The Transfer Game

If my hospitalist isn’t comfortable keeping the patient or we have no beds or no nurses available to care for them, I start calling larger hospitals that are closest to mine. The main campus of the same health system as my hospital is about an hour away and has essentially all the specialties I could need. They can handle nearly any complicated medical or trauma patient. However, they’re across a state line, which sometimes creates additional challenges.

The other major hospital system is also about an hour away, but in a different direction. They have a main campus as well as several smaller hospitals that are still considerably larger than mine. Those facilities are located in pretty much every direction from my hospital, most of them 1–2 hours away.

The transfer game begins when I call a central hub that fields all incoming transfer requests for that health system. It’s usually a phone tree. For truly time-sensitive or critical cases—unstable trauma, STEMIs, strokes, or patients who are actively dying—I press “#1” to jump to the front of the line. Other options include transferring stable patients directly to an inpatient unit, referring them to the receiving ER, or routing behavioral health patients.

There’s also usually an option to speak with a consultant or specialist about a patient who doesn’t actually need to be transferred. I use this for conditions I don’t see often, to confirm that my treatment plan is appropriate, to ask about any important nuances or recommendations before discharge, or to help arrange more timely follow-up.

I’m not an idiot, but I also don’t know everything. After nearly 20 years in medicine, I have a solid handle on treating a wide range of conditions. But I’m probably even better at recognizing what I don’t know—and more importantly, when I don’t know something. That’s when I call a specialist. Ideally, the specialist understands and respects my situation, and we have a polite, productive conversation about the patient. I adjust my plan accordingly, update the patient, and ideally get them seen in clinic relatively soon.

Occasionally, though, the specialist is unhelpful, condescending, or outright rude. Thankfully, this is the exception rather than the rule. Specialists are paid to be on call. Being rude or dismissive to someone who needs your expertise is unacceptable. Your opinion about what the caller “should” be able to handle is irrelevant. They’re in the position they’re in, with the knowledge and resources they have, and they’ve called you for help. Answer the phone. Be polite.

Back to the transfer game: once I get a live person on the line, I explain that I need to transfer a patient. We discuss the details—demographics, presenting complaint, current condition and vital signs, pertinent past medical history, and why I believe the patient needs transfer and to what level of care. This person usually stays on the line and helps connect me with the appropriate providers, filling in details or setting up conference calls with specialists as needed.

Wait—I skipped a step. If the hospital is on divert (meaning they’re not accepting any patients), that usually comes up early in the conversation so we don’t waste time on a lengthy discussion that leads nowhere. My only real option is to call back later and check again. The hospital won’t call me when they come off divert; it’s my responsibility to keep checking. That’s the phone game.

Sometimes a hospital is on divert but will put my patient on a waiting list. If a bed opens up—because someone is discharged, dies, or is transferred to a higher or lower level of care—my patient might get it. In those cases, we still go through the details, and the operator may connect me with a hospitalist so I can give sign-out. (I use “operator” for simplicity; it’s usually a nurse or someone with medical training who understands the transfer process, not just a basic call director.) This can be helpful if a bed opens while that same hospitalist is still on duty. Other times it isn’t—by the time a bed becomes available, that hospitalist may be off shift, and I have to give sign-out all over again.

This game has changed dramatically in the post-COVID era. Before the pandemic, I was often on the receiving end of these calls from all over the state. Working at a Level 1 trauma center and county hospital that also served as a tertiary care center, we accepted essentially everything. I took pride in how quickly I could accept patients. The sicker the patient, the faster I said yes. I could hear the urgency in the caller’s voice and the chaos of a frantic ER in the background. Some providers wanted to give me every detail—labs, imaging, the works. Most of the time I’d cut them off and simply say, “Send ’em.” That provider had better things to do than try to convince me to take the patient.

As a senior night doctor I greatly respect once taught me: it didn’t matter why the transferring provider needed to send the patient. They were in over their head—whether because of knowledge, resources, equipment, staffing, or even work ethic. Their call meant they could no longer safely care for the patient. The best thing for the patient was to get them to a place where they could be properly cared for. That place was us.

COVID didn’t break the healthcare system—it simply exposed its dysfunction. Bed and nurse shortages have persisted long after COVID largely disappeared. As I write this in mid-2023, it’s more common to find hospitals on divert than open to accepting transfers.

I haven’t yet mentioned the other major player in this game: the patient. After I tell the patient they need admission, the next conversation is about what that actually looks like. I usually give them a condensed version of the transfer game. Their input matters. Most patients are happy to be admitted to the hospital attached to the ER they came to—it’s convenient, after all. But things can shift quickly once I explain that we don’t have the resources to admit them here. Patients start weighing their options.

Some refuse transfer altogether. That may sound unreasonable to people with strong family support or good social networks, but EMS transport is generally a one-way trip. Spending a few nights in a hospital a couple of hours away might seem fine—until it’s time to get home. Not everyone has the means or support to manage that.

I’ve had patients flatly refuse to cross state lines because their insurance once refused to pay for transportation home after a previous out-of-state admission. I’ve had patients refuse a particular health system or hospital because of a bad prior experience. I’ve had patients insist I call one specific hospital and no others. And I’ve had patients simply refuse to be transferred at all—some demand to go home, while others who aren’t safe for discharge end up boarding in my ER. I sign them out at shift change with no disposition in place.

I always give patients my best recommendation—the same one I would give my own parents, siblings, partner, or children—and I explain it to them in those terms. What they ultimately decide is up to them. If they have decision-making capacity, they’re free to choose. I don’t force anyone.

Finally, there’s EMS. Patients are almost always transferred by ambulance (though family or friends occasionally drive them). Even after I have an accepting hospital and hospitalist, I’m often stuck in another holding pattern. Most operators won’t let me call EMS until a specific bed is assigned and confirmed clean and ready. (You’d be amazed how often a dirty room is the final bottleneck in patient care.)

Once I get that final confirmation, I call dispatch for an ambulance. As you might expect, there aren’t fleets of ambulances sitting idle at my hospital waiting for transfer calls. Depending on the EMS system, both BLS and ALS units are busy running 911 calls.

If the transfer game were just one conversation with each player, I wouldn’t call it a game—it would just be the normal workflow. Instead, it involves multiple back-and-forth conversations with everyone involved. It usually looks something like this (conversations abbreviated for clarity):

Me: You need to be admitted. I’ll talk to the hospitalist about keeping you here.

Patient: Okay.

(Keep in mind we’re only focusing on the admit/transfer part here. In reality, this conversation is often much longer, includes family members, and frequently drifts into speculation about the future—despite the fact that I can’t control other people or predict outcomes.)

Me: I have a patient who needs admission.

Hospitalist: Okay, I’ll review the chart and get back to you.

Me: I have a patient who needs admission.

Charge nurse: I’ll check on beds and call you back.

(Time passes—sometimes minutes, sometimes hours.)

Hospitalist: I think this patient needs a higher level of care.

Me: Okay. (after further discussion—the hospitalist holds the trump card)

or

Charge nurse: We don’t have any beds.

Me: Okay. (after further discussion—the charge nurse holds the trump card)

Me: We need to transfer you to another hospital.

Patient: Okay, wherever is fine.

Patient: Okay, but not across the state line.

Patient: Okay, but only to Hospital X.

Patient: Okay, but let me talk to my family first.

Patient: Okay, but not Hospital X.

(Patient: No, I’ll just go home.)

Me: Okay, I’ll start calling.

Let’s assume the patient is generally agreeable but has a ranked list of preferences based on distance, family proximity, or where their spouse feels comfortable driving. So I begin calling…

Me: Hi, this is Dr. Nystrom at Hospital A. I need a med/surg bed for a patient with…

Operator X: We’re on divert, but I can put you on the waitlist. Let me get some information.

Me: Sir, you’re on the waitlist at Hospital X. We can wait, or what’s your next choice?

Patient: Hospital Y.

Me: Hi, this is Dr. Nystrom. I need a med/surg bed for…

Operator Y: We’re on divert at all our facilities. Sorry—you can try back later.

Me: Sir, Hospital Y is on divert. What’s your next choice?

Patient: Hospital Z.

Me: Hi, this is Dr. Nystrom. I need a med/surg bed for…

Operator Z: Okay, let me get some details and connect you with a hospitalist.

(Time passes—usually less than an hour.)

Operator Z: Dr. Nystrom, I have Hospitalist Z on the line.

Hospitalist Z: Hello, this is Dr. Z. Go ahead and tell me about your patient.

Me: Thanks for calling back. This is a patient with…

Hospitalist Z: Sounds good. I’ll accept the patient.

Operator Z: Dr. Nystrom, we’ll call you back once we have a room number and bed assignment so we can take nurse-to-nurse report. Then you can arrange EMS transport.

(More time passes—minutes to hours.)

Operator Z: Dr. Nystrom, we have a bed for you. You can call EMS now.

Me: Dispatch, this is Dr. Nystrom. I need an ambulance to transfer a patient to Hospital Z.

Dispatch: I’ll page it out and call you back.

(Time passes—minutes to hours.)

Dispatch: Dr. Nystrom, Ambulance A can take your patient if they can find a backup crew.

(Even more time passes.)

Dispatch: Dr. Nystrom, the next crew gets off in two hours and is willing to stay late to do the transfer. Is that okay?

Me: Sure. (What choice do I have?)

Me: Sir, an ambulance will be here in about two hours to take you to Hospital Z.

Operator X: Dr. Nystrom, your patient was on our waitlist and a bed just opened up.

Now what? Hospital X is closer to the patient’s home, which would make things much easier for the family, and it was his preferred choice. But Hospital Z already accepted the patient and has a bed ready. EMS is being arranged for Hospital Z. Do I stand up Hospitalist Z? It’s like dating two people at once and getting caught—bad for everyone. I have an EMS crew committed in two hours, but if Hospital X doesn’t assign a bed by then, I’m gambling I’ll find another crew later.

And to make it even more fun, treat it like a choose-your-own-adventure story. Go back and change any answer—pick a different hospital, have the patient change their mind halfway through, make the wait times longer (they’re never shorter), have dispatch say no ambulance is available until tomorrow morning, or assume the helicopters aren’t flying because of weather. It’s an endless puzzle.

If you think that was painful, try living it every single day as part of your job.