3 Risks Must Be Considered When Transferring Critically Ill Regional Patients to Metro Area Hospitals

(Not a case in this article.)

In the last half-month, two seriously ill infants treated at a medical center in Hualien were automatically discharged by their parents and transferred to NTU Children's Hospital more than 100 kilometers away, which aroused public concern and discussion about the appropriateness of such transfers. Is the reason for this a response to the lack of medical capacity in the East, or is it a misperception and expectation of medical care on the part of the patient (the patient and his family)?

Let's first understand the difference between transfer and referral. Simply put, referral is the process by which a physician or medical team evaluates a patient's condition and determines that the condition is beyond the capabilities of the original medical institution, and recommends and arranges for the patient to be transferred to a different medical institution for further treatment.

If it is not the case, and the patient has requested to be transferred to another medical institution for some reason, then this is a "transfer", and the patient will usually have to go through the "AAD (Against Advise Discharge) process. The recent transfer of two critically ill babies from Hualien to the north was a case of transfer.

For every case like this, there is a dilemma of medical ethics. On a case-by-case basis, the circumstances of each case are not exactly the same, and it is impossible for those not involved to fully understand and appreciate the situation, so in the end, we should respect the patient's decision.

As in this case, the Hualien Tzu Chi Hospital has expressed that it has experience in neonatal medicine and is the only hospital in Hualien that is qualified to evacuate newborns with severe illnesses, "but with empathy, the family and the physician's considerations are different, and in the end, the family insisted on the decision to transfer to another hospital, which is something that the hospital is not in a position to comment on, and which it will respect.

In fact, this type of transfer case is not only in the east, but occurs almost every day across Taiwan, but it has not attracted as much attention as the two cases in the recent news.

I'm worried about the copycat effect, which creates an imbalance between hospitals at all levels

I'm worried about the copycat effect, which is that when these particular cases are disclosed in the media, they cause more patients to follow suit, lose confidence in their regional medical institutions, or have higher hopes for the metro area medical centers and travel farther away from their home base for no apparent reason, resulting in the Metro Area Medical Centers being overcrowded, and the non-metro area medical centers being overcrowded. This has led to negative outcomes such as overcrowding of metropolitan medical centers, inability of non-metropolitan healthcare to thrive, and imbalance of hospitals at all levels.

This article does not focus on individual cases, regions, or hospitals, but rather aims to present a broad range of relevant aspects of this topic for the medical community and the general public to consider.

Taiwan's healthcare system has no limitations on patients' choice of care, and with its small geographic size, many medical centers, and convenient transportation, the ease of access to healthcare for the public is probably "unparalleled".

The advantage of this system is that it provides a very high degree of proximity and the ability to transfer patients to other hospitals in pursuit of better care; however, the disadvantage is that the value of medical expertise is likely to be overlooked by patients, and the risks associated with patient care will be underestimated.

Perhaps we can start by thinking about the patient's perspective. What are some of the reasons why a patient might not want to stay at the same institution and seek care at another facility? Here are 3 possibilities:

1. Deep-rooted beliefs

The perception that hospitals in the region are not as resourceful and capable as the big hospitals in the metro area is a common one, and it is true to some extent.

Here's a quote from the news report:

Song Wenju, director of the Department of Pediatrics at Taipei Veterans General Hospital, believes that the biggest problem with Taiwan's healthcare is the uneven distribution of resources, which are concentrated in the western half of the country.

Xia Shaoxuan, director of the pediatric intensive care unit at Linkou Changgeng Hospital, also admitted that even medical centers have different manpower, strengths, and equipment, and that medical centers with children's hospitals are stronger when it comes to the treatment of serious pediatric illnesses.

Even if the disparity in the distribution of medical resources or hospital specialization exists, what conditions are appropriate for referral? Where to transfer to? are also not easy judgments.

2. The patient loses confidence in the doctor in the medical process or in the interaction between the doctor and the patient

The doctor-patient relationship is very delicate, and it is almost impossible to have a "perfect doctor" who is liked and trusted by every patient, not to mention the medical team. There is a saying in Taiwan that "the doctor's fate and the patient's blessing" means that the relationship between doctor and patient has to be catalyzed by fate, and it cannot be forced.

The wife of a friend of mine was diagnosed with an uncommon small bowel cancer in the gastroenterology department of a regional hospital, and was immediately referred to a general surgeon in the hospital who had good skills and experience to prepare for the surgery. However, during the pre-surgical briefing, the patient felt that the surgeon was not very patient in answering the questions, and decided to transfer the patient to another medical center for treatment.

3. When there is no progress, the patient is anxious, and if a friend or family member suggests something else, the patient is motivated to give it a try.
I heard of an elderly patient who was admitted to an intensive care unit with pneumonia, and whose condition continued to deteriorate. The physician recommended intubation, which made it difficult for the family to transfer to another hospital because they heard from a friend or family member that a certain physician at a certain medical center was able to treat the patient without intubation.

For these reasons, it is understandable that the patient's family would want to see the patient receive better care, and there is nothing wrong with giving the patient the opportunity to choose a medical institution that they trust and feel comfortable with.

Consider the risks of transferring a patient to a hospital

Any transfer involves risks that must be considered, especially in the case of a critically ill patient, and there are many risks associated with long-distance transfers, including:

1. The patient has to bear the risk of a change in his or her condition

Patients with acute and severe conditions are inherently fragile, and their conditions can deteriorate at any time. The process of transferring a patient to a hospital, where the medical equipment and staff are not as well equipped as in the hospital, is very risky, so the ambulance must be accompanied by nursing or ambulance staff. Even so, there are occasions when a patient's vital signs deteriorate during the transfer process and immediate emergency care is required.

2. Transportation risks for patients and ambulance crews during transfers

Last year, a patient on Lanyu Island was urgently transferred to Taitung via an Air Force helicopter, but due to weather conditions and poor visibility at night, the helicopter crashed, killing the patient, the paramedic, and the pilot on board. A few years ago, an ambulance from the Hualien Fenglin Township will be referred to the patient to Hualien Tzu Chi Hospital emergency, on the way to be another car hit by a car overturned, the patient and the driver was injured, accompanied by the nursing staff passed away.

3. The risk of successive diagnosis and treatment

The patient with small bowel cancer mentioned earlier was referred to the medical center, and after being transferred to the hospital, a variety of tests were re-examined to make sure that the diagnosis was correct and to arrange for surgical intervention, which had already been carried out for several months, and passed away due to a sharp decline in his condition after the radiation treatment, which, the family thought, would not have delayed for several months if he had stayed in the original hospital to undergo surgery and treatment. The family believes that if they had stayed in the original hospital to receive surgery and treatment, it would not have dragged on for months, and they are very remorseful for the decision to transfer to the hospital.

Mr. Hao Mingyi, a former national policy advisor, wrote a detailed account of his experience with his wife, who suffered from an unknown illness, and went through 3 or 4 major hospitals and tried various therapies. However, due to the physician's lack of certainty and the way he described the case, he did not feel confident and decided to be transferred to another hospital, which resulted in a lot of wasted time and effort.

With Taiwan's medical standards and regional healthcare networks, regional hospitals and medical centers should be able to handle the vast majority of cases, with only a very small number of rare diseases or special cases requiring referrals to other regional medical centers for more specialized medical teams to handle.
Many acute and critical care cases are focused on stabilizing the patient's condition and giving the patient a chance to recover, so in most cases, it is better to "move the needle" than to "stand still".

If the attending physician believes that the benefits of a referral far outweigh the possible risks of staying in the same hospital, he or she will take the initiative to advise the patient and make arrangements. It is believed that physicians and healthcare organizations make clinical decisions about whether to refer patients for treatment or care in the best interest of the patient. Patients and their families are encouraged to communicate with their physicians in depth, to share their concerns and ideas, and to listen to the physician's advice before making a decision.