San Francisco-based UCSF Medical Center recently implemented an Integrated Transfer Center (ITC). Patient access and clinical units work together to clinically and financially clear transfer patients.
“Our providers wanted one-stop shopping,” says Melanie Mata, the ITC’s manager. When providers called about a patient they wanted brought in for an urgent admission, or a patient who was being transferred from another facility, they wanted to be connected to the appropriate resources.
“In the old days, nursing units called each other to move patients from one unit to another,” says Mata. “It was not a coordinated process.”
Epic’s Bed Planning module allows patient access to see the status of available beds on the various units. “But we had to restructure our processes before that software solution would work,” says Mata.
A nurse was added to work with the intensive care unit (ICU) to prioritize patients. “At times, multiple patients are all vying for ICU beds at the same time,” Mata explains.
Previously, the process went through the admissions department. “But they weren’t able to collect what the patient’s clinical needs were and determine if we had a bed available,” says Mata. “Providers thought it was a very clunky process.”
Different processes were used previously, depending on the time of day. “We added extra nursing coverage during the daytime to clinically screen all of our urgent admissions,” says Mata. This change means there no longer are any surprises when patients show up in admitting. “Previously, some patients had urgent clinical needs that staff were unaware of,” says Mata.
In some cases, a patient would be brought to the hospital’s admitting department by ambulance, but no bed was available. “So the transport people would have to wait while we scrambled to find a bed for the patient,” says Mata.
Another problem was that providers sometimes sent patients to the emergency department (ED), without realizing that an inpatient bed was available. “By having a better process upfront, we hope that providers will no longer send patients to an ED that can be directly admitted when we do have an open nursing unit bed upstairs,” says Mata.
PROCESS: INTERNAL TRANSFERS
Prior to the ITC, the previous transfer center was responsible for bringing in patients from other hospitals who needed a higher level of care.
“We were alerted to the fact that we needed a workflow in place for our internal transfers across multiple sites,” says Mata. The centralized transfer center handles both types of transfers.
“Our nurses also handle the transfers from one building to another,” says Mata. “They arrange the bed on the other unit and also arrange the transport through a contracted ambulance service.”
Mata and her financial counseling team fall under the umbrella of patient access and work alongside the clinical side, which falls under the umbrella of nursing.
Laurie McCullagh, the ITC’s administrative nurse, says, “We have a shared management of the department, and our staff are sitting side by side in the same department. As problems come to us, we work together to put together a comprehensive response.”
In some cases, inpatients coming from other facilities are financially cleared first, but exceptions occasionally are made. Sometimes a physician would like to advocate for a patient and release a bed to an inpatient transfer despite lack of financial clearance. In this case, says Mata, “we have the option to secure an approval from the department chair for a physician override.”
There is no Emergency Medical Treatment and Labor Act (EMTALA) risk with this process, she explains, because it pertains only to inpatient transfers. ED transfers do not go through financial clearance prior to releasing a bed. “As long as UCSF has capability to treat the patient and capacity, we accept the ED transfer and release a bed to the referring hospital,” Mata says.
Transfers from the ED are financially cleared after the patients are brought in, in order to comply with EMTALA. “In the end, we do what’s right for our patients. The clinical component will always trump the financial,” says Mata.
Patient placement staff assist the transfer center nurses with medical/surgical placement; nursing staff place the ICU admits and transfers. “We troubleshoot problems across the medical center. It’s not uncommon for us to get calls from the ED, the PACU [post-anesthesia care unit], and the recovery area,” says Mata.
Nursing and financial counseling staff members are cross-trained to work in patient placement, transfer center, or handle urgent admit intake calls.
“When intake calls come in and they are trying to figure out the appropriate level of care, they work as a team to come up with the best plan,” says McCullagh.
On any given day, there might be nine transfer patients and eight ED patients, all waiting for a bed. “The team figures out who goes first,” Mata says.
For patients with a critical care diagnosis, the trauma center nurse works with the patient placement nurse to facilitate the transfer. In one case, says McCullagh, “when all the ICU beds were full, we arranged an ED patient to go straight to the neurological suite to have the procedure there.”
SOURCES
- Melanie Mata, Manager, Integrated Transfer Center, UCSF Medical Center, San Francisco. Phone: (415) 353-1878. Fax: (415) 353-9172. Email: [email protected].
- Laurie McCullagh, Administrative Nurse, Integrated Transfer Center, UCSF Medical Center, San Francisco. Phone: (415) 353-1376. Fax: (415) 353-9172. Email: [email protected].
