Discussion 2

Development of Transfer Review Process/Committee

As a regional referral center in northern Michigan currently seeking Level 2 trauma designation and serving 22 rural counties, one third of our unplanned admissions are transfers from other facilities.  These referral facilities are primarily critical access and/or community hospitals who lack the capability to provide higher level care (Dunne, 2001).   This post will discuss the development of a transfer review process/committee as a practicum project, the rationale for this focus, an overarching project goal, measurable objectives to determine success, and questions/concerns for colleague discussion.

Proposed Transfer Review Process/Committee

During this practicum, a transfer review process which can be initiated by any of the transfer participants will be developed utilizing input from our referring providers, accepting providers, the utilization review committee, the receiving hospital unit, the transfer emergency medical service (EMS) providers, and the house supervisors who participate on every transfer conference call.

Rationale for Focus

Less than one percent of our transfers are currently reviewed for quality interactions between providers, accuracy of initial patient assessment and early interventions, and referral customer perception of the service provided.  Patient updates and constructive feedback are not provided to the referring provider except through the patient’s discharge summary.  Outreach coordinators have incidental information regarding dissatisfaction with the transfer process; the interactions with the providers; the length of time transfer coordination requires; discussions of the futility of care; and delays in non-acceptance of higher acuity patients (Broman et al, 2017). 

Currently, referring physicians contact our switchboard through a dedicated transfer line.  Our Switchboard operator immediately asks “is this a ST elevation MI (STEMI) transfer?” If the answer to this question is yes, the operator automatically connects the on-call interventional cardiologist, the house supervisor, and the referring physician for a conference call.  This allows for rapid triage of the patient, acceptance for transfer, and mobilization of our cardiac catheterization laboratory for emergent intervention following the higher level of care emergency medical treatment and labor act (EMTALA) (Key Provisions of EMTALA, 2016).

If the answer is no to a STEMI, the house supervisor connects with the referring physician, listens to the patient’s history and current issue, and determines based on pre-determined criteria which of our providers should be on the transfer call.  The referring physician then disconnects from the call and is reconnected when our switchboard has gathered our necessary providers and the house supervisor on the phone.  As many as four or as few as one of our providers may be on the phone dependent on the patient’s condition.  The physicians on the phone will listen to the full report; ask questions or make recommendations prior to acceptance; will determine if we have the capability to accept the patient; and which physician will accept the patient for admission (Radwin, 2006).   The house supervisor then provides a bed number, a telephone extension for nurse to nurse report, and a fax number for demographics and medication reconciliation forms.  This multistep process leaves a lot of opportunity for errors, dissatisfaction, or inappropriate interactions by any of the participants (Meyer, 2016).

Overarching Project Goal

The overarching project goal of this practicum project is to provide a reliable, consistent means to review a patient transfer or declination of acceptance at the request of any participant in the process. 

Measurable Objectives

Success of the practicum will be determined by well-defined SMART objectives.  SMART objectives are specific, measurable, achievable, reliable, and timebound (Tempest, 2012).  Five objectives for the practicum include:

1. Within the eleven-week practicum, a transfer review process will be developed.

2. Within the eleven-week practicum, the transfer review process will be approved by the Senior Executive Team (SET)

3. Within the eleven-week practicum, the transfer review team will be identified and invited to participate.

4. Within the eleven-week practicum, organizational and referral transfer participants will be educated to the transfer review request process.

5. Within the eleven-week practicum, a SET discussion will occur regarding purchasing a program to record transfer calls.

These five objectives contain the elements of a successful peer review program (Eastes, 2010).  Including all five objectives in an eleven-week practicum may appear daunting; however, the objectives are closely related and pertain to the success of the project.

Questions/Concerns for Colleagues

1. My organization has an ethics review process, nursing peer review, and a medical peer review process; we are in the early stages of trauma peer review.  How well developed are the peer review processes at your organizations?

2. If you are involved in a peer review process at your organization, how does the referral process work?

3. Would you value peer review of a process you participated in?

4. What would you consider timely resolution of a concern brought forward in a peer review process?

Summary

The guiding principle for our organization is “to provide healthcare as we would expect for our own family” (Mission, vision, and guiding principle, n.d.).  Our SERVE values indicate we focus on safety, excellence, respect, value, and enthusiasm.  A transfer peer review process would ensure we are meeting both our guiding principal and SERVE values in our interactions with our referring providers and in the care we offer to both our local and our referral patients.  The development of a transfer review process/committee will enhance both our guiding principle and values.

References

Broman, K. K., Phillips, S. E., Ehrenfeld, J. M., Patel, M. B., Guillamondegui, O. M., Sharp, K. W., & ... Holzman, M. D. (2017). Identifying Futile Interfacility Surgical Transfers. American Surgeon, 83(8), 866-870.

Dunne, K. (2001). EMTALA: standard for patient transfer based on hospital's procedure. Journal of Law, Medicine & Ethics, 29(2), 236-237

Eastes, L. (2010). Best practice: Oregon's model for regional trauma system peer review. Journal Of Trauma Nursing, 17(3), 148-152. doi:10.1097/JTN.0b013e3181f52135

Key provisions of EMTALA. (2016). Modern Healthcare, 46(13), 0017.

Meyer, H. (2016). Why patients still need EMTALA. Modern Healthcare, 46(13), 0016.

Mission, vision, and guiding principles. (n.d.). Retrieved from http://www.mclaren.org/northernmichigan/mclaren-mission.aspx

Tempest, E. (2012). Leadership Academy. How to draw up SMART objectives that will work. Nursing Times, 108(41), [37].

Radwin, L. (2006). Thresholds for requesting transfers to tertiary care were influenced by perceptions of the current illness and differences in perceptions of the initial hospital and tertiary care centre. Evidence Based Nursing, 9(3), 93.