Level‐loading across a health system: A collaborative model for interhospital transfers

Abstract Background Emergency department (ED) boarding at academic health centers delays care and limits access to specialized services. We evaluated a systemwide level‐loading program that transferred clinically appropriate admitted ED patients from an academic health center to affiliate or partner community hospitals with available capacity. Methods We conducted a 28‐month pre‐post electronic medical record‐based evaluation from September 2023 through December 2025 in a multi‐hospital health system. The intervention included universal transfer center registered nurse screening of ED admissions, standardized patient communication, EMR‐integrated transfer tracking, hospitalist assumption of care for transfer‐pending patients, dedicated ambulance coverage, and a transfer receiving unit. Outcomes included transfer volume, ED boarding time, inbound transfers to the academic center, inpatient length of stay, early deterioration, mortality, readmissions, and transfer‐related adverse events. Results During the intervention, 537 patients were transferred. Transfer volume increased from 1.5 to 15.0 patients per week (rate ratio 10.3; p < .01). Among transferred patients, ED boarding time declined from 6.5 h in the first PDSA cycle to 2.9 h by the final cycle. In adjusted analyses, transfer status was associated with 14.8 fewer ED boarding hours ( p < .01), a 16.4‐percentage‐point lower probability of rapid response activation or ICU upgrade within 48 h ( p < .01), and no increase in mortality or length of stay. No transfer‐related adverse events were identified. Inbound transfers to the academic center increased 8% to 16%. Conclusions A multidisciplinary level‐loading program substantially increased interhospital transfers, shortened ED boarding for transferred patients, and expanded complex‐care access without observed transfer‐related adverse events.