 This is Think Tech Hawaii. Community matters here. Welcome to Much More Medicine. I'm your guest host this week, Tom Forney. I'm covering for Craig Thomas. And we have a special show for you today regarding transfers within the state of Hawaii. Over the past couple of weeks we've had a chance to talk with EMS directors and some of the challenges and opportunities of transporting patients. And now we get to talk more about how do we get inter-facility transportations. So our guest host today is Nicole Pap. She is the transfer center manager for the Queen's Health System. Thank you for being here. Thank you. I appreciate it. It's good to be here. First I just want to say thank you. The job that you and your team have done has truly been incredible over the past number of years and it's beacon for efficiency. Thank you. Thank you. And as we'll discuss later, there's been a number of other facilities starting to emulate what you've done. Yes. But first I'd like to start the discussion on just some of the uniqueness of Hawaii. You take calls from all over the state. Tell me a little bit about some of the challenges that we have here. For Hawaii it tends to be different from much of the mainland in that we're all islands. So the option of getting on the freeway and driving from Maui to Oahu isn't available. So majority of the time the way people are coming over is by air and that provides its own set of unique circumstances because even if you come as the patient you still have family members that have to figure out how to get here and then when they get here figure out what they're going to do if you're going to be here for several days because then you're looking at lodging, you're looking at food, you're looking at transportation in a multitude of different variables. So transfers really shouldn't be taken lightly in that it's you could just drive over and then go back home the next day or later on that day. There frequently is a lot of planning that needs to take place in regards to coming over here for care. It's amazing how many logistical challenges are involved. You're right, it's for most other places, you know, your local specialists are just down the road or at least within driving distance for here, we're mostly a rural state. You know, we have, there's Honolulu where we have all, generally all the specialists and most medical care can be completed here but outside of Honolulu whether you're on rural O'ahu or any of our neighbor islands, there's limited resources. And particularly, even though our neighbor islands have specialists and there's some specialty care, there's not everything can be covered and so truly there's interesting geographical challenges of, as you said, how do you get from, you know, Maui or say Helicide over to Honolulu to get the care that you need. And as you mentioned, there's the transportation problems of not just the getting to Honolulu but as you mentioned, once you're here, if your family comes over, they need hotel rooms, they need cars, they need, and once you get better and you get treated, you have to go home. You have to go, exactly. And then the follow-up care. It's, so it's fascinating how, just how unique it is for us. Yes, it is very fascinating and it does provide a whole new set of challenges that typically people from the mainland, they don't think about. Hawaii is isolated. There isn't another state that we could just go to. If we can't provide the care here, then it is another getting on a bigger plane for an even longer flight for an even bigger disturbance in your life and your family's life to get the care you need on the mainland. So it's, Hawaii is just different from everyone else and then the simple fact that you are flying over water as opposed to most of the mainland where it is flying over land, which is a different set of circumstances as well in regards to the risk and safety for those air ambulance people. Yeah, absolutely. You're right. There is the safety challenges of, you know, air ambulances, they fly daytime, nighttime. We have some challenging airports in Hawaii for flying in and out of and so there's real risks involved and there's real financial concerns as well and making sure that there's flight insurance, for instance. And so I think that's where your job is and what you've done with the transfer centers is so impressive. You've been able to, I believe you guys were started in 2006, is that right? Tell me a little bit about the history and what prompted the development of the transfer center. The history of the transfer center is there were a group of people that realized there is a need within the state of a centralized phone number that other facilities can call and they're not having to make four, five, six phone calls to get to that one physician that they can have a conversation with in regards to can I send the patient to you? Can you take care of this patient? Is this something that we could do? And we were able to centralize it to one phone number to call and once the call comes into the transfer center at that point we refer to our call list and figure out which specialty it is that a patient needs and gets the sending physician in contact with that other physician and they're able to have that real time conversation on the phone and through other technological advances we're able to send images such as CAT scans and MRIs and they're able to look at them. So it's not so much as let me read the report to you or let me try to explain what I'm seeing on the image. The physicians here can look at it and they can get their own reading on it, they can do their own impressions of it and have that conversation in real time in regards to the care of the patient and whether or not they do have to come over here or not. Yeah, no that's a good point. There's just the overall care coordination is so much better now having the transfer center. For myself as a referring physician I then can speak with the specialist and have a real discussion of does this patient need to go through all of those risks to make it to Honolulu or can they potentially stay in their home community in their home environment and get the care there that they need. You guys have been so successful. I think you guys started out with around 2,500 calls the first year that you had started and what are you guys up to now? 2016 is the last year we have data and that one was just over 7,800 transfers to Queens Punch Bowl. So essentially you've tripled the number of phone calls in 10 years? Yes. That's truly astounding. The number of transfers, correct. Yeah. And it's growing. It is and I think that plays into a couple of things. One, how efficient you guys have been. Two, honestly I think the commitment to Queens patients are all over the state and they realize that and they want to patients who need specialty care and patients who are Queens patients they want them to be able to be available and go to that facility. And so those numbers by itself truly state how effective you've been. I was surprised at how many of those transfers are from neighbor islands. Yes, about 70% of our transfers are from neighbor island and I think one of the good parts about it though is that we're able to look at those numbers and certain service lines are able to get that data and determine does it make sense to them or should they as a responsibility to that population on that island to have a clinic whether it's monthly, weekly to provide the service so that the patients aren't always having to fly over to Oahu for the follow-up care or even for that initial appointment. So I think in regards to the transfers that we have been getting, they've been able to bring access to other facilities and other islands because we are able to just pull those numbers and tell physicians not just anecdotally that I feel like I'm getting a lot of phone calls about this type of case. We're able to say yes, you are. These are the numbers that you're getting year over year and they can make the determination if it makes sense that they should go over there and it's easier just to fly the one person over there as opposed to the patient, the whole family, all the medical equipment, their ambulance crew and I think in the long run the patients prefer to stay at home and get the care at home as opposed to disrupting their lives completely to come over here. Yeah, it's amazing. So not only are we having better efficiency on getting appropriate patients into Honolulu but what you and your team are doing is you're also helping patients stay in their home environment when possible and whether that's having a part-time specialty clinic or working with providers to say hey, let's try to manage the case in this way and if they're getting better, they can stay. And while being open to if the patient is getting worse, okay let's expedite the transfer over to Honolulu. Yes, and that's been one of the pluses that we are able to have that physician-to-physician communication and sometimes the specialists or just the intensivists over at Punchbowl are able to talk to those referring physicians and give them suggestions that they can try for care in regards to keeping the patient there and then reassess the patient in four hours, six hours, 12 hours, whatever the case may be. And what may have been a transferable case a year to three years ago today is now being kept on those islands frequently and it is because of those conversations where the physician on the neighbor island doesn't feel like they're just by themselves having to figure out how to deal with caring for this patient. They're able to call us and we have some physicians that are able to provide suggestions on how to best care for the patient. Yeah, it's truly been impressive. And so I think where the next steps that we take with this are what you said is how can we best kind of triage the patients to who needs to come versus who potentially can stay in their home environment. And so with the, I think of all the phone calls that you guys receive, I think over 50% of them or so actually make it over. Yes. And so that's, I remember, so I think if we play the numbers, that's about 20 phone calls or so per day or at least initial requests. We are averaging at about 26. It's like last daily, yes. And so that means probably 10 to 12 patients from the neighbor islands are coming over. And I know we've been focusing on neighbor islands, but this is just as applicable to patients here on Oahu. If you're on central or north shore or on the west side, it's just as almost as rural as the main difference is you can hop in the car and drive as opposed to. You can go back home and feed the kids dinner if you need to while the other spouse or whatever is still in the hospital. So it's not as much of a challenge in the transfers that are on Oahu, but there are just as many and some of the north shore and central Oahu, they're just as limited in the resources as neighbor island. And so frequently we have those transfers that take place. And again, there are times where we have those same conversations with them of, hey, keep an eye on this, this, and this. Check this, this, and this. And maybe you can at least keep your patient in your community. And that way, especially for the elderly that don't have as much support necessarily sometimes to get the spouse down here and back home, it makes it easier for them. Or even the caregiver who now is split between coming into town and going to the north shore to keep an eye on two people that are in two different locations and some of the traffic barriers here. It is very true. Well, thank you, Nicole. We're going into break. I thank you all for watching Think Tech Hawaii, much more medicine, and we'll talk with you after the break. This is Think Tech Hawaii, raising public awareness. We're going to tell some veterans of all abilities to escape gravity right here on Earth. Search diveheart.org and imagine the possibilities in your life. I said I could play, so I ain't chance to play at all. That's my life. I love music. So we're doing it. Hello, everyone. I'm DeSoto Brown, the co-host of Human Humane Architecture, which is seen on Think Tech Hawaii every other Tuesday at 4 p.m. And with the show's host, Martin Desbang, we discuss architecture here in the Hawaiian Islands and how it not only affects the way we live, but other aspects of our life, not only here in Hawaii, but internationally as well. So join us for Human Humane Architecture every other Tuesday at 4 p.m. on Think Tech Hawaii. Hola. Welcome back to Much More Medicine. I'm your host, Tom Forney. And today, I have the opportunity to speak with Nicole Papp, Operations Manager for Queen's Health System and also Manager of the Transfer Call Center. In the last segment, we were talking about some of the history of the Transfer Call Center and how it's blossomed into a very busy, honestly, very efficient service and some of the challenges of trying to weigh, getting patients to Honolulu versus allowing them to stay in their home communities. And so to recap, you guys are taking about 26 requests for transfers per day at this point. And that's from all facilities across the state. And your success has been impressive. Thank you. We'd like to talk about how the more special cases on when should we transfer patients? And I know earlier we were talking about some of the costs and barriers and our goals for keeping patients some at their homes. And there's also challenges of what do you do when, say, a patient is too tall to fit in the airplane or too large to fit in the airplane? Could you share how that works? For a lot of those cases, it frequently involves a number of people to get involved. And for the most part, there are size requirements for the air ambulance fixed wing that do come over. And when the patient is not able to fit into those planes, at that point, it's the Coast Guard that gets involved in the C-130 that brings the patient over. And that one ends up becoming more logistically difficult in that all of a sudden you're not just calling one company to, hey, go pick up this patient. This is the story we have on them. You're getting the federal government involved. And they have been great though. They're aware that this does exist and they have been available. Typically, these will take a little bit longer because there are logistics that they have to overcome to get the plane over there, make sure they have the right crew and the rest periods and all that stuff for the crew and then bringing them back over here. But it happens often enough that it's not a surprise when those calls happen and we know what to expect and know how the procedure goes for that. But that is a whole other layer in some of the population that we are dealing with that we have certain size requirements and sometimes we have to think outside the box of how are we gonna get you over here? And then once you're over here, the certain requirements that we need to make on our end. And it ends up working out fairly well that we're able to adjust for that as well. And we sometimes need a couple of hours to situate the room differently for these patients. And so having that extra time from the Coast Guard does work out that we're not having to hustle and last minute do some last minute changes. We're able to get everything in place and have a seamless transfer occur for the patient. Again, the coordination of care that your department does is truly amazing. Yes, thank you. It's a lot of calls. Civilian to military involvement for transfers is not easy. And my understanding, the Transfer Call Center originally started as we're taking traumas specifically. And as... Because Queens is the primary transfer center within the state. My understanding is you guys are never close to traumas. And I believe for certain types of heart attacks as well as acute strokes also. Correct, yes. We are open 24-7 for those for trauma strokes and STEMIs. And we have specific protocols outlined to rush those cases in that we have phone numbers that we call to directly get a physician on the phone in order to have that physician-to-physician communication because a lot of these cases are time sensitive. And we don't want to spend unnecessary amounts of time paging people, waiting for them to call back. So we do have phone numbers to call them. Or if we are paging them, it is within 911 page so they know it is this type of specific emergency that we're dealing with and to call us back quickly. So we're able to get A, is the patient coming or not? And B, how fast do they have to come? Because certain ones, yes, they are gonna come regardless, but whether it's emergent in that they're gonna go to surgery or some sort of procedure right away, or is it something that they are coming because they need the higher level of care, but they don't need a procedure right away so it can be through the normal transfer processes. But for those emergent ones, then again, it's calling all the available resources to see who can move the patient the fastest to get them here first because they do have something that is time sensitive and we are respectful of that and want the patients on the neighbor islands to get care that is just as good as if it was happening here on Oahu. So we do what we need to do and do what we can to get the patients here quickly for those good outcomes and positive outcomes. And I wanna belabor that point a little bit. So as when I'm working in a Merge Department, if I have something that comes in that's critically time sensitive, I know that if I pick up the phone and call you, I have access to the accepting physician almost instantaneously, at least within a couple of minutes and we then can get that patient transferred and get the appropriate care that's needed. That is a big change from what it was previously as you mentioned of multiple phone calls, multiple pages and a prolonged time delay. And that's not what you want in that time sensitive critical patient. Me as a doc, I need to be focusing on the patient and getting them stabilized and getting them ready to get them transferred for the appropriate care. And so it sounds like on your end, it's similar. You know that patient needs to get over there and so you wanna get that accepting doctor so that you can then start working on, okay, let's create space and beds and how can we get them there. But even for the non-time critical ones, there oftentimes is a lot of just physical challenges that you guys have to go through. And so helping to facilitate the physician-to-physician communication then allows you to work with bed control and the other services to find space for those patients. For both the urgent transfers and the non-urgent ones, it ends up being the same thing because as you know with the code strokes, we have the telemedicine program and you have direct access to some of those no-intensivists that will kind of walk you through of, okay, yes, the patient needs to come over now or the patient can stay there or if you're giving TPA, they'll walk you through the guidelines of making sure you're giving the right dosage and making sure you're doing everything appropriately and correctly. So even for those ones that need to come over now, you have that physician and you have those options where you can talk to them and they can tell you, give them X, Y and Z before sending them or no hold X, Y and Z because of this or that. And same thing with the other transfers that aren't quite as urgent and emergent that the physicians can say, keep giving them fluids or try this antibiotic or try this medicine or that one and you guys can keep the patient stabilized a little bit longer and on our end, it allows us to do any shifting we need to do with beds to open up the appropriate bed for the patient as opposed to just inundating the emergency department, we try to get them to the right bed so they're not moving multiple times within the hospital. We try to get them to the right bed the first time. And I think that could be the overall model of right care, right place, right time. And truly your department has embodied that. I'd like to talk about cases that shouldn't go. I know we've talked about kind of encouraging patients to stay at their homes, but then there's another segment of transfers that maybe just shouldn't have been transferred. That one's, it depends on kind of what it is that's going on. Sometimes we have those cases that are futile where should they come or not because we know what the end result is gonna be and bringing that patient and the one person that gets to ride on the plane with him here to deal with some of those outcomes while the rest of the family is still on a neighbor island trying to get here. And especially when those happen at the middle of the night, it's not like you can just go to the airport and in an hour there's gonna be a flight over. Frequently you're waiting until morning and you have that one person that's here and we have our chaplains and everything available, but at times some of those things need to be discussed on the phones. And then there's also the other ones of is it just easier as opposed to sometimes working through the barriers that are on some of the neighbor islands of getting whatever care it is that that patient needs. And I think a lot of times we try to help facilitate the physicians on the other islands to help the patient stay there and offer suggestions of what they can do to try to keep the patient over there as opposed to when it was just easier to call you guys and send the patient over. Because then there's still the whole other backend of now we have to get the patient back as well as any family members that are here and the associated expenses to that family of having to come over here, especially when they aren't having limited resources. And particularly with those futile cases, it's we're putting other patients or other people at risk. You still have to, the air medic team still has to fly over. And sometimes that's at night and rain, windy weather. And I think for the most part all of us, if it's futile care, we would rather be with our friends and our family in our home environment. And so being mindful of not transferring somebody in those cases. And so again, I know I've said it a couple of times now, the work that you all have done as far as helping to facilitate getting patients to, well I say Honolulu, but you also are the transfer center for all of Queen's Health System. And so if a patient arrives and say Kona or Hilo, and they can receive appropriate care at North Hawaii in Waimea, you can then facilitate the patient getting transferred over there. Or if somebody and why and I need to get transferred to West Oahu, you also help with those transfers. So it's not just a punch bowl, it's all over. Yes, that's recently within the last year, we centralized the transfer center, whereas before North Hawaii was having to do their own transfers, and we kind of looked at everything and said, how about if everybody just calls one number to transfer the patients to all of the Queen's Health System numbers. And I think it's made impact on some of the other facilities in that you're able to free up that either house supervisor or the person that was in bed control there to focus more on their job and not have to focus on how many different people am I having to call, how many different times during the day and plus the hours that they're there or not there or are they available or not available because frequently it's one person. And if they're in the middle of responding to a code, they can't take that transfer center call and sometimes those codes can last a very long time. And with the calls being able to come to us, we're able to get in contact with the physicians that are over at those facilities. And I know for why and I, we're able to keep a lot more patients on the West side. And again, it's avoiding that traffic coming into Oahu and the shorter drive for them. That's very helpful. So thank you for helping facilitate transfers of all kinds across both neighbor islands as well as on Oahu and continue to take those multiple phone calls every day and I would like to end with saying that there's, you guys have been so successful that multiple other hospital systems throughout the state are starting to emulate the call center that you've developed. Yes. And so thank you. And so I would like to thank you all for watching Think Tech Why, much more medicine and we will see you next time. Aloha.