As a physician leader in post-acute and long term care settings, most of what I do aims to empower, coach and motivate teams to prevent unwanted hospital transfers. I confess that initially, many years ago, I dragged my feet on making prevention of hospital transfers a priority, probably because it was introduced to me as (or I perceived it to be) “just one more thing” dumped on facilities and their medical teams. 

But, with time, as I have worked with thousands of patients, hundreds of teams, dozens of initiatives and at least five large healthcare organizations, I have a better understanding and agreement towards the need to focus on hospital transfers.

My most recent understanding of the need to focus on this outcome, comes from a very recent case. One of my collaborating nurse practitioners had called me about this 62-year-old resident of a nursing facility who had been lethargic and had fluctuating blood pressure and blood sugar values. With a history of coronary artery disease, hard to control diabetes that required daily insulin, along with hypertension and history of wounds and other infections, he had been manifesting confusion (delirium). 

The practitioner, who had been in this facility now for five months, had initiated and participated in a weekly hospital transfer review process, almost creating a campaign to convince nurses that more can be done for patients in nursing homes, rather than just send them out when they get sick. 

In these weekly meetings (I get to join most of them), the team reviews all transfers for the week and then discusses any possible clinical flags (e.g., fever or cough that was not assessed etc.) that were missed for these cases in the preceding seven days. The team that includes the director of nursing, charge nurses and other team members, in a blame-free environment (that takes time to establish), labels each transfer as “avoidable” versus “unavoidable.” The director of nursing creates a list of best practices that is then used to teach others in the facility. Before adjourning, the team prepares to receive the patients back and does a deep-dive into polypharmacy, with plans to modify medications to minimize risks, on patient’s return.

It was obvious that the efforts of the practitioner had borne fruit because, in this case, despite a very engaged family who felt that the patient should be transferred to hospital, the nurses were happy to work with the practitioner to prevent his transfer. The practitioner had come up with a reasonable differential diagnosis (e.g., hyperglycemia and metabolic causes for his delirium, possible occult infection, drug-drug interactions, etc.) had ordered stat labs, a chest X-ray, and had started the patient on intravenous fluids. 

By the time the practitioner called me, the blood pressure and other vital signs were stable. We again went over the possibilities and given the improved vitals, agreed to stick with the plan and to monitor closely. By next day, the resident appeared to be himself again, as the delirium seemed to be resolving and his blood sugars too had steadied. A hospital transfer had been averted, sparing the resident from many hassles, and saving thousands of healthcare dollars!

Preventing a transfer, as is evident in this case, is not a function of a practitioner just being courageous and confident. I will actually argue that bold decisions, in the absence of a team that is well-aligned with the concepts and has the competence and confidence, may be risky. In this case, months of team-based learning that garnered team’s confidence in each other, had shifted the culture, and set the stage for collective and appropriate valiance.

When I reflected with the practitioner, she stated, “Arif, the fact that none of my nurses demanded that I send this patient out — which was not the case a few months ago — gave me the confidence that we as a team could do this.”

This reflection has helped me validate that preventing avoidable transfers needs a culture where team members trust and support each other, and that simplistic solutions, e.g., assigning after-hours calls to third-party partners with telehealth capabilities, are just not going to cut it.

Arif Nazir, MD, Chief Medical Officer for Abode Care Partners, is a leader in geriatric and frailty care. Besides practicing on the frontlines, Nazir oversees quality improvement and delivery of medical services across several large post-acute care organizations providing services across many states.

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