Caitlin Whyte (Host): This is Expert Insights. I'm your host, Caitlin Whyte, and welcome back. With us today is an emergency medicine specialist from Carle Richland Memorial Hospital, Dr. Watik Maghroudi. Join us as we discuss the crucial topic of managing transfers from a rural hospital. Doctor, so great to have you on the show today. My first question is, what are some common challenges in transferring patients from rural hospitals?

Watik Maghroudi, MD: Well, first of all, thank you very much for having me on today. And first off, I want to point out that we are actually in a better position at Richland than a lot of rural hospitals. We have more resources than most. We have, for example, 24 hours general surgery, cardiology, OB, urology, and 24 hours imaging.

So that give us the ability to manage a wide range of emergencies in-house. But despite all of that, we still have to transfer patients pretty regularly. And when we do, the challenges can be significant. One of the most consistent obstacles is finding an accepting hospital especially for patient who need critical care, specialized surgical services or advanced neurological support.

And it's not uncommon to call two, three, sometimes four tertiary centers and get the same response like, we're on diversion, or we don't have an ICU bed, or we cannot take that case right now. All the while the clock is ticking and that delay adds real stress, not just clinically but emotionally as well.

Because you are watching a sick patient who clearly needs to be somewhere else and you are powerless to speed things up. Another issue is a transport. Transport is another huge piece of the puzzle. Just because you found a bed somewhere else does not mean you can get that patient there. In our setting in the rural area, we rely on EMS and sometimes on air transport, but, those services are limited and weather is a huge factor, especially with helicopters and for example, if our local EMS units are tied up with other calls or if a long distance transfer will leave it currently uncovered, then there's a real chance you're going to wait and sometimes for long, long minutes. Another obstacle or challenge I will say is the administrative layer because transfers are not just medical. It has an entire logistic. Transfer logistics take a lot of coordination. You have charting, printing records, updating the family, calling the receiving facility, confirming the transport crew, dealing sometimes with the insurance. And it's not something you can hand off in five minutes. And the smaller your hospital, the more stretched your staff is.

For example, the ED clerk might be trying to fax records while also checking in a new patient.And another piece that actually does not get talked about enough is the EMR compatibility actually, because we still, in a world where many hospitals have different systems, so that means, for example, that imaging and labs do not always transfer electronically, for example. So you are sometimes I will say literally burning a CD of the scan and you have to send it with the patient. So that slows things down. But I think the hottest challenge is actually the to me at least, is that the human toll. Because you know, it's not just the case number, it's a person.

 The patient is scared, family's worried. You're trying to reassure them while also making calls, updating charts, caring for other patients, and planning next steps. So even when you do everything right, there's still this helpless feeling when the system itself just does not move fast enough.

And that's probably the part that sticks the most with me. So, so yeah, I'll say that we are fortunate at Richland to have strong resources in house. But transfer challenges don't go away just because you have a good ED. There are system issues, capacity, transport, communication that we all have to work around, and sometimes we're working around them while a life is literally on, on the line.

Host: Well, what would you say are some best practices for initiating and managing the inter-facility transfers?

Watik Maghroudi, MD: One of the biggest lessons I've learned is that speed matters, but clarity matters even more. When you think a transfer might be needed, you have to start preparing early, as early as possible. That does not mean pulling the trigger too fast, but it does mean getting your ducks in a row. You stabilize what you can, start collecting the key info and you communicate with your team that this may be heading toward a transfer.

And I found that when you have a structure in place, it really helps. For instance, in our department, the nurses, know what clinical updates we need to share with the accepting facility, the clerk knows what documents to prepare and who to call, and I know that my job is not just making the clinical case, but also keeping the lines of communication open between our hospital, the family, the transport team, and the receiving hospital.

 Another thing I've learned sometimes the hard way, is that a good transfer summary can make or break the process. If the receiving physician has to dig through 10 pages of notes to figure out what's going on, that's not really helpful. They need to have the story in less than 30 seconds, what happened, what you've done, what is your concern and what kind of support the patient needs.

That's it. And the clearer you are, the more confidence they will have in accepting the patient quickly. And this might sound simple and kind of logic, but it's important to be a good colleague. You treat the receiving doc with respect, speak clearly, show that you've taken care of the patient to the best of your ability.

They will usually meet you halfway. We have like built relationships with physician and we have a few referral centers over time. And those relationships make huge difference when things get chaotic. Sometimes a quick direct call to someone you trust is far more effective than going through layers of systems.

And finally, I will say that, we're talking about strategies that involving the patient and their family is a key factor as well. You want to keep them in the loop from the start. Let them know you are working on getting them to a higher level of care, that there might be some waiting and that you're not going anywhere.

I think when people feel seen and informed, they're much more able to cope with uncertainty that often comes with these situations.

Host: Now, how about the importance of this interdisciplinary collaboration? Can you go even more into that please, doctor?

Watik Maghroudi, MD: Oh, I will say it is actually everything. You cannot do transfer well, if you're trying to do them in isolation, there's no way. I've never had a smooth transfer that did not involve at least half a dozen of people doing their part and doing it well. In rural settings, we all wear multiple hats, and that can be a strength if we are community, if we communicate.

Our nurses, for example, are often the first to recognize that something's not quite right or that a patient is starting to slip. They're also the ones managing the pain, starting new drips, coordinating with families and prepping the patient for transport. So I lean on them a lot to catch things I might miss while I'm on the phone or writing orders.

Then there's the EMS personnel as well. I always say they're actually the unsung heroes of rural healthcare, and they're not just drivers. They're really critical thinkers. They love them for that, and they often manage high aquity patients during long transport. Sometimes like two hours, three hours, and sometimes with little backup. So we've had times when we needed to troubleshoot ventilator settings, for example, or titrate meds en route, and they will take care of it like pros. So involving them early in the process and giving them a full picture of what you expect is crucial. I will say the case management and all the administrative staff play a massive role as well.

We're talking about interdisciplinary coordination and honestly, I did not appreciate how much they were important until I became medical director, you know, because they're the ones tracking down better abilities, handling insurance authorizations, and that knows how complicated it is. Making sure records get faxed or uploaded, you know, stuff that sounds simple, but can hold up a transfer by hours if it's missed.

So having them looked in from the beginning makes a huge difference as well. Even beyond the big roles, I think collaboration shows up in little moments. You take a, a unit secretary calling the helicopter team, radiology tech, stay late to finish the scan or a lab tech rushing a drop.

Every one of those actions move the transfer forward. So when we talk about transfers, it's easy to focus on systems and protocols. Those are very important for sure, but at the heart of it, it's people. It's a team of humans, doing their best to get another human being to where they need to be.

And that spirit of collaboration is what makes it possible.

Host: And to wrap up today, Doctor, what are some strategies that teams could input to improve these transfers?

Watik Maghroudi, MD: I think improving transfers really starts with the knowledge that this process is both clinical and operational. It's not just about making the right medical decision. It's about building a system that allows that decision to be acted on quickly and safely. So for me, there are a few key strategies I've seen making a difference.

 First, it's being proactive and not reactive. If I even have a gut feeling that a patient might need a higher level of care, I start planning for possible transfer. But that doesn't mean, you know, call transport right away. But we do start prepping the chart, push images, for example, and loop in the team so no one's caught off guard if we decide to transfer 20 minutes later.

A few extra minutes of preparation upfront can save a lot of time when things escalate. Another point will be, you know, having standardizing internal process. That is a big one to me too. Like when you have internal checklists, that walk you through what needs to happen before transfer. It's huge.

Like, who calls EMS? Who faxes the records? Who communicates with the family? Having that structure means that we are not reinventing the wheel in the middle of a crisis. Another thing also is maybe running mock scenarios. Like you can simulate trauma and stroke drills every quarter.

You know, it's not fancy. It's usually some of the ED staff and someone from the EMS, but it, it helps a lot and it gives us a chance to refine communication, troubleshoot any gaps, and make sure everyone's clear on roles. Another one, actually, another measure strategy is maybe investing in telehealth partnership.

In some cases you can have a virtual consult with a neurologist or intensivist, for example. That can either expedite the transfer or in some cases help us manage the patient locally when we know that we have this close monitoring and remote support. So it can reduce unnecessary transfers and give us confidence when we are in that kind of gray zone.

And I would say one of the most underrated strategies is actually relationship building. When you know the names of the people at your referral center, when there's mutual respect and familiarity, everything goes faster. I know I've had a situation where a transfer that would normally take two hours was completed to 45 minutes just because I could call someone directly and they trusted my judgment.

Finally, I think it's important to have some tracking metrics and to reflect on them. To revisit them, just like five minutes to look at what held things up, whether it was transport, paperwork, communication, that small change can help us identify repeat issues and fix them. So overall, it's all about planning ahead, building systems and relationships.

That's how we protect our patients by making sure that when they need to go, we are already ready.

Host: Thank you so much for your time today, Doctor, and for doing this critical work. For more information and to get connected with one of our providers, please visit carle.org or for a listing of Carle providers and to view Carle sponsored educational activities, head on over to our website at carleconnect.com. And that wraps up this episode of Expert Insights with the Carle Foundation Hospital.

I'm Caitlyn Whyte. Thank you for listening.