Rethinking Rapid Discharge


A national study of trauma patients transferred from one hospital to another (J Trauma. 2010;69:602-606) has found significant rates of "secondary overtriage," which happens when the patient is discharged home less than a day after the transfer without undergoing a surgical procedure.

Such rapid discharge suggests that the transfer might not have been necessary in the first place, says lead author Hayley Osen, BA, research analyst at the University of California-San Diego Center for Surgical Systems and Public Health. The occurrence of secondary overtriage, which can cost nearly $6,000 ($12,000 for transfer by helicopter), was found to be higher among patients under 18 years of age (19.5%, versus 6.9% overall).

Hospitalists can be at both ends of these transfers, which often are between small or rural hospitals and regional medical centers. They can also play important roles in preventing unnecessary transfers, says Cleo Hardin, MD, SFHM, FAAP, section chief for pediatric hospital medicine and outreach at the University of Arizona in Tucson.

"Phone triage is absolutely vital as a first-line approach," Dr. Hardin says. Telemedicine links and teleradiology, the electronic transmission of X-rays for review by a specialist at the regional center, also help with the triage and management of patients at the referring institution, she adds.

Building good working relationships between the two facilities, establishing rapport between key connections, and knowing the resources within each facility can help, says Monika Gottlieb, MD, SFHM, who just left her job at Hospitalist Specialists in Spokane, Wash., to start a new position. "In these cases, a lot depends on understanding the capacity of the local facility, including nurses," she says.

It might be possible to establish mentorships with key specialists at regional centers, with mechanisms for how to reach them, Dr. Gottlieb explains, but hospitalists need to take responsibility for completing successful transfers and handoffs.

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