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

Bosk, Emily A. MSW, MA*; Veinot, Tiffany MLS, PhD; Iwashyna, Theodore J. MD, PhD

doi: 10.1097/MLR.0b013e31820fb71b
Original Articles

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.

*Department of Sociology and School of Social Work

School of Information and School of Public Health

Department of Internal Medicine, University of Michigan, Ann Arbor, MI

Supported by 1K08HL091249-01 from the NIH/NHLBI and by the Office of the Vice President for Research of the University of Michigan.

Reprints: Theodore J. Iwashyna, MD, PhD, Pulmonary and Critical Care, University of Michigan, 3A23 NIB, 300 North Ingalls, SPC 5419, Ann Arbor, MI 48109-5419. E-mail:

© 2011 Lippincott Williams & Wilkins, Inc.