Table 3.

Examples of facilitators* and barriers at the intersection of transfer categories and organisational factors

	Disposition	Preparation	Communication	Notification	Coordination
Protocol Development, Dissemination, Application	When a speciality service attending refuses a patient in the ED, the issue is usually not escalated to the leadership on duty, despite protocols dictating this process. Rather, the patient is often transferred to general medicine, as it represents the path of least resistance.	There is disagreement among providers about whether a care checklist in the EMR is a sufficient closure process to use before transferring patients.	A written, nonverbal nursing handoff tool was built into the EMR. Staff identified challenges with the new tool but were discouraged from addressing any concerns that would re-examine the decision to use verbal or nonverbal handoffs.	Each service line has a unique workflow for alerting the sending and receiving units about a bed assignment. Bed management must keep track of and apply these differing protocols when notifying teams about specific patient populations. The variations can be confusing and may contribute to mistakes.	The protocols for transfer timing are not aligned to ensure common understanding across departments: bed managers hold off on physician assignment as long as possible to try and balance the patient load among service lines, while the hospitalist providers request earlier assignment to help prepare for patient care.
Robust Technology	The admission order has fields that highlight specific patient needs, like isolation and telemetry. When the order is fully completed, the bed manager can assign the patient to the right unit the first time.	If the treatment team fills out the care complete checklist too early, patients may be transferred before the preparation process is complete. Patients can miss their last doses of medication or may not have their vital signs checked before leaving the unit.	The transfer summary is buried three to four pages into the daily nursing note. Those preceding pages are automatically populated by the EMR and contain information of varying utility.	Consistent notification is hampered by the range of devices in use, including a single admissions pager, individual cell phones, and automatic alerts within the EMR.	The nurse expediter can use the care complete checklist in the EMR to determine when patients can be transferred, which facilitates patient flow.
Culture of Teamwork	Residents and interns rotate through different departments, which gives them an understanding about which types of patients are appropriate for each unit.	The receiving team has an understanding of the patients they will receive because the medical director participates in interdisciplinary rounds on the sending unit.	Each hospital team views the patient through a different framework, whether it be trauma care, general medicine, and speciality services. Recognising and reconciling these differences is an enormous concern for providers.	Unit clerks from sending units call bed management to share pertinent information that may not be included in the admission order.	There is an erroneous belief that sending staff wait until change of shift to transfer patients to delay receipt of new patients. This perception fuels tension between departments.
Capacity	When MICU census is high, the least sick patient is transferred to General Medicine to free up a bed for a more critically ill patient.	The patient is transferred to an appropriate location that has the supplies and equipment needed for care. These can include isolation rooms for patients on contact precautions or bariatric beds and lifts for obese patients.	Transfer reports from residents often require more time and effort from receiving providers, as the residents have less experience and are still learning how to present cases and triage patient care.	Late or missed notifications about General Medicine patients boarding in the ED can lead to delays in care.	There are more admissions on the evening shift, which is also when there are fewer staff scheduled and less resources available to those staff.
Hospital Priorities	The hospital has prioritised reducing length of stay in the ED, by giving ED the authority to book a patient to general medicine without approval, leaving general medicine providers unable to question admissions or patient dispositions.	Sending teams focus on triaging patients and managing acute crises; these priorities are often in conflict with receiving teams’ emphasis on a deeper understanding of patient needs, and their desire for more diagnostic work in preparation for the transfer to the floor.	The hospital has eliminated many verbal handoffs to increase efficiency and improve patient flow. Nonverbal handoffs, which are completed through the EMR, often impede questioning from receiving teams.	Geographic localisation of staff is prioritised over continuity of care. Patients transferred to other units for speciality services or brief escalations of care are often returned to different general medicine floors.	Patient transport is coordinated through prompts from sending units. Receiving teams can be assigned multiple admissions at the same time, which increases the risk of safety events.

*Facilitators are in bold.