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Thresholds for requesting transfers to tertiary care were influenced by perceptions of the current illness and differences in perceptions of the initial hospital and tertiary care centre
  1. Laurel E Radwin, RN, PhD
  1. University of Massachusetts Boston
    Boston, Massachusetts, USA

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Q Why do patients or their surrogates request transfers to tertiary care?


Qualitative interview study with ethnographic decision modelling.


A large regional tertiary care centre in Baltimore, Maryland, USA.


Purposeful sample of 32 patients 37–92 years of age (mean age 64 y, 53% women, 87% white) (or their surrogate decision makers) who were transferred to tertiary care. Exclusion criteria were patients transferred as part of a regionalised care system, including psychiatry, trauma, and neonatal intensive care patients; and patients transferred for insurance purposes.


Semistructured interviews were conducted during the patients’ hospital stay at the accepting hospital within 2 weeks of transfer. Questions addressed patients’ roles in decision making, perceptions of the decision making process, reasons for transfer, and factors influencing the decision. Data collection and analysis used an iterative process. Ethnographic decision modelling was used to develop an influence diagram of the decision to request a transfer.


The threshold for requesting a transfer was influenced by perceptions of the severity, importance, and lack of resolution of the current illness; relationships and experiences with tertiary care; and perceptions and experiences with quality of care at the initial hospital. (1) Perceptions of illness. Perceptions that the current illness was severe, important, or had remained unresolved for too long contributed to a sense that a transfer would be worth the effort and discomfort. (2) Perceptions of tertiary care. Participants who had previous positive experiences with the tertiary care centre reported that they were more likely to request a transfer sooner or if the illness was less serious because they felt knowledgeable about the option and were familiar with the tertiary care centre. (3) Perceptions of the initial hospital. Participants’ negative perceptions of the initial hospital related to the inadequacy of resources or expertise, poor patient-physician communication, and lack of communication or leadership among physicians. As well, general concerns about the quality of care included safety issues such as the potential for errors, perceived mistakes during the current or previous hospital stays, and misdiagnosis or lack of diagnosis. 2 types of barriers at the initial hospital affected the threshold for transfer requests: perceived resistance from referring physicians and relationships with the referring hospital and physicians (ie, they trusted their physicians and wanted to “give them a chance”).


Thresholds for patient or surrogate requests for transfer to tertiary care were influenced by perceptions of the severity, importance, and lack of resolution of the current illness; negative perceptions and experiences with quality of care at the initial hospital; and familiarity and positive experiences with tertiary care.


Patients’ perceptions of their healthcare experiences are increasingly recognised as important indicators of care quality and are included in both the annual US National Healthcare Quality Report and the National Patient Survey undertaken by the UK Healthcare Commission. Dy et al found that patients’ perceptions of hospital care influenced their decisions to request transfer to tertiary care hospitals. These findings highlight the importance of patients’ perceptions of care within the context of their other decisions.

In the study by Dy et al, patients’ perceptions of inadequate physician expertise, poor physician-patient communication, poor physician-physician communication, and negative perceptions of local care quality were antecedents to a patient’s request for transfer. The authors did not identify whether patients’ requests for transfer were influenced by perceptions of nursing care. For example, did patients’ concerns about safety, errors, and mistakes include concerns about nurse competency? These questions are relevant because patients’ perceptions of hospital care quality are best predicted by their perceptions of nursing care.1

A parallel emergent literature showed that patients characterise high quality patient centred nursing care by effective patient-nurse and nurse-nurse communication and high levels of nursing technical competency and skill.2 In one study, excellent patient-nurse communication, according to patients, was exemplified by caring, attentiveness, and rapport. Excellent nurse-nurse communication enhanced care coordination and continuity. Moreover, patients identified and evaluated professional nurse competencies as indicators of care quality.3

Dy et al recommended that patients’ perceptions of care should be included when considering quality improvement targets. Their findings reinforce the importance of asking patients their perceptions of the quality of nurses’ communication, care coordination, and competence. Moreover, inclusion of such questions in national data sets would allow more targeted and effective interventions towards improvements in the quality of nursing care specifically, and hospital care more generally.


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  • For correspondence: Dr S M Dy, Bloomberg School of Public Health and School of Medicine, Johns Hopkins University, Baltimore, MD, USA. sdy{at}

  • Source of funding: not stated.

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