To determine if general, community hospitals show evidence of specializing in the nation's six highest volume, highest revenue-generating service lines, 2003-2007 data of hospitals throughout Florida, Virginia, and Nevada were analyzed using backward deletion, stepwise regression. Service lines selected for study were cardiac surgery, cardiology, invasive cardiology, orthopedics, labor and delivery, and pulmonary services. Results do show evidence of specialization, but characteristics of hospitals vary by service line. Findings suggest that the general, community hospital, traditionally a full-service provider, may be undergoing transformation including specialization. The study demonstrates the usefulness of studying specialization at the service line level.

Background: The safety of critically ill patients during inter-hospital transfer is recognised as a globally important issue. However, little evidence exists pertaining to the care provided by transfer nurses throughout the processes of inter-hospital transfer in rural community hospitals where there is a high risk of adverse clinical events occurring during transportation. Aim: The overall aim of the study was to explore transfer nurses' understanding of the delivery of quality of care during the transfer of critically ill patients from rural community hospitals to a tertiary regional hospital in Thailand. Design and Methods: The theory of symbolic interactionism (Blumer, 1986) and focused ethnography methodology were used. Data were collected using multiple qualitative methods including sixteen semi-structured interviews with transfer nurses, fourteen observations of critically ill patients' transfers from three rural community hospitals to a tertiary centre and twenty-three subsequent handover events and the analysis of transfer documents from four hospital settings (e.g. one regional hospital and three rural community hospitals) in Thailand. Translation from Thai into English and back translation into vernacular language was required. Inductive, thematic analysis was conducted to identify major themes by using qualitative data analysis software, NVivo 10 to assist data management during the analysis. Results: Five major themes emerged including (i) protective factors influencing safe transfer care, (ii) barrier factors influencing safe transfer care, (iii) behavioural patterns in transfer care processes, (iv) maintaining the health condition of the patients, and (v) overcoming adverse events. These particular themes elaborate the meaning of the quality and patient safety of transfer care, the provision of care for safe transfer care, and significant contextual factors that influence the quality of inter-hospital transfer care for critically ill patients. In addition, Donabedian's model (Donabedian, 1966, 1988) incorporated within the concept of context and culture was utilised to assist in conceptualising the framework for the quality of inter-hospital transfer care of critically ill patients in Thailand. Conclusion: The Donabedian model is useful as it is simple, but it does not include detail of the organisational context and culture as determinants of care quality. A conceptual framework for the quality of inter-hospital transfer care of critically ill patients in Thailand was therefore proposed. This study has expanded on current theoretical knowledge of the quality of inter-hospital transfer care by elaborating the patterns of thought and the behaviour of transfer nurses during provision of care throughout the processes of the inter-hospital transfer. It also highlights the limitations of organisational structure and the environment in which transfer work takes place, including issues on handover processes in hospital transfer care. The results can be useful to transfer nurses in that they facilitate greater understanding of the provision of better quality of care. They also help to inform hospital policy makers how to ensure safety of critically ill patients being transferred from community hospital settings.