Which Patients and Where: A Qualitative Study of Patient Transfers from Community Hospitals

Abstract

BACKGROUND: Interhospital transfer of patients is a routine part of the care at community hospitals, but the current process may lead to suboptimal patient outcomes. A microlevel analysis of the processes of patient transfer has not earlier been carried out. RESEARCH DESIGN: We conducted semistructured qualitative interviews with care providers at 3 purposively sampled community hospitals to describe patient transfer mechanisms, focusing on perceptions of transfers and transfer candidates, choice of transfer destination, and perceived process. We interviewed physicians, nurses, and care technicians from emergency departments and intensive care units at the hospitals, and analyzed the resultant transcripts by content analysis. RESULTS: Appropriate triage and the transfer of patients was a highly valued skill at the community hospitals. On the basis of participant accounts, the transfer process had 4 components: (1) Identifying transfer-eligible patients; (2) Identifying a destination hospital; (3) Negotiating the transfer; and (4) Accomplishing the transfer. There were common challenges at each component across hospitals. Protocolization of care was perceived to substantially facilitate transfers. Informal arrangements played a key role in the identification of the receiving hospital, but patient preferences and hospital quality were not discussed as important in decision making. The process of arranging a patient transfer placed a significant burden on the staff of community hospitals. CONCLUSIONS: The patient transfer process is often cumbersome, varies by condition, and may not be focused on optimizing patient outcomes. Development of a more fluid transfer infrastructure may aid in implementing policies such as selective referral and regionalization.