In residency, we had derisive nicknames for the hospitals in the surrounding rural areas that would frequently send us patients. After we were notified of the transfer, we stayed on edge until the patient arrived, unclear of what was going to show up. At best they were sending us a difficult patient who was going to require a great deal of work; occasionally, as we paged through the photocopied progress notes and labs, we expressed more and more righteous indignation at the decisions that were made that I as a cocky intern never would have done. In the end, it tended to leave us feeling like we were just a dumping ground for the outside hospital’s mistakes.

Now I’m the physician working in these areas. The memory of those nicknames drives me to do everything I possibly can to help my patients, but in the back of my mind is the knowledge that there are situations beyond my capabilities that require transfer. I understand that few hospitalists have worked in a truly rural setting and don’t understand the challenges this represents. It’s also easy to become myopic and forget the huge shifts that have occurred in the relationship between rural hospitals and larger referral centers over the past few years.

Rural counties in the U.S. suffer from multiple challenges that make caring for patients more difficult. There are roughly one-third of the total doctors and one-fifth of the specialists per capita to provide care in rural areas compared to urban ones. On top of this, the rate of smoking is higher, and the average patient is older and has a lower per-capita income.¹ These socioeconomic factors and the dearth of resources make transfers to tertiary care centers for consultation or procedures outside of the regular skill set of a hospitalist more likely.

Working in a critical access hospital is a different world from a tertiary care center or even a standard hospital in an urban setting. A critical access hospital is limited to 25 beds that are divided among the available service lines. Usually, that means I’m the only hospitalist on service and have a single general surgeon and orthopedic surgeon to help me deal with holes that need to be made or closed (usually with certified registered nurse anesthetist, rather than anesthesiologist support during those procedures). I have unfettered access to a CT scan and ultrasound but can’t get an MRI or echo on the weekends and my interventional radiology coverage is much more random than that. I can’t do dialysis, and all drips and vent-setting decisions are made by me (a geriatrician). In the before times this meant I got to care for relatively sick patients (our intensive care unit usually equated to a larger hospital’s intermediate care) with no pressure to consult unnecessarily, but could reach out to those smarter than me when I recognized I was in over my head. I had the time to get to know my patients and ensure they understood what I was doing, why I was doing it, and whether this was in line with their wishes.

The COVID-19 pandemic dramatically expanded what was “possible” at these smaller hospitals. In Wisconsin, we missed the initial wave that New York and Seattle experienced, but in early 2020 the number of COVID-19 pneumonia patients requiring bilevel positive airway pressure or intubation continued to rise. At first, it was a matter of keeping the high-flow and bilevel-positive-airway-pressure patients in the intensive care unit, hoping they would improve, and transferring them once they needed intubation. Within a week or two we could no longer transfer these patients despite calling upwards of 30 hospitals across multiple states. This left us to manage multiple vented patients with a respiratory-therapist crew that was never staffed to handle this.

With a bit of hand-holding from some amazing pulmonologists and a lot of reading, we managed some remarkable recoveries, but most patients did not recover. As the incidence of COVID-19 cases declined we hoped we would return to the old way of caring for patients who are just sick enough for our care, and be able to hand off the patients who needed a cardiologist to perform a coronary catheterization, or a gastroenterologist to perform an endoscopic retrograde cholangiopancreatography; but now these are the patients waiting in our hospital beds while we provide the best care we can while not being able actually treat the admitting diagnosis. This has become the new norm and is unlikely to change anytime soon.

There are two main types of patients we try to transfer to a larger center. The first is a patient who has declined despite our aggressive care; the second is if a reversible disease state requires a procedure that is unavailable at our facility. In either case, these patients arrived at the hospital appropriate for that setting but are now unable to be adequately cared for without a higher level of care. Despite my independent streak, I recognize my limitations, and when this situation presents itself, I’ve found a few methods that improve the chances of getting my patient transferred to receive the care they need on an expedited basis. These are not based on randomized studies or a large survey, just my experience getting thrown into the deep end and somehow keeping my head above water for the past three years:

1. Be very nice to the triage nurse or staff. They are doing their best and are never the person keeping your patient out of their hospital. They can also give you amazing tips, such as when discharges tend to occur, giving you the best time to call requesting one of their very rare beds.

2. Be realistic about which patients actually need to be transferred. I’ve found that I can perform a thorough workup for some pretty rare diagnoses when I have the help of a willing subspecialist to guide me. Consult with them early, and ask them which tests they would like drawn so you can at least start the workup. At the very worst you have the person’s attention, at best you’re starting the process that would have had to wait until the patient got transferred.

Regardless of the information provided, I never quote the physician I discussed the case with, as these conversations exist outside of a direct relationship with the patient, and I recognize that it is MY decision to perform these tests.

3. Maintain contact but recognize that frequent calls can lead to overuse of their triage service and keep you away from your patients.

4. Understand that larger institutions are also overfull and struggle to deal with their patients. Because of this, the truly sick will trump a lack of ability to perform a procedure that is not imminently lifesaving. Explore transfers for procedures alone (returning after the procedure is complete) or exchange your critically ill patient for one waiting for placement to a skilled nursing facility or an assisted living facility.

5. Work with your emergency department colleagues to define diagnoses that are beyond the care of your team, so these conversations can be started with the patient before your involvement begins. We’ve also tried to make the transfer process as efficient as possible with daily checks on beds available in surrounding hospital systems, a list of numbers for those access centers, defining a responsible person to reach out to those systems, and a note documenting which were reached out to, and what the response was.

6. Most importantly, be brutally honest. Soft-selling how sick the patient is might get them to the other hospital, but now those clinicians need to provide a higher level of care than they expected. Alternatively expounding endlessly on how sick the patient is only for them to find this patient didn’t need to be transferred will rapidly erode any goodwill you had and make future transfers more difficult.

Another issue that might be unknown to our city-mouse colleagues is the fact that a fair number of the patients who need to be transferred and have been placed on a waitlist, end up being admitted to our hospitalist services in the interim. This situation guarantees that I’m caring for a patient who requires something I cannot provide. It’s hard to describe the helplessness you feel walking into a patient’s room to tell them that while their troponin is still rising, you still don’t have a bed to send them to. In this situation please be considerate of our limitations. I can’t get a QuantiFERON TB gold test, so please don’t expect me to have IR-guided drainage occur on the weekend. If a lumbar puncture is indicated or a central line is necessary, we will get it done; but most other invasive procedures are the reason the patient is being transferred in the first place. I am thrilled to work alongside your team to begin any workup you recommend or to adjust my drip or vent settings per your preference, but obviously, I need to know what these are for me to carry them out. As always, communication is key here, and access to direct phone numbers, saving me the 20 minutes to contact you through your access team, would be very much appreciated.

I love the independence that comes with working in a rural setting and believe this is a core trait of those who choose to work in this setting. I don’t want to transfer patients unless I have to, and most patients want to stay as close to home as possible so family and friends can visit without the intimidation of having to drive in a metro area. I relocated to a rural practice once I realized that practicing here let me make the biggest difference I could to a group of people who needed it the most. I’ve worked hard to provide the same level of care for my patients that would be available anywhere else in the country. When I do call and request assistance, please be patient with me, and remember that I am simply trying to do the best thing I can for my patients. Hopefully, I will do a good enough job to avoid a snarky nickname for my hospital. 

Dr. Menet

Dr. Menet is the chief hospitalist officer at Beam Healthcare in Madison, Wis.

Reference

1. Hing E, Hsiao CJ. State variability in supply of office-based primary care providers: United States, 2012. NCHS Data Brief. 2014;(151):1-8.