Key takeaways:
• Low-acuity admissions presenting to academic centers can be successfully transferred to nearby community hospitals.
• Clinicians and staff don’t process protocols efficiently if they use them only occasionally.
• Routine load-balancing transfers between hospitals can help manage stabilize staffing.
CONTROLLING HOSPITAL capacity may be facilities’ No. 1 concern—and with health systems consolidating into city-wide or even regional powerhouses, some are starting to use their hospital networks to level-load patient volumes. Academic centers stretched to capacity have started transferring less acute patients to smaller hospitals in the same health system where beds may be empty.
A case in point is Intermountain Health, the regional behemoth based in Utah that serves more than 4 million patients in facilities across seven states. The four system’s four hospitals in greater Salt Lake City include the quaternary Intermountain Medical Center along with three smaller, community facilities.
At the height of the pandemic in October 2020, providers in the quaternary center began transferring less acute covid patients who needed to be admitted from their ED to one of the nearby community hospitals, all of which are within 15 miles. Since the end of the pandemic, that process—which the health system calls its load balancing protocol—is not only being used but is being expanded.
“We originally had a more restrictive concept of which diagnoses would be appropriate for transfer, but we trust our physicians.”
Harris Carmichael, MD, MSHP
Intermountain Health
In an October 2025 write-up in in the Journal of Hospital Medicine, Intermountain researchers detailed data from the first four years of that innovation, noting that the protocol has diverted more than 5,100 bed days from the quaternary center. That’s helped maintain capacity there for advanced care while stabilizing patient volumes at the other three hospitals.
That win-win for both the sending and the receiving facilities is one of several strategies Intermountain is using to manage capacity. But it’s also required a change in thinking and culture to look beyond individual facilities and start thinking of regional solutions.
Who makes the transfer decision?
Since the protocol was first launched, three separate physicians take part in the load-balancing process.
First, the ED doctor considers if a presenting patient might be eligible. If so, that physician approaches the patient to make sure they’re OK being transferred, then reaches out to the quaternary triage hospitalist.
That hospitalist, explains Harris Carmichael, MD, MSHP, a hospitalist who’s lead author of the JHM study, serves basically as “a quarterback within the hospital walls,” taking care of all transfers within the quaternary center and between services. Once the triage hospitalist assesses the patient’s information and makes sure the transfer is appropriate, the on-duty tele-hospitalist is alerted.
The tele-hospitalist is offsite in Intermountain’s virtual hospital, which houses the health system’s extensive remote services. The tele-hospitalist manages all transfers coming in for hospital medicine from Intermountain’s vast network as well as load-balancing transfers within Salt Lake City.
The tele-hospitalist has up-to-date information on bed availability at each receiving community facility. That physician also knows whether a specific hospital has the resources—such as dialysis—that a patient being load-balanced needs.
It’s the tele-hospitalist who makes the final transfer decision. If the hospitalist at the receiving community hospital is swamped, the quaternary triage hospitalist at the academic center can write a patient’s initial orders before the transfer. And to make sure nocturnists at receiving hospitals aren’t overwhelmed, the protocol is deployed only during day and early evening hours.
Only occasional use didn’t work
As Dr. Carmichael points out, load-balancing decisions are based on patient acuity, not specific diagnoses.
“We originally had a more restrictive concept of which diagnoses would be appropriate for transfer,” he says, “but we trust our physicians—and we didn’t want to slow the process down with too many criteria.” While the protocol comes with no diagnosis restrictions, “it really tends to be only five or six diagnoses.”
According to the last six months of data analyzed in the JHM study, the most common diagnoses transferred were sepsis (15%), pneumonia (8%), covid (5%), acute renal failure (3%), alcohol dependence with withdrawal (2%) and weakness (2%).
“We’re trying to change how we fundamentally view patient flow issues and how we work together.”
Nathan Starr, DO
Intermountain Health
Within Intermountain, the protocol also proved to be an object lesson in how processes need to be routine and consistent to be effective.
During the pandemic, the quaternary system was load balancing more than120 patients each month. But once the pandemic ended, the academic center used the protocol only occasionally when capacity hit a certain threshold. That turned out to be a problem.
During 2021 and 2022, for instance, when Dr. Carmichael found himself filling the quaternary triage hospitalist role, “I would say, ‘Oh, this looks like a great load-balancing patient.’ And the ED provider would say, ‘What’s that?’ ” he recalls.
Or if people were aware of the protocol, “they knew there was a script for that somewhere to get buy-in from patients, but they didn’t know how to find it. That ended up being a big hurdle to overcome.” Not only were ED doctors out of practice considering appropriate patients, but both the sending and receiving providers saw the infrequent internal transfers as added work.
The case for making the protocol routine
That’s when system leaders began to consider deploying the load balancing protocol routinely, not just PRN. The idea at first received a mixed reaction.
Some leaders at the quaternary center, for instance, wanted to keep the protocol threshold-driven, worried that too much volume would be siphoned away from the quaternary center.
But the community hospitals were enthusiastic. Lower or fluctuating volumes at those hospitals meant that some nursing shifts were being canceled due to low census. A set number of load-balanced patients each day would even out volumes and stabilize staffing.
And volume projections over the next few years were sobering. Right now, says Nathan Starr, DO, medical director of Intermountain Health’s home services and tele-hospitalist programs, Utah’s population is still relatively young compared to some parts of the country.
“Right now, we have capacity,” Dr. Starr says. “But our projections are that in five or 10 years, we’re going to need other solutions. The so-called ‘silver tsunami’ is just now starting to hit us.”
Leadership decided to make the protocol routine in March 2024, with a target of transferring one or two load-balancing patients to each of the three community hospitals every day. That target has since bumped up to three or four patients for each hospital per day, says Dr. Carmichael.
And two of the three receiving hospitals “still have plenty of capacity,” Dr. Starr points out. “Those hospitals are asking for more.”
The challenge of regional management
As for how patients approached for load balancing receive that request, Dr. Carmichael says their No. 1 question is, “How much will this cost me?” When they understand that the transfer doesn’t cost anything—the health system contracts with and pays an ambulance company for these transfers—patients are usually fine. Many appreciate being admitted to a hospital closer to where they live.
The protocol has been such a success that the health system is considering adopting it in Provo and Ogden. But, Dr. Starr admits, it’s a big shift to switch from managing capacity at one hospital to thinking of capacity in terms of regional management.
“We know we’re stronger when we work together, moving out of siloes and taking a system approach,” he says. However, “a lot of times, we don’t need this level-loading because we have capacity at our quaternary center. So for our frontline providers, this can feel like extra work.”
Still the system is planning for the future, says Dr. Starr. “We continue to educate our staff and providers on the long-term benefits, and we’re getting there. We’re trying to change how we fundamentally view patient flow issues and how we work together.”
Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.
Impressive load-balancing protocol at Intermountain Health diverting over 5,100 bed days from the quaternary center while stabilizing community hospitals.