Learning Objectives
By the end of this section, you will be able to:
- Describe steps for patient transfer to and from an external acute care facility
- Describe steps for patient transfer within the same facility
- Recognize the process for patient transfer to an extended care facility
- Identify how the nurse can ensure patient needs are met during transfer
Patient transfers occur between healthcare facilities, and even within the same facility. These transfers happen depending on the patient’s condition, and information between facilities and units must be clear and accurate.
There are many different units with varied specialties within the same hospital. Consider a patient who was admitted for several large lacerations on their body because of a construction accident. They had serious bleeding and required surgery to repair the damage. The patient’s vitals are tenuous and require blood product administration and surgery, so they are admitted from the emergency department (ED) directly to the operating room (OR). From the OR they may go to the intensive care unit (ICU) for close monitoring. The patient’s condition improves, and they are allowed to transfer to the step-down unit, and from there to the medical-surgical unit where they are eventually discharged back home. A step-down unit is an inpatient unit in many hospitals that serves as a transition point between intensive care and the medical-surgical unit, also known as the general medical unit, where the least critical patients who still require inpatient acute care are housed. The difference between these units lies in the acuity, or the severity and complexity of patient illness, and in patient care routines such as the frequency of vitals, assessments, and visitation limitations as discussed in 8.1 Patient Admission. For an initially emergent admission, it is vital that the patient’s medical information and condition are quickly and accurately conveyed between each of these points of care.
All aspects of the patient’s medical story are important, but nurses and healthcare providers must know what information is most important to the people currently caring for the patient and focus their transfer report accordingly. Priorities may change. For example, in the ED or ICU, the patient may be in a lot of pain and require significant pain medications and frequent assessments. Interventions such as physical therapy and rehabilitation for improving mobility are important but not necessary at this point. Once the patient begins to heal and is more stable, their care priorities may change. The nursing and medical staff must be able to adapt to the patient’s changing needs as they transfer from different units and facilities. Details such as wound care, a skin tear obtained on the unit, or consistently high blood sugar levels also need to be conveyed. Each point of transfer is another step in the patient’s healthcare journey, and each point has the potential for crucial information to not be conveyed, negatively affecting patient care.
Steps to a Patient Transfer
In an acute care setting, the process of patient transfer begins with decisions made by the patient’s primary team of providers. This can include doctors, surgeons, and/or specialists. Nurses and advanced practice providers such as physician assistants (PAs) and nurse practitioners (NPs) may also be a part of this team. Other providers can be social workers and case managers, who coordinate with insurance and sometimes Medicare and Medicaid to ensure the patient’s care is covered by the relevant entity. Pharmacy may be involved as well to give their input on medications the patient may need.
Once a decision is made to transfer a patient, multiple calls are made to the receiving unit or location. The doctors call and discuss the case with the receiving doctors. The transferring charge nurse speaks with bed management and the charge nurse on the receiving unit to arrange for report. Social work and case management may be involved if the patient is being transferred externally to a different facility. Once all approvals are in place, the nurse or charge nurse contacts the unit clerk and arranges for transportation, either via patient transport if the transfer is within the facility to another unit, or via EMS or an ambulance to an outside facility.
Patient Transfer between Facilities
Sometimes a patient is transferred from a community hospital to a larger facility for a higher level of care or for care that the smaller facility with fewer resources cannot handle. Sometimes transfers occur due to insurance issues. Whatever the case, larger hospitals—often in cities or sizeable metropolitan areas—are often affiliated with teaching universities or medical schools and thus have many resources at hand. When transferring a patient to a higher level of care, it is important to anticipate the questions the nurse will have and to try to have the information readily available if not already part of report. Transfers between healthcare facilities, also known as an interfacility transfer, are key points where information may be missed because many hospitals are not on the same charting or record-keeping system. A standardized report covering every possible, necessary piece of data ensures nothing is missed.
When receiving a transfer, it is key to assess the patient thoroughly, paying particular attention to important tasks such as checking the skin and bony prominences for bruises, cuts, scrapes, skin tears, or pressure ulcers. Check for any wounds, and if present, the dressings on the wounds. Any access lines such as IVs, gastric tubes, and urinary catheters should be carefully documented; per facility policy, some lines may need to be switched out. Drains should be documented and assessed. These points are all assessed under quality improvement measures and monitored by TJC, and if they are missed or not documented and addressed upon admission, the injury can become the responsibility of the facility and can negatively affect their reimbursements from CMS.
Patient Transfer within Facilities
Transfers within an acute care facility are some of the most frequent patient transfers that occur when a patient transitions from one level of care to another. Consider a patient who is transferred from the ED to the ICU and how nurses ensure the patient’s information is complete, ranging from the reason they are admitted to the condition of their skin after a four-hour operation. The key to having complete information is consistent assessments, standardized charting, and efficient reports between nurses upon each transfer. Information must be complete, focused, and relevant. If the patient is transferring from the OR to the ICU, the nurse needs to know what IV medications the patient is on and what their labs and vital signs are. Is there any damage to their skin? Do they have any wounds? Do they have surgical lines or drains? Their level of mobility or whether they were continent before the surgery is good to know but can be conveyed via nursing documentation in the patient’s chart. Later, when the patient transfers to the general medicine floor or to an outpatient rehab, report should focus on the relevant information the nurses will need there. Some necessary information will remain the same, such as vitals, labs, and skin condition. Information that was less relevant before, such as continence and mobility, become more relevant when the patient transfers to decreasing levels of acuity. In short, transfers between units must be complete but focused, thorough, and well documented.
Report between Units
Report between units is the point where information is conveyed from one unit to the next. Different levels of care require different areas to emphasize when giving report. If the patient is being transferred for observation, it is important to know the basics of their condition, the medications they require, and the status of their mobility and orientation. Understanding the patient’s medical conditions and needs when transferring them is vital to giving the receiving nurse a report with all the necessary information to care for the patient safely.
Clinical Safety and Procedures (QSEN)
Reformulating SBAR to ISBARR
To help facilitate safe patient transfers, evidence-based communication methods, such as SBAR (Situation, Background, Assessment, Recommendation), have been used. While SBAR works, the system can always be improved (Muller et al., 2018). Research has been done to improve the SBAR format to include an introduction when beginning to give report and a readback at the end (Figure 8.8).
Transfer of Personal Belongings
The transfer of patient belongings may seem minor, but it is a crucial part of the transfer process. Ensuring the patient’s possessions go with them preserves positive relationships and maintains a good rapport with the patient and their family. Items such as cell phones, tablets, phone chargers, eyeglasses, dentures, and earbuds frequently get lost in the transfer process. Canes, walkers, and crutches are also important belongings to keep track of for patients, as they are expensive and are often purchased through the patient’s insurance. Personal mementos, such as religious icons, greeting cards, and photos, are sometimes displayed in a patient’s room and should also be considered part of the patient’s transfer. If the patient is too ill to participate, make the primary family contact aware of the patient’s transfer so that expensive and valuable possessions such as cell phones and wallets can be located and perhaps taken home for safekeeping. Patients and their loved ones appreciate it when these details are as looked after and cared for as the patients themselves.
Family Notification of Transfer
Ideally, the patient’s family is closely involved in the care plan developed with the healthcare team and they are aware of the plan to transfer, but this does not always happen. Ensuring that the patient’s family is aware of the transfer ensures clear communication and positive relationships with the patient and family. Urgent notification of family is sometimes necessary as in the case of a decline in patient status requiring return to surgery or transfer to the ICU. For nonemergent transfers, if the family visits in the morning and it is several hours before the transfer is to occur, it is acceptable to inform them of the transfer at that time. However, if the family is unable to visit until closer to the transfer time or afterward, a simple phone call update is strongly suggested. It is a small amount of time that results in a large amount of appreciation and comfort for the family.
Transfer to an Extended Care Facility
When a patient no longer needs acute inpatient care but still has significant medical needs that their family cannot attend to, the patient may be admitted to an extended care facility. This includes nursing homes, LTC facilities, and LTAC facilities. Again, as with other transfers, it is important the patient’s entire story is communicated; however, report should be focused and specific on what the transferring facility needs to know. Facts that are most important, besides vitals, involve orientation, mobility, medications, and wounds. Report should be thorough, complete, and focused.
Mode of Transportation
There are many ways that a patient can be physically transferred from one facility to another. Depending on their acuity, they may be sent via EMS in an ambulance, or even a critical care specialist ambulance if the patient has a ventilator or certain IV medications that require special training. If the patient requires transfer from a very rural or remote area, the patient may be flown in via helicopter. Special teams of doctors and nurses staff these flight ambulances; they are trained in critical care life support and the use of medications, machines, and devices to sustain the patient until they arrive at their receiving facility. Patients may also be transferred via private ambulance, usually if the patient or the family wants a transfer to a particular facility. These transfers are usually arranged by the transferring facility, although sometimes the family arranges the service or transfers the patient themselves, though rarely. Regardless of the mode of transport, it is important that the nurse coordinates the patient’s departure with all involved parties: the doctors should be aware, the charge nurse and unit clerk must be notified, report must be given, belongings must be packed, and the must be patient prepared (dressed, cleaned, ambulated/toileted).
Transfer of Advance Directives
The patient’s code status and advance directives should also be clearly conveyed as part of transfer report, especially if the patient is being sent to an outside facility. The advance directives are rules that are legally set by the patient that dictate their end-of-life care. It is vitally important that this is communicated clearly, with no room for questions or error. Not communicating that a patient does not want chest compressions in the event their heart stops can cause great distress to the patient and family, as well as potential legal ramifications for the facility.
Ensuring Patient Needs Are Met during Transfer
Leaving the hospital for somewhere new can bring on a lot of anxiety for patients and family members, especially if the patient’s mobility or overall health has been impacted by their inpatient stay. There may even be fear or anger.
Consider where the patient is going. Report to an assisted living facility may be very different from report to an LTC facility or an inpatient rehab floor. Is the patient going home? Are there new medical devices going home with the patient? Who needs to be educated? What can the family or patient expect? What are the plans for follow-up? The rapport built with a patient will factor into how the nurse can help the patient transition to this next phase in their healthcare journey.
Patient Comfort
Patients may be very anxious upon transfer to a new unit. Their health may have drastically changed for better or worse since admission and this new transition can cause fears, anxieties, or even trauma to resurface. Nursing can play a large role in easing this process for patients as well as their family members. The nurse may need to provide medication before the transfer such as anti-anxiety or pain medications.
Be transparent about the process and the schedule. If a patient is leaving an acute care facility for an LTC facility, arrangements may take a while to find the right facility and ensure all medications and follow-up appointments and care are set up. Setting up post-hospital care with insurance, Medicare, or Medicaid can also be a long, arduous, and frustrating process. Educate the patient and family about what is happening. Do not scare them but be realistic about how long the process can take. Acknowledge and validate their feelings. Provide active listening and be empathetic.
Assist the patient by packing all belongings and ensuring nothing is forgotten. Assist the patient with any needs or bodily functions before transfer. Do they want to bathe or brush their teeth? See if the family wants to bring the patient clothes. Does the patient want help getting dressed? Are there any hospital supplies that can be sent with the patient, such as dressing change supplies or extra hygiene products? These are small and considerate touches that can help ease the transition for the patient and their loved ones.
Patient Safety
Patient safety is of the upmost importance during the transfer process. Scenarios, such as medication errors, unassessed wounds, falls, or skin breakdown from incontinence, can occur if a proper and thorough report is not given to the admitting facility. Nurses must include all pertinent information when giving a hand-off report, and this includes educating the patient and family about the transfer process. The following questions, in addition to standard hand-off report, can ensure information regarding patient safety is considered:
- What is the patient’s mobility status?
- Is the patient continent?
- Are they confused? Are they sundowning?
- Has patient and family education been completed?
Cultural Context
Cultural Considerations Regarding Patient Safety
Some cultures are very uneasy about letting anyone care for their loved ones other than direct family members. Asian and South Asian cultures may tend to feel it is a familial and filial duty to care for elders when they are not well. Not to take on that responsibility may possibly be seen as disrespectful, which can conflict with some Western and American perspectives. It can be difficult to reconcile these traditions with the level of care a patient requires, especially if it is care that the family may not be able to handle due to language barriers or financial concerns.
One way to open the conversation in such a situation is to arrange a family meeting with a translator (if needed) and the primary doctor or surgeon that has cared for the patient. Emphasize that keeping the patient as safe and healthy as possible is the common priority of everyone there. The ultimate decision and outcome may not be ideal or what was expected but it is the healthcare provider’s role to use their medical knowledge to educate and guide as best as possible.
Patient Teaching
Patient teaching largely depends on where the patient is being transferred to, and what the level of care is going to be. For example, consider a patient who is being treated for esophageal cancer and is going to an assisted living facility with a new percutaneous endoscopic gastrostomy (PEG) tube, a type of feeding tube inserted into the patient’s abdomen that enables them to receive tube feedings instead of being fed orally. The patient and family have never seen or heard of anything like this before and they are terrified. Teach the patient and their family about this tube, describing how to care for the tube site and how to work the feeding pump. Educate the patient and family on how to know when the PEG tube is normal and when they should call for assistance. The nurse should also get case management and social work involved to ensure the patient will have all the necessary supplies at their next facility, and that the details of the patient’s insurance coverage is worked out.
Unfolding Case Study
Unfolding Case Study #2: Part 2
Refer back to Unfolding Case Study #2: Part 1 for a review on the patient data.
| Nursing Notes | 0830: Assessment 12-lead ECG performed, ST depression noted, cardiology team aware. 2 L oxygen via nasal cannula applied with improvement in shortness of breath noted. Left AC IV inserted, nitroglycerin infusing per protocol. Patient reports improvement in chest pain. |
| Lab Results | LDL cholesterol: 165 mg/dL (normal: < 100 mg/dL) Troponin: 23 ng/mL (normal: < 0.04 ng/mL) |
| Diagnostic Test Results | Chest x-ray: no acute findings |
| Provider’s Orders | 0833: New orders Transfer to cardiac unit for close observation. |