5 Close to Home: Implementation of a transfer process for paediatric inpatients from tertiary to community care

Abstract

Background Patients presenting to the emergency department who require inpatient care are either admitted to our tertiary care inpatient units or transferred directly to a community hospital. When patients appropriate for community care cannot be transferred due to a lack of community beds and instead remain in a tertiary care bed, there are palpable downstream effects on patient flow. A pre-study audit confirmed that, once admitted, transfers from the inpatient unit to a community bed are rare. This project aimed to improve access to tertiary care beds by increasing inpatient transfers to community hospitals. Objectives The project aimed to transfer 25% of all eligible patients from the Paediatric Medicine inpatient units to community hospitals over a 4-month period by identifying eligible patients and streamlining the transfer process. Design/Methods An Ishikawa diagram with input from inpatient physicians and nurses and community hospital colleagues identified 4 modifiable barriers. A process map was created along with a simplified transfer process. Medical teams and nurse leaders were provided with the charts of contact numbers, geographic locations and levels of care for community hospitals. Intake nurses tracked eligible patients. Encrypted text messages were sent to inpatient physicians on their mobile devices every morning reminding them to assess specific patients for transfer. The outcomes of all identified patients including process and balancing measures were tracked. Results Multiple PDSA cycles focused on improving the success of identifying eligible patients at multiple points in the process. The study’s outcome measure was the rate of successful inpatient transfers for all eligible patients. From November 2018 to March 2019, 120 patients were identified as eligible for transfer at the time of admission: 45 (37.5%) were discharged within 24 hours, 42 (35%) were not considered clinically appropriate for transfer by the attending physician and 33 were considered appropriate for transfer. Twenty-four were approached for transfer (72.7%); 9 were not approached for non-clinical reasons. Six (18.2%) refused transfer and 10 (30%) were successfully transferred. These rates were sustained over the study period. Conclusion A streamlined transfer process can improve patient flow, optimize utilization of tertiary care beds and provide care closer to home. A more robust method of tracking patients that could flag patients and send physicians electronic reminders is needed. Most importantly, optimal use of tertiary care beds requires a culture shift to ensure every patient is considered for transfer to the community when medically appropriate.