Level-loading across a health system: A collaborative model for interhospital transfers

Emergency department (ED) boarding at academic health centers delays care and limits access to specialized services. We evaluated a systemwide level-loading program that transferred clinically appropriate admitted ED patients from an academic health center to affiliate or partner community hospitals with available capacity.

We conducted a 28-month pre-post electronic medical record-based evaluation from September 2023 through December 2025 in a multi-hospital health system. The intervention included universal transfer center registered nurse screening of ED admissions, standardized patient communication, EMR-integrated transfer tracking, hospitalist assumption of care for transfer-pending patients, dedicated ambulance coverage, and a transfer receiving unit. Outcomes included transfer volume, ED boarding time, inbound transfers to the academic center, inpatient length of stay, early deterioration, mortality, readmissions, and transfer-related adverse events.

During the intervention, 537 patients were transferred. Transfer volume increased from 1.5 to 15.0 patients per week (rate ratio 10.3; p < .01). Among transferred patients, ED boarding time declined from 6.5 h in the first PDSA cycle to 2.9 h by the final cycle. In adjusted analyses, transfer status was associated with 14.8 fewer ED boarding hours (p < .01), a 16.4-percentage-point lower probability of rapid response activation or ICU upgrade within 48 h (p < .01), and no increase in mortality or length of stay. No transfer-related adverse events were identified. Inbound transfers to the academic center increased 8% to 16%.

A multidisciplinary level-loading program substantially increased interhospital transfers, shortened ED boarding for transferred patients, and expanded complex-care access without observed transfer-related adverse events.