Eight out of 10 patient transfers between Ontario healthcare facilities found to be “routine and non-urgent”
A new study by University of Toronto researchers has found that 80 percent of patient transfers in Ontario are routine and non-urgent. Yet most of these inter-facility transfers rely on fully equipped ambulances staffed by highly-trained paramedics—the same system used for emergency 911 calls.
The study, published today in Healthcare Policy Journal (www.longwoods.com), is believed to be the first population-based analysis of inter-facility patient transfers in a Canadian province. It was made possible by a new system that collects detailed data on all patient inter-facility transfers in the province.
Here are some key findings from the study which was undertaken by researchers at the University of Toronto, Ornge Transport Medicine, Sunnybrook Health Sciences Centre, and the Institute for Clinical Evaluative Sciences (ICES).
Each year nearly 400,000 patient transfers—about 1,000 trips per day—take place in Ontario. The ambulances providing these transfers travel a distance equal to the circumference of the earth every 36 hours (or about 10.5 million kilometres).
The total cost of land-transfers during the study period was $283 million. The average cost for an individual, one-way inter-facility patient transfer was $704; round trip transfers averaged $1,408.
During the study period, 85,000 patients—or about a quarter of all transferred patients in the study group—were moved between healthcare facilities for non-urgent physician appointments, dialysis and return trips to the patient’s home facility or residence. The median age of transferred patients was 75 years.
The researchers found that the typical inter-facility patient transfer in Ontario involved a non-urgent appointment with a cardiologist or for a dialysis treatment and covered 10.5 kilometres. Most of the patients transported between facilities had health problems related to the circulatory system, followed by patients with musculoskeletal and connective tissue problems and genitourinary ailments.
While 70 percent of all transfers during the study period were to facilities within 25 kilometres, some covered greater distances. For example, transfers involving pregnant women and newborn babies required travelling a median distance of 40.3 kilometres for continued care. Cardiac patients (54,000 patient transfers per year) travelled an average of 24.2 kilometres to reach a catheterization lab for treatment and further investigation.
The study found a high rate of “lateral transfers”–the movement of patients between similarly classified hospitals. For example, more than 16,000 patients (4.7 percent of all transfers) were moved from one large, tertiary care teaching hospital to another and sometimes back again, most often for cardiac care. “Such lateral transfers may be symptomatic of hospital crowding, lack of available beds, staffing shortages at healthcare facilities and a lack of comprehensive services,” the researchers say.
The current findings are based on a random sample of 5,000 land transfers which took place in Ontario between June 2004 and May 2005 (from a total of 349,342 transfers). Trips completed by air were excluded.
“Our findings call into question the use of sophisticated, highly trained, expensive patient transfer resources to provide routine medical services in Ontario,” says lead author Victoria Robinson, a PhD candidate in the Institute of Medical Science at the University of Toronto. “This practice diverts resources from more emergent requests,” she adds. The study co-authors are Dr. Vivek Goel, president of the Ontario Agency for Health Protection and Promotion; Dr. Russell D. MacDonald, medical director of the Research Program at Ornge Transport Medicine and a physician at Sunnybrook; and Dr. Doug Manuel, senior scientist at the Ottawa Health Research Institute and at the Institute for Clinical Evaluative Sciences (ICES).
There are currently three levels of priority when it comes to transporting patients between Ontario healthcare facilities:
An emergent transfer involves a life-threatening situation, is time-sensitive and receives priority. An urgent transfer is not as serious as an emergent transfer, but may still be time-sensitive and should be completed within a specific timeframe. A non-urgent transfer is considered routine and does not involve an immediate threat to life or limb, or care that is time-sensitive.
The researchers acknowledge that patient transportation is a necessary part of any healthcare system, especially one as highly regionalized as Ontario’s. Regionalization of certain services has been found to improve patient outcomes, while maintaining a certain level of quality and efficiency.
“An unanticipated effect, however, at least in Ontario, is the amount of patient movement required to maintain continuity of care, and the consequent impact on emergency services when a high volume of routine transport is assumed by the ambulance system,” the researchers say, adding that the situation is likely to intensify. Data show that over a three-year period, inter-facility patient transfers in Ontario increased by 40 percent—from an average of 1,000 transfers per day in 2005 to 1,375 per day in 2008.
The researchers say other options should be explored to make the patient transportation system more efficient and accessible. This could involve greater balance between centralization and regionalization of services—for example, inter-facility patient transfer trends for dialysis appointments may mean more dialysis facilities are needed in Ontario.
“Inter-facility patient transfers in Ontario: Do you know what your local ambulance is being used for?” Victoria Robinson, Vivek Goel, Russell D. MacDonald and Doug Manuel, Healthcare Policy, Vol .4 No.3, 2009 (www.longwoods.com)
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As a result of restructuring and regionalization of healthcare services, Ontario patients are often moved through the healthcare system from facility to facility for care. Patients can no longer expect to have all their healthcare needs met at a single facility.
The majority of patient transportation in Ontario is completed through the public system; however, some inter-facility patient transfers are completed through contracts with private companies as a way for some hospitals to trim their costs and improve efficiency.
Emergency medical services (EMS) in Ontario are provincially mandated and regulated but locally administered, most often by municipal governments. The structure of emergency services varies greatly from province to province. For example, pre-hospital emergency services in British Columbia are wholly administered by the province. Alberta is centralizing its EMS structure to transfer responsibility to Alberta Health Services by April 2009.
At the other end of the spectrum, emergency services in Nova Scotia are regulated by the Department of Health but managed by a private company, Emergency Medical Care. The diversity of governance structures and administration of EMS across Canada makes sharing data and drawing comparisons difficult.
Ambulance services and other patient transportation are non-insured services under the Canada Health Act, and coverage is left up to the discretion of the provinces. In 2001, when Ontario municipalities assumed responsibility for ambulance services, they also accepted responsibility to provide 50 percent of the funding necessary to run them jointly with the Ministry of Health and Long-Term Care. Since then, it is widely acknowledged that costs have not been equally balanced, as municipalities now cover more than 50 percent of ambulance costs.
Some municipalities have reported an inability to cope with the current demand for ambulance use because of inter-facility patient transfers. As a result, their provincially mandated response times for 911 ambulance calls have suffered, and patient transfers are often delayed. According to the Association of Municipal Emergency Services of Ontario, increasing inter-facility patient transfer volume “results in hundreds of hours of lost availability to the EMS providers, which has a very negative impact on emergency response time. Previous research suggests that delays experienced in respect to low-priority inter-facility patient transfers has an extremely negative impact on the healthcare system as a whole.”
In 2003, in reaction to outbreaks of severe acute respiratory syndrome (SARS) in Toronto, the Provincial Transfer Authorization Centre (PTAC) was established to authorize all inter-facility patient transfers in the province of Ontario. Today, a patient transfer between two healthcare facilities may not proceed until authorization has been received from PTAC.
Until PTAC began to systematically collect detailed information about inter-facility patient transfers in a new database in 2003, little was known about inter-facility patient transfers in populations. At the urging of many interested groups, the Ministry of Health and Long-Term Care commissioned a consulting firm to examine the inter-facility patient transfer issue in Ontario in 2002. The findings confirmed the concerns and possible solutions raised by municipalities, EMS groups and others across the province.