Surgical Transfer Decision Making: How Regional Resources are Allocated in a Regional Transfer Network.

BACKGROUND: Tertiary care centers often operate above capacity, limiting access to emergency surgical care for patients at nontertiary facilities. For nontraumatic surgical emergencies there are no guidelines to inform patient selection for transfer to another facility. Such decisions may be particularly difficult for gravely ill patients when the benefits of transfer are uncertain. METHODS: To characterize surgeons' decision-making strategies for transfer, a qualitative analysis of semistructured interviews was conducted with 16 general surgeons who refer and accept patients within a regional transfer network. Interviews included case-based vignettes about surgical patients with high comorbidity, multisystem organ failure, and terminal conditions. An inductive coding strategy was used, followed by performance of a higher-level analysis to characterize important themes and trends. RESULTS: Surgeons at outlying hospitals seek transfer when the resources to care for patients' surgical needs or comorbid conditions are unavailable locally. In contrast, surgeons at the tertiary center accept all patients regardless of outcome or resource considerations. Bed availability at the tertiary care center restricts transfer capacity, harming patients who cannot be transferred. Surgeons sometimes transfer dying patients in order to exhaust all treatment options or appease families, but they are conflicted about the value of transfer, which displaces patients from their local communities and limits access to tertiary care for others. CONCLUSION: Decisions to transfer surgical patients are complex and require comprehensive understanding of local capacity and regional resources. Current decision-making strategies fail to optimize patient selection for transfer and can inappropriately allocate scarce tertiary care beds.