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 (F2,78 equals 24.2; p less than .01) and for participant's experience with interhospital transfer (F sub 2,39 equals 4.63; p equals .02). Significant improvement in mean scores occurred between time 1 (7.55 plus minus 1.84) and time 2 (9.48 plus minus 1.47) (t41 equals minus 6.21; p less than .01). The improvement in selecting appropriate escorts was maintained at time 3 (mean score 9.86 plus minus 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.