This article is written by Director of Clinical Operations for Regent Surgical Health Kathy Bernicky, RN, BSN. Hospital transfers/admissions can result in unplanned cost to the center, patient, and payers. The need for patient transfers from an ASC is an unanticipated outcome and can many times be avoided by having clear processes in place.
The Quality Collaboration definition for transfers includes:
Admission: completion of registration upon entry into the facility.
Hospital transfer/admission: any transfer/admission from an ASC directly to an acute care hospital including hospital emergency room.
Discharge: occurs when the patient leaves the confines of the ASC.
Below are six steps you can take to avoid patient transfers from your facility.
1. Implement an efficient prescreening process. Prescreen all patients to ensure they can be safely cared for at the ASC. Prescreening should include reviewing the type of procedure that is planned, the patient's current medical condition and their history to determine if they are an appropriate candidate for the ASC.
You should begin the prescreening process at least four to seven days prior to the procedure. This gives you time to request additional testing when needed. It also gives the patient the information/education they need earlier so they know what to expect and can make arrangements for their ride and home care. If the patient is a poor historian, additional time will be needed to speak to family members. It's important to pay close attention to the elderly. They can have multiple comorbidities and are often fragile.
It's usually helpful to have a designated prescreening nurse for continuity and accountability. This person must be knowledgeable and have critical thinking skills. An RN is a good fit in this position as they will need to know when there is a potential risk and can take initiative to follow up with additional testing, screening or discussing with the anesthesiologist. The prescreening nurse must be detail oriented and organized. This is a key position in the ASC.
2. Review the medical record. The anesthesia provider should review each medical record at least two days prior to the date of service and work closely with the prescreening RN. It's important that the anesthesiologist also has time to gather additional information for testing as necessary. If there are any concerns have the patient come in for a prescreening exam by the anesthesiologist. These added steps can prevent cancellations the day of surgery.
3. Deal with language barriers. Non-English speaking patients will need the assistance of an interpreter/family member for the pre-screening interview and an interpreter service the day of surgery. There are very reputable and reliable companies that will charge you a monthly fee or a fee per use depending on how often you need to use them.
4. Be prepared for unexpected outcomes. An asthma attack, allergic reaction, or anxiety attack are examples of situations that can be handled safely at the ASC if the staff are trained and have the equipment and medications needed easily available. By being prepared and having a strong clinical staff, a transfer may be avoided.
5. Investigate and learn from each transfer event. All transfers should be reviewed closely. This is part of the QA/PI process. When trends are identified, look at the screening process to identify possible areas of improvement. One example would be having the prescreening RN work later into the evening when finding it difficult to reach patients during the day. Many patients work and it's easier to reach them later in the day when they’re at home and have time to talk.
6. Benchmark your center against others. ASCA provides ASC benchmarks that can be beneficial for identifying potential performance improvement areas. The Q4 2012 benchmark from ASCA was one patient transfer per 1,000 patients. Internal benchmarking is also important and helpful. At Regent we benchmark this and other areas for performance improvement against all of our centers.
Keep in mind that not all patient transfers are the result of care at the ASC. Sometimes patients come in with an abnormal heart rhythm, develop chest pain or have abnormal lab results the day of service, resulting in the need to transfer or admit them to a hospital for further evaluation and care. However, implementing these steps will help you to take control and prevent as many transfers as possible.
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