Barriers Impacting Rapid Access to Tertiary Care for Time Sensitive Critically Ill Patients

Saturday, 26 July 2014: 9:10 AM

Scott M. Newton, RN, MHA, EMT-P
Lifeline Critical Care Transport Program, Johns Hopkins Hospital & Johns Hopkins University School of Nursing, Baltimore, MD


Interhospital transfer of critically ill patients between community hospitals and tertiary care centers are common within the United States. Medicare data from 2005, identifies an interfacility critical care transfer volume of 47,820 (Iwashyna et al, 2009). Approximately 4.5% of all critical care patient admissions to community hospitals experiences an interhospital critical care transfer. The process for interhopsital transfers is not optimized for favorable patient outcomes and is a significant problem to be addressed (Bosk, Vienot and Iwashyna, 2011).

Rapid access to tertiary care is paramount to the patient experiencing a time sensitive critical condition. Time sensitive critical conditions include acute ST-segment elevation myocardial infarction (STEMI) of which 30-50% are transferred to tertiary care (Iwashyna, 2012), acute stroke, major traumatic injury, non-traumatic surgical emergencies (such as intracranial hemorrhage, aortic dissection, neurovascular compromise, ruptured heart valve, etc.), and pediatric critical care (specialty expertise and skill at the tertiary care center). Delays in tertiary care may contribute to increased morbidity and mortality, a decrease in care system efficiency and effectiveness, an increase in costs of providing care, and a decrease in revenues for the tertiary care center (Ligtenberg et al, 2005).

The Problem

Barriers to tertiary care exist at the community hospital and the tertiary care center. Community hospital barriers include recognizing the need for tertiary care, regional knowledge of tertiary care resources, and sending provider’s willingness or ability to present a case for transfer. Barriers existing at the tertiary care center depend upon the efficiency of the patient transfer request process (Warren et al, 2004). The patient transfer request process includes an initial telephone answering point, the ability to quickly contact on-call specialty care providers, availability of an appropriate specialty care bed, awareness of and access to bed availability information and a way to emergently transport patients by critical care transport teams (ambulance, helicopter or airplane). Practice is variable at referring community hospitals when making the decision to transfer a patient and tertiary care access is variable in the ability to receive a patient resulting in delays (Bosk, Veinot and Iwashyna, 2011).

Variables and Factors

Several variables contribute to the problem. Recognizing the need to transfer a patient with a critical diagnosis by the community hospital provider, may prevent efforts to initiate transfer early in the patient encounter. Community hospitals care team knowledge of available tertiary care resources and proximity to a tertiary care center. Existing bed capacity at the tertiary care center; without an available bed to receive the patient, the transfer cannot occur. The availability of an accepting specialty care provider at the tertiary care center; this is the provider who assumes care of the patient once they arrive. Availability of appropriate medical transport; this is the clinical team that will safely and quickly transport the patient between the sending community hospital and receiving tertiary care center. The correct specialty care nurse staffing; this is the nursing team that will care for the patient once they arrive to the tertiary care center.  The efficiency of the patient referral process; the degree to which the telephone answering point is adequately equipped to quickly contact on-call specialty providers, interface with bed control for determining specialty bed availability, and to mobilize critical care transport teams impact overall access to tertiary care (Missouri Department of Health, 2010; Bosk, Veinot and Iwashyna, 2011).

Clinical Context

The community hospital setting typically involves the emergency department or the critical care unit. Staff involved includes emergency or critical care providers, nurses, ancillary (respiratory, laboratory, radiology, pharmacy, etc.) and support staff (clerical, housekeeping, central supply, etc.). The skill sets of these community hospital clinical providers may be exceeded by the needs of the patient that requires tertiary care. A time sensitive critical condition patient draws resources away from other patients and dilutes the overall capacity to deliver care for all the patients within the community hospital (Bosk, Veinot and Iwashyna, 2011).

At the tertiary care center the setting includes the telephone answering point where the request for transfer is received, the specialty care unit where the patient will be admitted and any interventional areas such as the cardiac catheterization laboratory or the operating room. Staff at the tertiary care center involved includes the specialty care providers, critical care nurses, ancillary staff, support staff and the critical care transport team (nurse, paramedic, emergency medical technician). Administrative or clinical operations staff is responsible for facilitating communications between the community hospital and tertiary care center care teams, confirming placement of the patient in the correct patient care unit bed, and arranging the logistics of transport (Iwashyna, Christie, Moody, Khan, and Asch, 2009).

Patients and Family Affected

Barriers impact patients and families who are experiencing a critical illness. Time sensitive critical conditions such as acute STEMI, acute stroke and trauma have increased morbidity and mortality when time to tertiary care intervention is delayed (Jacobs et al, 2006). For example, the odds of receiving tertiary intervention for acute stroke is decreased by 2.5% for every minute of time of onset until arriving to definitive care at a tertiary care center when thrombolytics are not available or the community hospital care providers are unable or unwilling to administer the thrombolytics (Prabhakaran et al, 2011). Patient transfer delays result in patients being cared for longer at the community hospital without tertiary care, which may lead to a worsening of their clinical condition. This may result in extended, reduced patient mobility and autonomy, increased dependence on family support for daily living, increased costs of post-acute care (such as physical rehabilitation, chronic ventilator dependency, etc.) and lack of employability due to a prolonged recovery, residual physical or cognitive impairment and potential need for adaptive job skills retraining (Bosk, Veinot and Iwashyna, 2011).

Impact on Communities and Care Systems

            Barriers to tertiary care result in reduced care system efficiency by reducing patient throughput. At the community hospital increased length of stay leads to decreased capacity to deliver care to the community because the patients are waiting to be transferred, consuming limited community resources (DeLia, 2007). Community hospitals have increased burdens to care for patients that exceed the resources available (such as nurses with specialty knowledge and skills). Critical condition patients also draw resources away from other patients, because patient acuity and instability requires community hospital staff to continuously care for the patient while waiting for transfer to a tertiary care center (Iwashyna, 2012).

At the tertiary care center, diagnostic procedures performed at the community hospital are often repeated upon the patient’s arrival due to issues such as variable image quality, conflicting diagnostic results or lack of clinical details from the community hospital (Jacobs et al, 2006). Repeated diagnostic procedures add cost and are generally not reimbursed by health insurance resulting in higher financial responsibility for the patient or tertiary care center. These issues contribute to the tertiary care center’s reputation, and increase the risk of it becoming damaged among community hospital providers, patients and families. A tertiary care center with a damaged reputation receives less patient referrals in the future, captures less of the market share in a region and has missed opportunities for revenue and growth (Iwashyna, 2012).

Impact on Society

            Society’s access to the healthcare system is decreased when access barriers to tertiary care exist. Patients, who would benefit from early intervention at a tertiary care center may become more ill, suffer complications and require more health care spending when access is delayed (Westfall et al, 2008). Tertiary care access barriers result in increased use of critical care resources at a higher cost (mechanical ventilation, vasopressors, invasive pressure monitoring) and increase the potential for complications such as hospital acquired infections, skin breakdown and prolonged mechanical ventilator use. These complications lead to an increased cost to society and persisting disabilities reduce the patients’ contribution to society through shorter and less healthy lives (Entenssoro et al, 2005).


            Patients who experience a time sensitive critical condition require rapid access to tertiary care. A consistent, barrier free process is important to the community hospitals, as they often do not have the capability to provide or sustain definitive care for time sensitive critical condition patients. Any barrier variable may cause a referring community hospital provider to abandon the process and keep the patient in the community hospital, or seek tertiary care services at an alternative or competing tertiary care system, that is less preferred or further away (Iwashyna et al, 2009). With the advent of health care reform in the United States, barriers impacting rapid access to tertiary care are a problem that is timely and relevant to the clinical, operational and financial performance of tertiary care centers and regional care systems.