Inter-hospital Transfer Decision-making During the COVID-19 Pandemic: a Qualitative Study

Abstract

Background

Inter-hospital patient transfers to hospitals with greater resource availability and expertise may improve clinical outcomes. However, there is little guidance regarding how patient transfer requests should be prioritized when hospital resources become scarce.

Objective

To understand the experiences of healthcare workers involved in the process of accepting inter-hospital patient transfers during a pandemic surge and determine factors impacting inter-hospital patient transfer decision-making.

Design

We conducted a qualitative study consisting of semi-structured interviews between October 2021 and February 2022.

Participants

Eligible participants were physicians, nurses, and non-clinician administrators involved in the process of accepting inter-hospital patient transfers. Participants were recruited using maximum variation sampling.

Approach

Semi-structured interviews were conducted with healthcare workers across Michigan.

Key Results

Twenty-one participants from 15 hospitals were interviewed (45.5% of eligible hospitals). About half (52.4%) of participants were physicians, 38.1% were nurses, and 9.5% were non-clinician administrators. Three domains of themes impacting patient transfer decision-making emerged: decision-maker, patient, and environmental factors. Decision-makers described a lack of guidance for transfer decision-making. Patient factors included severity of illness, predicted chance of survival, need for specialized care, and patient preferences for medical care. Decision-making occurred within the context of environmental factors including scarce resources at accepting and requesting hospitals, organizational changes to transfer processes, and alternatives to patient transfer including use of virtual care. Participants described substantial moral distress related to transfer triaging.

Conclusions

A lack of guidance in transfer processes may result in considerable variation in the patients who are accepted for inter-hospital transfer and in substantial moral distress among decision-makers involved in the transfer process. Our findings identify potential organizational changes to improve the inter-hospital transfer process and alleviate the moral distress experienced by decision-makers.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-023-08237-w.

INTRODUCTION

Inter-hospital patient transfers are essential to providing high-quality healthcare given variability in hospital resources and expertise^1,2. The COVID-19 pandemic has strained the U.S. healthcare system, at times leading to inadequate healthcare resources including insufficient bed availability and staffing shortages³. Strained healthcare settings may predispose patients to worse clinical outcomes, while transfer to hospitals with adequate capacity and resources may improve clinical outcomes^4,5. In the intensive care unit (ICU), increased patient acuity, a higher patient census, and a greater proportion of new admissions are associated with increased mortality⁶.

When all hospitals in a region are facing similar strain, it is unclear how healthcare workers should prioritize acceptance of transfers. Existing scarce resource allocation guidelines during the COVID-19 pandemic have not provided specific strategies to address this question, and the inter-hospital transfer decision-making acceptance process has not been previously characterized during times of severe resource strain^7–9.

To understand factors impacting inter-hospital patient transfer decision-making during a pandemic surge, we conducted a qualitative study consisting of interviews with hospital workers responsible for such decisions about their experiences. We theorized that decision-making would be impacted by factors including capacity strain and patient characteristics within the context of the COVID-19 pandemic.

METHODS

Using applied thematic analysis, which is an inductive, positivist approach, we conducted semi-structured interviews by telephone and computer-based video communication with physicians, nurses, and non-clinician administrators involved in the process of accepting or declining inter-hospital patient transfers¹⁰. We followed the Standards for Reporting Qualitative Research (SRQR) guidelines¹¹. The study design was approved by the institutional review board of the University of Michigan Medical School (IRBMED HUM00204085).

Sample

Eligible participants were physicians, nurses, and non-clinician administrators actively involved in their hospital’s transfer process triaging patient transfer requests. Participants were recruited from hospitals with Level I/II trauma center designation as they provide specialized medical care and would be expected to regularly accept inter-hospital transfers¹². Participants triaged transfer requests for all types of adult patients including general care, critical care, and trauma care. Patient transfers could be requested for any reason, including capacity constraints at requesting hospitals or family-initiated requests. We utilized maximum variation sampling to include hospitals serving geographically and socioeconomically diverse patient populations, recruiting participants who made transfer decisions at those hospitals¹³. To recruit participants, we called all eligible hospitals and requested to speak with the individual or department overseeing patient transfers on that day. Once connected, we ensured that the individual was directly involved in accepting patients transfers. Interviewers did not have existing relationships with participants. Participants were recruited between October 2021 and February 2022, during the peak of hospitalizations in Michigan for COVID-19 infection to date¹⁴.

Semi-structured Interviews

A semi-structured interview guide was created with input from team members with backgrounds in medicine, ethics, and public health and was informed by resource allocation literature emerging during the COVID-19 pandemic (see Supplemental Appendix for complete interview guide)⁸. The interview guide aimed to elicit the experiences of healthcare workers who triage inter-hospital patient transfers and to understand how patient transfer decisions were made during a time when hospital resources were very scarce. We pretested the guide with a non-participating healthcare worker with extensive involvement in triaging patient transfers to ensure that it would gather a wide range of experiences related to the transfer acceptance process¹⁵.

Interviews were conducted by two investigators (E.A.H. and E.M.). After conducting initial interviews jointly to ensure consistency, subsequent interviews were conducted by one investigator. Interviews were audio-recorded, transcribed, de-identified, and uploaded to Dedoose for qualitative analysis.¹⁶ Hospital characteristics were described using the American Hospital Association Annual Survey¹⁷. To determine if hospital characteristics of participants differed significantly from characteristics of non-participating hospitals, descriptive statistical analysis was performed using X² and t tests in Stata Version 17¹⁸. A P value of less than 0.05 was considered significant.

Analysis

Interviews were analyzed using thematic analysis¹⁹. E.A.H. has a background in medicine and bioethics. E.M. has a background in medicine and public health. J.F. has expertise in qualitative analysis and bioethics. A.G.S. has a background in medicine, scarce resource allocation, and bioethics. Each interview was coded independently by at least two investigators (E.A.H., E.M., J.F.), with differences in coding resolved by consensus. The research team (E.A.H., E.M., J.F., A.G.S.) met regularly and practiced reflexivity, defined as the process of evaluating how our prior experiences and beliefs could potentially influence analysis²⁰. Thematic coding was used to create a codebook, which was finalized based on analysis of the initial thirteen interviews¹⁹. The codebook was iteratively refined during regular meetings between the investigators as interviews were analyzed. Previously coded interviews were recoded after codebook revisions. After coding was completed, the research team met to refine themes into major domains. Constant comparative analysis was used to compare interview themes across the different groups of healthcare professionals²¹. Given the exploratory nature of this study and rich data gathered during the interviews, twenty-one interviews encompassing participants with various healthcare professional roles were sufficient to achieve information-rich yet manageable interviews, develop robust themes, and address the research question^19,22. For further immersion in the data, brief memos of interviewer reflections on each interview were written by two researchers and discussed by the research team after interviews were completed. Major domains of themes were mapped onto an existing organizational framework of ICU triage, as intensive care resources are an existing example of scarce healthcare resources often requiring triage²³. In this framework, the most important factors impacting ICU triage are organized into patient, physician, and environmental factors. For ICU triage, key patient factors include severity and reversibility of illness, prognosis, patient wishes, age, functional status, and comorbidities. Physician factors included amount of experience, and the major environmental factor was bed availability.

RESULTS

Semi-structured interviews were conducted with twenty-one individuals (Table 1). Participants were predominantly male (65.0%) with a mean age of 51.0 years (standard deviation 10.4 years). Participants were involved in the process of accepting or declining inter-hospital patient transfers at fifteen hospitals, representing 45.5% of the 33 eligible hospitals contacted to participate in the state (Table 2). Twenty percent of participating hospitals are in rural areas, defined by the 2019 American Hospital Association Annual Survey¹⁷. A third (33.3%) serve a patient population consisting of greater than 20% Medicaid-insured patients.

Table 1.

Characteristics of Decision-makers Involved in Inter-hospital Transfer Decision-making

Characteristics*	Participants (n = 21)
Age (mean, SD)	51.0 (10.4)
Male, no. (%)	13 (65.0)
Race/ethnicity, no. (%)*
White	18 (90.0)
Black	2 (10.0)
Profession, no. (%)
Physician	11 (52.4)
Nurse	8 (38.1)
Non-clinician administrator	2 (9.5)

^*One participant declined to provide age, gender, and race/ethnicity information

^**Demographics are similar to the state of Michigan²⁴

Table 2.

Characteristics of Michigan Level I and Level II Trauma Center Hospitals by Participant Inclusion Using 2019 American Hospital Association Data

Hospital characteristics*	Participating	Non-participating	P value†
N (%)	15 (46.9)	17 (53.1)
Hospital beds, no. (%)			0.73
< 400	7 (46.7)	9 (52.9)
≧400	8 (53.3)	8 (47.1)
ICU beds, no. (%)			0.61
< 30	4 (26.7)	6 (35.3)
≧30	11 (73.3)	11 (64.7)
Location, no. (%)			0.06
Rural	3 (20.0)	0 (0.0)
Urban	12 (80.0)	17 (100.0)
Rural referral center, no. (%)	4 (26.7)	6 (35.3)	0.60
Teaching hospital status			0.13
No residents	1 (6.67)	1 (5.9)
Minor teaching program	9 (60.0)	15 (88.2)
Major teaching program	5 (33.33)	1 (5.9)
Hospital ownership, no. (%)			0.36
Private	1 (6.7)	2 (11.8)
Non-profit	13 (86.7)	15 (88.2)
Government	1 (6.7)	0 (0.0)
Medicaid patients served			0.45
< 20% of admissions	10 (66.7)	9 (52.9)
≧20% of admissions	5 (33.3)	8 (47.1)

^*1 non-responding hospital did not participate in the AHA database. There are 33 Level I/II trauma center hospitals in the state of Michigan according to the Michigan Hospital Association. Diversity within the state of Michigan in many ways is a microcosm of the nation²⁵

^†A P value of less than 0.05 is considered significant

We identified three domains of factors impacting transfer decision-making: decision-maker factors, patient factors, and environmental factors (Fig. 1). Domains were organized based on an existing framework of ICU admission triage²³. We compared our findings to this existing ICU triage framework and expanded upon the framework to describe the impact of triage on the decision-maker. Participants described substantial moral distress related to the decision-making process, defined as the experience of wanting to do what one believes to be right but being constrained from doing so²⁶.

Fig. 1.

Patient transfer decision-making framework.

Decision-maker Factors

Decision-maker Professional Background

Eleven participants were physicians primarily responsible for making final transfer acceptance decisions based on patient factors. Physician participants were from Emergency Medicine, Critical Care Medicine, and Internal Medicine/Hospital Medicine. About half (45.5%) of physicians held administrative roles to oversee transfer acceptances as part of a multidisciplinary team and more commonly considered hospital capacity when making decisions. Nurses working on transfer teams communicated with other healthcare workers requesting to transfer patients and were involved in information-gathering, initial triaging, and coordinating transfers. For example, nurses were involved in declining transfers due to limited capacity and discouraging family-initiated transfers. Non-clinician administrators were involved in overseeing teams managing transfer intake and collaborated with physicians to make final decisions. Many participants noted a switch in their usual roles during the pandemic. New responsibilities included dedicated transfer triage roles as opposed to having transfer triage responsibilities along with clinical care duties.

Lack of Guidance for Transfer Decision-making

Participants were not aware of any guidelines outside their institution or system for how to approach transfers. As one participant remarked, “if something was out there that would help guide us in how to best approach transfer process in a pandemic…I think that information would be crucial to the success of providing patients with quality healthcare” (participant (P) 11). Decision-makers sought support from their colleagues. A participant described how they would “talk with [their] partners in the office…talk with our managers…and sometimes our hospitalist team is super amazing because you’ll call them and say, ‘Help me out here. Let’s talk about these two cases. What do you see or what do you think?’” (P6). Another participant discussing their hospital’s future plans for developing guidelines and creating an interdisciplinary team to make transfer decisions remarked: “…just people feeling more comfortable about the decisions that are made, ‘cause that’s hard for the supervisors right now, to make that decision on their own” (P5). Participants were unaware of any state, national, or professional recommendations for the transfer triage process and often sought support from colleagues.

Patient Factors

Patient Preferences for Medical Care

Patient preferences to avoid escalation of medical care such as intubation and mechanical ventilation impacted transfer decisions. One participant recalled how patient preferences factored into their decision to decline a patient transfer request: “We’ve had a couple of patients that were do not resuscitate, do not intubate…well, there’s no reason for us to move that person. Just be supportive care [sic] and hopefully they’ll get better at that location” (P8).

Severity of Illness

Transfer requests for more severely ill patients were prioritized over patients with less severe illness. One participant described how their hospital was a “safety net for a lot of small rural hospitals to send their sickest patients…we’re picking and choosing the sickest of the bunch to come in” (P20). Patients with a higher severity of illness were more likely to be accepted for transfer.

Predicted Chance of Survival

Decision-making was often based on the expected chance of patient survival with escalated medical care. Patients estimated to have a higher likelihood of survival based on age or comorbidities were prioritized for transfer. For example, a participant described how “we might have 10 [hospitals] that are calling to transfer a patient for possible ECMO for COVID…how do we decide?…We decide, based on data, we know younger patients do better. So the younger you are, the more likely you are to come in”. (P1). Another participant explained: “If you have a 500 pound patient with very bad diabetes, unvaccinated, lymphedema, coronary artery disease, CKD [chronic kidney disease], versus having a 26 year old, no past medical history, who has just single organ failure on the ventilator…you want to choose that person that has the highest chance of surviving…I’m gonna choose the 26 year old patient based on the fact that most likely this is the person that will make it” (P19). Participants considered a patient’s likelihood of survival with continued medical care when triaging patient transfer requests.

Need for Specialized Medical Care

Patients who required specialty care were prioritized for transfer. Participants described acceptance of patients requiring specific medical interventions including acute stroke management, trauma services, extracorporeal membrane oxygenation (ECMO), and interventional cardiology services. For example, a participant described how their hospital had multiple “hospitals that routinely send [them] their stroke patients for a thrombectomy, and so they were always sort of a high priority for us…keeping a critical care bed open that could ensure that we served those patients, was definitely important” (P13). Patients requiring specialized medical intervention were preferentially accepted for transfer.

Interaction of Patient Factors

Most commonly, individuals described that an identified need for specialty care and patient severity of illness took precedence over other patient factors when triaging transfers. Assessing likelihood of survival frequently often arose in the context of transfer for ECMO consideration. When specific patient preferences including those to forego resuscitation were known, they appeared to impact decisions more broadly and carried more weight than other factors. We did not find explicit examples of healthcare insurance or other financial concerns impacting transfer acceptance at the level of the decision-maker. Additionally, patient and family requests for transfer did not often influence transfer decision-making. One participant commented that they were “filtering out the family requests and the patient requests…because those are just a request, it’s not a clinical picture if they need to be transferred” (P3).

Environmental Factors

Impact of Scarcity on Transfer Acceptance

Patient transfer decisions were made within the context of environmental factors at the decision-maker’s hospital. All participants described capacity strain at their hospital impacting transfer acceptance at the time of the interview. For example, one participant noted how “the volume [of transfer requests] is much higher now, and I think that’s specifically ‘cause every hospital is full, pretty much across the state of Michigan, so it’s hard to find beds, so even our ICU and Critical Care Units are pretty much at capacity every day now, and actually our hospital system has been pretty much at or over capacity every single day” (P4). Scarce medical resources at participants’ hospitals frequently prevented patient transfers. Participants cited a lack of nurses; one explained how “there have been times where we have physical beds, but there’s not the nursing professionals available to care for the patients who would be laying (sic) on those beds” (P21). Lack of ward and intensive care unit space, as well as a shortage of ECMO circuits, also precluded transfers. As one participant questioned, “six or seven institutions [are] calling daily about an ECMO bed, and then one opens up, how do we make that decision of who gets that circuit potentially?” (P16). Scarce medical resources impacting patient transfer acceptance included clinical staff, hospital space, and medical equipment.

Restructuring of Transfer Process

Most participants described changes to the transfer process related to the increased frequency of transfer requests during the pandemic. Some hospital networks created centralized transfer centers while others developed new transfer center roles, such as a dedicated “physician triage officer to make clinical [transfer] decisions” (P15). Hospital workers sometimes described using a multi-disciplinary approach. One participant explained their role as a “triage officer, like adding that additional voice, along with the receiving provider and the transfer center nurse, the hope is that I’m alleviating some of the moral distress they face, just because I’m really coming more at it from a capacity piece” (P16). Increased transfer requests also prompted the development of hospital-specific clinical criteria to inform triage decisions. One decision-maker explained how they would not accept patients for transfer with COVID-19 infection unless they exceeded a certain oxygen requirement threshold. They shared, “we were setting just sort of a generic oxygen requirement” as a prerequisite for transfer (P17).

Participants employed different strategies to support hospitals requesting patient transfers when transfers were not feasible. Hospital systems increased use of virtual support at community regional hospitals to provide advice when patient transfers were not feasible. For example, one participant described how their hospital assisted another hospital with managing a stroke remotely through the hospital’s “telestroke and tele-neurology program” (P20). Another described how their hospital’s tele-ICU facilitated triage of transfers: “we do a ton of telephone and peer-to-peer support …rather than transferring the patient to the main center ICU, we’ve been able to expand our ICU capacity in our smaller hospitals by providing a virtual ICU coverage” (P16).

Characteristics of Requesting Hospitals

Factors outside the receiving hospital affected transfer decision-making, including requesting hospital specialty care availability, capacity, and hospital affiliation. For example, transfers were prioritized from hospitals with limited specialty care with one participant explaining “our teams really bend over backward because we recognize a resource…one bed for us is a lot different than one bed for those smaller facilities” (P8). Hospitals requesting transfer due to capacity constraints were variably considered, as one participant described “one [reason for transfer] would be technical expertise or procedural expertise, the other one was pure staffing shortages…or [the requesting hospital’s] bed availability” (P7). Transfers from affiliated hospitals were highly prioritized. One participant remarked, “we have had to remain relatively closed to non-affiliated hospitals” (P10).

Moral Distress

Decision-makers frequently described considerable moral distress associated with the burden of choosing which patients to accept from a long list of transfer requests. When faced with the decision to choose between two critically ill patients, one participant asked, “how do you decide between two young healthy women? It’s just impossible, it’s impossible. It’s just impossible” (P1). Another described how to approach multiple extracorporeal membrane oxygenation (ECMO) transfers, explaining “this is a moral dilemma…how do you decide which ECMO patient you take?” (P2). Participants described frustration and exhaustion related to transfer decision-making. As one participant said, “it’s exhausting. It’s extremely stressful. I’ve…never experienced anything quite like this, frustrating, all of those things” (P18). Eighteen participants (85.7%) described the experience of moral distress associated with transfer decision-making.

Declining all transfers when hospital capacity was limited was a source of moral distress described by participants. One participant recalled that declining transfers was “frustrating…because it’s an uncomfortable and sort of new situation to not be able to help [other hospitals]” (P21). Another recalled, “I don’t want anybody to ever think that any of us don’t want to do what’s right for all of the patients, ‘cause we really do…We wanna do what’s right, but we know that inside these four walls, people are struggling as well” (P5). One healthcare worker described being unable to accept a severely ill patient “like a car crash in slow motion,” proceeding to explain “to know that one of your colleagues is in distress and their patient’s in distress, and all you can do is try to use what you have available to try and change their situation for them, and sometimes you literally can’t do anything” (P17).

Comparing Triage Frameworks

Multiple factors impacting inter-hospital transfer decision-making were similar to those considered during ICU triage. Participants identified severity of illness, patient treatment limitations, and expected prognosis as key patient factors impacting transfer decision-making. These factors are also considered when making ICU triage decisions. However, key differences were identified between transfer decision-making about all adult patients during this pandemic surge and the existing ICU triage model in the context of severe resource strain. For example, environmental factors were considered less important than patient factors in the ICU triage framework, whereas resource constraints for both requesting and receiving hospitals were much more salient among our participants. While bed availability was the major environmental constraint identified in both ICU triage and transfer decision-making, our participants additionally noted staff shortages and medical equipment shortages (such as ECMO circuits). Lastly, participants described substantial moral distress related to decision-making. The emotional impact of decision-making is not described in the ICU triage framework.

DISCUSSION

Hospital workers involved in accepting inter-hospital patient transfers during a pandemic surge described specific decision-maker, patient, and environmental factors impacting decision-making and experienced considerable moral distress. Factors impacting decision-making were aligned with previously described utilitarian principles for scarce resource allocation during the COVID-19 pandemic: maximizing benefits for patients by prioritizing transfers of the sickest patients who could benefit from hospital resources⁸. Transfer decision-making had some similarities to an existing framework characterizing how intensivists triage patients to receive care in the ICU, a clinical scenario requiring allocation of scarce medical resources²³. Our findings expand on this framework by describing the considerable impact of triaging a scarce medical resource on the decision-maker as an individual.

Prior investigations of the inter-hospital transfer process have primarily explored the process of transferring patients, patient outcomes, and patient and provider experiences, demonstrating potentially improved outcomes for patients but possible harms including limiting family support^27–31. Additionally, previous inter-hospital transfer studies have focused on hospitals transferring patients out, describing challenges including the burden of finding an accepting hospital and improvement in the process with protocolization of care ³². However, previous work has not explored the process of transfer decision-making, particularly under conditions of extreme hospital capacity strain when patient transfer decisions become a form of scarce resource allocation. Our results build on this understanding by describing factors impacting decision-making, and by understanding how this process affects decision-makers.

Decision-makers experienced substantial moral distress. Moral distress has been similarly described by healthcare workers caring for patients in resource-constrained settings during the COVID-19 pandemic^33,34. Moral distress among healthcare workers has been associated with burnout, adverse psychological symptoms, and avoidance of professional roles where moral distress may be more likely to occur^35,36. It is possible that moral distress leading to burnout could impact transfer decision-making and clinical care, as burnout has been associated with cognitive effects including attention deficits and potentially errors³⁷. While our work does not directly measure the impact of moral distress on decision-making, future work in this area is needed to further explore the effects of moral distress in scarce medical resource allocation.

Decision-makers cited a lack of guidance regarding how to approach the patient transfer process during the pandemic. This is consistent with prior work demonstrating that healthcare workers often do not feel prepared to make clinical decisions in the context of scarce resource allocation, and are often expected to implicitly ration scarce resources^38–41. We are unaware of any cohesive resource specifically designed to assist or inform interhospital transfer requests, either before or during the COVID-19 pandemic, adding credence to the concerns raised by those interviewed. Implicit rationing at the individual level in the context of having limited guidance or training in scarce resource allocation introduces the potential for bias and also may help to explain the moral distress expressed by healthcare workers in our study⁴⁰. Medical comorbidities guided transfer decision-making and are known to disproportionately impact racial and ethnic minority groups, thereby increasing the possibility of bias in decision-making⁴². Additionally, while participants did not specifically discuss financial reasons for transfer acceptance, participants frequently accepted patients from affiliated hospitals, which could be seen as financially motivated at a system level. Even as COVID-19 hospitalizations decreased in recent months, ongoing capacity crises among adult and now pediatric hospitals underscore the need for improvement in transfer triaging^43–45. Therefore, there is a critical need to identify how the decision-making process can be improved and to implement these changes.

Participants sought decision-making support from other inter-disciplinary team members, either as part of a structured team or informally from colleagues. The concept of decision-making within a group of stakeholders to reach a consensus has been proposed as a solution to manage scarce healthcare resource allocation and may be a potential strategy to reduce the individual burden of decision-making in this situation^38,46. Creation of teams focused on managing inter-hospital transfers at the hospital or multi-hospital system level could reduce the moral distress experienced by sole decision-makers and potentially improve the efficiency of the transfer process.

Additional strategies to improve the process of inter-hospital decision-making might include formalized, but flexible, guidelines building on prior pandemic preparedness work^47–49. Guidelines may help clinicians navigate complex resource allocation decisions, and mitigate bias, even moral distress⁵⁰.There may also be a role for increasing training for healthcare workers involved in the transfer triage process to gain a better understanding of the ethical principles, logistical challenges, and clinical assumptions underlying the triage process³⁸.

Our study should be interpreted within its scope and context. Participants were limited to hospitals within Michigan, and experiences may differ geographically. Additionally, because our study was designed to understand experiences at the level of the individual decision-maker, we are unable to describe the process of inter-hospital transfers on an organizational or system-wide level. Finally, our interviews were conducted during the largest surge of COVID-19 hospitalizations in Michigan to date, resulting in limited hospital capacity across the state¹⁴. Further research during ongoing times of varying degrees of resource strain would provide meaningful comparisons.

CONCLUSION

We describe factors impacting inter-hospital patient transfer decision-making, expanding on an existing framework of allocating scarce medical resources by describing the considerable impact of triaging a scarce medical resource on the decision-maker. A lack of guidance in transfer decision-making may result in substantial moral distress among hospital workers involved in the transfer process. Developing a multidisciplinary structured approach to triaging hospital transfers and building resources to inform and support these processes may alleviate the individual burden of decision-making and ensure a more equitable process.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution

Drs. Shuman and Harlan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Shuman, Harlan, Goold

Acquisition, analysis, or interpretation of data: Harlan, Mubarak, Firn, Shuman

Drafting of the manuscript: Harlan, Firn, Shuman

Critical revision of the manuscript for important intellectual content: Harlan, Mubarak, Firn, Goold, Shuman

Statistical analysis: Harlan

Obtained funding: Shuman

Funding

This study was funded by an intramural grant through the Center for Bioethics and Social Sciences in Medicine at the University of Michigan.

Declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Disclaimer

The funding source played no role in the design, conduct, or analysis of this study. The authors have no conflicts of interests to disclose.