Impact of a transfer center on interhospital referrals and transfers to a tertiary care center.

BACKGROUND: The partnership of faculty physicians and senior clinical hospital administrators in the decision to accept interhospital transfers has not been fully studied. Transfers to academic medical centers on the basis of economics have been of particular concern. OBJECTIVES: To evaluate the impact of joint decision making on transfer acceptance, and to evaluate the basis for decisions to transfer patients to an academic medical center. METHODS: This was a database study of requested adult interhospital transfers, excluding psychiatric transfers, occurring between January 1, 2003, and December 31, 2003, by using data from a computerized patient-tracking system. Where possible, comparisons with the prior calendar year (i.e., prior to implementation of the administrative review process) were made. Incidence of refusal to accept requested transfers and payer mix of transfer patients were the main outcomes of interest. RESULTS: More than 90% of the adult patients were transferred for conditions that required tertiary care or met Emergency Medical Treatment and Labor Act (EMTALA) requirements. The patient conditions that did not meet tertiary care needs included obstetric patients who did not have prenatal care, patients who had hand and facial trauma, and patients who weighed more than 300 pounds. The payer mix of transfer patients remained stable when using the administrator and physician team to determine acceptance of transfers. During the evaluation period, approximately 91,500 patients statewide lost some level of Medicaid coverage. CONCLUSIONS: The value of an administrator and physician team as partners in the interhospital transfer process was demonstrated. Active management of interhospital transfers supports transfer of patients who require tertiary care or who meet EMTALA criteria, thus conserving limited bed capacity and ensuring financial equity, while caring for the uninsured and underinsured patients throughout the state.

The Holocaust as a context for telling life stories.

Using a narrative approach, this study explores the role of the Holocaust in the life stories of Survivors, contrasted with two comparison groups (one Jewish and one non-Jewish) whose direct experiences did not include surviving the Holocaust. Using the technique of the life line and measures such as number and type of life events identified, as well as the events marking the beginning and ending of the life story, several differences were found between the three groups. Survivors identified an average of 10 life events, fewer than the non-Jewish comparison group (18) but more than the Jewish comparison group (7). Most of these events were positive, although less so for the Jewish comparison group, with very few future events identified by any of the groups. The War marked the beginning of the life story for most of the survivors and their stories ended at an earlier age than did the stories of the comparison groups. Further, WWII events predominated in the stories of the survivors, as did family births and relationship events (comparably seen in the stories of the Jewish comparisons). In contrast, the comparison groups, and particularly the non-Jewish group, identified greater numbers of career, education, illness, and family death events. It is proposed that the pronounced effect of the Holocaust in the life stories of survivors (and to a lesser, though still evident, degree of the Jewish comparisons) serves as an anchoring and contextual influence on the nature and quality of life stories told. That is, the Holocaust sets the standard for what events merit mention and further determines the nature of the events reported and their distribution.