Original Title: État des connaissances - Modèles de coordination des transferts interhospitaliers en soins critiques

Authors' objectives: Interfacility transfers allow for patients in need of urgent care to be transported to another hospital to receive medical services that are otherwise unavailable at the initial healthcare facility. Intensive care overcrowding, the labor shortage, the challenges associated with hospital bed planning, the difficulties in access to specialized care for people residing in remote areas, as well as population ageing, are all contributing drivers to the rising demand for interhospital transfers (IHT) [Mitchell et al., 2022; Walton and Mohr, 2022; Valley and Noritomi, 2020; Seymour and Kahn, 2017]. In order to improve hospital-wide patient flows and ensure the quality of emergency care, the use of a coordination centre, which manages IHT requests from and towards multiple hospitals, seemed to be a viable option to better control patient throughput and warrant that resource allocation prioritizes the sickest [Ahlin et al., 2023]. As such, in 2018, the Centre d’optimisation des flux réseau (COFR) of the Centre hospitalier de l’Université de Montréal (CHUM) was mandated by the Ministère de la Santé et des Services sociaux (MSSS) with the task of developing the Centre d'optimisation - Occupation des lits de soins intensifs (COOLSI) to ensure the optimal coordination of intensive care unit (ICU) beds. COOLSI’s purpose to coordinate medical advice requests and intensive care patient transfers. This objective consists of three specific goals: promote patient access to the appropriate level of intensive care, ensure the optimal use of the healthcare network resources and facilitate communication between all stakeholders involved in patient transfers. At the moment, COOLSI is tasked with the coordination of inter-hospital ICU transfers across 111 hospitals1 in Quebec. As part of an IHT process optimization initiative in Québec, the MSSS has asked the Institut national d'excellence en santé et en services sociaux (INESSS) to report on the current organizational practices implemented in existing coordination centres across Canada and abroad.

Authors' results and conclusions: RESULTS: The gathered data have enabled the identification of 16 IHT coordination centres: 4 in Canada and 12 abroad. Seven coordination centres responded to the questionnaire, of which all were in Canada. (#1 TARGET POPULATION OF COORDINATION CENTRES ): In Canada and abroad, IHT requests pertain to the adult and pediatric populations, mainly in critical and acute care. • In Quebec, COOLSI coordinates transfers to intensive care. • The pandemic has led several facilities to broaden their clientele to include COVID-19 patients. Other coordination centres have been established specifically for the case management of those patients. (#2 MANAGEMENT APPROACHES IN COORDINATION CENTERS): Direct comparison of management practices identified among coordination centres is difficult. • In Ontario and Quebec, IHT management is centralized (i.e., managed by a single provincial coordination centre). In Alberta and British Columbia, in view of their geography, IHT management is subdivided between the northern and southern parts instead. • Overseas, this variety of management practices (i.e., regionalized and/or centralized) has also been observed according to territorial divisions and the existing healthcare system. • Coordination centres’ may be structurally dependent or independent of a hospital. In Quebec, the COOLSI is attached to the CHUM, whereas other Canadian coordination centres are stand alone.(#3 SERVICES OFFERED IN COORDINATION CENTRES): In Canada and abroad, the main services and activities offered in coordination centres consist of medical advice requests, receiving hospital identification, transport management and patient repatriation. • Quebec is the only province whose coordination centre does not manage patient transport, either independently or in cooperation with partners. (#4 STANDARDIZATION OF MANAGEMENT PRACTICES): Most centres use similar coordination procedures. According to the questionnaire’s results, the order in which they are used varies depending on each coordination centre. • In Canada and abroad: – Coordination centres are seldom the only approach to manage IHT requests. – Among the centres surveyed by questionnaire, British Columbia and France are the only ones to have a single access point, which is mandatory for IHT requests. – Most IHT requests are received through a dedicated phone number, and data collection is done over the phone. – Transfer destination and anticipation of medical needs are validated during tripartite communication (requesting hospital-coordination centre-receiving hospital). • Unlike most centres, Alberta’s transmits patient information to receiving hospitals through electronic means. Decisional algorithms are made available to healthcare professionals to help them determine at which point contacting the coordination centre for medical advice and/or a transfer request is necessary. • In Washington State, decisional algorithms guide the coordination centre staff through the patient’s clinical information gathering process and receiving hospital selection. (#5 HUMAN RESOURCES IN VARIOUS IHT COORDINATION CENTRES): There is little to no information on the competency requirements and the employee headcount of coordination centres in the literature, and the data is highly heterogenous across countries. • Incoming calls are received by specialized or non-specialized nurses, paramedics, emergency medical technicians or administrative technicians. • Identifying a receiving hospital requires more specialized medical knowledge as well as a good understanding of the healthcare network; this task is therefore generally performed by medical specialists. • Some coordination centres in the United States have teams of social workers, bed allocators and transport dispatchers. (#6 ATERIAL AND TECHNOLOGICAL RESOURCES TO SUPPORT IHT MANAGEMENT): According to the coordination centres surveyed by questionnaire and literature the most frequently used technological processes and tools are telemedicine, electronic records transmission, and the use of a dashboard. The dashboard’s monitoring indicators report information on call volume, network bed availability, transfer time, patients’ clinical conditions and other transfer-related issues such as refusal of care, repatriation, bed occupancy projections, etc. • In Canada, British Columbia alone uses a real-time, artificial intelligence-powered dashboard to facilitate receiving hospital selection and provide the best transport option based on the patient’s needs and according to road and weather conditions. • The interoperability of data captured systems and digital tools across the healthcare network prevents multiple entries and facilitates health professionals’ adherence to coordination systems. • Telemedicine is described, for all centres, as a way to maintain a direct communication link between the coordination centre and the doctors at the requesting and receiving hospitals. (#7 EFFICIENCY OF COORDINATION CENTRES): Very few monitoring indicators are clearly detailed in the scientific literature. The questionnaire’s results and literature findings suggest that the use of those indicators vary from one coordination centre to another. • Out of all data collected, no performance results associated with monitoring indicators were identified. (#8: OPTIMAL MANAGEMENT MODEL FOR COORDINATION CENTRES): Current literature does not enable the identification of an optimal organizational model for coordination centres. • The following transfer coordination models present interesting service and process management modalities: – The American hub-and-spoke model, in which transfer requests are handled by a single location (a hub), without a standalone coordination centre. – Newton and Fralic's theoretical model, in which transfer request management is structured around three components: 1) call-answering service, 2) bed coordination service, and 3) transportation management service. – The Canadian model of British Columbia’s Emergency Health Services (BCEHS) coordination centre, in which transfer request management includes the same components and processes as Newton and Fralic's theoretical model, though it is structured around two co-located components instead of three: 1) call-answering and bed management services, and 2) transportation management service. (#9 THE QUEBEC IHT COORDINATION MODEL: COOLSI): COOLSI coordinates IHT throughout the province (111 hospitals), but it is not a mandatory channel/route for transfer requests. • COOLSI handles patients bound for intensive care units and patients with COVID19. Patients for whom trajectories have already been defined are not handled by COOLSI (e.g., pediatric patients, coronary care unit patients, organ recipients, trauma patients, severe burn victims, amputation victims and stroke victims). • With the help of decision-making algorithms and in coordination with the requesting physician, nurses direct patients to intensive care units. • Patient redirection takes into account the geographical proximity of the receiving hospital and the specialized activities required for the patient's care. • Dashboards are updated several times a day by the intensive care units. (#10: OPTIMIZATION AVENUES FOR IHT COORDINATION): Extracted data highlight several avenues to optimize IHT coordination, such as: • Ensure continuity of care while optimizing transfer times. • Promote the integration of multidisciplinary teams with professionals who have indepth knowledge of the healthcare network. • Promote the integration of artificial intelligence into the dashboard. • Optimize transfer times with standardized protocols. • Establish monitoring indicators to evaluate centre performance. (#11 LIMITATIONS OF THE LITERATURE AND RESULTS): Very few articles address IHT coordination centre management. • The majority of studies reviewed within the scientific literature have an observational design, and the information of interest is mainly descriptive in nature. • All sources considered, Canadian coordination centres are the least detailed in the identified literature. • Data triangulation could not clearly and comprehensively demonstrate the differences and similarities between recognized IHT coordination models. No studies have evaluated the operational efficiency of coordination centres on IHTs. • Efficacy and efficiency assessment of IHT management models is difficult due to the lack of clearly defined monitoring indicators and quantitative metrics. CONCLUSION: This overview of the current state of knowledge on IHT coordination models has identified different organizational practices in IHT coordination centres across Canada and abroad. Although currently available data/the data generated does not allow for a main coordination model to be determined, it has highlighted several elements that could optimize IHT management and, as a result, promote/facilitate fair and timely access to specialized and ultra-specialized services for Quebecers.

Authors' methods: An environmental scan was completed to identify IHT management practices in critical care coordination centres across Canadian provinces and in other countries. A literature review was conducted to locate coordination centers around the world and determine the services and activities offered, the procedures used to manage IHT requests, as well as the human, material and technological resources involved in those procedures. To fill in the knowledge gaps of the scientific and grey literature, a questionnaire was sent out to the managers of all identified coordination centres to collect further information on the services, coordination processes, resources and monitoring indicators implemented/in use at their facility. Considering that methodological quality evaluated in literature reviews does not reflect the quality of practices at a coordination centre nor the information available on its organization, no formal methodological assessment of the quality of the included studies was conducted.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/modeles-de-coordination-des-transferts-interhospitaliers-en-soins-critiques.html

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/modeles-de-coordination-des-transferts-interhospitaliers-en-soins-critiques.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)