Industrial & Organizational Nurse
Safe Patient Transfer Center Design
Transfer Medicine is a relatively new concept, much like Tele Medicine and Tele Nursing. The increasing complexity of corporate healthcare increases risk of compromising patient safety, especially when patients are moving between acute care facilities for limited specialty services or resources. It is well-established that adequate to optimal nurse staffing, training, and education each positively impacts patient safety and clinical outcomes. There is also growing evidence that patient Transfer Centers, sometimes referred to as Command Centers, further enhance patient safety during these vulnerable transitions, as well as throughput, and efficient use of resources. Since IO Nurse LLC is based in Washington State and supports local healthcare systems, this page will focus on WA.
While various hospital systems have developed versions of patient transfer governance, standardization has not been established. Most hospitals rely on RN house supervisors, or shift administrators, to oversee patient flow from their emergency departments, as well as patient transfers from outside facilities, to in-patient acute care beds. Some larger systems have set up call centers that facilitate operations beyond transfers, where nurses and ancillary staff guide providers and patients through multiple transition pathways, such as a patient transferring within a facility, between facilities, having surgery or a procedure, or being admitted from the community, an emergency department, or elsewhere. These expanded scope Transfer Centers are typically referred to as Command Centers or Transfer and Operation Centers.
Whether a Transfer Center or Command Center, this clinical unit's goal is to facilitate safe patient transfers and enhance patient throughput through standardization. Current review of literature suggests that Transfer and Command Centers vary in scope and purpose. Some focus solely on inter-facility patient transfers. Others incorporate local campus emergency department admissions, surgical and procedural placement, campus staffing, system resource management, etc., many working in tandem with RN house supervisors. The standardization that is required for patient safety need not align between healthcare systems or Transfer Centers, but it must occur within each Transfer Center.
There are several toolkits and webpages designed as templates presenting process steps, metrics for evaluation, and considerations for implementation. Some of the greatest variations between Transfer Centers include case acuity, services provided, service area, and the staffing models that support patient safety. We will begin with a discussion of staffing these Transfer Centers as a core consideration for patient safety that has State-specific parameters.
Nurse Staffing and Administrative Support
It is important to note that in Washington State, direct patient care is defined as follows, and both definitions apply:
Direct Patient Care Definition
https://doh.wa.gov/sites/default/files/2024-07/505-176-DirectPatientCareDefinition.pdf
Centers for Disease Control and Prevention (CDC): Defines direct patient care as, "Hands on, face-to-face contact with patients for the purpose of diagnosis, treatment, and monitoring."
Labor and Industries (L&I): Defines it this way. "Direct patient care activities are those that involve contact with patients to provide care and services. Direct patient care activities include assessment, diagnosis, treatment, prevention of diseases and injuries, and health support and promotion activities. An individual may be considered to be involved in direct patient care activities when they are primarily stationed within a clinical unit and provide direct support to clinical staff by coordinating patient care and other services. Contact may be hands-on, remote or virtual, or other direct patient contact."
Per the above definitions, those who staff the Transfer Center and facilitate safe patient transfers are deemed by the WA Department of Health (DOH) to be providing direct patient care. This is important, because WA DOH and WA L&I regulate staffing ratios, committees, reporting, and meals and breaks, by these definitions. These definitions must be considered whether a system chooses to design a Transfer Center that utilizes staff who work from home or in a centralized office.
Hospital Staffing | Washington State Department of Health
https://doh.wa.gov/licenses-permits-and-certificates/facilities-z/hospitals/hospital-staffing
Transfer Centers can be staffed with clinical personnel, non-clinic staff, or a combination. A common theme is to have clinical personnel, often nurse, overseeing or facilitating clinical processes, while non-clinical staff perform clerical and administrative roles necessary to support safe patient transfers.
Staffing matrices depend on several factors, including call volume and acuity, number of facilities supported, number of services offered, technology and protocols in use, and the training, education, and expertise of the staff. When deciding between a Transfer Center and Command Center, a central element to evaluate is time. Consider the following example:
A nurse scheduled for a 12.5-hour shift has no more than 10.5 hours of productive time under ideal circumstances (functioning at 90% to 100% clinical productivity). The initial 120-minute reduction accounts for one or two 30-minute meal breaks and three to four 15-minute rest breaks, depending on the organization. As such, the nurse has up to 630 minutes to be applied to whatever serial clinical tasks the organization prioritizes. At 75% clinical productivity, the nurse has 472.5 minutes devoted to clinical tasks and patient safety. Since patient safety is a primary goal of any Transfer Center, the serial tasks to which the nurse devotes his or her time on shift should focus on the clinical pathways that keep patients safe.
This often means clinical staff focus on clinical triage, supervising calls between providers, documenting clinical conversations and decisions, ensuring appropriate level of care for patient needs, and aligning patient care with established guidelines and best practices for patient safety. This often leaves intake calls, loading face sheets, creating encounters, paging providers, retrieving records, pulling images, confirming available staff and resources, and placing patients on units to non-clinical personnel, though some systems blend these activities for continuity or convenience. However, the limiting factor remains time.
In this example, when considering a 12-hour shift (12.5 hours with a meal break), each nurse typically has from 472.5 to 567 minutes, within that 720- to 750-minute window, to support clinical tasks and patient safety, making it important for the facility or organization to prioritize to role of the nurse. Some organizations reduce this to 315 minutes by incorporating a 50% clinical productivity model. Generally, anything below 75% would not be best practice.
Generally, with moderate to high call volumes (15 to 30 calls per hour) and moderate to high patient acuity, a nurse might be expected to complete one safe patient transfer each hour, though multiple transfer requests may be in progress at any given time. Following the same example, the nurse must prioritize oversight of the clinical pathways and minimize non-clinical activities to work to the highest degree of their licensure. Competing tasks include, but are not limited to:
A. Critical clinical care pathway transfers (Dissecting aorta, Shock, Pulmonary embolism, Stroke, STEMI, etc.)
B. Critical care transfers (includes ICU/IMCU/PCU)
C. Specialty care transfers (services)
D. Routine care transfers (repatriation)
E. Consults (as required to access needs or non-transfers)
F. Admin/staffing/resource meetings (clerical)
G. Chart reviews for level of care oversight (clinical)
H. Bed placement (clerical once clinical needs are determined)
I. Obtaining transfer agreements (clerical)
J. Admin tasks (clinical or clerical)
K. Research (clinical or clerical)
L. Rest breaks (legal)
M. Meal breaks (legal)
N. Inter-office communication (necessary)
O. Brief bathroom breaks (necessary)
P. Educational updates, emails, projects, etc.
Q. The list goes on...
While systems vary in the data their Transfer Centers collect, consider this example of metrics:
Each completed safe patient transfer case consists of an intake, processing, evaluation, coordination or facilitation, and conclusion. The intake involves gathering information and accessing or creating a patient chart, which can involve requesting and loading face sheets or other identifiers, confirming the correct patient's name and date of birth, gathering records or images, etc. Typically, this step is thought to average about 15 minutes. Processing involves pulling all the necessary information together into a patient's chart and determining the resources, services, or providers needed for the transfer. An experienced nurse can do this in 5 to 15 minutes, depending on the complexity of the case. Evaluation of patient care needs happens quickly, but changes dynamically, so in a sense it is always a work in progress. Coordination involves connecting providers and facilitating care conversations, which can be another 15 minutes or more, typically over several phone calls. Transfers can average 4 to 5 calls, with each additional call beyond the intake lasting 5 to 10 minutes or more. Thus, a proposed standard in use at several facilities is one safe patient transfer case completed per 60 minutes of applied time. The applied time is not necessarily continuous and incorporates both clinical and non-clinical elements, supporting a blended staffing model.
Transfer Center personnel, whether clinical or non-clinical, can answer phone calls every minute, 60 times an hour if needed, but to be effective there must be enough staff to answer calls, perform intakes, process, evaluate, coordinate, and conclude. Here is one sample matrix per call volume, acuity, and tasking.
Staffing Matrix
Consider a Transfer Center with the following data:
Call Volume per time and day: 4650 minutes of clinical call time within 24 hours (1440 minutes). Some facilities track all clinical tasks such as chart reviews, level of care determinations, and research as clinical call time. Others distinguish between these clinical activities. Actual number of calls might double or triple this with the additional calls addressing clerical or administrative issues (non-clinical).
Day shift: (360 calls) - average duration of call 10 minutes
7am to 11am: 15 calls per hour (60 calls)
11am to 3pm: 30 calls per hour (120 calls)
3pm to 7pm: 45 calls per hour (180 calls)
3600 minutes of clinical call time
Night shift: (140 calls) - average duration of call 7.5 minutes
7pm to 11pm: 20 calls per hour (80 calls)
11pm to 3am: 10 calls per hour (40 calls)
3am to 7am: 5 calls per hour (20 calls)
1050 minutes of clinical call time
Based on call time data alone, an organization might be tempted to assign 5.0 nurses (3600/720) to the day shift and 1.458 nurses (1050/720) to the night shift. These numbers reflect 100% clinical productivity, but they do not account for clinical call volume changes over time. However, if the organization has established 24/7 services or made other promises to the community such as low wait times and prompt service, additional staff could be required. More importantly, if the organization has agreed to support time-sensitive critical clinical pathways, then ideally more than one nurse must be available at all times to facilitate those activities for patient safety. As such, the minimum number of nurses needed is always two or more to allow meals, rest breaks, and coverage. A minimum of three nurses would be best practice.
Furthermore, consider clinical productivity. At 75% clinical productivity, a nurse is focused on non-clinical tasks for 25% of their shift. Meaning a nurse can address clinical tasks for 472.5 minutes (7.875 hours) and non-clinical tasks for 157.5 minutes (2.625 hours) on average over the course of a 12.5-hour shift. Let's review three scenarios in which nurses are devoted to clinical tasks and calls at 90% (567 minutes), the more typical 75% (472.5 minutes), and 50% (315 minutes) clinical productivity.
While various hospital systems have developed versions of patient transfer governance, standardization has not been established. Most hospitals rely on RN house supervisors, or shift administrators, to oversee patient flow from their emergency departments, as well as patient transfers from outside facilities, to in-patient acute care beds. Some larger systems have set up call centers that facilitate operations beyond transfers, where nurses and ancillary staff guide providers and patients through multiple transition pathways, such as a patient transferring within a facility, between facilities, having surgery or a procedure, or being admitted from the community, an emergency department, or elsewhere. These expanded scope Transfer Centers are typically referred to as Command Centers or Transfer and Operation Centers.
Whether a Transfer Center or Command Center, this clinical unit's goal is to facilitate safe patient transfers and enhance patient throughput through standardization. Current review of literature suggests that Transfer and Command Centers vary in scope and purpose. Some focus solely on inter-facility patient transfers. Others incorporate local campus emergency department admissions, surgical and procedural placement, campus staffing, system resource management, etc., many working in tandem with RN house supervisors. The standardization that is required for patient safety need not align between healthcare systems or Transfer Centers, but it must occur within each Transfer Center.
There are several toolkits and webpages designed as templates presenting process steps, metrics for evaluation, and considerations for implementation. Some of the greatest variations between Transfer Centers include case acuity, services provided, service area, and the staffing models that support patient safety. We will begin with a discussion of staffing these Transfer Centers as a core consideration for patient safety that has State-specific parameters.
Nurse Staffing and Administrative Support
It is important to note that in Washington State, direct patient care is defined as follows, and both definitions apply:
Direct Patient Care Definition
https://doh.wa.gov/sites/default/files/2024-07/505-176-DirectPatientCareDefinition.pdf
Centers for Disease Control and Prevention (CDC): Defines direct patient care as, "Hands on, face-to-face contact with patients for the purpose of diagnosis, treatment, and monitoring."
Labor and Industries (L&I): Defines it this way. "Direct patient care activities are those that involve contact with patients to provide care and services. Direct patient care activities include assessment, diagnosis, treatment, prevention of diseases and injuries, and health support and promotion activities. An individual may be considered to be involved in direct patient care activities when they are primarily stationed within a clinical unit and provide direct support to clinical staff by coordinating patient care and other services. Contact may be hands-on, remote or virtual, or other direct patient contact."
Per the above definitions, those who staff the Transfer Center and facilitate safe patient transfers are deemed by the WA Department of Health (DOH) to be providing direct patient care. This is important, because WA DOH and WA L&I regulate staffing ratios, committees, reporting, and meals and breaks, by these definitions. These definitions must be considered whether a system chooses to design a Transfer Center that utilizes staff who work from home or in a centralized office.
Hospital Staffing | Washington State Department of Health
https://doh.wa.gov/licenses-permits-and-certificates/facilities-z/hospitals/hospital-staffing
Transfer Centers can be staffed with clinical personnel, non-clinic staff, or a combination. A common theme is to have clinical personnel, often nurse, overseeing or facilitating clinical processes, while non-clinical staff perform clerical and administrative roles necessary to support safe patient transfers.
Staffing matrices depend on several factors, including call volume and acuity, number of facilities supported, number of services offered, technology and protocols in use, and the training, education, and expertise of the staff. When deciding between a Transfer Center and Command Center, a central element to evaluate is time. Consider the following example:
A nurse scheduled for a 12.5-hour shift has no more than 10.5 hours of productive time under ideal circumstances (functioning at 90% to 100% clinical productivity). The initial 120-minute reduction accounts for one or two 30-minute meal breaks and three to four 15-minute rest breaks, depending on the organization. As such, the nurse has up to 630 minutes to be applied to whatever serial clinical tasks the organization prioritizes. At 75% clinical productivity, the nurse has 472.5 minutes devoted to clinical tasks and patient safety. Since patient safety is a primary goal of any Transfer Center, the serial tasks to which the nurse devotes his or her time on shift should focus on the clinical pathways that keep patients safe.
This often means clinical staff focus on clinical triage, supervising calls between providers, documenting clinical conversations and decisions, ensuring appropriate level of care for patient needs, and aligning patient care with established guidelines and best practices for patient safety. This often leaves intake calls, loading face sheets, creating encounters, paging providers, retrieving records, pulling images, confirming available staff and resources, and placing patients on units to non-clinical personnel, though some systems blend these activities for continuity or convenience. However, the limiting factor remains time.
In this example, when considering a 12-hour shift (12.5 hours with a meal break), each nurse typically has from 472.5 to 567 minutes, within that 720- to 750-minute window, to support clinical tasks and patient safety, making it important for the facility or organization to prioritize to role of the nurse. Some organizations reduce this to 315 minutes by incorporating a 50% clinical productivity model. Generally, anything below 75% would not be best practice.
Generally, with moderate to high call volumes (15 to 30 calls per hour) and moderate to high patient acuity, a nurse might be expected to complete one safe patient transfer each hour, though multiple transfer requests may be in progress at any given time. Following the same example, the nurse must prioritize oversight of the clinical pathways and minimize non-clinical activities to work to the highest degree of their licensure. Competing tasks include, but are not limited to:
A. Critical clinical care pathway transfers (Dissecting aorta, Shock, Pulmonary embolism, Stroke, STEMI, etc.)
B. Critical care transfers (includes ICU/IMCU/PCU)
C. Specialty care transfers (services)
D. Routine care transfers (repatriation)
E. Consults (as required to access needs or non-transfers)
F. Admin/staffing/resource meetings (clerical)
G. Chart reviews for level of care oversight (clinical)
H. Bed placement (clerical once clinical needs are determined)
I. Obtaining transfer agreements (clerical)
J. Admin tasks (clinical or clerical)
K. Research (clinical or clerical)
L. Rest breaks (legal)
M. Meal breaks (legal)
N. Inter-office communication (necessary)
O. Brief bathroom breaks (necessary)
P. Educational updates, emails, projects, etc.
Q. The list goes on...
While systems vary in the data their Transfer Centers collect, consider this example of metrics:
Each completed safe patient transfer case consists of an intake, processing, evaluation, coordination or facilitation, and conclusion. The intake involves gathering information and accessing or creating a patient chart, which can involve requesting and loading face sheets or other identifiers, confirming the correct patient's name and date of birth, gathering records or images, etc. Typically, this step is thought to average about 15 minutes. Processing involves pulling all the necessary information together into a patient's chart and determining the resources, services, or providers needed for the transfer. An experienced nurse can do this in 5 to 15 minutes, depending on the complexity of the case. Evaluation of patient care needs happens quickly, but changes dynamically, so in a sense it is always a work in progress. Coordination involves connecting providers and facilitating care conversations, which can be another 15 minutes or more, typically over several phone calls. Transfers can average 4 to 5 calls, with each additional call beyond the intake lasting 5 to 10 minutes or more. Thus, a proposed standard in use at several facilities is one safe patient transfer case completed per 60 minutes of applied time. The applied time is not necessarily continuous and incorporates both clinical and non-clinical elements, supporting a blended staffing model.
Transfer Center personnel, whether clinical or non-clinical, can answer phone calls every minute, 60 times an hour if needed, but to be effective there must be enough staff to answer calls, perform intakes, process, evaluate, coordinate, and conclude. Here is one sample matrix per call volume, acuity, and tasking.
Staffing Matrix
Consider a Transfer Center with the following data:
Call Volume per time and day: 4650 minutes of clinical call time within 24 hours (1440 minutes). Some facilities track all clinical tasks such as chart reviews, level of care determinations, and research as clinical call time. Others distinguish between these clinical activities. Actual number of calls might double or triple this with the additional calls addressing clerical or administrative issues (non-clinical).
Day shift: (360 calls) - average duration of call 10 minutes
7am to 11am: 15 calls per hour (60 calls)
11am to 3pm: 30 calls per hour (120 calls)
3pm to 7pm: 45 calls per hour (180 calls)
3600 minutes of clinical call time
Night shift: (140 calls) - average duration of call 7.5 minutes
7pm to 11pm: 20 calls per hour (80 calls)
11pm to 3am: 10 calls per hour (40 calls)
3am to 7am: 5 calls per hour (20 calls)
1050 minutes of clinical call time
Based on call time data alone, an organization might be tempted to assign 5.0 nurses (3600/720) to the day shift and 1.458 nurses (1050/720) to the night shift. These numbers reflect 100% clinical productivity, but they do not account for clinical call volume changes over time. However, if the organization has established 24/7 services or made other promises to the community such as low wait times and prompt service, additional staff could be required. More importantly, if the organization has agreed to support time-sensitive critical clinical pathways, then ideally more than one nurse must be available at all times to facilitate those activities for patient safety. As such, the minimum number of nurses needed is always two or more to allow meals, rest breaks, and coverage. A minimum of three nurses would be best practice.
Furthermore, consider clinical productivity. At 75% clinical productivity, a nurse is focused on non-clinical tasks for 25% of their shift. Meaning a nurse can address clinical tasks for 472.5 minutes (7.875 hours) and non-clinical tasks for 157.5 minutes (2.625 hours) on average over the course of a 12.5-hour shift. Let's review three scenarios in which nurses are devoted to clinical tasks and calls at 90% (567 minutes), the more typical 75% (472.5 minutes), and 50% (315 minutes) clinical productivity.
|
Day Shift at 50% clinical productivity
7am to 11am: 15 calls per hour (60 calls) 600 minutes of clinical call time (600/315) = 1.905 = 2 or 3 nurses 11am to 3pm: 30 calls per hour (120 calls) 1200 minutes of clinical call time (1200/315) = 3.81 = 4 or 5 nurses 3pm to 7pm: 45 calls per hour (180 calls) 1800 minutes of clinical call time (1800/315) = 5.714 = 6 or 7 nurses |
Night Shift at 50% clinical productivity
7pm to 11pm: 20 calls per hour (80 calls) 600 minutes of clinical call time (600/315) = 1.905 = 2 or 3 nurses 11pm to 3am: 10 calls per hour (40 calls) 300 minutes of clinical call time (300/472.5) = 0.952 = 2 nurses (for coverage) 3am to 7am: 5 calls per hour (20 calls) 150 minutes of clinical call time (150/315) = 0.476 = 2 nurses (for coverage) |
|
Day Shift at 75% clinical productivity
7am to 11am: 15 calls per hour (60 calls) 600 minutes of clinical call time (600/472.5) = 1.27 = 2 or 3 nurses 11am to 3pm: 30 calls per hour (120 calls) 1200 minutes of clinical call time (1200/472.5) = 2.54 = 3 or 4 nurses 3pm to 7pm: 45 calls per hour (180 calls) 1800 minutes of clinical call time (1800/472.5) = 3.81 = 4 or 5 nurses Day shift at 90% clinical productivity
7am to 11am: 15 calls per hour (60 calls) 600 minutes of clinical call time (600/567) = 1.058 = 2 or 3 nurses 11am to 3pm: 30 calls per hour (120 calls) 1200 minutes of clinical call time (1200/567) = 2.116 = 3 or 4 nurses 3pm to 7pm: 45 calls per hour (180 calls) 1800 minutes of clinical call time (1800/567) = 3.175 = 4 or 5 nurses |
Night Shift at 75% clinical productivity
7pm to 11pm: 20 calls per hour (80 calls) 600 minutes of clinical call time (600/472.5) = 1.27 = 2 or 3 nurses 11pm to 3am: 10 calls per hour (40 calls) 300 minutes of clinical call time (300/472.5) = 0.635 = 2 nurses (for coverage) 3am to 7am: 5 calls per hour (20 calls) 150 minutes of clinical call time (150/472.5) = 0.317 = 2 nurses (for coverage) Night Shift at 90% clinical productivity
7pm to 11pm: 20 calls per hour (80 calls) 600 minutes of clinical call time (600/567) = 1.058 = 2 or 3 nurses 11pm to 3am: 10 calls per hour (40 calls) 300 minutes of clinical call time (300/567) = 0.529 = 2 nurses (for coverage) 3am to 7am: 5 calls per hour (20 calls) 150 minutes of clinical call time (150/567) = 0.265 = 2 nurses (for coverage) |
More appreciable differences are seen when clinical productivity drops below 75% to 50% during peak calls times on day shift. It is important to emphasize that these numbers represent minimum nurse staffing allotments to support patient safety in this example.
