When the immediate transfer of a patient — whose care needs are beyond the scope of the hospital’s resources and trained staff — is not possible, the hospital must continue to care for the patient to the best of its abilities. 

Normally, a single, higher acuity patient may not overwhelm a hospital’s resources. However, compounding situations, such as several higher acuity patients, workforce shortages and surges in emergency department visits, could result in a crisis environment. If not already addressed, hospitals may benefit from policies and procedures addressing the following. 

• how care decisions are made in emergent and crisis situations (e.g., Crisis Standards of Care, advance directives, noncommunicative patients, etc.) 
• mitigation of staffing shortages, which may include elements from the latest Centers for Disease Control and Prevention guidance 
• alternative care models in disaster situations 
• how to secure nonroutine supplies, equipment and medications for higher acuity patients 

The following are helpful considerations when faced with the inability to transfer patients or similar situations that may cause the system to be overwhelmed. 

Documentation

• At any given time, there should be documented evidence of how the hospital is operating. This includes the everyday basics of staffing assignments, patient locations and surgery schedules, as well as more complex items like the implementation of a disaster plan; notable changes in operations or care models; and local, state and federal requests. 
• Routine and emergency staffing plans should be followed. This includes staffing schedules, on-call schedules, calls to agencies and existing staff, movement of patients, and other efforts to maximize staffing. A surveyor should be able to see where the steps outlined in various staffing policies or procedures were followed, including the outcome. 
• Document attempts to secure transfers, including the contacts made and the outcome of all contacts. Medical record documentation should fully reflect communications with other entities about the need for transfer and the outcome. For example: “Spoke to house supervisor at XXXXX regarding need to transfer patient XXXXX due to XXXXX. House Supervisor informed they were unable to accept patient transfer.” This does not include “talking to MHA” or “talking to HSG” in the patient chart. However, as part of the emergency response documentation, there may be note of outreach to local, state or federal entities for support, as well as the evaluation of patients for discharge to home or lower/same acuity of care to free up resources to care for higher intensity or higher volumes of patients. 
• Specialty logs like ED registration, incident reports, complaints and others could be forgotten. However, these are important documentation pieces that color the operational story. 

Communication

• Support of and communication with family always is important. It especially is important when the environment is challenged and they may not understand why their loved one is not being transferred. The family should be aware of steps the hospital is taking to ensure their loved one is being cared for, including attempts to secure a transfer.  
• Family and patient treatment goals should be known and documented, including the presence of advance directives and potential conversations with the patient that may impact care decisions. Hospital policies on care decisions when the patient is unable to speak for themselves are critical guides for staff and providers. 
• Staff and providers should be kept apprised of additional actions to find appropriate transfer options, close services to enhance resources or staffing, supplies, etc. The collective knowledge and experience of staff and providers may yield viable solutions to challenging situations when asked. 
• Ensure communication tools like EMResource — Missouri’s electronic hospital situational awareness platform — are used to communicate status with community emergency service providers and the Missouri Department of Health and Senior Services. 
• Especially for publicly owned hospitals, there could be resources at the local, county or regional level available to the hospital. 

Collaboration

• Check with facilities where there are transfer agreements in place first. Do staff know about these facilities? 
• Begin outreach on a regional and statewide basis. Utilize EMResource to locate available bed capacity. During medical surge incidents, including response to the COVID-19 pandemic, a bed availability query remains active to capture near real-time capacity.  Once available beds are identified through this or other platforms, securing a bed often is accomplished through phone calls. Again, document attempts and responses.   
• Explore conversations where reverse transfers may be an option. In this scenario, a lower acuity patient may be taken in order to transfer more acute and critically ill patients to the other facility. This type of conversation would be logged as part of emergency response documentation. 
• Consider patients who could be discharged to a skilled nursing facility, swing bed or home with community-based services to free up resources. 

Other

• Look to pharmacists to engage in complex cases and care plans, as well as to assist with medication management and consultation.  
• Seek agency support of critical care nurses, respiratory therapists and other needed care staff as appropriate. 
• Consider other professions who are trained in emergency care, like paramedics, to assist in the ED and critical care areas. 
• These situations and experiences can generate stress and challenge the resiliency of hospital staff and providers. Open lines of communication; frequent touchpoints; recognition; opportunities to express concerns and ideas; and hands-on ways to comfort patients, families and colleagues are vital to maintaining and building a resilient work environment.