Interhospital transfers: Decision-making in critical care areas

Objectives: To evaluate the training of clinical staff in the use of interhospital transfer guidelines and to examine the underlying decision making behavior in organizing patient transfers between hospitals. Design: Prospective assessment of clinical scenarios, given before (time 1), immediately after (time 2), and 3 months after (time 3) a program informing clinical staff about the use of interhospital transfer guidelines. Setting: Three emergency departments and one intensive care unit at three hospitals and a medical retrieval service in Sydney, Australia. Subjects: Physicians, nurses, and a paramedic working in critical care areas and at a medical retrieval service. Interventions: Fifteen minutes of training in the use of interhospital transfer guidelines, conducted by a trained nurse. Measurements and Main results: A questionnaire containing clinical scenarios was administered to clinical staff. There was a significant difference in mean scores for selecting the appropriate escort levels across time (F-2,F-70 = 24.2; p <.01) and for participant's experience with interhospital transfer (F-2,F-30 = 4.63; p =.02). Significant improvement in mean scores occurred between time 1 (7.55 +/- 1.84) and time 2 (9.48 +/- 1.47) (t(41) = -6.21; p<.01). The improvement in selecting appropriate escorts was maintained at time 3 (mean score 9.86 +/- 2.01). The error rate for inappropriate assignment of low levels of escorts decreased from 35% (time 1) to 10% (time 2) and 14% (time 3). Using conjoint analysis, there were large variations in the decision making behavior between each time period. The relative importance of each factor in influencing the decision to organize an escort at time 3 were as follows: treatment (43%); physiology (29%); patient age (24%); and diagnosis (4%). The decision-making model observed at time 3 had a high predictive value (87%) as compared with the model at time 1 (48%). Conclusion: Clinical staff can make informed and appropriate decisions by using standardized guidelines when organizing interhospital transfers.