Kiran Gupta writes about her experiences as a resident in the Department of Medicine at Brigham and Women's Hospital. She has done research on domestic health policy issues, including health care costs, medical errors, and end-of-life care, and is a former columnist for the Financial Times Weekend Magazine. Kiran received her A.B. in Government with a certificate in Health Policy from Harvard College and earned her M.D. from Harvard Medical School.
Mr. M arrived in the middle of the night. Like many patients transferred from surrounding community hospitals, he came with no advance notice, little time for preparation, and a pile of “outside hospital” records. I quickly rifled through the thick stack of papers that came with his chart, looking for a coherent summary of his medical history and reason for transfer. All I could find were lab results from several days earlier, barely-legible, handwritten daily progress notes, and a one-page X-ray report.
Mr. M himself was in no condition to provide a medical history. He failed to respond to my voice, and his eyes barely opened as I pressed my knuckles into his sternum. I had no idea what his latest blood tests showed, or how recently his mental state had deteriorated. But he needed to be intubated (attached to a ventilator to help him breathe) and transferred to the intensive care unit immediately. Making sense of the disorganized pile of papers would have to wait.
This scenario is, unfortunately, all too common. Complicated patients that require specialized clinical expertise or interventions unavailable at many smaller hospitals are often sent to large academic medical centers. Ironically, however, in seeking better care these “transfers” are often exposed to significant new risks in the very process of moving from one institution to the next.
Smooth transitions in care depend on accurate transmission of crucial information, advance preparation for a patient’s arrival, and the presence of appropriate medical personnel with the requisite expertise. But every time a patient is moved from one clinical setting to another -– be it from his physician’s office to the emergency room, from the wards to the ICU, or from one hospital to another -– opportunity for error is introduced. These transitions can be impeded by shift changes, staffing shortfalls, incomplete communication, disparate IT systems, and concerns over patient privacy.
Yet these challenges are far removed from patients’ and family members’ heightened expectations upon arriving at the referral hospital. They understandably believe that the receiving care team will be ready to immediately begin providing treatment that the referring institution could not. In reality, “transfers” typically arrive late in the evening (once other patients have been discharged and hospital beds open up), when staffing is lower and highly specialized services are frequently unavailable on-site.
Mr. M was rapidly intubated at the bedside and stabilized on a ventilator. We called the transferring institution to fax over missing records and ordered appropriate antibiotics, laboratory tests, and a head scan while we waited. The lab results revealed that Mr. M had severe electrolyte abnormalities—likely a contributing factor in his significantly altered mental status. Had we known upon his arrival, we could have started treating him right away.
As the faxed papers and exam results came through, we slowly began to piece together Mr. M’s complicated medical history. Hours later, after finally making sense of it all, we felt comfortable having an informed discussion with his family. By the early morning, Mr. M was in the ICU, the data in his chart organized, additional tests ordered, and his loved ones satisfied, their confidence in us restored. But those hours could have been better spent moving our patient’s care forward instead of wasting precious time and resources duplicating data and retracing steps.
This fragmented system in which patients are constantly shuttled from one place to another is frustrating, for them as well as those responsible for their care. These outside hospital transfers, or “OSHes” as we call them, raise important questions about why, in our current era of evolved technologies and interconnected networks, health care—an industry dependent on accurate, real-time data to inform effective clinical decision-making—continues to tolerate massive inefficiencies in information flow.
If we as providers are to ensure our patients the best care possible, the transfer process between health care institutions must be streamlined. Information needs to be in the hands of the receiving clinician before the patient arrives rather than hours later. Direct physician-to-physician communication is essential each time a patient moves from the care of one hospital’s medical team to the next. The receiving team should be updated on the incoming patient’s clinical status in real time, so that the patient can be triaged to the appropriate care setting as soon as he or she arrives. And every effort must be made to transfer extremely ill patients between institutions during the day, when staffing is optimal and experts are on hand.
Until such changes are implemented, those of us on hand in the middle of the night are merely plugging our fingers in gaping systemic holes in an attempt to keep the process afloat as best we can.Dr. Kiran Gupta can be reached at KiranGuptaMD@gmail.com.