Time to transfer – the clock is ticking: A quality improvement project

Abstract Background: Aggressive hematologic malignancies such as acute myeloid leukemia and aggressive lymphomas can be challenging to diagnose and manage at community-based hospitals. These diseases often require subspecialized oncologic care that is found at academic institutions. Patients are often transferred to these hospitals for further care, however experience prolonged wait times. This leads to delays in diagnosis and treatment of these aggressive hematologic malignancies, negatively impacting patient outcomes. Thomas Jefferson University Hospital Center City (TJUH CC) is a large, urban, quaternary referral center that provides subspecialty care for patients with hematologic malignancies and serves over 5 million residents in the Philadelphia metropolitan area, southern New Jersey and Delaware. The aim of this quality improvement project was to decrease the median time from patient acceptance to patient arrival at TJUH CC between 04/01/2024 04/01/2025, from 19 hours to 13.3 hours, a reduction of 30%, for patients with concern for aggressive hematologic malignancy. This project was completed as a part of the American Society of Hematology's Quality Improvement Training Institute. Methods: Patient data was obtained from the Jefferson Transfer Center for all patients transferred to the hematologic malignancy inpatient services. Reason for transfer, priority level of acceptance (critical, high, normal, low), and length of time from acceptance to arrival at TJUH CC were evaluated. The Plan Do Study Act method of quality improvement was used for this project. To identify the potential barriers to transfers, surveys were conducted to assess reasons for delays. Respondents included hematologic malignancy attendings and advanced practitioners, oncology fellows, and oncology inpatient nursing staff. Identified barriers included limited hospital bed availability, frequent planned chemotherapy admissions, lack of acceptance level guidelines, and overuse of high priority transfer prioritization. Most patients with aggressive hematologic malignancies were accepted as a high priority (transfer to occur within 24 hours). This is in comparison to critical priority (transfer as soon as possible). Data was collected for balancing measures of all hospital critical transfers to TJUH CC as well as all transfers to the medical oncology teams. Intervention: PDSA Cycle 1 (03/15/2024-11/03/2024) involved a policy change to the accepting practice for patients with aggressive hematologic malignancy. Patients should instead be accepted as critical priority instead of high. PDSA 2 (11/9/2024-01/15/2025) involved the creation of criteria to define the patient population of aggressive hematologic malignancies that warranted critical transfer. These guidelines were widely distributed to accepting providers, fellows, bed management, nursing staff, referring providers at community hospitals, and also published online on TJUH's navigation website. Results: PDSA 1 (03/15/2024-11/03/2024) data showed a decrease in median time to transfer from 19.1 hours to 8.1 hours. 56% of patients were accepted as critical priority and 42% of patients accepted as high priority (compared to baseline data showing 33% vs 67%, respectively). PDSA 2 data showed median time to transfer further decreased from 8.1 hours to 6.5 hours. Percentages of critical priority acceptance increased to 67%, and high priority decreased to 33%. There was no increase in transfer time for all other patients accepted to the inpatient medical oncology services. Evaluation of all hospital critical priority transfers showed no increase in time to transfer. Conclusion: Implementation of departmental guidelines and critical priority transfer criteria for the aggressive hematologic malignancy patient population improved median transfer time from 19.1 hours to 6.5 hours, a 66% reduction in median transfer time. Evaluation of balancing measures showed no detrimental impact of these process changes on other patients awaiting transfer to oncology services, or on any patient transfer listed as critical priority. We plan to further improve the sustainability of this project by continuing to collaborate with the institution's Transfer Center to optimize transfer phone calls. We plan to investigate whether improved time to transfer for patients with aggressive hematologic malignancies impacts their length of hospital stay, time to diagnosis, mortality, and other patient-important clinical endpoints.