PIP Spotlight: Reducing Inpatient Acute Care Transfers at an Inpatient Rehabilitation Facility

ABPMR diplomate Amirpasha Ehsan, MD, submitted this Practice Improvement Project (PIP) after being personally requested to start a quality improvement project to lower the acute care transfer (ACT) rate at his hospital, Encompass Health Rehabilitation Hospital of Bakersfield located in Bakersfield, CA. The hospital recognized that ACTs from inpatient rehabilitation caused an interruption of functional progress and were related to negative overall outcomes.

Dr. Ehsan completed his project alongside a team of individuals from admissions, nursing, therapy, and rehab physicians at Encompass Health Rehabilitation Hospital of Bakersfield. Dr. Ehsan and the team met their goal of reducing the ACT rate by implementing three protocols.

Thank you for sharing your PIP, Dr. Ehsan!

The PIP Spotlight is a periodic feature on News Center to highlight exemplary Practice Improvement Projects submitted by your fellow diplomates (or residents) for maintenance of certification (MOC) Part IV credit. Diplomates can use the PIP Spotlight as a tool to plan their own PIPs or as a way to connect with other diplomates doing similar work.

What is the problem you are trying to solve?

After accepting my position as medical director of a freestanding inpatient rehabilitation facility (IRF), I was requested to personally initiate a quality improvement project to lead a team and develop interventions to help lower our ACT rate. The ACT rate at our hospital in May 2019 was approximately 17%. The goal of our nationwide corporation is for the ACT rate to be less than 10%.

The goal of our committee was to lower our ACT rate to emergency rooms for any unnecessary transfers. ACTs negatively impact our hospital by interrupting the continuity of patient care and therapy, also causing anxiety and distress for patients which may lower our patient satisfaction scores. These transfers also increase the overall cost of care. Potential causes of unnecessary ACTs include suboptimal communication between nursing, therapy, and physicians. A transfer can also be caused by not identifying early signs of medical complications that could be treated early before patients become medically unstable.

When patients are transferred to local acute care emergency rooms, patients more often are admitted at that hospital for observation for more than three midnights, which by Medicare criteria is considered an acute care transfer requiring discharge from IRF. Some of these patients are sent to the ER for non-emergency reasons and require services not available at our IRF, such as IVC filter placement, paracentesis, and imaging studies. Thus, the lack of available non-emergency care services is also a cause for our increased ACT rate.

Our supervisors and key individuals met as a team regularly. The team was composed of individuals from several departments such as admissions, nursing, therapy, and rehab physicians. Additionally, our CEO and quality director would help with guidance on current hospital policies.

What data (objective measurements) do you have that supports this as a problem?

Our ACT rate for March 2019 was 18%, 15% in April 2019, and 17% in May 2019. ACTs included in the rate were patients that were transferred to an emergency room and subsequently admitted for more than three midnights per Medicare criteria. Patients who were sent to the emergency room but returned before three midnights were not included in the rate. Our average daily inpatient census ranged around 60–65 patients. The corporate national ACT rate averaged 12-13% at that time. The benchmark goal for hospital corporation is 10%.

ACT rates were optimal in Spring 2017, ranging from 9-10%. Since that time, many new staff members from therapy and nursing have been replaced. Also, two new physicians have credentialed with our hospital. Compared to our previous ACT rates in 2017, ACT rates in 2019 increased considerably. Overall CMI for patients in 2017 and 2019 stayed the same at 1.35-1.45 on average. The same spectrum of admitting diagnoses such as hip fractures, acute strokes, postoperative spinal surgery, and medically complex patients were admitted in 2017-2019.

The team determined that many ACTs within the spring of 2019 may have been avoided with proper coordination of care, early identification of medical complications, and proper triage of patients to the appropriate level of care required.

What is your opportunity statement? State the goal you hope to achieve.

Our ACT committee aimed to reduce ACTs to less than 10% by the end of 2019. Goals are to implement triage protocols and procedures for staff and physicians to follow to help mitigate unnecessary ACTs while optimizing patient care.

What is the underlying cause of the performance/quality problem?

The underlying cause of our higher ACT rate compared to previous years had been determined to be caused by suboptimal communication between disciplines and late identification of risk factors for acute care transfer. Our team also identified limitations in resources for performing non-emergency procedures that our IRF does not offer. Identification of community resources for assistance in-patient care was determined. The Medical Director set to establish new relationships with outpatient care facilities and physicians, avoiding ACT to emergency rooms which drive up costs, delay care, and cause unnecessary discomfort to patients.

What change(s) did you implement?

1). Acute care transfer triage protocol: A step-by-step guide for nurses and physicians to follow for patient issues that may need interventions or management not offered at our IRF. The goal is to limit the ACT rate and transfer patients to the most appropriate level of care. This protocol included recommendations on management and available community resources outside of the emergency room. Patient’s needs can be quickly identified and patients can be transferred to the emergency room, direct transfer to a partnering local acute care hospital for non-urgent expedited treatment. This local hospital has agreed to deliver care for our non-emergency patients in the shortest time required, helping to avoid a three midnight hospitalization.

Step 1:

  • BAR-Background, Assessment, Recommendations
  • Nursing to please discuss recommendations with physician and charge nurse before transfer

Step 2:

  • Determine higher level of care needed

A) Emergency services

  • Transfer to ER
  • Typically reserved for: Cardiac emergency, Pulmonary emergency, Acute unresponsiveness, Septic shock

B) Direct transfer to Heart Hospital MedSurg/telemetry level of care (See separate protocol, implementation #2)

  • Typically reserved for: Severe electrolyte abnormalities, Severe vital sign abnormalities, Stable arrhythmias requiring telemetry, Stable medical conditions requiring urgent specialist evaluation. Physician to call Dr. Sharma to get approval for transfer. Once patient approved, please call Bakersfield Heart Hospital Admission to obtain bed.

C) Non-urgent procedure

  • Typically reserved for: Paracentesis, Thoracentesis, IVC filter placement, Percutaneous drain placement, Gastrostomy tube placement, Treatment of vertebral fracture (kyphoplasty/vertebroplasty), Fistulogram/dialysis, Portacath placement, Renal/urological procedures, Biliary/bowel duct procedures
  • Gastrostomy tube Replacement: Please call physician immediately if G-tube falls out. Place Foley catheter through lumen and inflate bladder. Place traction on Foley to make air tight seal. May consider NGT placement to continue feeding until IR center appointment


  • Adventist Health Interventional Radiology outpatient center. Call IR Coordinator Nicole for appointment (XXX) XXX-XXXX. May ask for extra time slots at Quest on Stockdale Monday, Wednesday, Thursday. Ask for same day procedure if possible
  • Kern Radiology, Dr. XXX. XXX San Dimas St. Fax number: XXX-XXX-XXXX. Documents: Order for procedure, labs
  • Stockdale Radiology
  • Truxton Radiology
  • Dr. XX at Mercy can make room for add-ons occasionally

Prep: 24 hours prior to a procedure we will need:

  • H&P, pre-op labs CBC, PTT, INR, BUN, CR (within two weeks)
  • Place patient NPO at least six hours prior to procedure
  • Hold all blood thinners if indicated

2). Protocol for direct admission of non-emergency rehab patients to Heart Hospital: This protocol is to be used in conjunction to protocol from implementation 1 to further guide nursing and physicians on how to identify patients who need a higher level of non-emergency care.

Direct Admission Process Goal:

  • To provide urgent higher level of medical care for stable patients
  • To return the patient back to inpatient rehab within three midnights if indicated
  • Improve patient satisfaction and decrease patient anxiety Common direct admission diagnoses:
  • Pulmonary: Pneumonia failing treatment without severe hypoxia, acute exacerbation of chronic obstructive pulmonary disease with no signs of imminent respiratory failure
  • Cardiac: Chronic congestive heart failure with mild exacerbation not associated with an acute cardiac event, hypoxia with SPO2 less than 88%, imminent cardiovascular or respiratory failure, or ECG changes suspicious of acute cardiac event or ongoing ischemia
  • Renal: Acute renal failure without life-threatening complications like uremia or severe hyperkalemia
  • Abdominal/Endocrine: Uncontrolled diabetes requiring high doses of insulin who have failed treatment, lower gastrointestinal bleeding without symptoms of hemodynamic instability
  • Other: Electrolyte abnormalities, vital sign abnormalities, stable arrhythmias requiring telemetry, stable medical conditions requiring urgent specialist evaluation
  • Urgent intervention needed: Thoracentesis, IVC filter placement, Percutaneous drain placement, Gastrostomy tube placement, Gastrostomy tube Replacement.
  • Please call physician immediately if G-tube falls out. Place Foley catheter through lumen and inflate bladder. Place traction on Foley to make air tight seal. May consider NGT placement to continue feeding
  • Renal/urological procedures
  • Biliary/bowel duct procedures
  • Common excluding diagnoses— indications patient is not safe for direct admission or does not meet criteria for hospitalization. In general, any patient requiring urgent intervention and management with potential for ICU admission should be sent to ED for evaluation
  • Pulmonary: Respiratory failure or severe hypoxia
  • Neuro: Symptoms suspicious for stroke
  • Cardiac: Chest pain suspicious for angina or anginal equivalents requiring rule out of MI; severe hypotension unresponsive to treatment; deterioration of patient’s condition including worsening hypoxia, hypotension, tachycardia despite intervention; patient with ECG changes suspicious for ongoing myocardial ischemia; unstable cardiac rhythm with symptoms like syncope, dizziness, chest pain
  • Renal: Acute renal failure with life-threatening complications like uremia or severe hyperkalemia
  • Abdominal/Endocrine: Acute abdomen
  • Other: Patient does not qualify for criteria for admission or observation, like having a chronic stable disease without acute exacerbation or new related symptoms
  • Septic Shock

Contacting Heart Hospital

  • Physician to call or text Dr. XXX or covering physician to request direct admit, recommended unit (tele, med/surg)
  • If no beds available for direct admission, Dr. XXX will contact ER and discuss a plan for quick intervention and return to inpatient rehab, the patient may eventually be admitted if indicated
  • Contact nursing supervisor
  • Contact bed management
  • Nursing to fill out transfer sheet summary
  • Unit to admit: observation/tele/med surg
  • Acute admitting diagnosis
  • Secondary rehab admission diagnosis
  • Reason for admission/plan of care: Why needs direct admit and recommended intervention
  • Code status
  • Diet
  • Activity level
  • Allergies
  • Vital Signs
  • Medications
  • Abnormal Laboratory tests Considerations:
  • Admit status: Evaluation of cost and safety for direct admission vs. observation status
  • Need for acute hospital therapy services?
  • Discuss plan with Robert CFO to ensure meeting insurance criteria

3). Epistaxis protocol: Due to the high rate of ACTs to the emergency room for nose bleeds, an initial management protocol was made by me with the goals of limiting transfers for nose bleeds that our hospital could manage effectively.


  1. Identify

A) Determine Etiology

  • Traumatic: tubes, digital manipulation
  • Drug-induced: aspirin/Plavix, warfarin (check INR), Lovenox, steroid nasal sprays
  • Systemic: coagulopathy, HTN, thrombocytopenia, dehydration, liver failure
  • Environmental: dry air, nasal cannula O2

B) Pertinent Anatomy

  • Anterior Bleeds: identification near nares or nasal septum
  • Posterior bleeds: hard to see, maybe dripping in back of pharynx
  • Unclear: unable to determine
  1. Airway: suction, clear throat, apply pulse-ox monitoring

  2. Stop Bleeding

  • Nasal saline wash
  • Consider afrin spray for light anterior bleeds
  • Apply pressure: pinch lower nose for at least 10 minutes as tolerated
  • Silver nitrate cauterization of anterior bleed: If can visualize the site of bleed. Touch stick to area of concern. Pick only one spot, it burns
  • Nasal Packing: Cotton, gauze, surgical, Rhino Rocket if available. Leave in if working
  • Other considerations: vitamin K, platelets, invasive procedures (ACT)

Did you achieve your goal or target from your opportunity statement? What data do you have to support your conclusion?

Yes. After implementations were placed, the ACT rate was monitored on a monthly basis. The ACT rate from May 2019 to December 2019 reduced to an average of 8-9%. Implemented protocols were well received by physicians and staff and allowed consistency in triaging transfers. Furthermore, the ACT rate from December 2019 to May of 2020 continued to decrease to an average of 6-7%. The protocols not only limited emergency room visits that lead to acute inpatient three midnight admissions, but feedback from staff also stated an overall confidence of patients in the care provided at IRF.

Will you continue with the changes you have implemented?

The changes to my practice and the IRF’s management of acute care transfers included the following protocols:

1). Acute care transfer triage protocol

2). Protocol for direct admission of non-emergency rehab patients to Heart Hospital

3). Epistaxis protocol

We will continue with our protocols and continue to meet as a team to discuss patient transfers. We plan to continue to modify our protocols to adjust to the needs of our patients. Our approach will continue to focus on optimizing communication between nursing and physicians and to allow triage of patients to be safe, efficient, and appropriate. One issue that we continue to see at our IRF is that requests for outpatient procedures at times may be delayed. For the future, we hope to further strengthen our partnerships with the community, ensuring timely delivery of care not available at IRF.

Originally Published: September 28, 2020