Discussion

We surveyed hospitals participating in the SRN about interfacility transfer communication (IFTC) and associated protocols. Of the 54 hospital representatives who responded to the survey, most (72%) reported having a protocol in place for communicating information about MDRO or C. difficile infection or colonization at the time of patient transfer. Respondents from hospitals with IFTC protocols in place reported significantly fewer barriers to communication. Most respondents from hospitals without IFTC protocols in place reported a lack of clarity regarding expectations (80%) and did not know who should be receiving this information (67%). Presence of an IFTC protocol, however, did not affect whether respondents perceived such protocols as having a significant impact on infection prevention or antimicrobial stewardship. Among hospitals with IFTC protocols in place, we observed remarkable heterogeneity in how hospitals implemented IFTC protocols, with only 36% using a standardized form. Our findings suggest that IFTC protocols are recognized as important enough to incorporate into hospital protocols and can reduce barriers to communication at transfer, but optimal implementation strategies have yet to be defined.

Concerns about the lack of standardization in IFTC practices in this international sample of hospitals are consistent with our previous findings from a survey of Oregon hospitals and skilled nursing facilities, where documentation of IFTC has been mandatory by state law since 2014.^{Reference Ellingson, Noble and Tran19} In addition to lack of standardization in communication, more than one-third of respondents reported not knowing who or what department at the receiving facility would be receiving the information about the MDRO or C. difficile infection or colonization status of patients transferred from their hospitals. Other reported barriers to IFTC also align with previous reports, such as a lack of protocols for communicating pending laboratory tests from the transferring to receiving facility, and whether a patient will be accepted for transfer in light of infection and colonization status.^{Reference Walz, Smith, Cox, Sattin and Kind22,Reference Reynolds, Kim and Kaplan23}

One potential reason for uncertainty or confusion about IFTC protocols reflected in this survey is that most SRN members are infection preventionists or hospital epidemiologists, whereas the person responsible for IFTC was most frequently reported to be a case manager. Only 13% reported infection prevention as responsible for communicating this information. Recommendations to more explicitly incorporate infection prevention and hospital epidemiology departments into the IFTC process could improve standardization of processes, confidence in the reporting practices of other facilities, and utility of information about MDRO and C. difficile colonization status once it is received upon patient transfer.

This study has several limitations. First, the response rate of 40% yielded a relatively small sample size. However, there were no significant differences between respondents and nonrespondents in terms of hospital size, academic affiliation, or international status suggesting that respondents were representative of SRN hospitals in these variables. In addition, although relatively small, this is the first study of IFTC across state and international boundaries, so it provides a more expansive view of IFTC implementation practices, protocols, and perceptions than has been published previously. Furthermore, our small sample size limited our ability to meaningfully perform statistical adjustment by hospital characteristics. Finally, our survey respondents were typically infection preventionists or hospital epidemiologists who are not necessarily knowledgeable about every detail of the workflow at their institutions, which could have limited their ability to answer questions about transfer protocols. Future surveys should include larger and more representative samples. Furthermore, agencies responsible for surveillance and infection prevention monitoring, including the CDC or the Centers for Medicare and Medicaid Services, could consider incorporating IFTC protocols into surveys of healthcare facilities.

The spread of emerging infectious pathogens, such as carbapenem-resistant Enterobacteriaceae, Candida auris, and SARS-CoV-2, highlight the positive role of clear communication at patient transfer to prevent transmission between healthcare facilities.^{Reference Lin, Hsieh and Chi24} Required clear and standardized processes for communication of infection or colonization status at patient transfer could mitigate the frequent confusion and anxiety reported by patients and staff during care transitions.^{Reference Gadbois, Tyler and Shield25} This could include using available standardized tools, such as the CDC Infection Control Interfacility Transfer form,¹⁷ and support for future research to understand study feasibility and acceptability of IFTC strategies.^{Reference Ong, Magrabi and Post26} Finally, incorporation of health information exchange mechanisms, such as regional MDRO registries, through state and local health authorities would bolster IFTC by enabling the tracking of patients between facilities.^{Reference Lin, Lyles-Banks and Lolans10,Reference Pfeiffer, Cunningham and Poissant27}