Published February 27, 2003
By Jeff Strickler, RN, MA, CEN, EMT-P
Nurse Director: Emergency, Trauma, Burn, and Ambulatory Services
University of Kansas Hospital – KU Med
University of Kansas Hospital – KU Med
Marvin McLellan, BS, EMT-P
Director of Business Development
Interfacility transfers are often fraught with difficulties; however it is one of the most important processes for an institution. When done well, transfers can be a key piece of the overall hospital business plan. When it is not done well, it can be one of the most litigious areas of healthcare. This article will review the experience of KU Med, which gained control of this process through the development of a transfer center.
KU Med is a 600 bed Academic Medical Center located in Kansas City, Kansas. KU Med is the hospital authority associated with the University of Kansas Medical Center. The Medical Center is a tertiary hospital providing care for Kansas City and the NE Kansas/NW Missouri region. The hospital provides a full range of cardiac and cancer services as well as being a Level I Trauma Center and the Burn Center for the Kansas City metro area.
Several issues lead to the conclusion that KU Med had concerns with the transfer process. Direct discussions with practitioners in the area Emergency Departments revealed a frustration with the inability to easily contact and gain acceptance at KU Med. Historically, calls came into our facility through many directions – directly to the ED, hospital switchboard, direct to specialty units, and physician offices. As with many teaching hospitals, these calls bounced from one unit to the next and from one resident to another. Frustration with this practice led to KU Med losing favor as the institution of choice for transfers. Additional evaluation supported this conclusion when a lower than expected number of referrals to our hospital were noted. Several cases also led to concerns that we were not completely fulfilling obligations under EMTALA. Discussions with out physicians revealed that the majority had a poor understanding of both their obligations under EMTALA and the transfer process.
Informal discussions within the Trauma Service at KU Med on how to deal with these issues and increase referrals to our program led to the idea of developing a transfer center to better manage this process. This concept of a transfer center had been presented at a recent conference and the thought was that the concept might work at our institution. A literature search was done on this concept; however, there is a negligible amount written about this service. However, one article relayed that our experience with transfers was akin to the experience described by Albany Medical Center (Geehr, Norton, Whitman, and Metzger, Qual Assur Util Rev., 1991). As relayed by Geehr et al, we were unable to evaluate the appropriateness of each transfer, our nursing units knew little about these patients, our patient financial services often missed vital demographic or payor info, and often these patients arrived to hold in our over burdened ED due to the fact that a bed had not been requested. Discussions were then held with Life Com, an organization having some experience with this concept. Life Com is a division of Air Methods Corporation, which provides dispatch and flight following for their many vended flight programs around the country as well as having experience providing transfer and referral center services for other hospitals around the country. Additionally, a visit was made to the transfer center at Barnes Jewish in St. Louis. From these sources a concept paper was written and given to administration for evaluation. Our proposal for a transfer center would streamline the convoluted process to refer a patient to the institution and would facilitate easy access. The intent was to develop a “one call does it all” approach. The unique piece of our proposal was that the transfer center would not be the typical hospital based service rather the service would be outsourced. After review of the Life Com operations, it was determined that KU Med could not create a more cost effective operation that provided an equal level of technology and customer service. After ongoing discussions with administration, it was elected to enter into a business relation with Life Com to assist in the management of these calls. The initial proposal was given the approval to proceed to the level of creation of a business plan along with the holding of preliminary discussions with physician leaders. It was determined that the plan would revolve around the creation of a pilot phase. This phase would utilize a few key services, which represented the services that might be needed for emergent transfers (Figure 1). These services also offered the added benefits of having a history of accepting transfers and a desire to grow their referral volume. This business plan was presented to the Executive Team of the hospital as well as a group of physicians representing each of the targeted services. At this meeting, the full scope of the service was presented. The entire process from the time of call to post arrival by the patient was laid out.
The basic system would function as follows:
Referral call is received by the transfer center over a toll-free referral line (existing numbers used). The person answering the call is trained as an emergency medical service communications specialist so they are medically literate. The call is answered as KU Transfer Center.
The transfer center collects basic patient information i.e. name, location, injury or illness, time, callback number, etc.
If the call is in reference to an outpatient/clinic referral, the call would be transferred to KU Call Center, which was a previously operating system that refers these types of calls directly to physician clinics. If it is a request for an interfacility transfer, the acceptance process is started in either of two manners: the attending physician is notified to determine acceptance, or the patient is initially accepted (based upon developed protocols) in the name of the on-call physician for the requested service.
The transfer center offers transport services if needed. If air is needed, the closest service is dispatched.
If not previously contacted to determine acceptance, the appropriate receiving physician (trauma, cardiology, etc.) is contacted per an on-call schedule.
The receiving physician is advised of the transfer, expected time of arrival, and would connect the physician with the referring physician for addition physician-to-physician communication.
The transfer center would relay the above information to KUH admissions, Emergency Department, receiving unit, etc.
Follow up communication is provided to the referring center on patient condition and a survey of their satisfaction with our referral process is provided.
The advantages of this system are:
Facilitates referrals by having a centralized point of access to KU and allowing for one call acceptance and transport to KUMed – a “one call does it all” approach
Improves customer service by decreasing the amount of time spent on the phone to the referring hospital, which is a major factor for outlying hospitals in deciding who to call. Ultimately this system could increase referrals. Other studied systems had seen their call volume double since implementation of a similar system
Improves communication and control on acceptance of transfers
Allows the hospital to best fulfill their obligations under EMTALA.
Having a central communication point allows for accurate collection of data as to when and where referrals are coming and who is receiving these patients
Recording of call from the referring hospital and all calls are logged, therefore providing historical record that EMTALA considerations were covered
Allows for the call to be received by someone with basic medical training, i.e. EMT versus the usual system of using the hospital switchboard
Provides a link to the hospital for notification, bed assignment and insurance information needs
The initial phase of this project has been a resounding success. The Transfer Center has streamlined our process, and has accomplished the “one call does it all” approach that we were seeking. Conservative estimates show 10-20% increased call volumes. Some services such as the trauma program have carved out new markets. Internal physicians have called this new process “revolutionary”. External physicians state, “This is the best thing that KU has ever done”. A satisfaction survey was created and results show for both internal and external parties a 95% rating of the Transfer Center as very good to excellent. For the first time, our institution has a great deal of data on these referral calls. Among many things, we know where these patients come from and where they are going (see example Figure 2). When problems arise, we know about the issue immediately and more importantly in time to impact the situation. The fact that these calls are recorded has proven useful on many occasions. We are now moving to implementing this service for all referrals to this hospital.
This Transfer Center has enabled KUMed to gain control of our transfer process. IT has enabled our institution to turn around a less than favorable reputation and satisfy internal and external customers. Data and recordings from these calls have allowed us to make continual improvements in this process. By outsourcing this program, we have cost effectively accomplished these items. Any cost has been eclipsed by new business and the level of risk avoidance that we now have. A Transfer Center is a valuable tool to any hospital for managing the convoluted process of transfers.