New process to transition patients to home hospitals is working


It’s working.

A process designed to better move patients from tertiary care centres to their home hospitals is being trialled and is getting some great reviews from those involved.

Team 3 of the Saskatoon Health Region Better Every Day 14 Day Challenge was charged with coming up with a way to fast-track the implementation of a new patient transition process designed by a Rapid Process Improvement Workshop (RPIW) held at the end of January.

Moving patients from hospital to hospital is a complicated process. Traditionally, it has started with a physician deciding that a patient who is either from the rural part of Saskatoon Health Region, or from another region all-together, is ready to make the move from one of Saskatoon’s tertiary care centres to their home hospital. This would set the transition wheels in motion. However, that didn’t always mean the patient left the tertiary care centre right away.  Issues with bed and medication availability, or a lack of supplies, equipment or services  in their home hospital could delay for several days.

“When our team tracked the time from when a doctor said a patient could go and when they actually left the facility, it was 47 hours,” noted Patti Simonar, co-lead of Team 3.

After studying the issue in the RPIW, the recommendation was to start communicating with a home hospital about a possible transfer three days in advance of when a patient is expected to leave. This new process will ensure that everyone is ready for the transfer – from the patient to the ambulance service to the receiving hospital – and will avoid transfer delays.

For patients and their families, the earlier notification will help ensure a timely, safe transfer. It will also make sure that healthcare personnel at the receiving hospital have the information they need well in advance so that they can ensure the necessary supports are in place.

The new process will also enable more consistent physician to physician communication.

Key to this new process is the creation of a new position, a transition officer to act as the Region’s central point of contact regarding transfers. This office will keep track of patients about to be transitioned, communicate with hospitals involved in proposed transfers, keep physicians in the loop and help arrange ambulances.

Team Three managed to get a person set up to act as the transition officer this week and do some testing of the new process using some units at Royal University Hospital.  One of those first tests took just 3 hours and 27 minutes between a patient being ready to leave and actually leaving the facility – a dramatic improvement.

Home hospitals are also giving good reviews of the process. For instance, the pharmacy team in Humboldt thanked the team for the information provided to them ahead of a transfer which allowed them to ensure the right supports and medications were in place.

Daily huddle calls between the repatriation office, other regions, and inter-regional offices began last week, and replication of the process to other tertiary care centres will be looked at in the next 30 to 90 days.

“We will be working with units at RUH to work through the process and ensure it is working well here,” said Simonar. “The testing is allowing us to find out areas we need to improve, and make the appropriate adjustments.”

For more stories and information about the Better Every Day 14 Day Challenge, visit

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