Table 2. Additional representative quotes by domain and theme (full table in online supplemental appendix 3).
| Domain | Theme | Representative quotes |
| Information exchange and communication in IHT(Domain 1) | Information exchanged is missing, inaccurate, untimely and/or extraneous(Theme 1.1) | ‘…when you're not seeing the patient, and you're not able to look in the chart and look through the records, it’s hard to even know what you're missing… which is part of what makes doing the [transfer request] calls so difficult.’ Interview 18, Physician |
| ‘…another issue is, we're not trained to [take transfer acceptance calls] at all, no one is formally trained to do this. So, you kind of learn on the fly, by trial and error.’ Interview 5, Physician | ||
| Information Fragmentation(Theme 1.2) | ‘… the packets are either just huge and burdensome or disorganized, or both. They're missing things that have been done [and] that just results in repetitive testing and care.’ Interview 29, APP | |
| ‘…a discharge summary is for me far and away the most valuable… like a good synthesis of their admission…. I think having a clear picture of why they came into the outside hospital, in the beginning - what was their initial complaint, their biggest problem, and then some kind of chronologic description of what treatments they've had already, just a brief timeline of what they've had done procedure-wise, is helpful.’ Interview 11, APP | ||
| Responsibilities During IHT(Domain 2) | Pressures on clinicians at time of IHT acceptance(Theme 2.1) | ‘I also think you're accepting some level of liability and more importantly, for me professionally, responsibility for another person. Because moving them from one place to another is not without potential harm, as is the case with any transition of care. And then, … [as the admitting] provider, it’s unpleasant and frustrating to have someone or their family who feels like something was promised to them, which they then don't receive. And they went through all of the hassle, including potentially now having to travel way farther to see their loved one.’ Interview 15, Physician |
| Uncertainty around who is responsible for IHT patients on arrival(Theme 2.2) | [When things go well], the first step is that the floor nursing staff and administrative staff know who to reach out to. That’s clear that they can notify us right away. I can pass it on right away. The nurses don't feel sort of scared in a timeframe where they don't have a provider contact or they don't have orders… I mean, I think that’s probably one of the most important things is that [the nurses] know who to call and how to do it quickly.’ Interview 25, APP | |
| Expectations Management During IHT(Domain 3) | Nursing expectations of hospital medicine clinicians(Theme 3.1) | ‘When nursing gets these patients, I think they have the assumption that the way that patient is going to show up is the same way a patient presents from the emergency room, which is usually some basic orders and things have already been done for the patient. They expect that stuff right away. And they expect you to know that patient, like you got sign out from an emergency room doctor and not that you just read some note and didn't think that patient was coming for three days. So, I think management of expectation there is really hard.’ Interview 21, Physician |
| Patient expectations of care at the accepting hospital(Theme 3.2) | ‘…I empathize with them [patients and families] a lot, because we're also stuck in the middle, right? Because they're on our service, but perhaps they’re being transferred for a procedure that I don't actually do. And I would gladly help them, but I also have to be respectful of the team that I'm consulting and be respectful of their reservations, but you're also stuck in the middle and your hands are tied a lot because you can't make consultants do things, but sometimes it feels like a pointless transfer if you're like why were they transferred if nobody’s going to do anything?’ Interview 27, APP | |
| ‘I guess when people get transferred they always think that they're going to come in and get all these studies. It’s always hard [when] they think something is going to happen, and it actually doesn't happen. Those are always really hard conversations to have. … it just puts you in a bad place because you also feel horrible.’ Interview 30, Physician | ||
| Unrealistic expectations of what can be achieved on a floor-level unit(Theme 3.3) | ‘Even if all the communication has been perfect, sometimes patient status changes, and it really creates a lot of risk to patients when they are transferred to floor status, and then immediately require escalation of care.’ Interview 7, Physician | |
| ‘Oftentimes there can be a good amount of time that elapses in between that conversation and actually having the patient show up on your door. And that may not be something that we have any control over, particularly if beds are tight. I think that delays from that initial communication can be a big problem. I think there’s probably a missed opportunity for EMS, when they're transporting a patient because they may have been with the patient for hours, they may have a good amount of information about their vitals, their pain medicine requirement, are they clinically worsening? I think that information may be communicated to the nurses, but it’s not. There are so many breaks in the information chain that we're potentially missing some clinically relevant changes that were observed by somebody, but we just don't have a way to get that information. And then all of a sudden we just have to respond to what we're seeing in the moment. I think that’s another missed opportunity to have providers meet outside hospital transfers at the bedside.’ Interview 25, APP |
IHTinterhospital transfer