They say opportunity knocks, but at BWH it rings.
Until recently, that ringing came from phones in the Emergency Department (ED) and Admitting when a regional hospital called with a patient transfer for the Brigham’s ED or inpatient units. Missing the call meant losing the opportunity to care for another patient.
As transfer volumes at BWH have grown in recent years, so too has the need for a more efficient, centralized system to manage these calls and ensure more patients can receive care across Brigham Health. To address this, the Brigham Health Access Center launched April 1 so that referrals could be managed efficiently from a single location. Its goal is to facilitate timely, high-quality and safe patient transfers in just one phone call.
Based in Admitting, a team of Access Center nurses and transfer access coordinators triage transfer requests from referring hospitals from all over Massachusetts. The center’s staff ensures patients are sent to the most appropriate location for care, whether that is the BWH or BWFH ED, or an inpatient unit or outpatient clinic at either hospital.
“By having a knowledgeable, experienced and caring staff dedicated solely to transfers 24 hours a day, seven days a week, we are enabling more patients to access the high-quality care that Brigham Health is known for,” said Eric Goralnick, MD, MS, medical director of the Brigham Health Access Center and Emergency Preparedness.
Previously, personnel in the ED and Admitting operated independently from each other. For example, ED flow managers handled requests for transfers to the Brigham’s ED, but that model posed challenges. Primarily, flow managers had limited real-time insight into bed availability across the institution.
“Our goal is to provide a seamless process for our referring facilities and physicians to get easy access to Brigham Health. A centralized approach really simplifies the process for our care partners in the local community and beyond,” said Sheila Harris, executive director of the Brigham Health Access Center and Patient Access Services.
Previously, handling transfer requests was just one of many duties for the ED flow manager on a given shift. If he or she was on another call or had stepped away from the phone when a hospital called with a transfer, the delay might prompt the caller to hang up and try another facility.
In addition to having staff continuously available to take transfers, the Access Center is working on identifying ways to improve the transfer experience. All calls to the center are recorded, and surveys are sent to referring providers to gather feedback. In the future, the team hopes to incorporate telemedicine as another mechanism for more effectively triaging patients and improving access.
“This is a phenomenal opportunity to ensure that patients are transferred to us efficiently and smoothly,” said Ali Salim, MD, chief of the Division of Trauma, Burns and Critical Care. “It will undoubtedly benefit our patients and our community care partners.”
The Access Center was borne out of the Patients First Committee, a multidisciplinary group formed in late 2015 with the goal of identifying and addressing the obstacles in the transfer process. The committee, spearheaded by Ron M. Walls, executive vice president and chief operating officer of Brigham Health, consists of administrative and clinical representatives from Admitting, Emergency Medicine, Nursing, Process Improvement and other clinical departments and divisions.
Mitchel Harris, MD, chief of the Orthopaedic Trauma Service and chair of the committee, said having a multidisciplinary team has been “essential” to the group’s success.
“Unless you have everybody sitting in a room, you can’t recognize that everybody has a different perception of the problem,” he said. “Once each person sees the problem is not unique to them, then we get more engagement from the committee and the various clinical services.”
Determining Appropriateness of Care
While the committee’s immediate goals were to develop a more efficient transfer process – with the aim of improving the Brigham’s transfer acceptance rate – its members found another area for improvement as they studied the issues. It became clear during committee discussions that Brigham Health as a whole would benefit if protocols were established to better assess the appropriateness of where in BWH or BWFH a patient is transferred.
Inappropriate patient transfers can have a cascading effect on resource availability and the cost of care, explained Harris.
It can start when someone suffers a bad fall at home, he said. The person goes to the ED at a nearby community hospital, where doctors conclude the patient’s shoulder injury requires surgery. But the physicians there also recognize they don’t have the resources necessary to perform the surgery.
That’s when the phone rings in the Brigham’s Access Center with a request for a transfer. After the request is accepted, the patient arrives and is evaluated. “Yes, it’s a bad injury,” a physician in the BWH Orthopaedic Trauma Service may tell the patient, “and you will require surgery, but not emergency surgery.”
In fact, doctors might determine they could best serve the patient by treating the acute injury and pain in the local ED, and then arranging a follow-up appointment in one of the outpatient clinics within Brigham Health, Harris explained. In addition to the fact that the injury may not require urgent care, it might also be too swollen to operate on safely, or a nonsurgical treatment might be a preferable option, he said.
The Access Center team is working to develop the protocols to properly triage cases like this in order to improve affordability and free up beds for patients who require more urgent tertiary and quaternary care. Additionally, patients will experience fewer instances of redundant care. That is, rather than having patients be seen in two EDs, they might, when appropriate, be transferred directly from a community hospital ED to a Brigham Health inpatient unit.
“The ED is often perceived as the welcoming center, and when you have that mentality, you can’t accommodate everybody. There are too many patients and a limited amount of resources,” said Harris. “We want to take care of every single patient who wants to be part of our system, and in order to do that, we need to make sure that the patients who don’t necessarily need a higher level of resources at that time are treated outside the ED in an appropriate fashion.”