Transfer of Low-Risk Patients in Emergency General Surgery: Patient Survey on the Process of Care and Perceptions of Safety

Abstract

Background

Transfer of low-risk emergency general surgery (EGS) patients from a Level I Trauma tertiary care hospital and free-standing emergency department (FS-ED) to an affiliated community hospital saves tertiary care bed days and operating room (OR) time. Patient experience with this process is unknown. The study aims to evaluate the experience and satisfaction during their surgical care episode of transferred low-risk EGS patients.

Methods

EGS patients undergoing non-elective laparoscopic cholecystectomy or appendectomy were prospectively identified between May 2023 and March 2024. Patients were divided into groups based on initial assessment location and transfer status: (1) no transfer; (2) tertiary care-ED to community hospital; and (3) FS-ED to community hospital. Data collected included demographics, ED length of stay (ED-LOS), OR characteristics, and 30-day outcomes. Post-discharge, patients were surveyed on safety perceptions, satisfaction, and overall experience using five-point Likert scales and open-ended questions. Responses were analyzed using univariate and thematic analysis.

Results

Of 216 patients identified, 69 participated in the post-discharge survey (32%). There were no significant differences in baseline characteristics and 30-day outcomes between groups, except for hospital LOS (P < 0.01). Most transferred patients were satisfied with the transfer process (84% from FS-ED; 75% from tertiary care hospital). There were no significant differences in information clarity and feelings of preparedness and safety at discharge by discharge location.

Conclusions

Transfer of appropriate patients improves capacity and resources at tertiary care hospitals without decreasing patient satisfaction or increasing safety concerns. Standardized education on the transfer process is likely to positively impact patient experience.

Keywords

emergency general surgery triage free-standing emergency departments

• What is already known about this topic: EGS patients constitute a significant portion of hospital admissions, and interfacility transfer from tertiary care centers to lower-acuity hospitals have been proposed as method to minimize crowding in high-acuity hospitals.

• What this study adds: Our study demonstrates that low-risk EGS patients transferred from tertiary care centers to lower-acuity hospitals report similar or even higher satisfaction and perceptions of safety compared to those who remain in high-acuity settings, while also identifying communication gaps during the transfer and discharge process as areas needing improvement.

• How this study might affect research, practice, or policy: Our findings support the expansion of triage and transfer systems for low-risk EGS patients, suggesting these processes can maintain or improve patient satisfaction, and highlight the need for better communication strategies during transfers and discharges, which could influence hospital policies and patient triage practices.

Introduction

Emergency general surgery (EGS) patients represent a significant burden of hospital admissions, constituting 11%, totaling more than three million annually.¹ Many EGS patients are safely managed under hospital observation or outpatient care, suggesting that this number actually underestimates EGS utilization of hospital resources. Unfortunately, there is a correlation between heightened hospital capacity and adverse outcomes among EGS patients, including mortality and readmission rates.² Many high-acuity hospitals are consistently at full capacity; thus, opportunities to match appropriate patients with hospital resources are necessitated.

Strategies for EGS regionalization have emerged, concentrating high-risk operations within designated high-volume centers. This centralized approach facilitates the establishment of a triage system, whereby patients with higher acuity needs are transferred to proper facilities, often those with higher volumes and resources, to optimize outcomes.³ Despite the prevalence of interfacility transfer for many high-acuity patients, the same has yet to be achieved for the low acuity patient which could significantly benefit both tertiary care centers and population-level EGS outcomes.

Recently, our group began to evaluate low-risk surgery patients for transfer from a tertiary care Level I Trauma Center and free-standing emergency department (FS-ED) to an affiliated community hospital.⁴ This triage not only maintained high-quality care and outcomes, but also saved bed days and operating room (OR) time at the tertiary care center. While this process has clear benefit for hospitals and for utilization of health care resources at the population level, the individual patient perception of care, including satisfaction and safety perceptions, for low-risk patients undergoing transfer from one facility to another had yet to be evaluated.^6,7

Many factors influence patient satisfaction, and perceptions of safety with processes of care appearing to have a leading role.^5,6 Thus, the aim of this study was to prospectively query transferred EGS patients about satisfaction with the process of care and perceptions of safety. We hypothesize that patients who present to a lower-acuity hospital or FS-ED will have improved perception of the process of care and safety compared with those transfer from a higher acuity hospital and that patients discharged from the community hospital will report greater satisfaction with postoperative instructions compared to patients discharged from the tertiary care hospital. Further, we hypothesize that a high social vulnerability index (SVI) will be associated with worse perceptions of discharge information and understanding.

Methods

This study was focused at a large health care system that consists of more than 1400 acute care centers and 40 hospitals across four states. The flagship hospital is the only Level I Trauma Center in the region. Only 1.3 miles away lies an affiliated community hospital that shares a medical license with the flagship hospital. The community hospital <200 beds, hosts a limited blood bank, virtual intensive care unit (ICU) overnight, and limited surgical subspecialties. The general surgery section that covers elective and emergent cases at both hospitals is made up of eight surgeons, specializing in EGS and advanced laparoscopic surgery. Patients were triaged per the described protocol by Baimas-George et al. The general surgery section that covers elective and emergent cases at both hospitals is made up of eight surgeons, specializing in EGS and advanced laparoscopic surgery. All patients presenting at Carolinas Medical Center Emergency Department (CMC-ED) were screened virtually by one of the EGS surgeons for their transfer appropriateness. These criteria included their hemodynamics, comorbidity profile, diagnostic testing, ED provider evaluation, and potential hospital resource needs as described previously.⁴

Between May 2023 and March 2024, all EGS adult patients who underwent a non-elective laparoscopic cholecystectomy or laparoscopic appendectomy at either the community hospital or the tertiary care hospital were prospectively identified. Exclusion criteria included patients who were non-English speaking, were not able to provide informed consent, or were transferred to the tertiary care center (rarely indicated for patients with significant comorbidities). The patients were divided into three cohorts based on their initial and final location: (1) tertiary care hospital-ED with transfer to community hospital; (2) community hospital-ED with direct admission to community hospital or tertiary care hospital-ED with direct admission to the tertiary care hospital; (3) FS-ED with transfer to community hospital (Figure 1). Patients undergoing transfer had the options of either taking their own private vehicle (friend, family, personal), non-medical shuttles (hospital-funded shuttles), or medical transports (hospital-funded ambulance transfer).

Quantitative data was obtained from the electronic medical record and included demographics, American Society of Anesthesiologists (ASA) classification, ED length of stay (LOS), OR characteristics, hospital LOS, 30-day outcomes, and insurance status. Patient race/ethnicity was analyzed as non-Hispanic white (hereafter referred to as “White”), non-Hispanic Black (hereafter referred to as “Black”), Hispanic and other. ED-LOS was defined as time from ED admission to ED discharge time. OR characteristics included procedure duration and American Association for the Surgery of Trauma (AAST) grade of disease severity (based on preoperative imaging, operative note documentation and pathology report). The 30-day outcomes included any 30-day hospital utilization including ED visit, observation, or inpatient readmission. Socioeconomic status was determined using the social vulnerability index (SVI), a tool that uses U.S. census variables to determine the social vulnerability of every census tract.⁷ Subject census tracts were identified using subject addresses and geospatial information software (ArcGIS).

Survey questions were initially developed with input from the research team, based on feedback shared by patients in the past. Likert scale questions were developed with open-ended questions to obtain addition information about the process from the patient perspective. Patient health literacy was assessed with the Single-Item Literacy Screener (SILS) which has been shown to be a simple estimate for adult health literacy. A Likert response was measured by asking the patients’ need for assistance when reading medical pamphlets.⁸ The survey was also reviewed by the Wake Forest Biostatistics, Epidemiology and Research Design survey team (https://ctsi.wakehealth.edu/service/data-and-design/biostatistical-support).

All eligible patients were identified and contacted by a telephone call within two days of discharge. Three total call attempts were made at the following intervals: (1) first call; (2) second call 10 minutes later—voicemail left; (3) third call several days later. When patient connection was made, a standard information sheet was used as a guide for patient-researcher communication. All patients who verbally consented to participate were given 19 questions—12 questions were based on a five-point Likert scale and seven questions assessed qualitative components of the transfer experience. The questions addressed information regarding clarity, safety, and satisfaction with the admission/transfer process and with the discharge process. For open-ended questions, a thematic review was used to identify potentially common themes among different experiences.

Statistical Analysis

Univariate analyses were used to compare the responses among similar Likert style questions regarding patient safety experiences. For categorical variables, Fisher’s exact test was applied when more than 20% of results had expected frequencies less than five; otherwise, the Pearson chi-square test was used. For continuous variables, the Kruskal-Wallis or Wilcoxon two-sample test was used. The two-tailed P values were calculated for all tests, and P < 0.05 was considered the statistically significant test. SAS 9.4 (SAS Institute Inc., Cary, NC) was used for all data analysis.

The study was approved by the Wake Forest University School of Medicine Institutional Review Board (IRB). The study was reviewed under expedited status and was granted a waiver of signed consent, waiver of consent, and waiver of authorization.

Results

Demographics and Outcomes

During the study period there were 216 patients who met inclusion criteria (of 305 patients). There were no significant differences in median age, gender, ethnicity, or insurance status across groups (Table 1). Patients who either were not transferred or were transferred from tertiary care hospital to the community hospital had a significantly longer hospital LOS than patients transferred from a FS-ED (P < 0.01) (Table 2). There were no significant differences in procedure type, ASA classification, total operative time, or 30-day readmissions between groups.

Table 1.

Patient Demographics.

	No transfer	FS-ED to CH	TC-ED to CH	P-value
	N = 89	N = 59	N = 68	P-value
Age in years, median, n (IQR)	37 (26-55)	40 (28-55)	39 (30-52)	0.65
Female gender, n (%)	61 (68.5%)	38 (65.1%)	45 (66.2%)	0.93
Race/Ethnicity, (%)				0.05
White	48.3%	74.6%	64.7%
Black	32.6%	13.6%	25.0%
Hispanic or Latino	10.1%	5.1%	5.9%
Others	9.0%	6.6%	4.4%
Insurance, (%)				0.52
Commercial & Medicare	71.9%	78.0%	69.1%
Medicaid & Self-Pay	24.7%	18.6%	22.1%
Other	3.4%	3.4%	8.8%
High SVI (>75), (%)	43.2%	20.3%	23.5%	0.004

Abbreviations: FS-ED, free-standing emergency department; TC-ED, trauma center emergency department; CH, community hospital.

Table 2.

Index Encounter Characteristics.

	No transfer	FS-ED to CH	TC-ED to CH	P-value
	N = 89	N = 59	N = 68	P-value
Hospital length of stay (hours), n (IQR)	6.1 (4-9.2)	4.4 (3.5-6.4)	6.8 (5.6-8.9)	0.0002
Total operation time (minutes), n (IQR)	58 (37-73)	53 (34-80)	58 (42-84.5)	0.59
Procedure type, (%)				0.52
Laparoscopic Appendectomy	61.8%	54.1%	52.9%
Laparoscopic Cholecystectomy	38.2%	45.8%	47.1%
AAST grading, (%)				0.09
Grade 1	82.0%	86.4%	73.5%
Grade 2	4.5%	3.4%	13.2%
Grade 3	9.0%	8.5%	5.9%
Grade 4	2.3%	0%	7.4%
Grade 5	8.1%	8.8%	4.6%
30-day readmission, (%)				0.63
Yes	8.1%	8.5%	4.5%
No	92.0%	91.5%	95.5%
ASA classification, (%)				0.52
1 (No Disturb)	15.7%	22.0%	23.5%
2 (Mild Disturb)	50.6%	52.5%	55.9%
3 (Severe Disturb)	30.3%	23.7%	20.6%
4 (Life Threat)	3.4%	1.7%	0.0%

Abbreviations: FS-ED, free-standing emergency department; TC-ED, trauma center emergency department; CH, community hospital; AAST, American Association for the Surgery of Trauma; ASA, American Society of Anesthesiologists.

Survey Responses

Of the 216 patients who met inclusion criteria, 69 patients (32%) were able be contacted and agreed to complete the survey. Of the 69 patients who responded to the survey, 63 were cared for at the community hospital and participated in the post-discharge survey with responses from 18 from non-transfer patients, 26 from FS-ED transfers and 19 from tertiary care hospital-ED. Thematic analysis of their responses is reflected in Table 5. For patients who underwent transfer for their surgical care, patients transferred from the tertiary care hospital to the community hospital reported longer waiting times before ED discharge when compared to those from the FS-ED (Table 3). Satisfaction with the instructions regarding the transfer were similar between groups with the majority of patients being satisfied. Overall satisfaction with the process was also similar between groups with the majority of patients reporting satisfaction with the transfer process. The majority of transfer groups of FS-ED to community hospital and tertiary care-ED to community hospital utilized their own personal vehicles (84% and 65%, respectively). For patients who were not transferred and remained in the same hospital, there were equivalent levels of satisfaction noted for instructions regarding admission (69.3%) and a lower level for the overall process (61.5%, Figure 1). There were overall no differences in the health literacy between transferred patients and direct admitted patients utilizing the SILS single question (Table 4).

Table 3.

Patient Survey Responses Regarding Transfer Process.

	No transfer	FS-ED to CH	TC-ED to CH	P-value
	N = 18	N = 26	N = 19	P-value
Patients can travel from one hospital to another in different ways. Did you travel by				0.2
Private vehicle	-	84.0%	65.0%
Non-medical shuttle (public transit)	-	8.0%	5.0%
Medical transport	-	8.0%	30.0%
Once it had been communicated to you that you were going to go to the community hospital for your ongoing surgical care, how long did you wait until you left the emergency department?				0.02
<1 hour	-	64.0%	25.0%
1-3 hour	-	32.0%	50.0%
>3 hours	-	4.0%	20.0%
Unsure	-	0%	5.0%
How satisfied were you with the instructions on the transfer process, including what to expect during the transfer and how long it would take?				0.94
Very unsatisfied	11.5%	8%	15%
Unsatisfied	11.5%	8%	5%
Neutral	7.7%	16%	15%
Satisfied	23.1%	20%	25%
Very satisfied	46.2%	48%	40%
Did you have any worried about safety during transfer process?				1.00
No		96%	100%
Yes		4%	0%

Abbreviations: FS-ED, free-standing emergency department; TC-ED, trauma center emergency department; CH, community hospital.

Table 4.

Patient Survey Responses Regarding Discharge Process.

	Discharge from TC	Discharge from CH	P-value
	N = 8	N = 63	P-value
The instructions for taking my prescription medications at home were explained clearly to me. This includes instructions on when and how to take medications, as well as any potential side effects			0.70
Strongly disagree	0%	4.9%
Disagree	12.5%	8.2%
Neutral	25.0%	1.6%
Agree	37.5%	32.8%
Strongly agree	25.0%	52.5%
The instructions for taking non-prescription (also called “over the counter”) medications at home were explained clearly to me. Examples of common non-prescription medications include tylenol, ibuprofen, and stool softeners (such as Miralax or Colace). This includes instructions on when and how to take these medications			0.46
Strongly disagree	0%	1.6%
Disagree	12.5%	8.2%
Neutral	25.0%	1.6%
Agree	37.5%	32.8%
Strongly agree	25.0%	52.5%
The instructions for wound care and personal hygiene were explained clearly to me			0.10
Strongly disagree	12.5%	1.6%
Disagree	0%	1.6%
Neutral	25.0%	4.8%
Agree	12.5%	39.7%
Strongly agree	50.0%	50.8%
The instructions for physical activity, including exercise or other activity limitations were explained to me clearly			0.30
Strongly disagree	0%	3.2%
Disagree	25.0%	4.8%
Neutral	0%	4.8%
Agree	37.5%	33.3%
Strongly agree	37.5%	54.0%
Finally, patients are given written discharge instructions. Did you review the written instructions?			0.63
Yes	25.0%	17.5%
No	75.0%	82.5%
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?			0.08
Never	62.5%	52.4%
Rarely	25.0%	27.0%
Sometimes	0%	20.6%
Often	12.5%	0%
Always	0%	0%
Overall, I felt well prepared for my discharge to home			0.85
Strongly disagree	0%	3.2%
Disagree	12.5%	6.4%
Neutral	0%	4.8%
Agree	37.5%	41.3%
Strongly agree	50.0%	44.4%

Abbreviations: FS-ED, free-standing emergency department; TC-ED, trauma center emergency department; CH, community hospital.

Discharge Survey

There were no significant differences between survey responses from all three groups regarding discharge instructions (Table 4). In general, the majority of patients in all three groups reported good information clarity and feeling prepared for discharge. There were no significant differences in discharge satisfaction between patients with high SVI and vs those with low SVI.

Post-Discharge Free Responses

Of the 216 patients, 63 participated in the post-discharge survey with 18 from non-transfer patients, 26 from FS-ED transfers and 19 from tertiary care hospital-ED. There were common themes identified across the three groups regarding their post-discharge experiences (Table 5). In general, improved communication between transfer facilities, clarity regarding patient expenses, and reduced time delays were identified as areas for enhancement. Positive staff interactions and efficient transfer teams were highlighted as strengths, particularly in tertiary care-ED to the community hospital. Overall, all three groups expressed a desire for better communications of follow-up appointments and clinical information for discharge education (Table 6).

Table 5.

Thematic Representation of Post-Discharge Survey Group Participants’ Experience. Outcomes Reported as Counts.

	No transfer	FS-ED to CH	TC-ED to CH
	N = 18	N = 26	N = 19
Are there any parts of your transfer that could be improved?
Communication and Coordination between two facilities	-	5	4
Expenses discussed for transfer options	-	3	9
Time delay for when patients reached to CH	-	16	3
None	-	2	3
What would you say was the most positive aspect during the process of transition from the emergency department to the inpatient room/preoperative holding?
Efficiency of the transfer team	7	8	7
Positive staff interactions	5	4	7
Transportation options available	-	10	-
Satisfactory clinical care provided	1	-	-
Multiple options available for transport	-	-	5
None	5	4	-
Is there any information that would have been helpful to know prior to transition from the emergency department to the inpatient room?
Cost of the transfer	-	3	-
Overall time for transfer duration	2	-	-
Process details	-	5	4
Providing clinical information to the patient	4	2	-
Interfacility handoff	-	-	1
None	12	16	12
How did you decide where to go to get emergency care?
Did not decide	-	3	-
Other reasons	-	2	2
Prior experience coming to the ED	4	3	8
Proximity	7	18	5
Recommendations	7	1	4
What parts of the discharge education could be made better?
Communications of follow-up/Clinical information	2	7	5
Inconsistent information between providers	-	1	-
Clarity and providing reiteration	4	-	1
Speed of the discharge service	1	-	1
Verbal explanations of the discharge education	3	-	-
Discharge restrictions and its reiteration	1	-	-
Other reasons	-	1	-
None	7	15	12
What parts of the discharge education were most helpful?
Being able to have a take-home paper material	3	7	1
Discharge restrictions and expectations	-	-	-
Discharge Medications	1	-	6
Follow-up information	2	-	-
Provider interaction	2	-	-
None	10	18	12
Was there anything about the written instructions that was most helpful?
Completeness of the instructions	-	4	3
Printed paper made it more accessible	14	4	-
Discharge information overall	4	-	6
None	-	17	10
Was there anything about the written instructions that could be improved?
Follow-up information	-	4	1
Discharge restrictions	1	-	-
Other	-	2	2
None	17	19	16

Abbreviations: FS-ED, free-standing emergency department; TC-ED, trauma center emergency department; CH, community hospital.

Table 6.

Discharge Questions by SVI.

	Low SVI	High SVI	P-value
	N = 151	N = 67	P-value
The instructions for taking prescription medications at home were explained clearly to me
Strong disagree	3.57%	7.14%	0.65
Disagree	8.93%	7.14%
Neutral	5.36%	7.14%
Agree	30.4%	42.9%
Strongly agree	51.8%	35.7%
The instructions for taking non-prescription medications at home were explained clearly to me
Strongly disagree	0%	6.25%	0.45
Disagree	8.93%	12.5%
Neutral	5.36%	6.25%
Agree	33.93%	31.25%
Strongly agree	51.79%	43.75%
The instructions for wound care and personal hygiene were explained clearly to me
Strongly disagree	5.36%	6.25%	0.82
Disagree	1.79%	0%
Neutral	5.36%	12.5%
Agree	37.5%	31.25%
Strongly agree	50%	50%
The instructions for physical activity, including exercise or other activity limitations were explained to me clearly
Strongly disagree	3.57%	6.25%	0.85
Disagree	7.14%	6.25%
Neutral	3.57%	6.25%
Agree	32.14%	37.5%
Strongly agree	53.57%	43.75%

Abbreviations: SVI, Social Vulnerability Index.

Discussion

EGS patients are a vulnerable cohort that constitute a significant portion of hospital admissions.² Given escalation of overcrowding and capacity issues at many tertiary care facilities, interventions to counterpose population demands include low-risk patient triage to lower-level hospitals. Prior data demonstrate interfacility triage maintains outcomes and high-quality care while improving resource utilization for tertiary care centers.⁴ This study captures the patient experience of such triage, finding transferred patients have similar—if not higher—perceptions of care, safety, and satisfaction when compared with non-transferred patients. Although patients selected for transfer were clinically categorized as “low-risk,” 14% of transferred patients had AAST grade 4 or 5 disease and 10% had ASA class 3 or 4. The designation of “low-risk” reflects broader clinical considerations rather than any individual data point, including patient stability, anticipated clinical course, and resource needs, rather than comorbidities or disease severity alone.

This study contributes to the growing body of literature and clinical emphasis placed on patient experiences within the health care system. Increasingly health care optimization focus has centered around patient experience and satisfaction, denoting it as one of the three pillars of quality care.⁹ Recent congressional acts have mandated reporting of satisfaction measures and have intertwined patient satisfaction results with provider and hospital reimbursement.¹⁰ Online physician and hospital ratings also hold considerable impact, emphasizing the power of the patient experience in the modern day.¹⁵ Beyond economics and reputation, studies have demonstrated associations between patient satisfaction and quality of clinical care.¹¹ Satisfied patients are also more trusting and more likely to follow care recommendations and less likely to over-utilize health care services, boosting proficiency and outcomes of the health care system overall. Further, there is intrinsic value to quantifying and encouraging patient experience feedback to enhance provider satisfaction and professional fulfillment.¹² Ultimately, it is paramount as health care providers to assess and optimize the patient experience as we continue to aim for highest quality care.¹³

This study demonstrated similar levels of patient-reported satisfaction and perceptions of safety for transferred patients when compared with non-transferred patients. Higher satisfaction rates in the transferred cohort suggest that the triage process is not only beneficial for hospitals and population health, but also for patient experience. These findings may be in part due to the efficient disposition the triage system allowed, avoiding delays due to physician- or hospital-dependent competing priorities inherent in a tertiary care center.⁴ Additionally, the majority of transfer group patients utilized their own vehicle, suggesting that the pre-transfer debrief provided sufficient preparedness among patients to navigate to the final destination. Further, transitions to a lower-level facility may allow for increased provider-patient interactions, given smaller patient census and lower patient acuity commonly found at the community hospital. This takes advantage of matching the right patient with the most appropriate resources and may create an opportunity to offer more personalized care.

Despite findings of high overall satisfaction with the transfer process, our study uncovered other aspects of transfer experience that require intervention. Across all groups, less than 70% of all patients reported being satisfied with instructions on the transfer/admission process. Reasons for dissatisfaction were primarily regarding improved communication—ranging from directions and transportation options to expenses and clinical care. Based on this information, work has begun to partner with local patient experience teams and patient stakeholders to create standardized informational videos and/or brochures for patients to review prior to transfer.

Other studies evaluating patient perceptions of care have found United States hospitals have considerable room for improvement with 63% of patients giving their overall care a high rating and 79% reporting good communication with physicians.¹¹ These ratings and patient satisfaction were found to directly correlate with the quality of clinical care received as well as the ratio of nurses to patient-days. Other studies with similar results have identified areas of high impact to include nursing services, discharge instructions, and communication.^14,15 Given that readmission rates are of long-standing academic interest, are used as quality outcomes, and even have the potential for institutional financial penalties, it is surprising to find discharge instruction communication is still lacking.¹⁶ Beyond influencing readmission rates, poor discharge communication also increases ED utilization and adverse drug events.¹⁷ Interventions for improval suggest pre- and post-discharge interventions including patient education, discharge “coaches,” and patient-centered instructions.¹⁷

The impetus for this work evaluating patient experience was the novel concept of transferring patients to a lower risk hospital. For patients who present to a FS-ED, they are more likely to anticipate the need for transfer if surgical intervention is recommended, which may potentially be very different than patients who initially present to a hospital whose ability to provide the surgical care may be primarily limited by capacity—a factor that may not be well understood by the general public. Prior research has demonstrated virtual triage of surgical patients at FS-EDs to be efficient and safe.¹⁸ In evaluation of our data, responses of patients who underwent tertiary care hospital transfer to a community hospital were compared to patients who were transferred from a FS-ED, under the assumption that patient expectations are likely different and may influence their experience. There was no difference in patient experience between patients who underwent virtual triage and transfer from a FS-ED vs those who underwent evaluation at the tertiary care hospital followed by transfer. There was higher reported satisfaction by patients transferred from a FS-ED, albeit not statistically significant (84% vs 75%). This discrepancy may be due to the significantly increased time to transfer at the tertiary care hospital-ED, with 70% of patients waiting more than one hour in comparison with only 36% of patients from the FS-ED. This data offers further support to the continued development and utilization of FS-EDs with recommendation to consider association with EGS-verified centers.

Satisfaction with discharge instructions was higher for community hospital patients compared to tertiary care hospital patients, although not statistically significant. While the patient-reported satisfaction in this study is higher than national rates, there remains room for improvement with patients describing a need for improved clarity and communication on follow-up appointments and restrictions. Other factors that likely influence patient perception of discharge instructions include variation in communication styles, cultural factors, and/or degree of health care team efforts to ensure understanding.

The impact of socioeconomic status of patient satisfaction is not well defined with most studies finding it to have a minor association at most with patient experience.¹⁹ Our study similarly found no difference between patient-reported understanding of discharge instructions and prescriptions by low and high SVI. We hypothesized that higher SVI may be associated with barriers such as limited health literacy, language, or inadequate access to resources; this was an encouraging finding suggesting that our health care instructions are using accessible and literacy-appropriate communication and resources.

Our study has several limitations that should be acknowledged. First, the study was conducted at a single institution, limiting the generalizability of the findings. However, it is also one of the first studies to examine EGS patient transfer experience and should be a steppingstone to encourage other hospital institutions to implement similar novel triage strategies to mitigate hospitals from suffering from limited capacity and limited OR availability. The sample size included only basic general surgery cases (cholecystectomy and appendectomy) with two transfer facilities, and one direct admit control. Secondly, the study relied on self-reported survey data, which are subject to recall bias and social desirability bias. To minimize survey burden, one question was used to assess health literacy, with no difference by patient group. Thus, we were not able to explore potential confounding variables such as patient education level which could influence satisfaction. Additionally, the interval between hospital presentation at the referring facility and operation start time at the receiving hospital was not reported as there are multiple factors influencing this timeframe—including time to diagnosis/surgical consultation, NPO status, OR availability, etc. Further evaluation of time to OR and factors that impact this may be important components that could influence patient perceptions of care. Another limitation is that our study excluded non-English patients. It is possible that non-English speaking populations may have a different distribution of SVI.²⁰ Notably, English language proficiency is one component of the household characteristic component of SVI. Therefore, our assessment of lack of correlation between SVI and satisfaction with the discharge process may have different findings in a population that was able to include non-English speaking patients. Finally, although our survey response rate was not abnormally low, there was an overall small number of patients who contributed to the patient survey data.

Conclusion

The patient experience within the health care system is a highly emphasized variable, impacting clinical care, facility reimbursement, and health care efficiency. While interfacility transfers may seem burdensome, patients report positive experiences with equivalent satisfaction to non-transferred patients. Future studies will aim to create standardized educational packets for transferred patients to improve upon communication.

Supplemental Material

Supplemental Material - Transfer of Low-Risk Patients in Emergency General Surgery: Patient Survey on the Process of Care and Perceptions of Safety

Supplemental Material for Transfer of Low-Risk Patients in Emergency General Surgery: Patient Survey on the Process of Care and Perceptions of Safety by Min Hyuk Jang, V. Christian Sanderfer, Debra Manning, Maria Baimas-George, HuaPing Wang, Lynnette Schiffern, Brent Matthews, and Caroline E. Reinke in The American Surgeon™.

Footnotes

Acknowledgments

Davyia Burgess and Gerri Chadwick.

ORCID iD

Min Hyuk Jang

Author Contributions

Conceptualization: Reinke, Matthews, Schiffern, Wang, Baimas-George. Investigation: Reinke, Wang, Sanderfer, Jang. Methodology: Reinke, Wang. Data curation: Jang, Manning, Burgess, Sanderfer, Wang, Baimas-George Roles/Writing – original draft: Jang, Reinke, Sanderfer, Wang, Baimas-George. Writing – review and Editing: Sanderfer, Reinke, Matthews, Schiffern, Wang, Baimas-George. Supervision: Reinke.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Grant funding provided by the 2023 Wake Forest MSRP and the 2023 SAGES Medical Student Research Grant, Society of American Gastrointestinal and Endoscopic Surgeons, Wake Forest School of Medicine.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online

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