Optimizing Patient Flow and Growing Referring-Hospital Transfers

As a quaternary academic referral center, The Ohio State University Wexner Medical Center (OSUWMC) is heavily reliant on transfers from referring hospitals and experiences a high volume of such transfers, which comprise nearly one-quarter of admissions. Inpatient care is provided at two sites: the larger main campus and Ohio State University (OSU) East Hospital, which is staffed by OSU faculty and provides academic center expertise at a smaller, community-sized hospital five miles away. OSU East Hospital’s capacity is 200 beds (18% of the total system capacity), and it offers comprehensive services, though fewer than at the main campus. The Division of Hospital Medicine (DOHM) East services include a daily complement of 17 physicians across various shifts. OSUWMC faced capacity constraints, particularly at the main campus, where fiscal year 2024 occupancy averaged 92%. OSU East Hospital consistently had greater bed availability; however, its capacity remained underused, with fiscal year 2024 occupancy averaging 80%. This underutilization negatively affected the overall patient flow and DOHM East services.

Solution Overview

A similar hospital system has addressed capacity constraints by implementing a load balancing protocol that directs stable, lower acuity admissions from the quaternary academic hospital emergency department (ED) to nearby community hospitals.¹ OSUWMC has variably employed a similar approach; however, impact has been limited by the timely availability of transportation between campuses. Given that transfers from referring hospitals comprise a significant share of inpatient admissions at OSUWMC, focusing efforts on these patients offered considerable potential.

Process enhancements were needed to optimize overall system flow, maximize bed utilization at OSU East Hospital, improve timely access for patients (particularly from referring hospitals), and ensure steady staffing levels to justify the specialized academic care provided by OSU East Hospital’s DOHM services. There was recognition that clinicians had a bias toward transferring patients to the main campus despite the ability to safely receive care at OSU East Hospital due to a lack of recognition that this “community hospital” offered specialized care that could benefit patients transferred from community hospital partners. Key opportunities for improvement were identified, including inconsistent strategies for targeting OSU East Hospital for incoming transfers, the absence of an accessible, comprehensive clinical guideline to inform medical decision making for optimal patient placement, and a lack of engagement and accountability in triage decisions.

A work group was formed, comprising leaders representing the academic medical center, OSU East Hospital, and the medicine service line, several of whom were hospitalists. Through active discussion and collaboration, the team introduced three innovative solutions to address these challenges. These included creating a comprehensive OSU East Services Availability Guideline, establishing an “East-First” strategy to target transfers from referring hospitals, and implementing “Destination Decline” reasons to track those patients who were instead targeted to the main campus.

The OSU East Services Availability Guideline was developed as a priority, as it serves as a crucial tool for providing clinical guidance and facilitating effective triage decisions while ensuring safe patient care. Specific tracking of decline reasons was implemented to create increased accountability for making intentional triage decisions based on clinical factors rather than preference, and was felt to be necessary for change management. In line with the intention of focusing on clinical factors, it was decided that patient preference for the main campus would not be accommodated when the needed services were available at OSU East Hospital.

Implementation Process

Beginning in November 2024, the transfer center medical director and leadership revised standard operating procedures and educated transfer center nurses to prioritize OSU East Hospital for all non-cancer transfer requests. This directive was communicated through operations meetings, individual discussions between leadership and staff, and education sessions. Despite these efforts, an increase in transfers from referring hospitals was not observed, and it was determined that more extensive work would be required to achieve the desired outcome.

While examining opportunities surrounding the limited response, an internal transfer center document detailing OSU East Hospital services was evaluated and determined to be incomplete, lacking adequate clinical guidance to inform triage, not accessible to those outside the transfer center, and not able to support targeted, real-time updates when needed. Therefore, it was concluded that replacing this with the OSU East Services Availability Guideline would be essential to deliver the necessary clinical guidance for effective triage. To ensure strategic alignment, a kickoff meeting was held, bringing together patient flow, transfer center, OSU East Hospital, and DOHM East leadership, and establishing a dedicated work group. The meeting clarified objectives, facilitated operational planning, assigned responsibilities, and set timelines.

Figure 1. Example of OSU East Hospital Services Availability Guideline

Following this, work began on creating the guideline. OSU East Hospital leadership identified the respective leaders for each service area. In total, 44 physician leaders and staff contributed to and validated the content (see Figure 1 for an example of the guideline). Following final approvals, the guideline was published and distributed to all OSU East Hospital Medical Staff, published on an internal website for widespread accessibility, and presented directly to DOHM East physicians, ensuring awareness and enhancing transparency regarding service availability to inform DOHM practices. Transfer center nurses received extensive guidance and education on using the guideline to inform triage decisions, with support from triage physicians when needed.

Additionally, the transfer center introduced “Destination Decline” reason documentation within the electronic health record. This initiative aimed to improve accountability in triage decisions by transfer center nurses and facilitate analysis of the population of transfers deemed inappropriate for OSU East Hospital, thereby identifying future opportunities to expand care capacity. Five decline reasons were established to capture meaningful and actionable data: three based on triage decisions informed by using guideline information (“Consultant not available,” “Procedure/surgery not available,” and “Patient-specific factor”); “Provider discretion” for declines outside of the guideline scope; and “Bed capacity” for cases directed to the main campus due to limited progressive-care or intensive-care bed availability at that time.

Outcomes and Impact

The interventions were fully implemented in March 2025. Volumes of transfers from referring hospitals to OSU East Hospital were assessed monthly (see Figure 2). Comparing the eight months before intervention (July 2024 to February 2025) with the subsequent eight months (March 2025 to October 2025), transfers to OSU East Hospital rose from 980 to 1,248 (a 27.3% increase), with those to DOHM East services exhibiting an increase from 721 to 956 (32.3%). Notably, this post-intervention growth has been sustained with continued record-setting transfer volumes. In a year-to-date analysis of fiscal year 2026 compared to 2025, transfers to OSU East Hospital grew by 115 (22.9%), and those to DOHM East services increased by 113 (30.2%).

Figure 2. Monthly external transfer volume comparison with rolling averages

It was considered that increasing transfers from referring hospitals to OSU East Hospital could potentially lead to a rise in the subsequent need for transfers from OSU East Hospital to the main campus. While a modest increase was expected due to the larger volumes, it was determined that a substantial increase would be detrimental to patient flow and would not support the intended objectives. An analysis was conducted to determine the volume of patients who were initially transferred from a referring hospital to OSU East Hospital, then subsequently required a transfer to the main campus at any point during their stay. When comparing the eight months preceding the intervention to the eight months following implementation, such cases increased slightly from 108 to 112 (3.7%), a change that was not felt to be significant and may have been related to seasonal variables. A year-to-date analysis of fiscal year 2026 compared to 2025 showed a decrease of 20 cases (31.7%), which exceeded expectations.

Since monitoring began for OSU East Destination Decline reasons, the results have been as follows: “Consultant not available” accounted for 36.7%, “Patient-specific factor” for 25.6%, “Procedure/surgery not available” comprised 19.7%, “Provider discretion” represented 16.3%, and “Bed capacity” made up 1.8%.

Transfer center nurses have indicated that establishing a consistent “East-First” standard operating procedure, rather than activating this process only during periods of system capacity strain, facilitated its integration into their daily workflow. This approach shifted nurses’ perspectives from viewing OSU East Hospital as an option for select patients to considering it as a default destination for all patients until otherwise determined.

Given that transfer triage at OSUWMC is largely nurse-driven, the OSU East Services Availability Guideline provided more comprehensive guidance, enabling nurses to perform their roles more effectively and support increased patient transfers to OSU East Hospital. It also equipped them with resources for more informed discussions with physicians regarding triage decisions when needed and the tools to advocate for OSU East Hospital when appropriate. This has cultivated a sense of ownership and engagement among the transfer center nurses to maximally use system capacity, and the success achieved through these initiatives has been a significant source of pride for the team. Including Destination Decline reasons and regularly reviewing relevant group and individual data with each team member has promoted accountability.

Lessons Learned

This work provides valuable insights for hospital systems and hospitalist programs considering initiatives to address patient flow and capacity constraint challenges. One system has improved patient flow by balancing admissions from the emergency department.1 OSUWMC showcases a different approach, focusing on transfers from referring hospitals. This allows removal of patient preference from consideration, as we did not accommodate patient preference for the main campus when the needed services were available at OSU East Hospital. As transportation is already part of a hospital transfer, this represents a net-neutral transportation need compared to other models and does not require arranging or providing for transportation, which is coordinated by the referring hospital. This offers a significant advantage compared to other models for systems that face limited transportation options. A cumulative effect would likely be seen in systems able to employ both strategies.

Initial attempts to increase transfers to OSU East Hospital did not deliver positive results until broader collaboration and commitment were established. The most impactful intervention was the development of the OSU East Services Availability Guideline, which gave triage nurses the requisite guidance to inform triage decisions. The difference witnessed before and after publishing this guideline highlights its value, acknowledging that the effect is a cumulative effect of all interventions. By empowering nurses with the guidance needed, the initiative minimized the need for practitioner involvement in triage, freeing them up for direct patient care.

Ensuring the guideline was readily accessible and easily updatable was an additional key factor in our success. By posting the guideline on an internal site, we facilitated consistent access. This approach enabled the posting of revised versions in a centralized location, ensuring that all users consistently referenced the most current document. As a result, we have implemented multiple incremental updates informed by case reviews since the initial release.

Future Directions

As hospital services continue to evolve, these changes must be promptly reflected in the guidelines to ensure ongoing success and growth in transfer volumes. Incremental updates are regularly implemented as necessary, with a comprehensive annual review cadence planned with involvement from the leaders of each service.

With the available data that have been created with the implementation of the “OSU East Destination Decline” reasons, there is an opportunity to conduct more detailed clinical analyses of specific cases. This may yield actionable insights to further improve triage practices, boost service line engagement at OSU East Hospital, and identify ways to serve more patients by expanding available services and showcasing use cases for those services.

Although the transfer center has excelled overall and played a key role in the initiative’s success, some variability among frontline staff remains. During monthly performance reviews with staff, data related specifically to OSU East Hospital transfer performance is reviewed with each nurse, with the goal of elevating the performance of the entire group. This allows for assessments of further opportunities, goal setting, and implementation of educational strategies for those performing below expectations.

Revisiting a load balancing protocol for patients presenting to the main campus emergency department and admitting them to OSU East Hospital, using the experience of another hospital, is worthy of future exploration.1 Using the foundation created by the OSU East Services Availability Guideline would allow for optimal patient selection and is a crucial addition not previously available during attempts at this approach in the past. Unfortunately, historically limited transportation options remain a significant barrier and are largely outside of our control. 

Dr. Buettner

Dr. Rai

Mr. Tumberg

Dr. Buettner is the medical director of the transfer center and assistant professor of internal medicine at The Ohio State University Wexner Medical Center in Columbus, Ohio. Dr. Rai is the medical director of patient flow and assistant professor of internal medicine at The Ohio State University Wexner Medical Center in Columbus, Ohio. Mr. Tumberg is the director of patient flow operations at The Ohio State University Wexner Medical Center in Columbus, Ohio.

Reference

1. Carmichael HL, et al. Optimizing patient care and hospital operations through interhospital admission transfers: The load balancing protocol. J Hosp Med. 2026;21(5):585-589. doi:10.1002/jhm.70174.