Does the journey change the destination? Exploring unusual patient journeys through the hospital and their impacts

Posted 2022.10.27

Every year at our annual conference we recognise well-presented and rigorous research through our Future Leaders in Health Services Research Awards, supported by Elsevier and the International Journal of Nursing Studies (IJNS). Future Leaders award winner and PhD candidate Estera Mendelson, reflects on her research and what winning the award means to her.


Before starting my PhD, I had a mental picture of hospitals as one really big team of staff treating patients in, more or less, one really big ward – which looked a bit like the setting of the children’s book, ‘You’re in Good Paws’, but with fewer paws. 

Patients arrived at the hospital, got treated, and were (hopefully) discharged. They were always in the right place (the hospital) and spent most of their time in one room. I soon found the reality is much more like a ‘Look Inside a Hospital’ fact book, which unfolds to reveal a maze of different wards and patients frequently moving between them.

Hospitals are really ensembles of many speciality teams, working on different wards, sometimes in different buildings, and even across different hospital sites that make up a single hospital ‘trust’. Getting patients to the right place, at the right time to receive the right care, is not a straightforward task. The movement of patients between wards to receive specific care and create space for other patients (known as patient flow) is one of the biggest challenges in healthcare. For example, currently in the UK, emergency department waiting times are at their highest in two years. This can result in more patients being admitted to any available ward as opposed to the most clinically appropriate.  This means that they may not be cared by the most relevant clinical specialty team. The transfer patterns of those patients who may not be in the right place or under the right specialty team are more complex and unusual.

In this retrospective cohort study, we examined the differential impacts of atypical and regular intrahospital transfers. We did this by using patient electronic health record data to audit ward usage and derive their specialties in a data-driven way rather than from the a priori expected usage of the ward.  We used this data to create a systematic definition for regular transfers as movements between wards which share patient specialities and atypical transfers as transfers between wards with no overlapping specialities. We found that among adult emergency patients admitted to hospital, each additional atypical transfer resulted in an estimated increase in average length of stay by 2.8 days. By comparison, regular ward transfers had an effect size of 1.9 days. Moving between hospital sites had the largest impact on increasing length of stay, but these were associated with lower odds of mortality, while atypical transfers had no association with readmission or mortality. This shows that it’s not just the patient’s destination that matters, but the journey may impact on their outcomes, including how quickly they are able to be discharged.

Our study provides a method for identifying atypical transfers and their impacts, but we cannot know the reasons underlying these transfers from data alone. Exploring healthcare workers’ perspectives of the findings through qualitative work is our next step. Patient transfers happen every day in every hospital, but few studies have investigated how these decisions impact patient outcomes. More research is needed to understand the decision-making behind unusual journeys and their consequences.

I was so delighted to receive one of HSR UK’s future leaders award for this work alongside a very warm welcome from the community at the HSR UK conference! I hope to carry on working on improving patient experiences of secondary care services beyond my PhD, and that other researchers are encouraged to research this important area.

Watch Estera's award winning presentation from the HSR UK conference 2022.