW, director, Clinical Support Services Administration; Ronald Walters, MD, MBA, associate vice president for medical operations and informatics; and Wenonah B. Ecung, MS, associate vice president for clinical programs; The University of Texas MD Anderson Cancer Center, Houston.
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