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Delayed Transfers and the Dilemma They Pose for Physicians

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"Hi, is this Dr. Williams?” I asked the referring physician. “This is Neelaysh Vukkadala with otolaryngology. I heard you have a potential transfer patient." Interacting with the transfer system has been a new experience for me as an attending. In residency, my experience was limited to knowing that a patient was accepted by our service and would be coming at some point, but until they physically arrived at the hospital, they were out of sight and out of mind.

"Yes, thank you for calling back. This is a middle-aged patient with a history of diabetes who came in with a neck infection involving the parapharyngeal and retropharyngeal space. We consulted the otolaryngologist here but they don't feel comfortable draining the infection, so we're requesting to transfer for surgical management. We're treating them with IV antibiotics on the floor right now and they look reasonably stable." 

"OK, I'm happy to help. I just have to let you know that the hospital is extremely full and the wait for a bed can be several days. If there's anything your local surgeon can do to at least decompress the area, that would be very important to keep this from expanding."

As an attending, I am now much more familiar with the details of patients’ conditions. I have received calls from hospitalists or intensivists desperate to transfer a patient with a serious but still early-stage and treatable condition before they deteriorate further. Unfortunately, the transfer process largely functions on a first-come, first-served basis. Aside from a life and limb categorization, which emergently bumps a transfer to the front of the line, there is no triaging of transfer requests based on condition. And logistically speaking, it is difficult to implement such a model. Who would adjudicate whether a patient with posterior epistaxis should be prioritized over a patient with an upper GI bleed, or whether a patient with a deep-neck space infection needs to be transferred more urgently than a patient needing an extremity amputation?

A week later, the transfer patient finally arrived at our hospital, this time in the ICU. By this point, they had been intubated for airway protection. Despite broad spectrum antibiotics, they were continuing to spike fevers. The scans were a few days old so we repeated them. They showed extensive abscesses involving multiple deep-neck spaces and tracking toward the upper mediastinum. I took them urgently for transcervical incision and drainage and washout. There was infection everywhere in the neck. After widely opening up all the abscesses, I left multiple, large Penrose drains in place. 

I met the family in the waiting room after the surgery was done. The patient's spouse, sister, and two adult children had all driven in from four hours away, and they listened politely as I described what had happened and the next steps. I told them that the surgery had gone well, that the infection had been severe but that, if all went well, they should make a full recovery. 

After I was done sharing my update, the patient's son asked, "Could this have been prevented if they had surgery earlier? Should we have brought her to a different hospital?"

I demurred, offering some vague response about how the doctors at the other hospital were doing their best, and how I would be doing my utmost now that their family member was here. Monday morning quarterbacking is fun when it comes to football, but generally a poor habit when it comes to medicine. I do not know this other hospital's resources and staffing, nor do I know what the local ENT's skill and comfort level is. 

A day later, the patient was extubated, and a couple days after that, they were transferred to the floor. Aside from a prolonged hospital stay and the need for local wound care, they had an overall successful outcome and left the hospital without long-lasting sequelae. Yet there have been patients who are not so fortunate, for whom the delay in reaching appropriate care costs their life.  

As transfers get delayed day after day and, in a couple of instances, week after week, I often hear about a patient slowly decompensating at another hospital. It is distressing to be aware of suffering and yet largely powerless to act. Do I pull the life and death emergency card and bump these patients to the front of the line? What are the unintended consequences on other transfer patients? And if I choose not to bring them in sooner, what is my moral responsibility in whatever negative outcome they suffer?

At times, I have even considered advising the clinicians to discharge the patient so they can drive straight to our ED and get the appropriate care. In speaking to more senior colleagues, a couple have indeed actually provided this type of advice off the record. 

In a system where physicians are already overworked and our hospitals are already teeming with too many patients and too few beds and staff, it can seem overwhelming to consider the needs of patients who are far away. What is our obligation to patients who are outside the walls of our hospital?

How might the patient transfer system be improved? Share your thoughts in the comment section.

Dr. Neelaysh Vukkadala completed his residency in otolaryngology-head and neck surgery at Stanford University and is currently a laryngology fellow at UCLA. He is interested in medical ethics, quality improvement and teaching. He enjoys writing, hiking and landscape photography and can be found on Instagram at @picturesbynv. Dr. Vukkadala is a 2022-2023 Doximity Op-Med Fellow.

Illustration by April Brust

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