When we have to facilitate a hospital transfer, we have to shift into high gear. Not only do we have to ensure a safe and smooth patient transition, we have to re-route other facility operations as we shift focus, all while being concerned for our patient requiring transfer, and supportive of our staff. It is even more challenging when a patient is requiring urgent or emergent care and transfer coordination is imminently necessary.
CMS has updated the regs that guide the process as well. Here’s a recommended blueprint to make the process easier.
CMS has changed how it defines a “local hospital”, recognizing that the best facility for transfer may be further than the closest based on the type of care it provides. As an example, a patient with a cardiac emergency may be better served at the hospital five miles away instead of two. If you will be negotiating a transfer agreement, this may impact your hospital selection.
Although not new, as part of your emergency process, your physicians need to have admitting privileges at your receiving hospital or your facility will need a transfer agreement: We need to have one or the other, and the receiving facility needs to be Medicare participating. If you are transferring to a facility where your physician has privileges, check their credentialing file to make sure there is evidence of such and make it part of the credentialing process.
You don’t need a transfer agreement with a transport service, just utilize 911. If the patient requires acute care and is not stable for discharge, best to send them with trained professionals and monitoring. This saves the “how do we transfer” discussion.
One of the new requirements states that we need to communicate to the transferring hospital, and that our policy and documentation supports this. Update your policy to include the communication requirement. If you utilize a transfer form, update the form with a check box indicating the communication took place.
Review your policy to determine if the process supports printing or copying the medical record as part of the transfer. The receiving hospital will want the record. Don’t forget to check out the Advance Directive status of the patient as part of the transfer communication.
Have progress notes with your transfer forms for quick access so the transferring and/or treating physician can document the event. If your anesthesia physician and surgeon are both involved, request they both document.
When the nurse completes and hands off care, have them also document the event as an incident report separate from the medical record.
Utilize a transfer checklist that includes the actions and paperwork involved in the transfer. Include items like belongings disposition, notification of family, to whom report was given, that chart was provided, and that progress notes documenting the event were completed and sent.
I like to maintain an emergency transfer book with the crash cart that includes the policy, forms and checklist so everything is easily accessible when needed.
Practice the process as a scenario for your next code drill, and document the response. You’ll feel more confident if they need to transfer a patient, and the patient will benefit from your preparation.
On a personal note, I want to take a moment to thank all of you for subscribing to my blog. I am grateful for each of you.
If you are anything like me, policy review and revision is something I tend to dread.
Sometimes, there is an exhaustive thick policy book that rivals War and Peace.
Sometimes, there are several books that have been divided up by category. Always, no matter how they are arranged, how many policies exist, or how often they are reviewed and revised, (at least annually to meet the regs, right?) it is definitely a chore, not to mention time consuming!
Doesn’t it also seem that, no matter how diligent we are, and how comprehensive we think our policies to be, we are always scrambling for that one reference, and either a) can’t find it, or b) don’t have it? I know it has happened to me.
Having recently had to both implement and revise policies, I decided I needed to make the process more simple. I created a “Bones” list that I refer to as “Core Policies”. E mail me at firstname.lastname@example.org if you want a copy. I can’t promise it includes every policy you need for the bones of your policy book, but I reviewed both the current CMS and AAAHC guidelines as I developed it.
To make life simple, I alphabetized it. To me, I’d rather look a policy up in alpha order than by type or category. I also numbered it. As I add policies to the core list, they can be added as alpha, so no shuffling, and much easier to fix the table of contents.
As I built the Core Policy book, I pulled the existing policies related to the need, reviewed and revised, then sent them to the Governing Board to approve. If no policy met the requirement, I phoned a friend or googled one. For those facilities that had existing policies, I lined through the ones I pulled from the table of contents, and indicated “Moved to Core Policy Book”. As for the remaining policies, it provided me the luxury to prioritize the most important policies, then review the rest in small doses.
With those remaining policies, I tend to treat them like spring cleaning my closet. Will I need it ever? Is it covered in another policy? Does it define or support a process? If the answer is yes, I dust it off and give it a new home. It can live with the bones, or can live in a new book, maybe “Process Policies”. If the answer is no, I retire it with the board’s blessing.
I save all my policies on Dropbox and share with key staff so the most current revision electronically accessible. Once the process is complete, I mark my Outlook calendar a year out minus a month or more to review again. Now, when I need that key policy to reference, it will be easy to find and relevant.
We can’t always get the surgeon there on time, but we can take steps to make sure we are ready when they get there. Here are a few tips that may help all that dirty work seem a little easier and off to a clean start:
- Interview the patient prior to physician arrival. Murphy’s law will prove true and the patient will have to use the bathroom one more time, the patient or family has questions, or the consent is missing a key element. Better to have resolved these issues prior to retrieving the patient.
- Have everything ready for the case. Pick cases prior to the day before surgery. Picking the case means instruments and implants, too. I have been stuck without a correct sized implant when the staff assumed it is in consignment or I assumed the rep was bringing it. If the rep is bringing an implant, supply or instrument, I call the day before (even if we have already discussed it) just to be sure.
- Signing off on “The Pick”. You may want to create check off form. I like using brightly colored paper with three lines: supplies, instruments, implants. The same paper can be used to communicate any arrangements made as well; ie: Joe the rep is bringing the bone putty. The staff member completing the pick signs the form. Have someone double check that all are done at the end of the day and report off prior to leaving for the day.
- Accountability is key. All OR staff pick cases for the next day. No one leaves until cases are picked, which means the early room down and staff with down time pick. Before a staffer leaves, they report to somebody that the pick is complete. And they can’t soak the pans!
Soaking the pans is my analogy for fairly sharing the work. When I was a teenager, my family had a dishwasher…my brother and me. We both hated doing dishes with a passion. As you can imagine, the dishes were always ahead of whatever social plans we may have had for the evening. So, one of us would wash the dishes as quickly as possible, and put water and soap in the pan(s), so when asked if the dishes were done, we would say “yes” leaving the soaking pan for the other person. If I left a soaking pan for my brother he would then have to wash, he would also then find a way re-pay me. It was war… Needless to say it still gets brought up as legendary fodder at the holiday table. So, to keep the OR peaceful, make sure that everybody picks and that all the “pans are washed” at the end of the day.
And as for those tardy docs, I welcome any suggestions!