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Suen CG, Wood AJ, Burke JF, Guterman EL. Emergency department and inpatient interhospital transfers for patients with status epilepticus. Epilepsia 2025. [PMID: 39797606 DOI: 10.1111/epi.18254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 12/18/2024] [Accepted: 12/19/2024] [Indexed: 01/13/2025]
Abstract
OBJECTIVE Interhospital transfers for status epilepticus (SE) are common, and some are avoidable and likely lower yield. The use of interhospital transfer may differ in emergency department (ED) and inpatient settings, which contend with differing clinical resources and financial incentives. However, transfer from these two settings is understudied, leaving gaps in our ability to improve the hospital experience, cost, and triage for this neurologic emergency. We aimed to describe interhospital transfer for SE and examine the relationship between the site of transfer and hospital length of stay. METHODS We performed a cross-sectional study of adult patients with SE who underwent interhospital transfer using data from the State Emergency Department Databases and State Inpatient Databases of Florida (2016-2019) and New York (2018-2019). The primary outcome was discharge after undergoing transfer. Secondary outcomes were discharge within 1 day, discharge after 30 days, receipt of electroencephalography (EEG), and discharge disposition. RESULTS There were 10 461 encounters for SE. Of 1790 ED encounters without admission to the same hospital, 324 (18.1%) resulted in transfer. Of 8671 hospitalizations, 629 (7.3%) resulted in transfer. Patients transferred from the ED were younger, more likely were White, more likely were in a metro area, and had fewer medical comorbidities than patients transferred from the inpatient setting. The median time to discharge was 5 days (interquartile range [IQR] = 2.0-9.0) after ED transfer and 10 days (IQR = 4.0-20.0) after inpatient transfer. There were 58 (17.9%) patients who were discharged within 1 day after undergoing transfer from an ED. ED transfers had higher rates of discharge at 30 days and higher likelihood of undergoing EEG at the receiving hospital and being discharged home. SIGNIFICANCE A high proportion of patients with SE are discharged shortly after undergoing interhospital transfer, particularly those transferred from the ED. Understanding reasons for transfer is a crucial next step in triaging limited inpatient epilepsy resources and reducing costs associated with interhospital transfer.
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Affiliation(s)
- Catherine G Suen
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Andrew J Wood
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - James F Burke
- Department of Neurology, Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Elan L Guterman
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
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Soliman M, Alenzi H, Alfenaikh R, Aletreby A, Alenzi M, Alenzi H, Gano J, Alrashed R, Altaymani Y, Al-Odat M, Aletreby W. Outcomes of Patients Transferred to Tertiary Center by Life-Saving System in Saudi Arabia. A Propensity Score Matching Observational Study. J Crit Care Med (Targu Mures) 2024; 10:368-375. [PMID: 39829730 PMCID: PMC11740695 DOI: 10.2478/jccm-2024-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 09/06/2024] [Indexed: 01/22/2025] Open
Abstract
Background Inter-hospital transfer is intended to provide access to centralized special care for critically ill patients, when resources in their hospitals are not available. However, an empirical gap exists in available evidence, as outcomes of transferred patients to higher centers are inconsistent. Method Single center propensity score matching retrospective observational study. Life-Saving transfers during 2023 were matched to direct admissions to the ICU. Hospital mortality, ICU length of stay, and costs of both groups were compared. Results During the study period, 328 Life-Saving transfers were matched to 656 direct admissions. Propensity score matching eliminated all imbalances between groups. Hospital mortality was not different between groups, there were 114 (34.8%) hospital mortalities of Life-Saving transfers, while there were 216 (32.9%) hospital mortalities of direct admissions, with a percent difference of 1.9% (95% CI: -4.5%, 8.4%); p value = 0.6, this result persisted in the sensitivity analysis. There were no differences in mortality risks for all the studied subgroups except pediatric patients. ICU length of stay of direct admissions and Life-Saving transfers were 10 ± 13.1 and 11.6 ± 12.4 days respectively, mean difference was statistically significant (-1.6 [95% CI: -3.2, 0.1]; p = 0.005). Life-Saving transfers entailed significantly higher costs per admission by 28,200 thousand SAR (95% CI: 26,400 - 30,000; p < 0.001). Conclusion Our study shows no difference in hospital mortality between Life-Saving transfers and direct admissions to ICU, however, Life-Saving transfers had a longer ICU length of stay, and higher costs per admission.
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Affiliation(s)
| | - Hanan Alenzi
- King Saud Medical City, Riyadh, Ar Riyad, Saudi Arabia
| | | | - Ahmed Aletreby
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Malak Alenzi
- King Saud Medical City, Riyadh, Ar Riyad, Saudi Arabia
| | - Hend Alenzi
- King Saud Medical City, Riyadh, Ar Riyad, Saudi Arabia
| | - Jennifer Gano
- King Saud Medical City, Riyadh, Ar Riyad, Saudi Arabia
| | - Rana Alrashed
- King Saud Medical City, Riyadh, Ar Riyad, Saudi Arabia
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Edmondson ME, Reimer AP. Outcomes After Interhospital Critical Care Transfer. Air Med J 2024; 43:406-411. [PMID: 39293917 DOI: 10.1016/j.amj.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/07/2024] [Indexed: 09/20/2024]
Abstract
OBJECTIVE Patients who undergo interhospital transfer, particularly for intensive care unit (ICU) care, experience greater length of stay and mortality. There is evidence that patients transferred for surgical ICU care experience higher mortality rates; however, differences in length of stay or mortality across other ICU types remain unclear. The goals of this work were to assess how length of stay and mortality differ by ICU subspecialties. METHODS We conducted a retrospective analysis of an existing critical care transfer data repository. We used multiple and logistic regression to identify significant factors that contribute to differences in length of stay and mortality for surgical ICU patients. RESULTS There were no differences in length of stay or mortality based on ICU subspecialty. For every 1-year increase in age, mortality odds increased by 8.6% (P = .002). Patients transferred from an ICU had a longer length of stay by 6.3 days (P < .001). Non-Caucasian patients had a shorter length of stay by 3.4 days (P = .012). CONCLUSION Length of stay and mortality are not influenced by ICU subspecialty. Further research is needed to determine the mechanism by which sending unit type and race influence length of stay and identify other factors that predict mortality for SICU patients.
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Affiliation(s)
- Meghan E Edmondson
- Case Western Reserve University, Frances Payne Bolton School of Nursing, Cleveland, OH.
| | - Andrew P Reimer
- Case Western Reserve University, Frances Payne Bolton School of Nursing, Cleveland, OH; Critical Care Transport, Cleveland Clinic, Cleveland, OH
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4
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McDougall G, Loubani O. Interfacility transfer of the critically ill: Transfer status does not influence survival. J Crit Care 2024; 82:154813. [PMID: 38636357 DOI: 10.1016/j.jcrc.2024.154813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE To estimate differences in case-mix adjusted hospital mortality between adult ICU patients who are transferred during their ICU-stay and those who are not. METHODS 19,260 visits to 12 ICUs in Nova Scotia (NS), Canada April 2018-September 2023 were analyzed. Data were obtained from the NS Provincial ICU database. Generalized additive models (GAMs) were used to estimate differences in case-mix adjusted hospital mortality between patients who underwent transfer and those who did not. RESULTS 1040/19,260 (5%) ICU visits involved interfacility-transfer. No difference in hospital mortality was identified between transferred and non-transferred patients by GAM (OR, 0.99, 95% CI, 0.82 to 1.19; p = 0.91). No mortality difference was observed between patients undergoing a single transfer versus multiple (OR, 0.87; 95% CI, 0.45 to -1.69; p = 0.68). A GAM including the categories no transfer, one transfer, and multiple transfers identified a difference in hospital mortality for patients that underwent multiple transfers compared to non-transferred patients (OR, 0.68; 95% CI, 0.46 to 1.00, p = 0.05), but no difference was identified in a post-hoc matched cohort sensitivity analysis (OR, 0.68; 95% CI, 0.46 to 1.01, p = 0.05). CONCLUSION The transfer of critically ill patients between ICUs in Nova Scotia did not impact case-mix adjusted hospital mortality.
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Affiliation(s)
- Garrett McDougall
- Department of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Osama Loubani
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada.
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Harlan EA, Venkatesh S, Morrison J, Cooke CR, Iwashyna TJ, Ford DW, Moscovice IS, Sjoding MW, Valley TS. Rural-Urban Differences in Mortality among Mechanically Ventilated Patients in Intensive and Intermediate Care. Ann Am Thorac Soc 2024; 21:774-781. [PMID: 38294224 PMCID: PMC11109907 DOI: 10.1513/annalsats.202308-684oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/19/2024] [Indexed: 02/01/2024] Open
Abstract
Rationale: Intermediate care (also termed "step-down" or "moderate care") has been proposed as a lower cost alternative to care for patients who may not clearly benefit from intensive care unit admission. Intermediate care units may be appealing to hospitals in financial crisis, including those in rural areas. Outcomes of patients receiving intermediate care are not widely described. Objectives: To examine relationships among rurality, location of care, and mortality for mechanically ventilated patients. Methods: Medicare beneficiaries aged 65 years and older who received invasive mechanical ventilation between 2010 and 2019 were included. Multivariable logistic regression was used to estimate the association between admission to a rural or an urban hospital and 30-day mortality, with separate analyses for patients in general, intermediate, and intensive care. Models were adjusted for age, sex, area deprivation index, primary diagnosis, severity of illness, year, comorbidities, and hospital volume. Results: There were 2,752,492 hospitalizations for patients receiving mechanical ventilation from 2010 to 2019, and 193,745 patients (7.0%) were in rural hospitals. The proportion of patients in rural intermediate care increased from 4.1% in 2010 to 6.3% in 2019. Patient admissions to urban hospitals remained relatively stable. Patients in rural and urban intensive care units had similar adjusted 30-day mortality, at 46.7% (adjusted absolute risk difference -0.1% [95% confidence interval, -0.7% to 0.6%]; P = 0.88). However, adjusted 30-day mortality for patients in rural intermediate care was significantly higher (36.9%) than for patients in urban intermediate care (31.3%) (adjusted absolute risk difference 5.6% [95% confidence interval, 3.7% to 7.6%]; P < 0.001). Conclusions: Hospitalization in rural intermediate care was associated with increased mortality. There is a need to better understand how intermediate care is used across hospitals and to carefully evaluate the types of patients admitted to intermediate care units.
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Affiliation(s)
- Emily A. Harlan
- Division of Pulmonary and Critical Care, Department of Medicine
- Center for Bioethics and Social Sciences in Medicine, Medical School
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- VA Ann Arbor Healthcare System, U.S. Department of Veterans Affairs, Ann Arbor, Michigan
| | | | - Jean Morrison
- Department of Biostatistics and Center for Statistical Genetics, School of Public Health, and
| | - Colin R. Cooke
- Division of Pulmonary and Critical Care, Department of Medicine
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Theodore J. Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dee W. Ford
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Ira S. Moscovice
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota; and
| | | | - Thomas S. Valley
- Division of Pulmonary and Critical Care, Department of Medicine
- Center for Bioethics and Social Sciences in Medicine, Medical School
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- VA Ann Arbor Healthcare System, U.S. Department of Veterans Affairs, Ann Arbor, Michigan
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Fernandes-Taylor S, Yang Q, Yang DY, Hanlon BM, Schumacher JR, Ingraham AM. Greater patient sharing between hospitals is associated with better outcomes for transferred emergency general surgery patients. J Trauma Acute Care Surg 2023; 94:592-598. [PMID: 36730565 PMCID: PMC10038852 DOI: 10.1097/ta.0000000000003789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Access to emergency surgical care has declined as the rural workforce has decreased. Interhospital transfers of patients are increasingly necessary, and care coordination across settings is critical to quality care. We characterize the role of repeated hospital patient sharing in outcomes of transfers for emergency general surgery (EGS) patients. METHODS A multicenter study of Wisconsin inpatient acute care hospital stays that involved transfer of EGS patients using data from the Wisconsin Hospital Association, a statewide hospital discharge census for 2016 to 2018. We hypothesized that higher proportion of patients transferred between hospitals would result in better outcomes. We examined the association between the proportion of EGS patients transferred between hospitals and patient outcomes, including in-hospital morbidity, mortality, and length of stay. Additional variables included hospital organizational characteristics and patient sociodemographic and clinical characteristics. RESULTS One hundred eighteen hospitals transferred 3,197 emergency general surgery patients over the 2-year study period; 1,131 experienced in-hospital morbidity, mortality, or extended length of stay (>75th percentile). Patients were 62 years old on average, 50% were female, and 5% were non-White. In the mixed-effects model, hospitals' proportion of patients shared was associated with lower odds of an in-hospital complication; specifically, when the proportion of patients shared between two hospitals doubled, the relative odds of any outcome changed by 0.85. CONCLUSION Our results suggest the importance of emergent relationships between hospital dyads that share patients in quality outcomes. Transfer protocols should account for established efficiencies, familiarity, and coordination between hospitals. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Sara Fernandes-Taylor
- Corresponding Author: , Wisconsin Surgical Outcomes Research Program, University of Wisconsin Department of Surgery, 600 Highland Ave, CSC, Madison, WI 53792-7375, 608-265-9159
| | - Qiuyu Yang
- Department of Surgery, University of Wisconsin-Madison
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin-Madison
| | - Bret M. Hanlon
- Departments of Biostatistics and Medical Informatics, University of Wisconsin-Madison
| | | | - Angela M. Ingraham
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin-Madison
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Reimer AP, Schiltz NK, Koroukian SM. High-risk diagnosis combinations in patients undergoing interhospital transfer: a retrospective observational study. BMC Emerg Med 2022; 22:187. [PMID: 36418974 PMCID: PMC9685892 DOI: 10.1186/s12873-022-00742-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/04/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is limited research on individual patient characteristics, alone or in combination, that contribute to the higher levels of mortality in post-transfer patients. The purpose of this work is to identify significant combinations of diagnoses that identify subgroups of post-interhospital transfer patients experiencing the highest levels of mortality. METHODS This was a retrospective cross-sectional study using structured electronic health record data from a regional health system between 2010-2017. We employed a machine learning approach, association rules mining using the Apriori algorithm to identify diagnosis combinations. The study population includes all patients aged 21 and older that were transferred within our health system from a community hospital to one of three main receiving hospitals. RESULTS Overall, 8893 patients were included in the analysis. Patients experiencing mortality post-transfer were on average older (70.5 vs 62.6 years) and on average had more diagnoses in 5 of the 6 diagnostic subcategories. Within the diagnostic subcategories, most diagnoses were comorbidities and active medical problems, with hypertension, atrial fibrillation, and acute respiratory failure being the most common. Several combinations of diagnoses identified patients that exceeded 50% post-interhospital transfer mortality. CONCLUSIONS Comorbid burden, in combination with active medical problems, were most predictive for those experiencing the highest rates of mortality. Further improving patient level prognostication can facilitate informed decision making between providers and patients to shift the paradigm from transferring all patients to higher level care to only transferring those who will benefit or desire continued care, and reduce futile transfers.
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Affiliation(s)
- Andrew P. Reimer
- grid.67105.350000 0001 2164 3847Frances Payne Bolton School of Nursing, Case Western Reserve University, 2120 Cornell Dr10900 Euclid Ave, Cleveland, OH 44106, 216-368-7570 USA ,grid.239578.20000 0001 0675 4725Critical Care Transport, Cleveland Clinic, 9800 Euclid Ave, Cleveland, OH USA
| | - Nicholas K. Schiltz
- grid.67105.350000 0001 2164 3847Frances Payne Bolton School of Nursing, Case Western Reserve University, 2120 Cornell Dr10900 Euclid Ave, Cleveland, OH 44106, 216-368-7570 USA
| | - Siran M. Koroukian
- grid.67105.350000 0001 2164 3847Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH USA
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Matoba N, Kwon S, Collins JW, Davis MM. Risk factors for death during newborn and post-newborn hospitalizations among preterm infants. J Perinatol 2022; 42:1288-1293. [PMID: 35314759 DOI: 10.1038/s41372-022-01363-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 02/14/2022] [Accepted: 02/25/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To examine risk factors for mortality among preterm infants during newborn and subsequent hospitalizations, and whether they differ by race/ethnicity. STUDY DESIGN We conducted a cross-sectional analysis using the 2016 Kids Inpatient Database. Hospitalizations of preterm infants were categorized as "newborn" for birth admissions, and "post-newborn" for all others. Multivariate logistic regression was performed to calculate associations of mortality with sociodemographic factors. RESULTS Of 285915 hospitalizations, there were 7827 (2.7%) deaths. During newborn hospitalizations, adjusted OR (aOR) of death equaled 1.14 (95% CI 1.09-1.20) for males, 68.73 (61.91-76.30) for <29 weeks GA, and 0.81 (0.71-0.92) for transfer. Stratified by race/ethnicity, aOR was 0.69 (0.61-0.71) for Medicaid only among black infants. During post-newborn hospitalizations, death was associated with transfer (aOR 5.02, 3.31-7.61). CONCLUSIONS Risk factors for death differ by hospitalization types and race/ethnicity. Analysis by hospitalization types may identify risk factors that inform public health interventions for reducing infant mortality.
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Affiliation(s)
- Nana Matoba
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Soyang Kwon
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - James W Collins
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Matthew M Davis
- Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Haug EC, Pehlivan H, Macdonell JR, Novicoff W, Browne J, Brown T, Cui Q. Higher cost of arthroplasty for hip fractures in patients transferred from outside hospitals vs primary emergency department presentation. World J Orthop 2022; 13:725-732. [PMID: 36159622 PMCID: PMC9453283 DOI: 10.5312/wjo.v13.i8.725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/23/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In 2016 Centers for Medicare and Medicaid Services proposed bundled payments for hip fractures to improve the quality and decrease costs of care. Patients transferred from other facilities may be imposing a financial risk on the hospitals that accept these patients.
AIM To determine the costs associated with patients that either presented to the emergency department or were transferred from another hospital or skilled nursing facility (SNF) with the diagnosis of a hip fracture requiring operative intervention.
METHODS A retrospective single institution review was conducted for all arthroplasty patients from 2010 to 2015. Inclusion criteria included a total or partial hip replacement for a hip fracture. Exclusion criteria included pathologic, periprosthetic, and fracture non-union. Data was collected to compare total observed costs for patients from the emergency department, patients from skilled nursing facilities, and patients from an outside hospital.
RESULTS A total of 223 patients met the inclusion criteria. 135 (60.54%) of these patients presented primarily to the emergency department, 58 patients (26.01%) were transferred from an outside hospital, and 30 patients (13.43%) were transferred from a SNF. Cost data analysis showed that outside hospital patients demonstrated significantly greater total cost for their hospitalization ($43302) compared to emergency department patients ($28875, P = 0.000) and SNF patients ($28282, P = 0.000).
CONCLUSION Patients transferred from an outside hospital incurred greater costs for their hospitalization than patients presenting from an emergency department or SNF. This is a strong argument for risk-adjustment models when bundling payments for the care of hip fracture patients.
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Affiliation(s)
- Emanuel C Haug
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908, United States
| | - Hakan Pehlivan
- Department of Orthopedic Surgery, Preferred Pediatric Orthopedic Surgery, Ridgewood, NJ 07450, United States
| | - J Ryan Macdonell
- Department of Orthopedic Surgery, Asheville Orthopedic Associates, Asheville, NC 28801, United States
| | - Wendy Novicoff
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908, United States
| | - James Browne
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908, United States
| | - Thomas Brown
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908, United States
| | - Quanjun Cui
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908, United States
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Schumacher C. Effectiveness of hospital transfer payments under a prospective payment system: An analysis of a policy change in New Zealand. HEALTH ECONOMICS 2022; 31:1339-1346. [PMID: 35384112 PMCID: PMC9325395 DOI: 10.1002/hec.4508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 03/13/2022] [Accepted: 03/13/2022] [Indexed: 06/14/2023]
Abstract
Prospective payment systems reimburse hospitals based on diagnosis-specific flat fees, which are generally based on average costs. While this encourages cost-consciousness on the part of hospitals, it introduces undesirable incentives for patient transfers. Hospitals might feel encouraged to transfer patients if the expected treatment costs exceed the diagnosis-related flat fee. A transfer fee would discourage such behavior and, therefore, could be welfare enhancing. In 2003, New Zealand introduced a fee to cover situations of patient transfers between hospitals. We investigate the effects of this fee by analyzing 4,020,796 healthcare events from 2000 to 2007 and find a significant reduction in overall transfers after the policy change. Looking at transfer types, we observe a relative reduction in transfers to non-specialist hospitals but a relative increase in transfers to specialist facilities. It suggests that the policy change created a focusing effect that encourages public health care providers to transfer patients only when necessary to specialized providers and retain those patients they can treat. We also find no evidence that the transfer fee harmed the quality of care, measured by mortality, readmission and length of stay. The broader policy recommendation of this research is the introduction or reassessment of transfer payments to improve funding efficiency.
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Affiliation(s)
- Christoph Schumacher
- School of Economics and FinanceMassey Business SchoolMassey UniversityAucklandNew Zealand
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11
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Nadig NR, Brinton DL, Simpson KN, Goodwin AJ, Simpson AN, Ford DW. The Impact of Timing on Clinical and Economic Outcomes During Inter-ICU Transfer of Acute Respiratory Failure Patients: Time and Tide Wait for No One. Crit Care Explor 2022; 4:e0642. [PMID: 35261978 PMCID: PMC8893307 DOI: 10.1097/cce.0000000000000642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Approximately one in 30 patients with acute respiratory failure (ARF) undergoes an inter-ICU transfer. Our objectives are to describe inter-ICU transfer patterns and evaluate the impact of timing of transfer on patient-centered outcomes. DESIGN Retrospective, quasi-experimental study. SETTING We used the Healthcare Cost and Utilization Project State Inpatient Databases in five states (Florida, Maryland, Mississippi, New York, and Washington) during 2015-2017. PARTICIPANTS We selected patients with International Classification of Diseases, 9th and 10th Revision codes of respiratory failure and mechanical ventilation who underwent an inter-ICU transfer (n = 6,718), grouping as early (≤ 2 d) and later transfers (3+ d). To control for potential selection bias, we propensity score matched patients (1:1) to model propensity for early transfer using a priori defined patient demographic, clinical, and hospital variables. MAIN OUTCOMES Inhospital mortality, hospital length of stay (HLOS), and cumulative charges related to inter-ICU transfer. RESULTS Six-thousand seven-hundred eighteen patients with ARF underwent inter-ICU transfer, 68% of whom (n = 4,552) were transferred early (≤ 2 d). Propensity score matching yielded 3,774 well-matched patients for this study. Unadjusted outcomes were all superior in the early versus later transfer cohort: inhospital mortality (24.4% vs 36.1%; p < 0.0001), length of stay (8 vs 22 d; p < 0.0001), and cumulative charges ($118,686 vs $308,977; p < 0.0001). Through doubly robust multivariable modeling with random effects at the state level, we found patients who were transferred early had a 55.8% reduction in risk of inhospital mortality than those whose transfer was later (relative risk, 0.442; 95% CI, 0.403-0.497). Additionally, the early transfer cohort had lower HLOS (20.7 fewer days [13.0 vs 33.7; p < 0.0001]), and lower cumulative charges ($66,201 less [$192,182 vs $258,383; p < 0.0001]). CONCLUSIONS AND RELEVANCE Our study is the first to use a large, multistate sample to evaluate the practice of inter-ICU transfers in ARF and also define early and later transfers. Our findings of favorable outcomes with early transfer are vital in designing future prospective studies evaluating evidence-based transfer procedures and policies.
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Affiliation(s)
- Nandita R. Nadig
- Department of Medicine, Division of Pulmonary, Critical Care Medicine and Sleep, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Daniel L. Brinton
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC
| | - Kit N. Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC
| | - Andrew J. Goodwin
- Department of Medicine, Division of Pulmonary, Critical Care Medicine and Sleep, Medical University of South Carolina, Charleston, SC
| | - Annie N. Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC
| | - Dee W. Ford
- Department of Medicine, Division of Pulmonary, Critical Care Medicine and Sleep, Medical University of South Carolina, Charleston, SC
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Huq F, Manners E, O'Callaghan D, Thakuria L, Weaver C, Waheed U, Stümpfle R, Brett SJ, Patel P, Soni S. Patient outcomes following transfer between intensive care units during the COVID-19 pandemic. Anaesthesia 2022; 77:398-404. [PMID: 35226964 PMCID: PMC9111416 DOI: 10.1111/anae.15680] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/25/2022]
Abstract
Transferring critically ill patients between intensive care units (ICU) is often required in the UK, particularly during the COVID-19 pandemic. However, there is a paucity of data examining clinical outcomes following transfer of patients with COVID-19 and whether this strategy affects their acute physiology or outcome. We investigated all transfers of critically ill patients with COVID-19 between three different hospital ICUs, between March 2020 and March 2021. We focused on inter-hospital ICU transfers (those patients transferred between ICUs from different hospitals) and compared this cohort with intra-hospital ICU transfers (patients moved between different ICUs within the same hospital). A total of 507 transfers were assessed, of which 137 met the inclusion criteria. Forty-five patients underwent inter-hospital transfers compared with 92 intra-hospital transfers. There was no significant change in median compliance 6 h pre-transfer, immediately post-transfer and 24 h post-transfer in patients who underwent either intra-hospital or inter-hospital transfers. For inter-hospital transfers, there was an initial drop in median PaO2 /FI O2 ratio: from median (IQR [range]) 25.1 (17.8-33.7 [12.1-78.0]) kPa 6 h pre-transfer to 19.5 (14.6-28.9 [9.8-52.0]) kPa immediately post-transfer (p < 0.05). However, this had resolved at 24 h post-transfer: 25.4 (16.2-32.9 [9.4-51.9]) kPa. For intra-hospital transfers, there was no significant change in PaO2 /FI O2 ratio. We also found no meaningful difference in pH; PaCO2 ;, base excess; bicarbonate; or norepinephrine requirements. Our data demonstrate that patients with COVID-19 undergoing mechanical ventilation of the lungs may have short-term physiological deterioration when transferred between nearby hospitals but this resolves within 24 h. This finding is relevant to the UK critical care strategy in the face of unprecedented demand during the COVID-19 pandemic.
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Affiliation(s)
- F Huq
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - E Manners
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - D O'Callaghan
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - L Thakuria
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - C Weaver
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - U Waheed
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - R Stümpfle
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK.,Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - S J Brett
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - P Patel
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK.,Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - S Soni
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK.,Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
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13
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Ross SW, Reinke CE, Ingraham AM, Holena DN, Havens JM, Hemmila MR, Sakran JV, Staudenmayer KL, Napolitano LM, Coimbra R. Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues. J Am Coll Surg 2022; 234:214-225. [PMID: 35213443 DOI: 10.1097/xcs.0000000000000044] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.
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Affiliation(s)
- Samuel W Ross
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Caroline E Reinke
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Angela M Ingraham
- University of Wisconsin School of Medicine and Public Health, Madison, WI (Ingraham)
| | - Daniel N Holena
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Holena)
| | - Joaquim M Havens
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA (Havens)
| | - Mark R Hemmila
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Joseph V Sakran
- Johns Hopkins University School of Medicine, Baltimore, MD (Sakran)
| | | | - Lena M Napolitano
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Loma Linda, CA (Coimbra)
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14
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Rubens M, Ramamoorthy V, Saxena A, Appunni S, Sundil S, Veledar E, McGranaghan P, Tonse R, Fitz SJT, Chuong MD, Odia Y, Kotecha R, Mehta MP, Kotecha R. Relationship between insurance status and interhospital transfers among cancer patients in the United States. BMC Cancer 2022; 22:121. [PMID: 35093015 PMCID: PMC8801067 DOI: 10.1186/s12885-022-09242-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 01/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background The relationship between insurance status and interhospital transfers has not been adequately researched among cancer patients. Hence this study aimed for understanding this relationship using a nationally representative database. Methods A retrospective analysis was conducted using National Inpatient Sample (NIS) data collected during 2010–2016 and included all cancer hospitalization between 18 and 64 years of age. Interhospital transfers were compared based on insurance status (Medicare, Medicaid, private, and uninsured). Weighted multivariable logistic regressions were used to calculate the odds of interhospital transfers based on insurance status, after adjusting for many covariates. Results There were 3,580,908 weighted cancer hospitalizations, of which 72,353 (2.02%) had interhospital transfers. Uninsured patients had significantly higher rates of interhospital transfers, compared to those with Medicare (P = 0.005) and private insurance (P < 0.001). Privately insured patients had significantly lower rates of interhospital transfers, compared to those with Medicare (P < 0.001) and Medicaid (P < 0.001). Logistic regression analyses showed that the odds of having interhospital transfers were significantly higher among uninsured (adjusted odds ratio [aOR], 1.57, 95% CI: 1.45–1.69), Medicare (aOR, 1.38, 95% CI: 1.32–1.45) and Medicaid (aOR, 1.23, 95% CI: 1.16–1.30) patients when compared to those with private insurance coverages. Conclusion Among cancer patients, uninsured and Medicare and Medicaid beneficiaries were more likely to experience interhospital transfers. In addition to medical reasons, factors such as affordability and socioeconomic status are influencing interhospital transfer decisions, indicating existing healthcare disparities. Further studies should focus on identifying the causal associations between factors explored in this study as well as additional unexplored factors. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09242-8.
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15
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Laupland KB, Ramanan M, Shekar K, Kirrane M, Clement P, Young P, Edwards F, Bushell R, Tabah A. Is intensive care unit mortality a valid survival outcome measure related to critical illness? Anaesth Crit Care Pain Med 2021; 41:100996. [PMID: 34902631 DOI: 10.1016/j.accpm.2021.100996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/01/2021] [Accepted: 10/12/2021] [Indexed: 11/01/2022]
Abstract
RATIONALE Use of death as an outcome of intensive care unit (ICU) admission may be biased by differential discharge decisions. OBJECTIVE To determine the validity of ICU survival status as an outcome measure of all cause case-fatality. METHODS A retrospective cohort of first admissions among adults to four ICUs in North Brisbane, Australia was assembled. Death in ICU (censored at discharge or 30 days) was compared with 30-day overall case-fatality. RESULTS The 30-day overall case-fatality was 8.1% (2436/29,939). One thousand six hundred and thirty-one deaths occurred within the ICU stay and 576 subsequent during hospital post-ICU discharge within 30-days; ICU and hospital case-fatality rates were 5.4% and 7.4%, respectively. An additional 229 patients died after hospital separation within 30 days of ICU admission of which 110 (48.0%) were transferred to another acute care hospital, 80 (34.9%) discharged home, and 39 (17.0%) transferred to an aged care/chronic care/rehabilitation facility. Patients who died after ICU discharge were older, had higher APACHE III scores, were more likely to be elective surgical patients, and were less likely to be out of state residents or managed in a tertiary referral hospital. Limiting determination of case-fatality to ICU information alone would correctly detect 95% (780/821) of all-cause mortality at day 3, 90% (1093/1213) at day 5, 75% (1524/2019) at day 15, 72% (1592/2244) at day 21, and 67% (1631/2436) at day 30 of follow-up. CONCLUSIONS Use of ICU case-fatality significantly underestimates the true burden and biases assessment of determinants of critical illness-related mortality in our region.
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Affiliation(s)
- Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Marianne Kirrane
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Pierre Clement
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Patrick Young
- Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Felicity Edwards
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Rachel Bushell
- Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia
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16
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Chen E, Longcoy J, McGowan SK, Lange-Maia BS, Avery EF, Lynch EB, Ansell DA, Johnson TJ. Interhospital Transfer Outcomes for Critically Ill Patients With Coronavirus Disease 2019 Requiring Mechanical Ventilation. Crit Care Explor 2021; 3:e0559. [PMID: 34729490 PMCID: PMC8553251 DOI: 10.1097/cce.0000000000000559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Studying interhospital transfer of critically ill patients with coronavirus disease 2019 pneumonia in the spring 2020 surge may help inform future pandemic management. OBJECTIVES To compare outcomes for mechanically ventilated patients with coronavirus disease 2019 transferred to a tertiary referral center with increased surge capacity with patients admitted from the emergency department. DESIGN SETTING PARTICIPANTS Observational cohort study of single center urban academic medical center ICUs. All patients admitted and discharged with coronavirus disease 2019 pneumonia who received invasive ventilation between March 17, 2020, and October 14, 2020. MAIN OUTCOME AND MEASURES Demographic and clinical variables were obtained from the electronic medical record. Patients were classified as emergency department admits or interhospital transfers. Regression models tested the association between transfer status and survival, adjusting for demographics and presentation severity. RESULTS In total, 298 patients with coronavirus disease 2019 pneumonia were admitted to the ICU and received mechanical ventilation. Of these, 117 were transferred from another facility and 181 were admitted through the emergency department. Patients were primarily male (64%) and Black (38%) or Hispanic (45%). Transfer patients differed from emergency department admits in having English as a preferred language (71% vs 56%; p = 0.008) and younger age (median 57 vs 61 yr; p < 0.001). There were no differences in race/ethnicity or primary payor. Transfers were more likely to receive extracorporeal membrane oxygenation (12% vs 3%; p = 0.004). Overall, 50 (43%) transferred patients and 78 (43%) emergency department admits died prior to discharge. There was no significant difference in hospital mortality or days from intubation to discharge between the two groups. CONCLUSIONS AND RELEVANCE In a single-center retrospective cohort, no significant differences in hospital mortality or length of stay between interhospital transfers and emergency department admits were found. While more study is needed, this suggests that interhospital transfer of critically ill patients with coronavirus disease 2019 can be done safely and effectively.
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Affiliation(s)
- Elaine Chen
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine and Section of Palliative Medicine, Rush University Medical Center, Chicago, IL
| | - Joshua Longcoy
- Department of Health Systems Management, Rush University, Center for Community Health Equity, Rush University Medical Center, Chicago, IL
| | - Samuel K McGowan
- Department of Internal Medicine, Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California-San Francisco, San Francisco, CA
| | - Brittney S Lange-Maia
- Department of Preventive Medicine, Center for Community Health Equity, Rush University Medical Center, Chicago, IL
| | - Elizabeth F Avery
- Department of Preventive Medicine, Center for Community Health Equity, Rush University Medical Center, Chicago, IL
| | - Elizabeth B Lynch
- Department of Preventive Medicine, Center for Community Health Equity, Rush University Medical Center, Chicago, IL
| | - David A Ansell
- Department of Internal Medicine, Center for Community Health Equity, Rush University Medical Center, Chicago, IL
| | - Tricia J Johnson
- Department of Health Systems Management, Rush University, Center for Community Health Equity, Rush University Medical Center, Chicago, IL
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17
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Follette C, Halimeh B, Chaparro A, Shi A, Winfield R. Futile trauma transfers: An infrequent but costly component of regionalized trauma care. J Trauma Acute Care Surg 2021; 91:72-76. [PMID: 34144558 DOI: 10.1097/ta.0000000000003139] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Appropriate interfacility transfers are a key component of highly functioning trauma systems but transfer of unsalvageable patients can overburden the resources of higher-level centers. We sought to identify the occurrence and associated reasons for futile transfers within our trauma system. METHODS Using prospectively collected data from our system database, a retrospective cohort study was conducted to identify patients who underwent interfacility transfer to our American College of Surgeons level I center. Adult patients from June 2017 to June 2019 who died, had comfort measures implemented, were discharged, or went to hospice care within 48 hours of admission without significant operation, procedure, or radiologic intervention were examined. Futility was defined as resulting in death or hospice discharge within 48 hours of transfer without major operative, endoscopic, or radiologic intervention. RESULTS A total of 1,241 patients transferred to our facility during the study period. Four hundred seven patients had a length of stay less than or equal to 48 hours. Eighteen (1.5%) met the criteria for futility. The most common reason for transfer in the futile population was traumatic brain injury (56%) and need for neurosurgical capabilities (62%). Futile patients had a median age and Injury Severity Score of 75 and 21. The main transportation method was ground 9 (50%) with 8 (44.4%) being transported by helicopter and 1 (5.6%) being transported by both. Combining transport costs with hospital charges, each futile transfer was estimated to cost US $56,396 (interquartile range, 41,889-106,393) with a total cost exceeding US $1.7 million. With an estimated 33,000 interfacility transfers annually for trauma in the United States, the cost of futile transfers to the American trauma system would exceed 27 million dollars each year. CONCLUSION Futile transfers represent a small but costly portion transfer volume. Identification of patients whose conditions preclude the benefit of transfer due to futility and development of appropriate support for referral will significantly improve appropriate allocation of health care resources. LEVEL OF EVIDENCE Economic; Care management, level IV.
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Affiliation(s)
- Craig Follette
- From the Department of Surgery at the University of Kansas Medical Center, Kansas City, Kansas
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18
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Baig SH, Gorth DJ, Yoo EJ. Critical Care Utilization and Outcomes of Interhospital Medical Transfers at Lower Risk of Death. J Intensive Care Med 2021; 37:679-685. [PMID: 34080443 DOI: 10.1177/08850666211022613] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate utilization and mortality outcomes of interhospital transferred critically-ill medical patients with lower predicted risk of hospital mortality. MATERIALS & METHODS Multisite retrospective cohort analysis of patients with Acute Physiology and Chronic Health Evaluation (APACHE) IV-a predicted mortality of ≤20% from 335 ICUs in 208 hospitals in the Philips eICU database between 2014-2015. Differences in length-of-stay (LOS) and mortality between transferred and local patients were evaluated using negative binomial logistic regression and logistic regression, respectively. Stratified analyses were conducted for subgroups of predicted mortality: 0%-5%, 6%-10%, 11%-15%, and 16%-20%. RESULTS Transfers had a higher risk of longer ICU and hospital LOS across all risk strata (IRR 1.12; 95% CI 1.09-1.16, P < 0.001 and IRR 1.11; 95% CI 1.07-1.14, P < 0.001 respectively). Mortality was higher among transfers, largely driven by the 6%-10% mortality risk strata (OR 1.30; 95% CI 1.09-1.54, P = 0.003). CONCLUSIONS Interhospital transfer of critically-ill medical patients with lower illness severity is associated with higher ICU and hospital utilization and increased mortality. Better understanding of factors driving patient selection for and characteristics of interhospital transfer for this population will have an impact on ICU resource utilization, care efficiency, and hospital quality.
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Affiliation(s)
- Saqib H Baig
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, PA, USA
| | - Deborah J Gorth
- Sidney Kimmel Medical College, Thomas Jefferson University, PA, USA
| | - Erika J Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, PA, USA
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19
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Le D, Alfarah Z, Kunupakaphun S, Eamranond P. Preventing unnecessary interhospital transfers to urban medical centers. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2020. [DOI: 10.1080/20479700.2018.1563315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Dat Le
- Lawrence General Hospital, Lawrence, MA, USA
| | - Ziad Alfarah
- Lawrence General Hospital, Lawrence, MA, USA
- Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | | | - Pracha Eamranond
- Lawrence General Hospital, Lawrence, MA, USA
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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20
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Kitchlu A, Shapiro J, Slater J, Brimble KS, Dirk JS, Jeyakumar N, Dixon SN, Garg AX, Harel Z, Harvey A, Kim SJ, Silver SA, Wald R. Interhospital Transfer and Outcomes in Patients with AKI: A Population-Based Cohort Study. KIDNEY360 2020; 1:1195-1205. [PMID: 35372873 PMCID: PMC8815504 DOI: 10.34067/kid.0003612020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/14/2020] [Indexed: 05/01/2023]
Abstract
BACKGROUND Patients with AKI may require interhospital transfer to receive RRT. Interhospital transfer may lead to delays in therapy, resulting in poor patient outcomes. There is minimal data comparing outcomes among patients undergoing transfer for RRT versus those who receive RRT at the hospital to which they first present. METHODS We conducted a population-based cohort study of all adult patients (≥19 years) who received acute dialysis within 14 days of admission to an acute-care hospital between April 1, 2004 and March 31, 2015. The transferred group included all patients who presented to a hospital without a dialysis program and underwent interhospital transfer (with the start of dialysis ≤3 days of transfer and within 14 days of initial admission). All other patients were considered nontransferred. The primary outcome was time to 90-day all-cause mortality, adjusting for demographics, comorbidities, and measures of acute illness severity. We also assessed chronic dialysis dependence as a secondary outcome, using the Fine and Gray proportional hazards model to account for the competing risks of death. In a secondary post hoc analysis, we assessed these outcomes in a propensity score-matched cohort, matching on age, sex, and prior CKD status. RESULTS We identified 27,270 individuals initiating acute RRT within 14 days of a hospital admission, of whom 2113 underwent interhospital transfer. Interhospital transfer was associated with lower rate of mortality (adjusted hazard ratio [aHR], 0.90; 95% CI, 0.84 to 0.97). Chronic dialysis dependence was not significantly different between groups (aHR, 0.98; 95% CI, 0.91 to 1.06). In the propensity score-matched analysis, interhospital transfer remained associated with a lower risk of death (HR, 0.88; 95% CI, 0.80 to 0.96). CONCLUSIONS Interhospital transfer for receipt of RRT does not confer higher mortality or worse kidney outcomes.
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Affiliation(s)
- Abhijat Kitchlu
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Joshua Shapiro
- Division of Nephrology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - K. Scott Brimble
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Stephanie N. Dixon
- ICES, Toronto, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Amit X. Garg
- ICES, Toronto, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Division of Nephrology, Western University, London, Ontario, Canada
| | - Ziv Harel
- Division of Nephrology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Harvey
- Division of Nephrology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - S. Joseph Kim
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Samuel A. Silver
- Division of Nephrology, Queen’s University, Kingston, Ontario, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
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21
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Viglianti EM, Bagshaw SM, Bellomo R, McPeake J, Molling DJ, Wang XQ, Seelye S, Iwashyna TJ. Late Vasopressor Administration in Patients in the ICU: A Retrospective Cohort Study. Chest 2020; 158:571-578. [PMID: 32278780 PMCID: PMC7417379 DOI: 10.1016/j.chest.2020.02.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/31/2020] [Accepted: 02/16/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Little is known about the prevalence, predictors, and outcomes of late vasopressor administration which evolves after admission to the ICU. RESEARCH QUESTION What is the epidemiology of late vasopressor administration in the ICU? STUDY DESIGN AND METHODS We retrospectively studied a cohort of veterans admitted to the Veterans Administration ICUs for ≥ 4 days from 2014 to 2017. The timing of vasopressor administration was categorized as early (only within the initial 3 days), late (on day 4 or later and none on day 3), and continuous (within the initial 2 days through at least day 4). Regressions were performed to identify patient factors associated with late vasopressor administration and the timing of vasopressor administration with posthospitalization discharge mortality. RESULTS Among the 62,206 hospitalizations with at least 4 ICU days, late vasopressor administration occurred in 5.5% (3,429 of 62,206). Patients with more comorbidities (adjusted OR [aOR], 1.02 per van Walraven point; 95% CI, 1.02-1.03) and worse severity of illness on admission (aOR, 1.01 per percentage point risk of death; 95% CI, 1.01-1.02) were more likely to receive late vasopressor therapy. Nearly 50% of patients started a new antibiotic within 24 h of receiving late vasopressor therapy. One-year mortality after survival to discharge was higher for patients with continuous (adjusted hazard ratio [aHR], 1.48; 95% CI, 1.33-1.65) and late vasopressor administration (aHR, 1.26; 95% CI, 1.15-1.38) compared with only early vasopressor administration. INTERPRETATION Late vasopressor administration was modestly associated with comorbidities and admission illness severity. One-year mortality was higher among those who received late vasopressor administration compared with only early vasopressor administration. Research to understand optimization of late vasopressor therapy administration may improve long-term mortality.
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Affiliation(s)
- Elizabeth M Viglianti
- Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
| | - Joanne McPeake
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland; Intensive Care Unit, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, Scotland
| | - Daniel J Molling
- HSR&D Center for Innovation, Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
| | - Xiao Qing Wang
- Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI
| | - Sarah Seelye
- HSR&D Center for Innovation, Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
| | - Theodore J Iwashyna
- Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI; HSR&D Center for Innovation, Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI; Institute for Social Research, Ann Arbor, MI
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22
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Arthur KR, Kelz RR, Mills AM, Reinke CE, Robertson MP, Sims CA, Pascual JL, Reilly PM, Holena DN. Interhospital Transfer: An Independent Risk Factor for Mortality in the Surgical Intensive Care Unit. Am Surg 2020; 79:909-13. [DOI: 10.1177/000313481307900929] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Interhospital transfer (IHT) is associated with mortality in medical and mixed intensive care units (ICUs), but few studies have examined this relationship in a surgical ICU (SICU) setting. We hypothesized that IHT is associated with increased mortality in SICU patients relative to ICU patients admitted within the hospital. We reviewed SICU and transfer center databases from a tertiary academic center over a 2-year period. Inclusion criteria included age 18 years or older and SICU admission 24 hours or greater. Demographic data, admission service, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were captured. The primary end point was ICU mortality. Univariate logistic regression was used to test the association between variables and mortality. Factors found to be associated with mortality at P < 0.1 were entered into a multivariable model. Of 4542 admissions, 416 arrived by IHT. Compared with the non-IHT group, the IHT group was older (age 58.3 years [interquartile range, 47.8 to 70.6] vs 57.8 years [interquartile range, 44.1 to 68.8] years, P = 0.036), sicker (APACHE II score 16.5 [interquartile range, 12 to 23] vs 14 [interquartile range, 10 to 20], P < 0.001), and more likely to be white (82% [n = 341] vs 69% [n = 2865], P < 0.001). Mortality rates in IHT patients were highest on the emergency surgery (18%), transplant surgery (16%), and gastrointestinal surgery (8%) services. After adjusting for age and APACHE II score, IHT remained a risk factor for ICU mortality (odds ratio, 1.60; 95% confidence interval, 1.04 to 2.45; P = 0.032) in SICU patients. Interhospital transfer is an independent risk factor for mortality in the SICU population; this risk is unevenly distributed through service lines. Further efforts to determine the cause of this association are warranted.
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Affiliation(s)
| | - Rachel R. Kelz
- Departments of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela M. Mills
- Departments of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caroline E. Reinke
- Departments of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Carrie A. Sims
- Departments of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jose L. Pascual
- Departments of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M. Reilly
- Departments of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel N. Holena
- Departments of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
The emergence of pay-for-performance systems pose a risk to an academic medical center's (AMC) mission to provide care for interhospital surgical transfer patients. This study examines quality metrics and resource consumption for a sample of these patients from the University Health System Consortium (UHC) and our Department of Surgery (DOS). Standard benchmarks, including mortality rate, length of stay (LOS), and cost, were used to evaluate the impact of inter-hospital surgical transfers versus direct admission (DA) patients from January 2010 to December 2012. For 1,423,893 patients, the case mix index for transfer patients was 38 per cent (UHC) and 21 per cent (DOS) greater than DA patients. Mortality rates were 5.70 per cent (UHC) and 6.93 per cent (DOS) in transferred patients compared with 1.79 per cent (UHC) and 2.93 per cent (DOS) for DA patients. Mean LOS for DA patients was 4 days shorter. Mean total costs for transferred patients were greater $13,613 (UHC) and $13,356 (DOS). Transfer patients have poorer outcomes and consume more resources than DA patients. Early recognition and transfer of complex surgical patients may improve patient rescue and decrease resource consumption. Surgeons at AMCs and in the community should develop collaborative programs that permit collective assessment and decision-making for complicated surgical patients.
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Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management. Pediatr Emerg Care 2019; 35:568-574. [PMID: 31369494 DOI: 10.1097/pec.0000000000001887] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Few studies have evaluated impact of emergency department (ED) management on delayed transfers to the pediatric intensive care unit (PICU). Our study objectives were to describe patient characteristics of PICU transfers less than or equal to 12 hours of admission and determine the reason for transfer. METHODS We conducted a retrospective chart review of patients transferred to PICU less than or equal to 12 hours of admission. We extracted patient demographics, emergency severity index category, ED, floor and PICU length of stay (LOS), and PICU "significant" interventions. Charts were reviewed independently by the study principal investigator and a PICU attending who classified transfers as secondary to progression of disease or error in ED management. Furthermore, errors were classified as diagnostic, management, or disposition errors. RESULTS A total of 164 patients met inclusion criteria. Most were male (86/164, 52.4%), with emergency severity index category 2 (116/164, 70.7%) and respiratory diagnosis (98/164, 59.8%). Most transfers (136/164, 82.9%) resulted from progression of illness. No significant interventions were performed in 48.8% (80/164) of patients. Of 164 transfers, 28 (17.1%) resulted from ED error, and half of these were management errors. Compared with disease progression, the ED error group had a significantly shorter median floor LOS {3.45 [interquartile range (IQR): 2.15, 7.56] vs 6.58 (IQR: 3.70, 9.20); P = 0.005}, more PICU interventions [1.5 (IQR: 0, 4) vs 0 (IQR: 0, 2); P = 0.006], and longer PICU LOS [2.50 (IQR: 1.09, 4.25) vs 1.36 (IQR: 0.80, 2.50); P = 0.013]. CONCLUSIONS Most PICU transfers less than or equal to 12 hours after admission result from illness progression. Half of these do not require significant interventions. The PICU transfers after ED management error had significantly shorter floor LOS, longer PICU LOS, and more interventions.
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Percentage of Mortal Encounters Transferred in Emergency General Surgery. J Surg Res 2019; 243:391-398. [PMID: 31277017 DOI: 10.1016/j.jss.2019.05.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/26/2019] [Accepted: 05/29/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Despite the frequent occurrence of interhospital transfers in emergency general surgery (EGS), rates of transfer of complications are undescribed. Improved understanding of hospital transfer patterns has a multitude of implications, including quality measurement. The objective of this study was to describe individual hospital transfer rates of mortal encounters. MATERIALS AND METHODS A retrospective review was undertaken from 2013 to 2015 of the Maryland Health Services Cost Review Commission database. Two groups of EGS encounters were identified: encounters with death following transfer and encounters with death without transfer. The percentage of mortal encounters transferred was defined as the percentage of EGS hospital encounters with mortality initially presenting to a hospital transferred to another hospital before death at the receiving hospital. RESULTS Overall, 370,242 total EGS encounters were included, with 17,003 (4.6%) of the total EGS encounters with mortality. Encounters with death without transfer encompassed 15,604 (91.8%) of mortal EGS encounters and encounters with death following transfer 1399 (8.2%). EGS disease categories of esophageal varices or perforation, necrotizing fasciitis, enterocutaneous fistula, and pancreatitis had over 10% of these total mortal encounters with death following transfer. For individual hospitals, percentage of mortal encounters transferred ranged from 0.8% to 35.2%. The percentage of mortal encounters transferred was inversely correlated with annual EGS hospital volume for all state hospitals (P < 0.001, r = -0.57). CONCLUSIONS Broad variability in individual hospital practices exists for mortality transferred to other institutions. Application of this knowledge of percentage of mortal encounters transferred includes consideration in hospital quality metrics.
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Hardy K, Metcalfe J, Clouston K, Vergis A. The Impact of an Acute Care Surgical Service on the Quality and Efficiency of Care Outcome Indicators for Patients with General Surgical Emergencies. Cureus 2019; 11:e5036. [PMID: 31501728 PMCID: PMC6721875 DOI: 10.7759/cureus.5036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Acute care surgery (ACS) models address high volumes of emergency general surgery and emergency room (ER) overcrowding. The impact of ACS service model implementation on the quality and efficiency of care (EOC) outcomes in acute appendicitis (AA) and acute cholecystitis (AC) cohorts was evaluated. Methods A retrospective chart review (N=1,229) of adult AA and AC patients admitted prior to (pre-ACS; n=507; three hospitals; 2007) and after regionalization (R-ACS; n=722; one hospital; 2011). Results R-ACS time to ER physician assessment was significantly longer for AA (3.4 ± 2.3 versus 2.4 ± 2.6 hr; p ≤ 0.001). Surgical response times (1.3 ± 1.2 vs 2.6 ± 4.3 hr for AA; 1.8 ± 1.5 vs 4.1 ± 5.0 hr for AC; p ≤ 0.0001) and acquisition of imaging (4.1 ± 4.1 vs 6.9 ± 9.9 hr for AA, p ≤ 0.0001; 7.8 ± 1.9 vs 13.2 ± 18.5 hr for AC, p ≤ 0.008) occurred significantly faster with R-ACS. R-ACS resulted in a significant increase in night-time appendectomies (21.7% vs 11.1%; p ≤ 0.002), perforated appendices (29.1 % vs 18.9 %; p ≤ 0.006), 30-day readmissions (4.56% vs 0.82%; p ≤ 0.01), and lower rate of intraoperative complications for AC patients (2.78% vs 7.69%; p ≤ 0.02). Conclusions Despite the increased volume of patients seen with the implementation of R-ACS, surgical assessments and diagnostic imaging were significantly more prompt. EOC measures were maintained. Worse AA outcomes highlight areas for improvement in delivering R-ACS.
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Affiliation(s)
- Krista Hardy
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
| | - Jennifer Metcalfe
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
| | - Kathleen Clouston
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
| | - Ashley Vergis
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
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Odetola FO, Gebremariam A. Transfer hospitalizations for pediatric severe sepsis or septic shock: resource use and outcomes. BMC Pediatr 2019; 19:196. [PMID: 31196011 PMCID: PMC6567483 DOI: 10.1186/s12887-019-1577-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 06/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sepsis is a major cause of child mortality and morbidity. To enhance outcomes, children with severe sepsis or septic shock often require escalated care for organ support, sometimes necessitating interhospital transfer. The association between transfer admission for the care of pediatric severe sepsis or septic shock and in-hospital patient survival and resource use is poorly understood. METHODS Retrospective study of children 0-20 years old hospitalized for severe sepsis or septic shock, using the 2012 Kids' Inpatient Database. After descriptive and bivariate analysis, multivariate regression methods assessed the independent relationship between transfer status and outcomes of in-hospital mortality, duration of hospitalization, and hospital charges, after adjustment for potential confounders including illness severity. RESULTS Of an estimated 11,922 hospitalizations (with transfer information) for pediatric severe sepsis and septic shock nationally in 2012, 25% were transferred, most often to urban teaching hospitals. Compared to non-transferred children, transferred children were younger, and had a higher frequency of extreme illness severity (84% vs. 75%, p < .01), and of multiple organ dysfunction (32% vs. 24%, p < .01). They also had higher use of invasive medical devices including arterial catheters, invasive mechanical ventilation, and central venous catheters; and of specialized technology, including renal replacement therapy (6.2% vs. 4.6%, p < .01) and extracorporeal membrane oxygenation (5.7% vs. 1.8%, p < .01). Transferred children had longer hospitalization and accrued higher charges than non-transferred children (p < .01). Crude mortality was higher among transferred than non-transferred children (21.4% vs.15.0%, p < .01), a difference no longer statistically significant after multivariate adjustment for potential confounders (Odds Ratio:1.04, 95% Confidence interval: 0.88-1.24). Similarly, adjusted length of hospital stay and hospital charges were not statistically different by transfer status. CONCLUSION One in four children with severe sepsis or septic shock required interhospital transfer for specialized care associated with greater use of invasive medical devices and specialized technology. Despite higher crude mortality and resource consumption among transferred children, adjusted mortality and resource use did not differ by transfer status. Further research should identify quality-of-care factors at the receiving hospitals that influence clinical outcomes and resource use.
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Affiliation(s)
- Folafoluwa O. Odetola
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Critical Care Medicine, 6C07, 300 North Ingalls Street, Ann Arbor, MI 48109 USA
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109 USA
| | - Achamyeleh Gebremariam
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109 USA
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Lauerman MH, Herrera AV, Albrecht JS, Chen HH, Bruns BR, Tesoriero RB, Scalea TM, Diaz JJ. Interhospital Transfers with Wide Variability in Emergency General Surgery. Am Surg 2019. [DOI: 10.1177/000313481908500622] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Interhospital transfer of emergency general surgery (EGS) patients is a common occurrence. Modern individual hospital practices for interhospital transfers have unknown variability. A retrospective review of the Maryland Health Services Cost Review Commission database was undertaken from 2013 to 2015. EGS encounters were divided into three groups: encounters not transferred, encounters transferred from a hospital, and encounters transferred to a hospital. In total, 380,405 EGS encounters were identified, including 12,153 (3.2%) encounters transferred to a hospital, 10,163 (2.7%) encounters transferred from a hospital, and 358,089 (94.1%) encounters not transferred. For individual hospitals, percentage of encounters transferred to a hospital ranged from 0 to 30.05 per cent, encounters transferred from a hospital from 0.02 to 14.62 per cent, and encounters not transferred from 69.25 to 99.95 per cent of total encounters at individual hospitals. Percentage of encounters transferred from individual hospitals was inversely correlated with annual EGS hospital volume ( P < 0.001, r = -0.59), whereas percentage of encounters transferred to individual hospitals was directly correlated with annual EGS hospital volume ( P < 0.001, r = 0.51). Individual hospital practices for interhospital transfer of EGS patients have substantial variability. This is the first study to describe individual hospital interhospital transfer practices for EGS.
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Affiliation(s)
- Margaret H. Lauerman
- Division of Acute Care and Emergency Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland and
| | - Anthony V. Herrera
- Division of Acute Care and Emergency Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland and
| | - Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland
| | - Hegang H. Chen
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland
| | - Brandon R. Bruns
- Division of Acute Care and Emergency Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland and
| | - Ronald B. Tesoriero
- Division of Acute Care and Emergency Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland and
| | - Thomas M. Scalea
- Division of Acute Care and Emergency Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland and
| | - Jose J. Diaz
- Division of Acute Care and Emergency Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland and
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Factors Associated With the Interhospital Transfer of Emergency General Surgery Patients. J Surg Res 2019; 240:191-200. [PMID: 30978599 DOI: 10.1016/j.jss.2018.11.053] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 10/22/2018] [Accepted: 11/26/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Transferred emergency general surgery (EGS) patients constitute a highly vulnerable, acutely ill population. Guidelines to facilitate timely, appropriate EGS transfers are lacking. We determined patient- and hospital-level factors associated with interhospital EGS transfers, a critical first step to identifying which patients may require transfer. METHODS Adult EGS patients (defined by American Association for the Surgery of Trauma International Classification of Diseases, Ninth Revision diagnosis codes) were identified within the 2008-2013 Nationwide Inpatient Sample (n = 17,175,450). Patient- and hospital-level factors were examined as predictors of transfer to another acute care hospital with a multivariate proportional cause-specific hazards model with a competing risk analysis to assess the effect of risk factors for transfer. RESULTS 1.8% of encounters resulted in a transfer (n = 318,286). Transferred patients were on average 62 y old and most commonly had Medicare (52.9% [n = 168,363]), private (26.7% [n = 84,991]), or Medicaid insurance (10.8% [n = 34,279]). 67.7% were white. The most common EGS diagnoses among transferred patients were related to hepatic-pancreatic-biliary (n = 90,989 [28.6%]) and upper gastrointestinal tract (n = 60,088 [18.9%]) conditions. Most transferred patients (n = 269,976 [84.8%]) did not have a procedure before transfer. Transfer was more likely if patients were in small (hazard ratio 2.52, 95% confidence interval 2.28-2.79) or medium (1.32, 1.21-1.44) versus large facilities, government (1.19, 1.11-1.28) versus private facilities, and rural (4.58, 3.98-5.27) or urban nonteaching (1.89, 1.70-2.10) versus urban teaching facilities. Patient-level factors were not strong predictors of transfer. CONCLUSIONS We identified that hospital-level characteristics more strongly predicted the need for transfer than patient-related factors. Consideration of these factors by providers as care is delivered in the context of the resources and capabilities of local institutions may facilitate transfer decision-making.
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Reimer AP, Schiltz NK, Ho VP, Madigan EA, Koroukian SM. Applying Supervised Machine Learning to Identify Which Patient Characteristics Identify the Highest Rates of Mortality Post-Interhospital Transfer. BIOMEDICAL INFORMATICS INSIGHTS 2019; 11:1178222619835548. [PMID: 30911219 PMCID: PMC6425528 DOI: 10.1177/1178222619835548] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/04/2019] [Indexed: 01/15/2023]
Abstract
Objective: To demonstrate the usefulness of applying supervised machine-learning analyses to identify specific groups of patients that experience high levels of mortality post-interhospital transfer. Methods: This was a cross-sectional analysis of data from the Health Care Utilization Project 2013 National Inpatient Sample, that applied supervised machine-learning approaches that included (1) classification and regression tree to identify mutually exclusive groups of patients and their associated characteristics of those experiencing the highest levels of mortality and (2) random forest to identify the relative importance of each characteristic’s contribution to post-transfer mortality. Results: A total of 21 independent groups of patients were identified, with 13 of those groups exhibiting at least double the national average rate of mortality post-transfer. Patient characteristics identified as influencing post-transfer mortality the most included: diagnosis of a circulatory disorder, comorbidity of coagulopathy, diagnosis of cancer, and age. Conclusions: Employing supervised machine-learning analyses enabled the computational feasibility to assess all potential combinations of available patient characteristics to identify groups of patients experiencing the highest rates of mortality post-interhospital transfer, providing potentially useful data to support developing clinical decision support systems in future work.
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Affiliation(s)
- Andrew P Reimer
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA.,Critical Care Transport, Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas K Schiltz
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Vanessa P Ho
- Division of Trauma/Burn Care, MetroHealth Medical Center, Cleveland, OH, USA
| | | | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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Duke G, Santamaria J, Shann F, Stow P. Outcome-based Clinical Indicators for Intensive Care Medicine. Anaesth Intensive Care 2019; 33:303-10. [PMID: 15973912 DOI: 10.1177/0310057x0503300305] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The clinical indicator is a tool used to monitor the quality of health care. Its use in the Intensive Care Unit (ICU) is desirable for many reasons: the maintenance of minimum standards, the development of best practice and the delivery of cost-effective health care. The utility of clinical indicators in ICU is limited by the lack of universal, robust, transparent, evidence-based and risk-adjusted measures of quality, and the difficulties in defining “quality care” and “good outcome”. Monitoring of adverse events, system descriptors, and resource indicators is valuable but they have a limited relationship to the quality of care. ICU mortality prediction models provide a global measure of quality and, despite their inherent deficiencies, remain one of the most robust and useful clinical indicators.
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Affiliation(s)
- G Duke
- Critical Care Department, The Northern Hospital, Epping, Victoria
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Abstract
We undertook a three-month prospective cohort study of critically ill adult patients referred to the Intensive Care Units 7(ICUs) of public hospitals in metropolitan Melbourne and Geelong, Victoria. The aim was to ascertain the prevalence and immediate consequences of “refused” admission amongst patients appropriately referred to the ICU of first choice. Between August 1 and October 31, 1999, 10 (out of 12) public hospitals collected data. Three thousand and four patients were referred to these ICUs, and “refusals” were reported by all hospitals. A total of 282 (9.4%) patients were unable to be admitted to the ICU of first choice, giving a rate of 3.1 “refusals” per day. The reasons for “refusal” were limited staffing (52%) and shortage of beds (46%.) Acute inter-hospital transfer (1.7 per day) was the most common immediate triage outcome (57%). These rates are higher than previously reported figures. We conclude that refused admission to the ICU of first choice, and acute inter-hospital transfer in this region and time period, were common events.
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Affiliation(s)
- G J Duke
- Australian and New Zealand Intensive Care Society (Victorian Region), Carlton, Victoria
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Comparisons of the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center. Int J Colorectal Dis 2018; 33:1617-1625. [PMID: 29679151 DOI: 10.1007/s00384-018-3052-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Intestinal obstruction is a leading cause of patient mortality and the most common reason for emergent operation in colorectal surgery. The influence of inter-hospital transfer on patients' outcomes varies greatly in different diseases. We aimed to compare the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center. METHODS All intestinal obstruction patients operated in Cleveland Clinic from Jan 2012 to Dec 2016 were collected from a prospectively maintained database. Preoperative characteristics; surgical outcomes, including intraoperative complication, postoperative complication, readmission, reoperation, and postoperative 30-day mortality; and medical cost were collected. All parameters were compared between two groups before and after propensity score match. Multivariate logistic analysis was used to explore risk factors of surgical outcomes. RESULTS A total of 576 patients were included, with 75 in the transferred group and 501 in the directly admitted group. Before match, the transferred patients had longer waiting interval from admission to surgery (p < 0.001), more contaminated or infected wounds (p = 0.02), different surgical procedures (p = 0.02), and similar surgical outcomes and total medical cost (all p > 0.05), compared with the directly admitted group. Multivariate analysis showed that inter-hospital transfer was not an independent predictor of any surgical outcome. After matching to balance the preoperative characteristics between two groups, no significant differences were identified in all surgical outcomes and total medical cost between two groups (all p > 0.05). CONCLUSIONS Compared with directly admitted patients, transferred intestinal obstruction patients are associated with similar surgical outcomes and similar medical costs.
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Maclure PT, Gluck S, Pearce A, Finnis ME. Patients retrieved to intensive care via a dedicated retrieval service do not have increased hospital mortality compared with propensity-matched controls. Anaesth Intensive Care 2018; 46:202-206. [PMID: 29519224 DOI: 10.1177/0310057x1804600210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study was performed to estimate the effect of the retrieval process on mortality for patients admitted to a mixed adult intensive care unit (ICU) compared with propensity-matched, non-retrieved controls. Patients retrieved to the Royal Adelaide Hospital (RAH) ICU between 2011 and 2015 were propensity-score matched for age, gender, Aboriginal and Torres Strait Islander status, Acute Physiology and Chronic Health Evaluation (APACHE) III score and diagnostic group with non-retrieved ICU patients to estimate the average treatment effect of retrieval on hospital mortality. Factors associated with mortality in those retrieved were assessed by multiple logistic regression. Retrieved patients comprised 1,597 (14%) of 11,641 index ICU admissions; this group were younger, mean (standard deviation) 53 (18.5) versus 59 (17.7) years, had higher APACHE III scores, 61 (30.3) versus 56 (27.5), were more likely to be Indigenous (5.1% versus 3.7%) and to have sustained trauma (34% versus 9%). The average treatment effect for retrieval on hospital mortality, risk difference (95% confidence interval), was -0.7% (-2.8% to 1.3%), <i>P</i>=0.50. Variables independently associated with hospital mortality in those retrieved included age, APACHE III score and diagnostic category. Time from retrieval team activation to arrival with the patient, rural location, radial distance from the RAH and population size at the retrieval location were not significantly associated with mortality. The hospital mortality for retrieved patients was not significantly different when compared with propensity-matched controls. Mortality in those retrieved was associated with increasing age, APACHE III score and diagnostic category; however, was independent of time from team activation to arrival with the patient.
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Affiliation(s)
| | | | - A Pearce
- Consultant, Emergency Department, The Royal Adelaide Hospital; Adelaide, South Australia
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Jones RE, Gee KM, Burkhalter LS, Beres AL. Correlation of payor status and pediatric transfer for acute appendicitis. J Surg Res 2018; 229:216-222. [PMID: 29936993 DOI: 10.1016/j.jss.2018.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/15/2018] [Accepted: 04/03/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tertiary referral centers provide specialty and critical care for patients presenting to hospitals that lack these resources. There is a notion among tertiary centers that outside hospitals are more likely to transfer uninsured or underinsured patients. We examined funding status of patients transferred to our tertiary pediatric hospital for surgical management of appendicitis, hypothesizing that transferred patients were more likely to have unfavorable coverage. MATERIALS AND METHODS The electronic medical record was queried for all cases of laparoscopic appendectomy at our hospital between 2011 and 2015. Insurance was grouped into three categories: commercial, Medicaid/Children's Health Insurance Plan, or none. Transferred patients were compared to patients who presented directly. RESULTS A total of 5758 patients underwent laparoscopic appendectomy during the study period, of which 1683 (29.2%) were transfer patients. Transfer patients were more likely to be older, with a median age of 10.5 y versus 9.8 y in nontransferred patients (P ≤ 0.0001), and were more likely to be identified as non-Hispanic (50.0% versus 36.5%; P ≤ 0.0001). Insurance coverage was similar between groups. However, subgroup analysis of the hospitals that most frequently used our transfer services revealed a trend to transfer a higher proportion of Medicaid/Children's Health Insurance Plan patients. CONCLUSIONS Overall, pediatric patients transferred for laparoscopic appendectomy had similar insurance coverage to patients admitted directly, but subgroup analysis shows that not all centers follow this trend. Transfer patients were more frequently older and non-Hispanic. This builds upon the existing literature regarding the correlation of funding and transfer practices and highlights the need for additional research in this area.
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Affiliation(s)
- Ruth Ellen Jones
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
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Reimer AP, Dalton JE. Predictive accuracy of medical transport information for in-hospital mortality. J Crit Care 2018; 44:238-242. [PMID: 29175048 PMCID: PMC5831478 DOI: 10.1016/j.jcrc.2017.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/10/2017] [Accepted: 11/11/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Andrew P Reimer
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States; Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, United States.
| | - Jarrod E Dalton
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States
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Patient and Hospital Characteristics Associated with Interhospital Transfer for Adults with Ventilator-Dependent Respiratory Failure. Ann Am Thorac Soc 2018; 14:730-736. [PMID: 28199137 DOI: 10.1513/annalsats.201611-918oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Patients with ventilator-dependent respiratory failure have improved outcomes at centers with greater expertise; yet, most patients are not treated in such facilities. Efforts to align care for respiratory failure and hospital capability would necessarily require interhospital transfer. OBJECTIVES To characterize the prevalence and the patient and hospital factors associated with interhospital transfer of adults residing in Florida with ventilator-dependent respiratory failure. METHODS We performed a retrospective, observational study using Florida Healthcare Cost and Utilization Project data. We selected patients 18 years of age and older with International Classification of Diseases, Ninth Revision, codes of respiratory failure and mechanical ventilation during 2012 and 2013, and we identified cohorts of patients that did and did not undergo interhospital transfer. We obtained patient sociodemographic and clinical variables and categorized hospitals into subtypes on the basis of patient volume and services provided: large, medium (nonprofit or for-profit), and small. RESULTS Interhospital transfer was our primary outcome measure. Patient sociodemographics, clinical variables, and hospital types were used as covariates. We identified 2,580 patients with ventilator-dependent respiratory failure who underwent interhospital transfer. Overall, transfer was uncommon, with only 2.9% of patients being transferred. In a hierarchical model, age less than 65 years (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.77-2.45) and tracheostomy (OR, 3.19; 95% CI, 2.80-3.65) were associated with higher odds of transfer, whereas having Medicaid was associated with lower odds of transfer than having commercial insurance (OR, 0.65; 95% CI, 0.56-0.75). Additionally, care in medium-sized for-profit hospitals was associated with lower odds of transfer (OR, 1.37 vs. 2.70) than care in medium nonprofit hospitals, despite similar hospital characteristics. CONCLUSIONS In Florida, interhospital transfer of patients with ventilator-dependent respiratory failure is uncommon and more likely among younger, commercially insured, medically resource-intensive patients. For-profit hospitals are less likely to transfer than nonprofit hospitals. In future studies, researchers should test for geographic variations and examine the clinical implications of selectivity in interhospital transfer of patients with ventilator-dependent respiratory failure.
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Suresh K, Gouveia CJ, Kern RC, Cramer JD. The Association of External Transfer Status with Adverse Outcomes in Otolaryngology. Otolaryngol Head Neck Surg 2018; 158:848-853. [PMID: 29337650 DOI: 10.1177/0194599817753611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To compare rates of morbidity and mortality in patients treated by otolaryngologists who undergo interhospital transfers vs those who do not and to quantify conditions requiring interhospital transfers in this population. Study Design Cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program. Subjects and Methods We identified patients requiring surgery by otolaryngologists in the National Surgical Quality Improvement Program database from 2006 to 2013. We compared patients who were transferred from an outside institution to those admitted from home. Multivariate regression was used to adjust for patient characteristics, comorbidities, and case mix. The primary outcome was overall morbidity and mortality within 30 days of surgery. Results We identified 60,498 patients; 488 (0.8%) were transferred from another institution. Operations that were more common in the transferred group were incision and drainage (24.0% vs 1.2%), facial trauma repair (9.0% vs 3.1%), and oropharyngeal hemorrhage control (3.9% vs 0.4%). External transfer patients had significantly longer hospital stays (44.1% vs 4.4% >7 days, P < .05). On unadjusted analysis, transferred patients had a significantly higher rate of morbidity and mortality (odds ratio [OR], 11.3; 95% confidence interval [CI], 9.4-13.5). On multivariate analysis, transferred patients had a significantly greater rate of morbidity and mortality (OR, 3.1; 95% CI, 2.4-4.0). Conclusion Transfer from another institution is associated with worse outcomes independent of case mix, demographics, and preoperative comorbidities in acute otolaryngology conditions requiring surgery. Practitioners should be aware of this when caring for transfer patients, and transfer status should be considered when measuring hospital quality.
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Affiliation(s)
- Krish Suresh
- 1 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christopher J Gouveia
- 2 Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,3 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Robert C Kern
- 2 Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John D Cramer
- 2 Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,4 Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Blecha S, Dodoo-Schittko F, Brandstetter S, Brandl M, Dittmar M, Graf BM, Karagiannidis C, Apfelbacher C, Bein T. Quality of inter-hospital transportation in 431 transport survivor patients suffering from acute respiratory distress syndrome referred to specialist centers. Ann Intensive Care 2018; 8:5. [PMID: 29335831 PMCID: PMC5768581 DOI: 10.1186/s13613-018-0357-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/10/2018] [Indexed: 12/31/2022] Open
Abstract
Background The acute respiratory distress syndrome (ARDS) is a life-threatening condition. In special situations, these critically ill patients must be transferred to specialized centers for escalating treatment. The aim of this study was to evaluate the quality of inter-hospital transport (IHT) of ARDS patients. Methods We evaluated medical and organizational aspects of structural and procedural quality relating to IHT of patients with ARDS in a prospective nationwide ARDS study. The qualification of emergency staff, the organizational aspects and the occurrence of critical events during transport were analyzed. Results Out of 1234 ARDS patients, 431 (34.9%) were transported, and 52 of these (12.1%) treated with extracorporeal membrane oxygenation. 63.1% of transferred patients were male, median age was 54 years, and 26.8% of patients were obese. All patients were mechanically ventilated during IHT. Pressure-controlled ventilation was the preferred mode (92.1%). Median duration to organize the IHT was 165 min. Median distance for IHT was 58 km, and median duration of IHT 60 min. Forty-two patient-related and 8 technology-related critical events (11.6%, 50 of 431 patients) were observed. When a critical event occurred, the PaO2/FiO2 ratio before transport was significant lower (68 vs. 80 mmHg, p = 0.017). 69.8% of physicians and 86.7% of paramedics confirmed all transfer qualifications according to requirements of the German faculty guidelines (DIVI). Conclusions The transport of critically ill patients is associated with potential risks. In our study the rate of patient- and technology-related critical events was relatively low. A severe ARDS with a PaO2/FiO2 ratio < 70 mmHg seems to be a risk factor for the appearance of critical events during IHT. The majority of transport staff was well qualified. Time span for organization of IHT was relatively short. ECMO is an option to transport patients with a severe ARDS safely to specialized centers. Trial registration NCT02637011 (ClinicalTrials.gov, Registered 15 December 2015, retrospectively registered)
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Affiliation(s)
- Sebastian Blecha
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
| | - Frank Dodoo-Schittko
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Susanne Brandstetter
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Magdalena Brandl
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Michael Dittmar
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Bernhard M Graf
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Christian Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Thomas Bein
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
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Lai S, Ton E, Lovejoy M, Graham W, Amin A. Venous Thromboembolism Rates in Transferred Patients: A Cross-Sectional Study. J Gen Intern Med 2018; 33:42-49. [PMID: 28917026 PMCID: PMC5756159 DOI: 10.1007/s11606-017-4166-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 06/26/2017] [Accepted: 08/11/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients undergoing a transfer during a hospitalization may be more likely to be diagnosed with a venous thromboembolism (VTE) than patients who are not transferred. OBJECTIVE To determine whether transferred patients have an increased prevalence of VTE diagnosis. DESIGN This was a cross-sectional study comparing VTE diagnosis rates between transferred patients and non-transferred patients. For the years 2012-2014, the University HealthSystem Consortium database of multiple community and academic medical centers throughout the United States was parsed using ICD-9 VTE diagnosis codes and patient's point of origin. PATIENTS Patients were included in the analysis as transferred patients if their point of origin was a skilled nursing facility, another acute care facility or another facility. Non-transferred patients were those whose point of origin was a clinic or those with a non-facility point of origin. MAIN MEASURES The primary comparison of VTE prevalence during hospitalization between transferred and non-transferred patients in the years 2012-2014. Subgroup analysis looked at level I trauma status and case mix index (CMI) to determine whether these had an effect on VTE prevalence. KEY RESULTS From 2012 to 2014, a total of 225 unique hospitals and 12,036,029 patients were analyzed, and the prevalence of VTE in transferred patients and non-transferred patients was 3.43% and 1.91% (RR 1.80; 95% CI 1.78-1.81; P <0.001), respectively. VTE prevalence in transferred versus non-transferred patients at level I trauma centers was 3.42% versus 1.88% (RR = 1.82; 95% CI 1.80-1.85; P <0.001). The 3-year average CMI of transferred versus non-transferred patients was 3.53 versus 2.26 (P < 0.001). CONCLUSIONS Transferred patients have a higher prevalence of VTE than non-transferred patients, regardless of level I trauma designation. Higher VTE rates in transferred versus non-transferred patients was minimally correlated with CMI.
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Affiliation(s)
- Samuel Lai
- University of California, Irvine Medical Center, Orange, CA, USA
| | - Eric Ton
- Kaiser Sunset Medical Center, Los Angeles, CA, USA
| | - Marianne Lovejoy
- University of California, Irvine Medical Center, Orange, CA, USA
| | | | - Alpesh Amin
- University of California, Irvine Medical Center, Orange, CA, USA.
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Kummerow Broman K, Ward MJ, Poulose BK, Schwarze ML. Surgical Transfer Decision Making: How Regional Resources are Allocated in a Regional Transfer Network. Jt Comm J Qual Patient Saf 2018; 44:33-42. [PMID: 29290244 PMCID: PMC5751937 DOI: 10.1016/j.jcjq.2017.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Tertiary care centers often operate above capacity, limiting access to emergency surgical care for patients at nontertiary facilities. For nontraumatic surgical emergencies there are no guidelines to inform patient selection for transfer to another facility. Such decisions may be particularly difficult for gravely ill patients when the benefits of transfer are uncertain. METHODS To characterize surgeons' decision-making strategies for transfer, a qualitative analysis of semistructured interviews was conducted with 16 general surgeons who refer and accept patients within a regional transfer network. Interviews included case-based vignettes about surgical patients with high comorbidity, multisystem organ failure, and terminal conditions. An inductive coding strategy was used, followed by performance of a higher-level analysis to characterize important themes and trends. RESULTS Surgeons at outlying hospitals seek transfer when the resources to care for patients' surgical needs or comorbid conditions are unavailable locally. In contrast, surgeons at the tertiary center accept all patients regardless of outcome or resource considerations. Bed availability at the tertiary care center restricts transfer capacity, harming patients who cannot be transferred. Surgeons sometimes transfer dying patients in order to exhaust all treatment options or appease families, but they are conflicted about the value of transfer, which displaces patients from their local communities and limits access to tertiary care for others. CONCLUSION Decisions to transfer surgical patients are complex and require comprehensive understanding of local capacity and regional resources. Current decision-making strategies fail to optimize patient selection for transfer and can inappropriately allocate scarce tertiary care beds.
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Assareh H, Achat HM, Levesque JF. Accuracy of inter-hospital transfer information in Australian hospital administrative databases. Health Informatics J 2017; 25:960-972. [PMID: 29254419 DOI: 10.1177/1460458217730866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inter-hospital transfers improve care delivery for which sending and receiving hospitals both accountable for patient outcomes. We aim to measure accuracy in recorded patient transfer information (indication of transfer and hospital identifier) over 2 years across 121 acute hospitals in New South Wales, Australia. Accuracy rate for 127,406 transfer-out separations was 87 per cent, with a low variability across hospitals (10% differences); it was 65 per cent for 151,978 transfer-in admissions with a greater inter-hospital variation (36% differences). Accuracy rate varied by departure and arrival pathways; at receiving hospitals, it was lower for transfer-in admission via emergency department (incidence rate ratio = 0.52, 95% confidence interval: 0.51-0.53) versus direct admission. Transfer-out data were more accurate for transfers to smaller hospitals (incidence rate ratio = 1.06, 95% confidence interval: 1.03-1.08) or re-transfers (incidence rate ratio > 1.08). Incorporation of transfer data from sending and receiving hospitals at patient level in administrative datasets and standardisation of documentation across hospitals would enhance accuracy and support improved attribution of hospital performance measures.
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An Innovative Framework to Improve Efficiency of Interhospital Transfer of Children in Respiratory Failure. Ann Am Thorac Soc 2017; 13:671-7. [PMID: 26783878 DOI: 10.1513/annalsats.201507-401oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE High mortality and resource use burden are associated with hospitalization of critically ill children transferred from level II pediatric intensive care units (PICUs) to level I PICUs for escalated care. Guidelines urge transfer of the most severely ill children to level I PICUs without specification of either the criteria or the best timing of transfer to achieve good outcomes. OBJECTIVES To identify factors associated with transfer, develop a modeling framework that uses those factors to determine thresholds to guide transfer decisions, and test these thresholds against actual patient transfer data to determine if delay in transfer could be reduced. METHODS A multistep approach was adopted, with initial identification of factors associated with transfer status using data from a prior case-control study conducted with children with respiratory failure admitted to six level II PICUs between January 1, 1997, and December 31, 2007. To identify when to transfer a patient, thresholds for transfer were created using generalized estimating equations and discrete event simulation. The transfer policies were then tested against actual transfer data. MEASUREMENTS AND MAIN RESULTS Multivariate logistic regression revealed that the absolute difference of a patient's pediatric logistic organ dysfunction score from the admission value, high-frequency oscillatory ventilation use, antibiotic use, and blood transfusions were all significantly associated with transfer status. The resulting threshold policies led to average transfer delay reduction ranging from 0.5 to 2.3 days in the testing dataset. CONCLUSIONS Current transfer guidelines are devoid of criteria to identify critically ill children who might benefit from transfer and when the best time to transfer might be. In this study, we used innovative methods to create thresholds of transfer that might reduce delay in transfer.
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Abstract
OBJECTIVES To evaluate for any association between time of admission to the PICU and mortality. DESIGN Retrospective cohort study of admissions to PICUs in the Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database from 2009 to 2014. SETTING One hundred and twenty-nine PICUs in the United States. PATIENTS Patients less than 18 years old admitted to participating PICUs; excluding those post cardiac bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 391,779 admissions were included with an observed PICU mortality of 2.31%. Overall mortality was highest for patients admitted from 07:00 to 07:59 (3.32%) and lowest for patients admitted from 14:00 to 14:59 (1.99%). The highest mortality on weekdays occurred for admissions from 08:00 to 08:59 (3.30%) and on weekends for admissions from 09:00 to 09:59 (4.66%). In multivariable regression, admission during the morning 06:00-09:59 and midday 10:00-13:59 were independently associated with PICU death when compared with the afternoon time period 14:00-17:59 (morning odds ratio, 1.15; 95% CI, 1.04-1.26; p = 0.006 and midday odds ratio, 1.09; 95% CI; 1.01-1.18; p = 0.03). When separated into weekday versus weekend admissions, only morning admissions were associated with increased odds of death on weekdays (odds ratio, 1.13; 95% CI, 1.01-1.27; p = 0.03), whereas weekend admissions during the morning (odds ratio, 1.33; 95% CI, 1.14-1.55; p = 0.004), midday (odds ratio, 1.27; 95% CI, 1.11-1.45; p = 0.0006), and afternoon (odds ratio, 1.17; 95% CI, 1.03-1.32; p = 0.01) were associated with increased risk of death when compared with weekday afternoons. CONCLUSIONS Admission to the PICU during the morning period from 06:00 to 09:59 on weekdays and admission throughout the day on weekends (06:00-17:59) were independently associated with PICU death as compared to admission during weekday afternoons. Potential contributing factors deserving further study include handoffs of care, rounds, delays related to resource availability, or unrecognized patient deterioration prior to transfer.
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Broman KK, Phillips SE, Ehrenfeld JM, Patel MB, Guillamondegui OM, Sharp KW, Pierce RA, Poulose BK, Holzman MD. Identifying Futile Interfacility Surgical Transfers. Am Surg 2017. [DOI: 10.1177/000313481708300838] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surgeons perceive that some surgical transfers are futile, but the incidence and risk factors of futile transfer are not quantified. Identifying futile interfacility transfers could save cost and undue burdens to patients and families. We sought to describe the incidence and factors associated with futile transfers. We conducted a retrospective cohort study from 2009 to 2013 including patients transferred to a tertiary referral center for general or vascular surgical care. Futile transfers were defined as resulting in death or hospice discharge within 72 hours of transfer without operative, endoscopic, or radiologic intervention. One per cent of patient transfers were futile (27/ 1696). Characteristics of futile transfers included older age, higher comorbidity burden and illness severity, vascular surgery admission, Medicare insurance, and surgeon documentation of end-stage disease as a factor in initial decision-making. Among futile transfers, 82 per cent were designated as do not resuscitate (vs 9% of nonfutile, P < 0.01), and 59 per cent received a palliative care consult (vs 7%, P < 0.01). A small but salient proportion of transferred patients undergo deliberate care de-escalation and early death or hospice discharge without intervention. Efforts to identify such patients before transfer through improved communication between referring and accepting surgeons may mitigate burdens of transfer and facilitate more comfortable deaths in patients’ local communities.
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Affiliation(s)
- Kristy Kummerow Broman
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center (GRECC)
- Surgery Service, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Murfreesboro, Tennessee
| | | | - Jesse M. Ehrenfeld
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology
- Department of Bioinformatics
- Department of Health Policy
| | - Mayur B. Patel
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center (GRECC)
- Surgery Service, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Murfreesboro, Tennessee
- Department of Neurosurgery, and
- Department of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Kenneth W. Sharp
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard A. Pierce
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgery Service, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Murfreesboro, Tennessee
| | - Benjamin K. Poulose
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael D. Holzman
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Chiou H, Jopling JK, Scott JY, Ramsey M, Vranas K, Wagner TH, Milstein A. Detecting organisational innovations leading to improved ICU outcomes: a protocol for a double-blinded national positive deviance study of critical care delivery. BMJ Open 2017; 7:e015930. [PMID: 28615274 PMCID: PMC5541524 DOI: 10.1136/bmjopen-2017-015930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION There is substantial variability in intensive care unit (ICU) utilisation and quality of care. However, the factors that drive this variation are poorly understood. This study uses a novel adaptation of positive deviance approach-a methodology used in public health that assumes solutions to challenges already exist within the system to detect innovations that are likely to improve intensive care. METHODS AND ANALYSIS We used the Philips eICU Research Institute database, containing 3.3 million patient records from over 50 health systems across the USA. Acute Physiology and Chronic Health Evaluation IVa scores were used to identify the study cohort, which included ICU patients whose outcomes were felt to be most sensitive to organisational innovations. The primary outcomes included mortality and length of stay. Outcome measurements were directly standardised, and bootstrapped CIs were calculated with adjustment for false discovery rate. Using purposive sampling, we then generated a blinded list of five positive outliers and five negative comparators.Using rapid qualitative inquiry (RQI), blinded interdisciplinary site visit teams will conduct interviews and observations using a team ethnography approach. After data collection is completed, the data will be unblinded and analysed using a cross-case method to identify themes, patterns and innovations using a constant comparative grounded theory approach. This process detects the innovations in intensive care and supports an evaluation of how positive deviance and RQI methods can be adapted to healthcare. ETHICS AND DISSEMINATION The study protocol was approved by the Stanford University Institutional Review Board (reference: 39509). We plan on publishing study findings and methodological guidance in peer-reviewed academic journals, white papers and presentations at conferences.
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Affiliation(s)
- Howard Chiou
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
- Emory University School of Medicine Medical Scientist Training Program and Department of Anthropology, Emory University, Atlanta, USA
| | - Jeffrey K Jopling
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
- Gordon and Betty Moore Foundation, Palo Alto, USA
| | - Jennifer Yang Scott
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
| | - Meghan Ramsey
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
| | - Kelly Vranas
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
- Oregon Health & Science University, Portland, OR, USA
| | - Todd H Wagner
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
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Choudhuri AH, Chakravarty M, Uppal R. Influence of Admission Source on the Outcome of Patients in an Intensive Care Unit. Indian J Crit Care Med 2017; 21:213-217. [PMID: 28515605 PMCID: PMC5416788 DOI: 10.4103/ijccm.ijccm_7_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Aim of the study: The admission in the Intensive Care Unit (ICU) occurs from various sources, and the outcome depends on a complex interplay of various factors. This observational study was undertaken to describe the epidemiology and compare the differences among patients admitted in a tertiary care ICU directly from the emergency room, wards, and ICUs of other hospitals. Materials and Methods: A retrospective study was conducted on 153 consecutive patients admitted from various sources in a tertiary care ICU between July 2014 and December 2015. The primary endpoint of the study was the influence of the admission source on ICU mortality. The secondary endpoints were the comparison of the duration of mechanical ventilation, length of ICU stay, and the ICU complication rates between the groups. Results: Out of the 153 patients enrolled, the mortality of patients admitted from the ICUs of other hospital were significantly higher than the patients admitted directly from the emergency room or wards/operating rooms (60.5% vs. 48.2% vs. 31.9%; P = 0.02). The incidence of ventilator-associated lung injury was lower in the patients admitted directly from the emergency room (23.4% vs. 50% vs. 50%; P = 0.03). Multivariate logistic regression analysis revealed higher age, increased disease severity, longer duration of mechanical ventilation, and longer ICU stay as independent predictors of mortality in the patients shifted from the ICUs of other hospitals. Conclusion: The study demonstrated a higher risk of ICU mortality among patients shifted from the ICUs of other hospitals and identified the independent predictors of mortality.
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Affiliation(s)
- Anirban Hom Choudhuri
- Department of Anaesthesiology and Intensive Care, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Mitali Chakravarty
- Department of Anaesthesiology and Intensive Care, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Rajeev Uppal
- Department of Anaesthesiology and Intensive Care, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Differences in Impact of Definitional Elements on Mortality Precludes International Comparisons of Sepsis Epidemiology-A Cohort Study Illustrating the Need for Standardized Reporting. Crit Care Med 2017; 44:2223-2230. [PMID: 27352126 DOI: 10.1097/ccm.0000000000001876] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Sepsis generates significant global acute illness burden. The international variations in sepsis epidemiology (illness burden) have implications for region specific health policy. We hypothesised that there have been changes over time in the sepsis definitional elements (infection and organ dysfunction), and these may have impacted on hospital mortality. DESIGN Cohort study. SETTING We evaluated a high quality, nationally representative, clinical ICU database including data from 181 adult ICUs in England. PATIENTS Nine hundred sixty-seven thousand five hundred thirty-two consecutive adult ICU admissions from January 2000 to December 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS To address the proposed hypothesis, we evaluated a high quality, nationally representative, clinical, ICU database of 967,532 consecutive admissions to 181 adult ICUs in England, from January 2000 to December 2012, to identify sepsis cases in a robust and reproducible way. Multinomial logistic regression was used to report unadjusted trends in sepsis definitional elements and in mortality risk categories based on organ dysfunction combinations. We generated logistic regression models and assessed statistical interactions with acute hospital mortality as outcome and cohort characteristics, sepsis definitional elements, and mortality risk categories as covariates. Finally, we calculated postestimation statistics to illustrate the magnitude of clinically meaningful improvements in sepsis outcomes over the study period. Over the study period, there were 248,864 sepsis admissions (25.7%). Sepsis mortality varied by infection sources (19.1% for genitourinary to 43.0% for respiratory; p < 0.001), by number of organ dysfunctions (18.5% for 1 to 69.9% for 5; p < 0.001), and organ dysfunction combinations (18.5% for risk category 1 to 58.0% for risk category 4). The rate of improvement in adjusted hospital mortality was significant (odds ratio, 0.939 [0.934-0.945] per year; p < 0.001), but showed different secular trends in improvement between infection sources. CONCLUSIONS Within a sepsis cohort, we illustrate case-mix heterogeneity using definitional elements (infection source and organ dysfunction). In the context of improving outcomes, we illustrate differential secular trends in impact of these variables on adjusted mortality and propose this as a valid reason for international variations in sepsis epidemiology. Our article highlights the need to determine standardized reporting elements for optimal comparisons of international sepsis epidemiology.
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Differences in Hospital Risk-standardized Mortality Rates for Acute Myocardial Infarction When Assessed Using Transferred and Nontransferred Patients. Med Care 2017; 55:476-482. [PMID: 28002203 DOI: 10.1097/mlr.0000000000000691] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND One in 5 patients with acute myocardial infarction (AMI) are transferred between hospitals. However, current hospital performance measures based on AMI mortality exclude these patients from the evaluation of referral hospitals. OBJECTIVE To determine the relationship between risk-standardized mortality for transferred and nontransferred patients at referral hospitals. RESEARCH DESIGN This is a retrospective cohort study. SUBJECTS Fee-for-service Medicare claims from 2011 for patients hospitalized with a primary diagnosis of AMI, at hospitals admitting at least 15 patients in transfer. MEASURES Hospital-specific risk-standardized 30-day mortality rates (RSMRs) for 2 groups of patients: those admitted through transfer from another hospital, and those natively admitted without a preceding or subsequent interhospital transfer. RESULTS There were 304 hospitals admitting at least 15 patients in transfer. These hospitals cared for 77,711 natively admitted patients (median, 254; interquartile range, 162-321), and 11,829 patients admitted in transfer (median, 26; interquartile range, 19-46). Risk-standardized mortality rates were higher for natively admitted patients than for those admitted in transfer (mean, 11.5%±1.2% vs. 7.2%±1.1%). There was weak correlation between hospital performance as assessed by RSMR for patients natively admitted versus those admitted in transfer (Pearson r=0.24, P<0.001); when performance was arrayed by quartile, 102 hospitals (33.6%) differed at least 2 quartiles of performance across the 2 patient groups. CONCLUSIONS For Medicare patients with AMI, hospital-specific RSMRs for natively admitted patients are only weakly associated with RSMRs for patients transferred in from another hospital. Current AMI performance metrics may fail to provide guidance about hospital quality for transferred patients.
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Strauch U, Bergmans DCJJ, Habers J, Jansen J, Winkens B, Veldman DJ, Roekaerts PMHJ, Beckers SK. QUIT EMR trial: a prospective, observational, multicentre study to evaluate quality and 24 hours post-transport morbidity of interhospital transportation of critically ill patients: study protocol. BMJ Open 2017; 7:e012861. [PMID: 28283485 PMCID: PMC5353331 DOI: 10.1136/bmjopen-2016-012861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION It is widely accepted that transportation of critically ill patients is high risk. Unfortunately, however, there are currently no evidence-based criteria with which to determine the quality of various interhospital transport systems and their impact on the outcomes for patients. We aim to rectify this by assessing 2 scores which were developed in our hospital in a prospective, observational study. Primarily, we will be examining the Quality of interhospital critical care transportation in the Euregion Meuse-Rhine (QUIT EMR) score, which focuses on the quality of the transport system, and secondarily the SEMROS (Simplified EMR outcome score) which detects changes in the patient's clinical condition in the 24 hours following their transportation. METHODS AND ANALYSIS A web-based application will be used to document around 150 pretransport, intratransport and post-transport items of each patient case.To be included, patients must be at least 18-years of age and should have been supervised by a physician during an interhospital transport which was started in the study region.The quality of the QUIT EMR score will be assessed by comparing 3 predefined levels of transport facilities: the high, medium and low standards. Subsequently, SEMROS will be used to determine the effect of transport quality on the morbidity 24 hours after transportation.It is estimated that there will be roughly 3000 appropriate cases suitable for inclusion in this study per year. Cases shall be collected from 1 April 2015 until 31 December 2017. ETHICS AND DISSEMINATION This trial was approved by the Ethics committees of the university hospitals of Maastricht (Netherlands) and Aachen (Germany). The study results will be published in a peer reviewed journal. Results of this study will determine if a prospective randomised trial involving patients of various categories being randomly assigned to different levels of transportation system shall be conducted. TRIAL REGISTRATION NUMBER NTR4937.
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Affiliation(s)
- Ulrich Strauch
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joachim Habers
- Emergency Medical Service district of Aachen, Aachen, Germany
| | - Jochen Jansen
- Emergency Medical Service South Limburg, Geleen, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands
| | - Dirk J Veldman
- Maastricht University, MEMIC Center for Data and Information Management, Maastricht, The Netherlands
| | - Paul M H J Roekaerts
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
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