Interhospital patient transfer. The case for informed consent

Unnecessary Emergency Transfers for Evaluation by a Plastic Surgeon: A Burden to Patients and the Health Care System

BACKGROUND

Plastic surgeons are frequently consulted for hand and facial injuries, and patients are often transferred to trauma centers for evaluation of these problems. The authors sought to identify the frequency and impact of "unnecessary" transfers for emergency evaluation by a plastic surgeon at a Level I trauma center.

METHODS

The authors reviewed more than 32,000 consecutive emergency department encounters at their institution between April of 2009 and April of 2013 and found 1181 patients transferred for evaluation by plastic surgery. Using a retrospective chart review, necessity of transfer was determined based on the intervention performed at the authors' institution and the availability of resources at the transferring site.

RESULTS

Of all the patients referred for "emergency" evaluation, 860 (74.1 percent) were unnecessary. Transfers for hand-related issues were more likely to be coded as unnecessary compared with referrals for facial trauma and infection (76 percent versus 66 percent; p < 0.001). The average time from referral to discharge from the emergency department was 412 minutes. The expense for these unnecessary transfers exceeded $4.6 million.

CONCLUSIONS

This is the first intervention-based study evaluating the impact of unnecessary transfer for evaluation of hand and facial emergencies. Using a framework based on objective outcomes, the authors found that fewer than one-third of patients required emergent transfer for evaluation by a plastic surgeon, and almost half did not receive an intervention following transfer. Based on patient time and financial expenses for these unnecessary evaluations, improvements could be made in both quality and cost of care by limiting inappropriate emergency department referrals.

Consent for anaesthesia

Current professional guidelines concerning information and consent for anaesthesia are a fair representation of English law. However, they reject the need for specific, written consent for anaesthesia, a position which is in accordance with other Western jurisdictions. This is understandable, as there would be a number of problems inherent in such an approach: the consent process would be unnecessarily labour and time intensive, the generic nature of the information to be disclosed would not allow for operator-dependent variables, and many of the disclosable risks continue to be of uncertain incidence. Moreover, written consent is not needed in order to defend cases of assault by anaesthetists. However, for the very reason that there are a large number of risks associated with anaesthesia (risks that are unknown to the majority of surgeons), together with the possibility of the courts moving towards a reasonable patient standard of information disclosure (as a result of the introduction of human rights legislation into English law), it is our view that the Association of Anaesthetists of Great Britain and Ireland should change their guidelines and advise anaesthetists to obtain separate, written affirmation from patients that certain risks and consequences of anaesthesia have been explained to them. In addition, a standardised consent form for anaesthesia may prove invaluable in retrospectively defending a claim of negligence founded around information disclosure, by recording exactly the risks and consequences of interventions discussed by the anaesthetist and the patient.

Putting the squeeze on emergency medicine. The many pressures on today's ED

Whether it's indigent care, cost containment, transfer laws, financially wary HMOs, overcrowding, reimbursement, or emergency-department inefficiency, the factors "putting the squeeze" on emergency medicine seem to multiply with each new survey. These pressures, the authors feel, are not only weakening the provision of emergency care but also strengthening the argument for a national health plan.

Sociodemographic determinants in the hospitalization decision: evaluation of an emergency department interhospital transfer policy

STUDY OBJECTIVES

To evaluate an emergency department's "treat and transfer" policy during a two-month period of reduced inpatient capacity by determining the number and characteristics of transferred patients not admitted as planned to the receiving hospital.

DESIGN

Matched case-control analysis.

SETTING

Public hospital adult ED.

TYPE OF PARTICIPANTS

Patients transferred to other hospitals for admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twelve percent of patients (16 of 135) were not admitted after transfer during the first month, and 8% during the two-month period. Only IV drug use was found to be significantly associated with an increased risk of discharge without admission (odds ratio = 9.5; 95% confidence interval, 1.9 to 47.8).

CONCLUSION

Patients transferred from the public hospital ED resulted in admission to the receiving hospital in 92% of transfers. A history of IV drug use was the only characteristic found to be associated with discharge without admission to the accepting hospital.

Transfer between psychiatric hospitals: symptom, social function and patient attitude changes in long-term patients

This study followed up a ward group of long-term, mainly schizophrenic patients after transfer from Bexley Hospital, a large institution in South East London, to small purpose built rehabilitation unit in a distant hospital, and used a matched control group of patients remaining in Bexley Hospital for comparison. There was no pattern of symptomatic improvement or deterioration with time in either group, but social functioning and behaviour did improve in those transferred. The patients transferred were well informed about the process, became more favourable about the medical advice offered to them but remained sure, as did patients in the control group, that they wanted to leave hospital eventually. We suggest that the successful transfer of patients between hospitals must involve clear information to prepare patients and relatives, the consent of patients, staff enthusiasm, the provision of a full range of services after transfer, including occupational therapy, and staff continuity.

Informed consent for patient transfers to a Veterans Affairs medical center

OBJECTIVE

To evaluate whether informed consent was obtained prior to transfers of patients from a community hospital to a Veterans Affairs medical center.

DESIGN

Cross-sectional study.

SETTING

A Department of Veterans Affairs medical center.

PARTICIPANTS

Eighty-six consecutive interhospital-transferred patients. Nearly all were white men, with a median age of 62.5 years. Fifty percent had three or more active medical problems and 17% had been transferred from intensive care units.

MEASUREMENTS AND MAIN RESULTS

The authors defined informed consent as a discussion of benefits, risks, and alternatives to transfer. Following transfer, patients and physicians were interviewed using standardized parallel questionnaires. Physician-patient communication regarding the benefits and risks of transfer was infrequent. Informed consent was reported for none of the transfers by patient interview, compared with 11% of the transfers assessed by physician interview. Risks of transfer were discussed infrequently according to both physicians (17%) and patients (13%). Physicians perceived a risk to the patient in 21% of patient transfers, and in 36% of transfers defined by objective criteria as high-risk. Physicians recalled discussing benefits of transfer more frequently than did patients (80% vs. 42%,t test, p less than 0.001). Physicians also recalled discussing alternatives to transfer more frequently than did patients (61% vs. 18%, t test p less than 0.001).

CONCLUSIONS

Verbal informed consent is obtained infrequently prior to interhospital transfer of patients. Risks of transfer are seldom perceived and discussed with patients.

Interhospital relocation of long-stay psychiatric patients: a prospective study

The reorganization of psychiatric services in the United Kingdom has resulted in relocation of many long-stay patients, but such transfers are seldom evaluated. Twenty-four chronic psychiatric patients destined for interhospital relocation were investigated prospectively. After transfer, no fatality occurred, but the group showed a significant deterioration in behaviour, with some changes persisting at 6 months.