Achieving regionalization through rural interhospital transfer

Health system regionalization's infrastructural dimensions: A scoping review

Regionalized health systems provide a coordinated chain of services for a specific population. The development of regionalized systems not only means the establishment of regionalized centers providing health services, but also consideration of several structural dimensions. The present study aimed to identify the dimensions of developing a regionalized health system. The study employed a scoping review method using Joanna Briggs Institute's (2015) protocol in 2022. A total of 2128 related articles were identified from ISI Web of Science, PubMed, Scopus, and Google Scholar databases from 2002 to 2022. Finally, 26 articles and documents met the study criteria to enter the review process for thematic content analysis, and extracted the structural dimensions for developing health system regionalization. The results of the analysis revealed health system regionalization's structural dimensions categorized into seven main themes including contextual, financial/economic, managerial, organizational, legal and procedural, service provision, capacities and strategies in the health system; as well as 85 subthemes. Development and implementation of health system regionalization require several essential structural dimensions to be taken into consideration to enhance and facilitate system regionalization process.

Emergency department and inpatient interhospital transfers for patients with status epilepticus

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.

Predictors of mortality among sepsis patients transferred from a rural, low-volume ED to an urban, high-volume hospital

INTRODUCTION

We investigated the extent to which demographic characteristics, clinical care aspects, and relevant biomarkers predicted sepsis-related mortality among patients transferred from a rural, low-volume emergency department (ED) to an urban, high-volume, level-2 trauma center.

METHODS

We conducted an observational study among adult severe sepsis patients (N = 242) who, within a community-based regional healthcare system, presented to one of the four rural, low-volume EDs and were subsequently transferred to the urban, high-volume, level-2 trauma center, and were identified as septic at either location. We evaluated in-hospital and 30 days after discharge mortality.

RESULTS

In-hospital mortality rate was predicted by previous admission to an ICU (OR 5.02, 95 % CI: 1.89-15.94, p = 0.002), identification of sepsis prior to transfer (OR 0.29, 95 % CI: 0.11-0.74, p = 0.01), and a moderately abnormal lactate level (OR 0.22, 95 % CI: 0.05-0.79, p = 0.03). Mortality 30 days after discharge was predicted by previous admission to an ICU (OR: 3.28, 95 % CI: 1.62-6.97, p = 0.001), abnormal red cell distribution width (OR: 2.23, 95 % CI: 1.11-4.60, p = 0.03), identification of sepsis prior to transfer (OR: 0.26, 95 % CI: 0.12-0.54, p < 0.001), and a moderately abnormal lactate (OR: 0.32, 95 % CI: 0.12-0.79, p = 0.02).

DISCUSSION

Early identification of sepsis, as well as attention to prior ICU admission or comorbidities and abnormal red cell distribution width, could facilitate better care and prevent mortality among patients with sepsis who are transferred from a rural, low-volume emergency department to an urban-high volume facility.

A proposed method for identifying Interfacility transfers in Medicare claims data

OBJECTIVE

To develop a method of consistently identifying interfacility transfers (IFTs) in Medicare Claims using patients with ST-Elevation Myocardial Infarction (STEMI) as an example.

DATA SOURCES/STUDY SETTING

100% Medicare inpatient and outpatient Standard Analytic Files and 5% Carrier Files, 2011-2020.

STUDY DESIGN

Observational, cross-sectional comparison of patient characteristics between proposed and existing methods.

DATA COLLECTION/EXTRACTION METHODS

We limited to patients aged 65+ with STEMI diagnosis using both proposed and existing methods.

PRINCIPAL FINDINGS

We identified 62,668 more IFTs using the proposed method (86,128 versus 23,460). A separately billable interfacility ambulance trip was found for more IFTs using the proposed than existing method (86% vs. 79%). Compared with the existing method, transferred patients under the proposed method were more likely to live in rural (p < 0.001) and lower income (p < 0.001) counties and were located farther away from emergency departments, trauma centers, and intensive care units (p < 0.001).

CONCLUSIONS

Identifying transferred patients based on two consecutive inpatient claims results in an undercount of IFTs and under-represents rural and low-income patients.

Health service access and quality of care provided by the Western NSW Local Health District Virtual Rural Generalist Service: a retrospective analysis of linked administrative data

OBJECTIVE

To evaluate the quantity and quality of medical care provided by the Western NSW Local Health District Virtual Rural Generalist Service (VRGS).

DESIGN

Retrospective cohort study; analysis of emergency department and administrative hospital data.

SETTING

Twenty-nine rural or remote hospitals in the Western NSW Local Health District at which the VRGS was providing medical care in the emergency department (ED) and/or inpatient setting. The VRGS was providing predominantly virtual medical support when local doctors needed relief or were unavailable, typically for lower acuity ED presentations and scheduled inpatient ward rounds.

PATIENTS

All patients who presented or were admitted to a Western NSW Local Health District hospital serviced by the VRGS between 1 July 2021 and 30 June 2022.

MAIN OUTCOME MEASURES

Treatment completions, transfers, ED departure within 4 hours, length of stay, and hospital mortality.

RESULTS

During 2021-22, 34% of ED presentations (13 660/39 701) and 40% of admissions (2531/6328) involved VRGS care. For ED presentations, after adjusting for socio-demographic and clinical factors, patients attended by VRGS doctors had higher odds of not waiting (adjusted odds ratio [aOR], 3.69; 95% CI, 2.79-4.89), lower odds of transfer to another hospital (aOR, 0.66; 95% CI, 0.60-0.72) and slightly lower odds of ED departure within 4 hours (aOR, 0.92; 95% CI, 0.86-0.98) when compared with patients not attended by VRGS doctors (ie, those provided usual care). For admissions, after adjusting for socio-demographic and clinical factors, inpatients attended exclusively by VRGS doctors had higher odds of discharging at their own risk (3.33; 95% CI, 1.98-5.61) and lower odds of being a long stay outlier (aOR, 0.51; 95% CI, 0.35-0.74) when compared with inpatients not attended by VRGS doctors. The odds of inpatient mortality were equivalent when comparing VRGS and non-VRGS care (aOR, 0.78; 95% CI, 0.48-1.28) and when comparing combined (VRGS and non-VRGS) and non-VRGS care (aOR 1.21; 95% CI, 0.91-1.61).

CONCLUSIONS

In the current environment of rural medical workforce shortages, the VRGS achieved similar outcomes on routinely collected measures of quality of care. It is demonstrably an option for complementing and enhancing the delivery of medical care in rural and remote communities with limited or no local medical services.

Factors influencing secondary overtriage in trauma patients undergoing interhospital transfer: A 10-year multi-center study in Hong Kong

BACKGROUND

With the development of regionalised trauma networks, interhospital transfer of trauma patients is an inevitable component of the trauma system. However, unnecessary transfer is a common phenomenon, and it is not without risk and cost. A better understanding of secondary overtriage would enable emergency physicians to make better decisions about trauma transfers and allow guidelines to be developed to support this decision making. This study aimed to describe the pattern of secondary overtriage in Hong Kong and identify its associated factors.

METHODS

This was a retrospective review of 10-years of prospectively collected multi-center data from two trauma registries in the New Territories of Hong Kong (2013-2022). The primary outcome is secondary overtriage, which was defined as early discharge alive within 48 h, Injury Severity Score (ISS) <15, and no surgical operation done. Patient characteristics, physiology, anatomy and investigation variables were compared against secondary overtriage using univariate and multivariable analyses.

RESULTS

During the study period, 3852 patients underwent interhospital transfer from a non-trauma center to a trauma center, and 809 (21 %) of the transfers were considered secondary overtriage. The secondary overtriage rate was higher in pediatric age groups at 34.8 % (97/279). Logistic regression analysis showed secondary overtriage to be associated with blunt trauma and an Abbreviated Injury Scale (AIS) score of <3 for head or neck, thorax, abdomen and extremities.

CONCLUSION

Interhospital transfer is an essential component of the trauma system. However, over one-fifth of the transfers were considered unnecessary in Hong Kong, and this could be considered to be an inefficient use of resources as well as cause inconvenience to patients and their families. We have identified related factors including blunt trauma, AIS <3 scores for head or neck, thorax, abdomen and extremities, and opportunities to establish and improve on transfer protocols. Further research should be aimed to safely reduce interhospital transfers in the future to improve the efficiency of the Hong Kong trauma system.

Implications of interhospital patient transfers for emergency medical services transportation systems in the Netherlands: a retrospective study

OBJECTIVES

Interhospital patient transfers have become routine. Known drivers are access to specialty care and non-clinical reasons, such as limited capacity. While emergency medical services (EMS) providers act as main patient transfer operators, the impact of interhospital transfers on EMS service demand and fleet management remains understudied. This study aims to identify patterns in regional interhospital patient transfer volumes and their spatial distribution, and to discuss their potential implications for EMS service demand and fleet management.

DESIGN

A retrospective study was performed analysing EMS transport data from the province of Drenthe in the Netherlands between 2013 and 2019 and public hospital listings. Yearly volume changes in urgent and planned interhospital transfers were quantified. Further network analysis, including geomapping, was used to study how transfer volumes and their spatial distribution relate to hospital specialisation, and servicing multihospital systems. Organisational data were considered for relating transfer patterns to fleet changes.

SETTING

EMS in the province of Drenthe, the Netherlands, 492 167 inhabitants.

PARTICIPANTS

Analyses are based on routinely collected patient data from EMS records, entailing all 248 114 transports (137 168 patients) of the Drenthe EMS provider (2013-2019). From these interhospital transports were selected (24 311 transports).

RESULTS

Interhospital transfers represented a considerable (9.8%) and increasing share of transports (from 8.6% in 2013 to 11.3% in 2019). Most transfers were related to multihospital systems (47.3%, 11 509 transports), resulting in a considerable growth of planned EMS transports (from 2093 in 2013 to 3511 in 2019). Geomapping suggests increasing transfer distances and diminishing resource efficiencies due to lacking follow-up rides. Organisational data clarify how EMS fleets were adjusted by expanding resources and reorganising fleet operation.

CONCLUSIONS

Emerging interhospital network transfers play an important role in EMS service demand. Increased interhospital transport volumes and geographical spread require a redesign of current EMS fleets and management along regional lines.

Optimising acute non-critical inter-hospital transfers: A review of evidence, practice and patient perspectives

INTRODUCTION

Patients who present to hospital with an acute non-critical illness or injury, which is considered outside the capability framework of that hospital to treat, will require inter-hospital transfer (IHT) to a hospital with a higher level of capability for that condition. Delays in IHT can negatively impact patient care and patient outcomes.

OBJECTIVE

To review and synthesis academic evidence, practitioner insights and patient perspectives on ways to improve IHT from regional to metro hospitals.

DESIGN

A rapid review methodology identified one review and 14 primary studies. Twelve practitioner interviews identified insights into practice and implementation, and the patient perspectives were explored through a citizen panel with 15 participants.

FINDINGS

The rapid review found evidence relating to clinician and patient decision factors, protocols, communication practices and telemedicine. Practitioner interviews revealed challenges in making the initial decision, determining appropriate destinations and dealing with pushback. Adequate support and communication were raised as important to improve IHT. The citizen panel found that the main concern with IHT was delays. Citizen panel participants suggested dedicated transfer teams, education and information transfer systems to improve IHT.

DISCUSSION AND CONCLUSION

Common challenges in IHT include making the initial decision to transfer and communicating with other health services and patients and families. In identifying the appropriateness of transferring acute non-critical patients, clear and effective communication is central to appropriate and timely IHT; this evidence review indicates that education, protocols and information management could make IHT processes smoother.

A retrospective observational study of vCare: a virtual emergency clinical advisory and transfer service in rural and remote Australia

BACKGROUND

Provision of critical care in rural areas is challenging due to geographic distance, smaller facilities, generalist skill mix and population characteristics. Internationally, the amalgamation telemedicine and retrieval medicine services are developing to overcome these challenges. Virtual emergency clinical advisory and transfer service (vCare) is one of these novel services based in New South Wales, Australia. We aim to describe patient encounters with vCare from call initiation at the referring site to definitive care at the accepting site.

METHODS

This retrospective observational study reviewed all patients using vCare in rural and remote Australia for clinical advice and/or inter-hospital transfer for higher level of care between February and March 2021. Data were extracted from electronic medical records and included remoteness of sites, presenting complaint, triage category, camera use, patient characteristics, transfer information, escalation of therapeutic intervention and outcomes. Data were summarised using cross tabulation.

RESULTS

1,678 critical care patients were supported by vCare, with children (12.5%), adults (50.6%) and older people (36.9%) evenly split between sexes. Clinicians mainly referred to vCare for trauma (15.1%), cardiac (16.1%) and gastroenterological (14.8%) presentations. A referral to vCare led to an escalation of invasive intervention, skill, and resources for patient care. vCare cameras were used in 19.8% of cases. Overall, 70.5% (n = 1,139) of patients required transfer. Of those, 95.1% were transferred to major regional hospitals and 11.7% required secondary transfer to higher acuity hospitals. Of high-urgency referrals, 42.6% did not receive high priority transport. Imaging most requested included CT and MRI scans (37.2%). Admissions were for physician (33.1%) and surgical care (23.3%). The survival rate was 98.6%.

CONCLUSION

vCare was used by staff in rural and remote facilities to support decision making and care of patients in a critical condition. Issues were identified including low utilisation of equipment, heavy reliance on regional sites and high rates of secondary transfer. However, these models are addressing a key gap in the health workforce and supporting rural and remote communities to receive care.

Effect of the Implementation of the French Hospital Regionalization Policy on Patient Mobility

A new law was voted in France in 2016 to increase cooperation between public sector hospitals. Hospitals were encouraged to work under the leadership of local referral centers and to share their support functions (e.g., information systems) with newly created hospital groups, called "Regional Hospital Groups." The law made it compulsory for each public sector hospital to become affiliated with one of 136 newly created hospital groups. The policy's aim was to ensure that all patients were sent to the hospital best qualified to treat their unique condition, among the hospitals available at the regional level. Therefore, we aimed to assess whether this regionalization policy was associated with changes in observed patterns of patient mobility between hospitals. This nationwide observational study followed an interrupted time series design. For each stay occurring from 2014 to 2019, we ascertained whether or not the stay was followed by mobility toward another hospital within 90 days, and whether or not the receiving hospital was part of the same Regional Hospital Group as the sender hospital. The proportion of mobility directed toward the same regional hospital group increased from 22.9% in 2014 (95% CI 22.7-23.1) to 24.6% in 2019 (95% CI 24.4-24.8). However, the absence of discontinuity during the policy change year was consistent with the hypothesis of a preexisting trend toward regionalization. Therefore, the policy did not achieve major changes in patterns of mobility between hospitals. Other objectives of the reform, including long-term consequences on the healthcare offer, remain to be assessed.

A retrospective observational study examining interhospital transfers from six New Zealand rural hospitals in 2019

OBJECTIVE

The aim of this study was to identify the percentage of patients that were transferred from rural hospitals and who received an investigation or intervention at an urban hospital that was not readily available at the rural hospital.

METHODS

A retrospective observational study.

DESIGN

Patients were randomly selected and clinical records were reviewed. Patient demographic and clinical information was collected, including any interventions or investigations occurring at the urban referral hospital. These were compared against the resources available at the rural hospitals.

SETTING

Six New Zealand (NZ) rural hospitals were included.

PARTICIPANTS

Patients that were transferred from a rural hospital to an urban hospital between 1 Jan 2019 and 31 December 2019 were included.

MAIN OUTCOME MEASURES

The primary outcome measure was the percentage of patients who received an investigation or intervention that was not available at the rural hospital.

RESULTS

There were 584 patients included. Overall 73% of patients received an intervention or investigation that was not available at the rural hospital. Of the six rural hospitals, there was one outlier, where only 37% of patients transferred from that hospital received an investigation or intervention that was not available rurally. Patients were most commonly referred to general medicine (23%) and general surgery (18%). Of the investigations or interventions performed, 43% received a CT scan and 25% underwent surgery.

CONCLUSIONS

Most patients that are transferred to urban hospitals receive an intervention or investigation that was not available at the rural hospital.

Travel for medical or dental care by race/ethnicity and rurality in the U.S.: Findings from the 2001, 2009 and 2017 National Household Travel Surveys

The travel burden for medical or dental care is a well-documented barrier to healthcare access, particularly in rural areas. There is limited research providing national estimates of the travel trends for medical/dental care, particularly among racial/ethnic groups, and among rural and urban populations. We analyzed data from the 2001, 2009, and 2017 National Household Travel Surveys. Main outcomes were the average travel distance (in miles), average travel time (in minutes), and travel burden, characterized as the percentage of trips lasting ≥ 30 miles or minutes for medical/dental care. We used ordinary least squares and multivariable logistic regressions to examine trends in the travel time/distance and travel burden, controlling for socio-demographic and travel dynamics. Among rural residents, the average travel distance for medical/dental care increased by 17.8% between 2001 and 2017, while no increase was observed among urban residents. Thirty-six percent of trips among rural residents lasted ≥ 30 minutes in 2001 but increased to 47.4% in 2017. Logistic regression estimates show that though Blacks experienced higher odds of a travel time burden compared to Whites, the burden lessened over time. In 2017, urban Blacks (OR = 0.41, 95% C.I. = 0.26,0.66), and rural Blacks (OR = 0.16, 95% C.I. = 0.05,0.55) were less likely to spend ≥ 30 minutes traveling for medical/dental care compared to Whites, using the year 2001 as the baseline. The travel distance and time for medical/dental care have increased in rural areas. However, the travel burden among rural and urban Black residents has decreased. Continuing to alleviate excess burdens of transportation may be beneficial.

Left behind: Exploring the concerns of emergency department staff when personnel are utilised for inter-hospital transfer

BACKGROUND

Inter-Hospital Transfer (IHT) may require an escort from the referring hospital, either a Registered Nurse (RN), physician or both, leading to a sudden drop in staffing levels within the referring department potentially increasing risk to patients and staff.

AIMS

To explore the perspectives of RNs and physicians of differing experience levels when left behind due to an escorted IHT, and the decision-making protocols for IHT.

METHOD

A qualitative exploratory approach of 5 RNs and 4 physicians selected using purposeful sampling. Data were collected through semi-structured interviews and thematically analysed.

FINDINGS

Five themes were identified: the impact of being left behind; the burden of transfer; missed care; a triangulation of competing needs upon the decision-making process; and the effect of inter-hospital transfers on staff with different experience levels.

CONCLUSION

IHT is described differently by less experienced RNs compared to their more experienced counterparts especially concerning safety and risk. Physicians described the department as vulnerable with ad-hoc decision-making protocols surrounding IHT the norm.

Telehealth consultation before inter-hospital transfer after falls in a subacute hospital (the PREVENT-2 study)

OBJECTIVE

Inter-hospital transfers are increasingly common due to the regionalisation of healthcare, but are associated with patient discomfort, high costs and adverse events. The aim of the present study was to evaluate the effectiveness of a trauma outreach service for preventing inter-hospital transfers to a major trauma centre.

METHODS

This was an observational pre- and post-intervention study over a 12-month period from 1 October 2020 to 30 September 2021. Eligible patients sustained a fall at Caulfield Hospital, a subacute care hospital specialising in community services, rehabilitation, geriatric medicine and aged mental health. The intervention was delivery of site-specific education at Caulfield Hospital and a trauma outreach service by specialist trauma clinicians at The Alfred Hospital who provided remote assessment, assisted with clinical management decisions and advised on appropriateness of transfer.

RESULTS

The present study included 160 patients in the pre-intervention phase and 203 after the intervention. The primary outcome of transfer occurred in 19 (11.9%) patients in the pre-intervention phase and 4 (2.0%) in the post-intervention phase (P < 0.001). In the subgroup of patients without pelvis or long bone fractures, pre-intervention transfer occurred for 17 (10.9%) patients and post-intervention transfer occurred for 4 (2.0%) patients (P < 0.001). CT imaging was performed for 54 (33.8%) patients in the pre-intervention and 45 (22.2%) patients in the post-intervention group (P = 0.014).

CONCLUSIONS

Telehealth consultation with a trauma specialist was associated with significant reduction of inter-hospital transfers, and significant reduction of CT imaging. This supports continuation of the service with scope for expansion and evaluation of patient-centred outcomes.

A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks

Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism.

CONTEXT

Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers.

METHODS

To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research.

FINDINGS

The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity.

CONCLUSIONS

The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.

Operation of national coordinating service for interhospital transfer from emergency departments: experience and implications from Korea

BACKGROUND

Since 2014, Korea has been operating the National Emergency Medical Situation Room (NEMSR) to provide regional emergency departments (EDs) with coordination services for the interhospital transfer of critically ill patients. The present study aimed to describe the NEMSR's experience and interhospital transfer pattern from EDs nationwide, and investigate the factors related to delayed transfers or transfers that could not be arranged by the NEMSR.

METHODS

This study was a retrospective cross-sectional analysis of the NEMSR's coordination registry from 2017 to 2019. The demographic and hospital characteristics related to emergency transfers were analyzed with hierarchical logistic models.

RESULTS

The NEMSR received a total of 14,003 requests for the arrangement of the interhospital transfers of critically ill patients from 2017 to 2019. Of 10,222 requests included in the analysis, 8297 (81.17%) successful transfers were coordinated by the NEMSR. Transfers were requested mainly due to a shortage of medical staff (59.79%) and ICU beds (30.80%). Delayed transfers were significantly associated with insufficient hospital resources. The larger the bed capacity of the sending hospital, the more difficult it was to coordinate the transfer (odds ratio [OR] for transfer not arranged = 2.04; 95% confidence interval [CI]: 1.48-2.82, ≥ 1000 beds vs. < 300 beds) and the longer the transfer was delayed (OR for delays of more than 44 minutes = 2.08; 95% CI: 1.57-2.76, ≥ 1000 beds vs. < 300 beds).

CONCLUSIONS

The operation of the NEMSR has clinical importance in that it could efficiently coordinate interhospital transfers through a protocolized process and resource information system. The coordination role is significant as information technology in emergency care develops while regional gaps in the distribution of medical resources widen.

Social network analysis of nationwide interhospital emergency department transfers in Taiwan

Transferring patients between emergency departments (EDs) is a complex but important issue in emergency care regionalization. Social network analysis (SNA) is well-suited to characterize the ED transfer pattern. We aimed to unravel the underlying transfer network structure and to identify key network metrics for monitoring network functions. This was a retrospective cohort study using the National Electronic Referral System (NERS) database in Taiwan. All interhospital ED transfers from 2014 to 2016 were included and transfer characteristics were retrieved. Descriptive statistics and social network analysis were used to analyze the data. There were a total of 218,760 ED transfers during the 3-year study period. In the network analysis, there were a total of 199 EDs with 9516 transfer ties between EDs. The network demonstrated a multiple hub-and-spoke, regionalized pattern, with low global density (0.24), moderate centralization (0.57), and moderately high clustering of EDs (0.63). At the ED level, most transfers were one-way, with low reciprocity (0.21). Sending hospitals had a median of 5 transfer-out partners [interquartile range (IQR) 3-7), while receiving hospitals a median of 2 (IQR 1-6) transfer-in partners. A total of 16 receiving hospitals, all of which were designated base or co-base hospitals, had 15 or more transfer-in partners. Social network analysis of transfer patterns between hospitals confirmed that the network structure largely aligned with the planned regionalized transfer network in Taiwan. Understanding the network metrics helps track the structure and process aspects of regionalized care.

Health-related reasons patients transfer from a clinic or health post to the Emergency Department in a District Hospital in Botswana

Introduction

Rural health clinics in low-resource settings worldwide are usually staffed with health care workers with limited knowledge and skills in managing acute emergencies. The Emergency Centre (EC) at the district hospital or primary hospital serves as an entry point for patients with diverse medical needs from health posts and community clinics. The study described the socio-demographic characteristics, primary diagnosis, and disposition of patients transferred from the clinics and health posts to the district hospital in the Kweneng district.

Method

This study is a chart audit of the triage sheets and admitting medical records (Botswana Integrated Patient Management System, IPMS) conducted for the period June through to December 2020. Descriptive statistics were used to analyze the quantitative data. Frequencies, percentages, and measures of central tendency were calculated using the software, SPSS version 27.

Results

A total of 1565 charts were reviewed; 56% (n = 877) were females and 43.5% (n = 681) were males. Half of the patients presenting to the EC ranged from ages 21 to 50, with a mean age of 36.49. The most frequently reported reason for referral was “trauma,” (23.5%, n = 368) whereas the second common reason for referral was abortion-related complications (14.2%, n = 222). The highest admissions were from abortion-related complications (20.2%, n = 169). Most patients’ transfers were from clinics and health posts outside Molepolole (59.4%, n = 930). More than half of the patients (64.2%, n = 537) transferred from outside Molepolole were admitted than discharged from the EC.

Discussion

Our study has shown significant transfers to a higher facility for emergency care. The higher number of transfers are trauma-related cases, whereas most patients were admitted for abortion-related complications indicating the need for skill-building in trauma care and management of abortions.

Emergency Interhospital Transfer of Patients With ST-Segment-Elevation Myocardial Infarction: Call 9-1-1-The American Heart Association Mission: Lifeline Program

The American Heart Association Mission: Lifeline program objectives are to improve the quality of care and outcomes for patients with ST-segment-elevation myocardial infarction. Every minute of delay in treatment adversely affects 1-year mortality. Transfer of patients safely and timely to hospitals with primary percutaneous coronary intervention capability is needed to improve outcomes. But treatment times continue to show delays, especially during interhospital transfers. A simple 3-step process of an interhospital "Call 9-1-1" protocol may expedite this process. This STAT TRANSFER process uses a systems approach that considers diverse ways in which patients access care, how EMS responds and determines destinations, how referring hospital transfers are performed, urban and rural differences, and how receiving hospitals prepare for an incoming patient with ST-segment-elevation myocardial infarction. This initiative suggests a strategy to reduce variability in interhospital transfer times using a STAT TRANSFER and a Call 9-1-1 process in a system of care that involves all stakeholders.

Interhospital transfer (IHT) in emergency general surgery patients (EGS): A scoping review

Background/Aims of study

Interhospital transfer of emergency general surgery patients continues to rise, and no system for transfer of emergency general surgery patients exists. This has major implications for cost of care and patient experience. We performed a scoping review to understand outcomes related to transfer and the associated factors and to identify any opportunities for improvement.

Methods

Studies involving emergency general surgery patients with interhospital transfer were identified by searching OVID MEDLINE, EMBASE, Cochrane Library, and Scopus. There were 1,785 records identified. After duplicates were removed, there were 1,303 articles screened in the initial phase. Fifty-eight articles were included in the second phase. Eventually, 21 articles were included in the review. Thirty-seven articles were removed during the full-text screening phase due to the following: wrong publication type (2), wrong population (8), abstract (11), outside the United States (3), and wrong study design (6).

Results

Transferred patients had a higher mortality rate, were older, were more likely to be male and to undergo reoperation, and had higher resource utilization compared to patients who were not transferred. All emergency general surgery patients had a high burden of chronic disease. Unnecessary transfer, typically defined by lack of intervention and discharge within 72 hours, was reported to be 8.8% to 19%.

Conclusion

Emergency general surgery patients have a high rate of comorbidities. Limited physiologic status information prior to patient transfer limits understanding of the necessity for transfer. Areas for improvement include assigning a physiologic status for all patients and utilizing telehealth. More detailed information needs to be captured to determine the appropriateness of transfer.

An economic and health outcome evaluation of telehealth in rural sepsis care: a comparative effectiveness study

Aim: Sepsis is a top contributor to in-hospital mortality and, healthcare expenditures and telehealth have been shown to improve short-term sepsis care in rural hospitals. This study will evaluate the effect of provider-to-provider video telehealth in rural emergency departments (EDs) on healthcare costs and long-term outcomes for sepsis patients. Materials & methods: We will use Medicare administrative claims to compare total healthcare expenditures, mortality, length-of-stay, readmissions, and category-specific costs between telehealth-subscribing and control hospitals. Results: The results of this work will demonstrate the extent to which telehealth use is associated with total healthcare expenditures for sepsis care. Conclusion: These findings will be important to inform future policy initiatives to improve sepsis care in rural EDs. Clinical Trial Registration: NCT05072145 (ClinicalTrials.gov).

An Overview of Hospital Capacity Planning and Optimisation

Health care is uncertain, dynamic, and fast growing. With digital technologies set to revolutionise the industry, hospital capacity optimisation and planning have never been more relevant. The purposes of this article are threefold. The first is to identify the current state of the art, to summarise/analyse the key achievements, and to identify gaps in the body of research. The second is to synthesise and evaluate that literature to create a holistic framework for understanding hospital capacity planning and optimisation, in terms of physical elements, process, and governance. Third, avenues for future research are sought to inform researchers and practitioners where they should best concentrate their efforts. In conclusion, we find that prior research has typically focussed on individual parts, but the hospital is one body that is made up of many interdependent parts. It is also evident that past attempts considering entire hospitals fail to incorporate all the detail that is necessary to provide solutions that can be implemented in the real world, across strategic, tactical and operational planning horizons. A holistic approach is needed that includes ancillary services, equipment medicines, utilities, instrument trays, supply chain and inventory considerations.

Impacts and Lessons Learned of the First Three COVID-19 Waves on Cross-Border Collaboration in the Field of Emergency Medical Services and Interhospital Transports in the Euregio-Meuse-Rhine: A Qualitative Review of Expert Opinions

Background

In the Euregio-Meuse-Rhine (EMR), cross-border collaboration is essential for resource-saving and needs-based patient care within the emergency medical service (EMS) systems and interhospital transport (IHT). However, at the onset of the novel coronavirus SARS-COV-2 (COVID-19) pandemic, differing national measures highlighted the fragmentation within the European Union (EU) in its various approaches to combating the pandemic. To assess the consequences of the pandemic in the EMR border area, the aim of this study was to analyze the effects and "lessons learned" regarding cross-border collaboration in EMS and IHT.

Method

A qualitative study with 22 semi-structured interviews was carried out. Experts from across the EMR area, including the City of Aachen, the City region of Aachen, the District of Heinsberg (Germany), South Limburg (The Netherlands), and the Province of Limburg, as well as Liège (Belgium), took part. The interviews were coded and analyzed according to changes in cross-border collaboration before and during the pandemic, as well as lessons learned and recommendations.

Results

Each EU member country within the EMR area, addressed the pandemic individually with national measures. Cross-border collaboration between regional actors was hardly or not at all addressed at the national level during political decision- or policymaking. Previous direct communication at the personal level was replaced by national procedures, which made regular cross-border collaboration significantly more difficult. The cross-border transfer regulations of patients with COVID-19 proved to be complex and led, among other things, to patients being transported to hospitals far outside the border region. Collaboration continues to be seen as valuable and Euregional emergency services including hospitals work well together, albeit to different degrees. The information and data exchange should, however, be more transparent to use resources more efficiently.

Conclusion

Effective Euregional collaboration of emergency services is imperative for public safety in a multi-border region with strong economic, cultural, and social cross-border links. Our findings indicate that existing (pre-pandemic) structures which included regular meetings of senior managerial staff in the region and a number of thematic working groups were helpful to deal with and to compensate for the disruptions during the crisis. Regional cross-border agreements that are currently based on mutual but more or less informal arrangements need to be formalized and better promoted and recognized also at the national and EU level to increase resilience. The continuous determination of synergies and good and best practices are further approaches to support cross-border collaboration especially in preparation for future crises.

Regular feedback on inter-hospital transfer improved the clinical outcome and survival in patients with multiple trauma: a retrospective cohort study

Background

Undertriage of major trauma patients is unavoidable, especially in the trauma system of rural areas. Timely stabilization and transfer of critical trauma patients remains a great challenge for hospitals with limited resources. No definitive measure has been proven to improve the outcomes of patients transferred with major trauma. The current study hypothesized that regular feedback on inter-hospital transfer of patients with major trauma can improve quality of care and clinical outcomes.

Method

This retrospective cohort study retrieved data of transferred major trauma patients with an injury severity score (ISS) > 15 between January 2010 and December 2018 from the trauma registry databank of a tertiary medical center. Regular monthly feedback on inter-hospital transfers was initiated in 2014. The patients were divided into a without-feedback group and a with-feedback group. Demographic data, management before transfer, and outcomes after transfer were collected and analyzed.

Results

A total of 178 patients were included: 69 patients in the without-feedback group and 109 in the with-feedback group. The with-feedback group had a higher ISS (25 vs. 27; p = 0.049), more patients requiring massive transfusion (14.49% vs. 29.36%, p = 0.036), and less patients with Glasgow Coma Scale ≤8 (30.43% vs. 23.85%, p <  0.001). After adjusting for confounding factors, the with-feedback group was associated with a higher rate of blood transfusion before transfer (adjusted odds ratio [aOR]: 2.75; 95% confidence interval [CI]: 1.01–7.52; p = 0.049), shorter time span before blood transfusion (− 31.80 ± 15.14; p = 0.038), and marginally decreased mortality risk (aOR: 0.43; 95% CI: 0.17–1.09; p = 0.076).

Conclusion

This study revealed that regular feedback on inter-hospital transfer improved the quality of blood transfusion.

Evaluating delays for emergent CT scans from a rural British Columbia hospital

OBJECTIVES

Computed Tomography (CT) scans help diagnose and triage life-threatening and time-sensitive emergency conditions, but most rural hospitals in British Columbia do not have access to a local CT scanner. We investigate how many transfers from a rural British Columbia hospital were for CT scans and describe the time delays to emergent CT imaging.

METHODS

This was a prospective cohort study, over a 1-year period, on all patients requiring a transfer from the Golden and District Hospital, located 247 km from the closest CT scanner. Data collection forms were completed prospectively and the main measurements included age, transport triage level, reason for transfer, referral hospital, transfer request time, and CT scan time. The time interval between the CT request and CT imaging was calculated and represents the 'delay to CT scan' interval.

RESULTS

The study hospital received 8672 emergency department (ED) visits and 220 were transferred to referral centres (2.5%). 61% of all transfers received a CT scan. Transfers for time-sensitive emergencies took an average of 6 h 52 min. Patients with acute stroke experienced a 4 h 44 min time interval. Less urgent and non-urgent conditions entailed an even greater time delay.

CONCLUSIONS

This study highlights that the lack of a rural CT scanner is associated with increased transfers and significant time delays. Improving access to CT scanners for rural communities may be one of the many steps in addressing healthcare disparities between rural and urban communities.

Caring for critically ill patients during interhospital transfers: A qualitative study

BACKGROUND

The coronavirus pandemic has resulted in an increased number of interhospital transfers of patients with artificial airways. The transfer of these patients is associated with risks and has been experienced as highly challenging, which needs to be further explored.

AIMS AND OBJECTIVES

To describe critical care nurses' experiences of caring for critically ill patients with artificial airways during interhospital transfers.

DESIGN

A cross-sectional study using a qualitative approach was conducted during spring 2020. Participants were critical care nurses (n = 7) from different hospitals (n = 2).

METHODS

The data were collected through semi-structured interviews based on an interview guide. A qualitative content analysis using an inductive approach was performed.

RESULTS

The analysis resulted in one main theme, "Preserving the safety in an unknown environment," and three sub-themes, "Being adequately prepared is essential to feel secure," "Feeling abandoned and overwhelmingly responsible," and "Being challenged in an unfamiliar and risky environment."

CONCLUSIONS

Critical care nurses experienced interhospital transfers of critically ill patients with artificial airways as complex and risky. It is essential to have an overall plan in order to prevent any unpredictable and acute events. Adequate communication and good teamwork are key to the safe transfer of a critically ill patient in that potential complications and dangers to the patient can be prevented.

RELEVANCE TO CLINICAL PRACTICE

Standardized checklists need to be created to guide the transfers of critically ill patients with different conditions. This would prevent failures based on human or system factors, such as lack of experience and lack of good teamwork.

Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study

BACKGROUND

Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers.

METHODS

This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility- and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence.

RESULTS

Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%).

CONCLUSIONS

VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.

Double inter-hospital transfer in Sepsis patients presenting to the ED does not worsen mortality compared to single inter-hospital transfer

PURPOSE

Sepsis is a leading cause of hospital deaths. Inter-hospital transfer is frequent in sepsis and is associated with increased mortality. Some sepsis patients undergo two inter-hospital transfers (double transfer). This study assessed the (1) prevalence, (2) associated risk factors, (3) associated mortality, and (4) hospital length-of-stay and costs of double-transfer of sepsis patients.

MATERIALS AND METHODS

Retrospective cohort study using 2005-2014 administrative claims data in Iowa. Multivariable generalized estimating equations adjusted for potential confounding variables, with a primary outcome of mortality. Secondary outcomes included hospital length-of-stay and costs. Hospital-specific cost-to-charge ratios estimated hospital costs. Hospitals were categorized into quintiles based on sepsis-volume.

RESULTS

Of 15,182 sepsis subjects, there were 45.2% non-transfers and 2.1% double-transfers. Double-transfers had worse mortality than non-transfers but not single-transfers. Of the non-transfers, 44.9% presented to a top sepsis-volume hospital compared to 22.8% of double-transfers and 25.1% of single-transfers. After transfer from first to second hospital, 93.4% of the single-transfers and 92.2% of the double-transfers were at a top sepsis-volume hospital. Double-transfers had longer length-of-stay and more in total hospital costs than single-transfers.

CONCLUSIONS

Double-transfer occurs in 2.1% of Iowa sepsis patients. Double-transfers had similar mortality and increased length of stay and costs compared to single-transfers.

Comparison of Urologic Transfers to Academic Medical Centers: A Multi-institutional Perspective

OBJECTIVE

To examine urologic transfers and rate of tertiary center interventions from 4 geographically distinct academic medical centers.

METHODS

Four academic medical centers were selected for this study including Baylor College of Medicine, University of Alabama at Birmingham, University of Kentucky, and University of Pennsylvania Hospital (Penn). Baylor College of Medicine and Penn primarily service large metropolitan city centers and University of Kentucky and University of Alabama at Birmingham primarily service large rural populations. Transfer logs were pulled for each institution over a 2-year period, and a retrospective chart review was performed to evaluate transfer diagnosis and need for procedural management upon admission. Date of transfer, transfer diagnosis, and interventions performed during tertiary center admission were extracted from the transfer log data sets. The transfer diagnosis was categorized into 1 of 11 mutually exclusive categories.

RESULTS

Overall, 984 urologic transfers were included. Sixty-nine percent (682/984) of patients were transferred to the 2 rural centers, and 30.7% (302/984) were transferred to the 2 metropolitan centers. The most common reason for transfer was nephrolithiasis at 26% (256 of 984 transfers). The overall surgical intervention rate for all urologic transfers in this study was 44.4% (437 of 984 total transfers). Rural center transfers had a lower rate of surgical intervention than metropolitan centers (42.7% vs 48.3%) as well as a markedly higher number of total transfers during the study period (682 vs 302).

CONCLUSION

Given that a majority of patients did not require surgical intervention, methods for avoiding unnecessary urologic transfers are warranted.

Modifying Interhospital Hepatopancreatobiliary Transfers Based on Predictive Analytics: Moving from a Center of Excellence to a Health-Care System of Excellence

Regionalization of complex surgical care has increased interhospital transfers to quaternary centers within large health-care systems. Risk-based patient selection is imperative to improve resource allocation without compromising care. This study aimed to develop predictive models for identifying low-risk patients for transfer to a fully integrated satellite hepatopancreatobiliary (HPB) service in the northeast region of the health-care system. HPB transfers to the quaternary center over 15 months from hospitals in proximity to the satellite HPB center. A predictive tool was developed based on simple pretransfer variables and outcomes for 30-day major complications (Clavien grade ≥ 3), readmission, and mortality. Thresholds for “low risk” were set at different SDs below mean for each model. Predictive models were developed from 51 eligible northeast region patient transfers for major complications (Brier score 0.1948, receiver operator characteristic (ROC) 0.7123, P = 0.0009), readmission (Brier score 0.0615, ROC 0.7368, P = 0.0020), and mortality (Brier score 0.0943, ROC 0.7989, P = 0.0023). Thresholds set from 2 SD below the mean for all models identified 2 as “low risk.” Adjusting the threshold for the serious complication model to only 1 SD below the mean increased the “low-risk” cohort to five patients. These models demonstrate an easy-to-use tool to assist surgeons in identifying low-risk patients for diversion to a fully integrated satellite center. Improved interhospital transfers within a region could begin a transition from centers of excellence toward health-care systems of excellence.

Effect of Specialized Critical Care Transport Unit on Short-Term Mortality of Critically ILL Patients Undergoing Interhospital Transport

Objective: To minimize risk and prevent harmful incidents during interhospital transport, the critical care transport unit service called Seoul Mobile Intensive Care Unit (SMICU) was organized and initiated its service within the city of Seoul. We sought to evaluate the effectiveness of critical care transport units on outcomes of critically ill patients undergoing interhospital transport in Seoul. Methods: A retrospective observational case-control study was designed to evaluate the effectiveness of critical care transport units on outcomes of critically ill patients undergoing interhospital transport. ED patients transported from other hospitals in Seoul during 2016 were identified in the National Emergency Department Information System (NEDIS) and according to use of the SMICU. One-to-one propensity matching was performed to balance covariates between groups. The association of SMICU transport on survival outcome was calculated in a multivariable logistic regression model. Results: Among 42,188 ED patients transported from other hospitals in 2016, 482 (1.1%) of patients were transported by SMICU. Patients transported by SMICU had a higher proportion of severe emergency disease and use of a mechanical ventilator. The adjusted odds ratio for 24-hour mortality after interhospital transport was 0.45 (95% CI: 0.26-0.81) in total cohort and was 0.34 (95% CI: 0.16-0.71) in a one-to-one propensity-matched cohort. Conclusions: Transport by specialized critical care transport unit for patients undergoing interhospital transport was associated with lower 24-hour mortality, demonstrating the benefits of the SMICU.

Texting as a Means of Reducing Pediatric Adolescent Psychiatric Emergency Encounters Wait Times

RATIONALE

There is no universal system to facilitate communication between emergency rooms (ERs) and pediatric mental health providers, which leads to long wait times. This project tested the concept that a group texting application (GroupMe) could improve communication between providers and could reduce wait times by allowing frontline workers to contact multiple providers simultaneously.

METHODS

We compared total wait times or overall length of service of 906 ER encounters before and 921 encounters after the GroupMe texting application was implemented. To reduce differences between preintervention and postintervention time points, we utilized propensity score matching to generate a matched group of controls (total sample n = 831 ER encounters before and n = 831 ER encounters after).

RESULTS

Although there were no differences in total wait times when using the GroupMe application, there was a significant decrease in wait times after patients were diagnosed in ER by psychiatric provider both before (mean difference, 96.4 minutes saved; t = 2.23; P < 0.05) and after propensity score matching (mean difference, 88.0 minutes saved; t = 2.48; P < 0.05) for disposition type and acuity level.

CONCLUSIONS

Use of a group texting application has the potential to improve communication and wait times. However, its ability to reduce overall wait times is hampered when the limited availability of pediatric psychiatry providers results in delays in diagnosis and treatment decisions.

Telemedicine Is Associated with Faster Diagnostic Imaging in Stroke Patients: A Cohort Study

BACKGROUND

Meeting time goals for patients with time-sensitive conditions can be challenging in rural emergency departments (EDs), and adopting policies is critical. ED-based telemedicine has been proposed to improve quality and timeliness of care in rural EDs.

INTRODUCTION

The objective of this study was to test the hypothesis that diagnostic testing in telemedicine-supplemented ED care for patients with myocardial infarction (MI) and stroke would be faster than nontelemedicine care in rural EDs.

MATERIALS AND METHODS

This observational cohort study included all ED patients with MI or stroke in 19 rural critical access hospitals served by a single real-time contract-based telemedicine provider in the upper Midwest (2007-2015). The primary outcome for the MI cohort was time-to-electrocardiogram (EKG) and for the stroke cohort was time-to-head computed tomography (CT) interpretation. To measure the relationship between telemedicine and timeliness parameters, generalized estimating equations models were used, clustering on presenting hospital.

RESULTS

Of participating ED visits, 756 were included in the MI cohort (29% used telemedicine) and 140 were included in the stroke cohort (30% used telemedicine). Time-to-EKG did not differ when telemedicine was used (1% faster, 95% confidence interval [CI] -4% to 7%), or after telemedicine was implemented (4% faster, 95% CI -3% to 10%). Head CT interpretation was faster for telemedicine cases (15% faster, 95% CI 4-26%). No differences were observed in time to reperfusion therapy.

CONCLUSIONS

Telemedicine implementation was associated with more timely head CT interpretation for rural patients with stroke, but no difference in early MI care. Future work will focus on the specific manner in which telemedicine changes ED care processes and ongoing professional education.

Safety of Back-Transfer to Local Hospitals During an Acute Care Hospitalization

PURPOSE

This paper investigates patient outcomes including length of stay (LOS), cost of hospitalization, bounce-back rates, transition to hospice care, and mortality, following back-transfer.

METHODS

This study was an observational case-control study of adults hospitalized in Iowa between 2005 and 2013 to identify back-transferred patients. Back-transfer was defined as the transfer of rural patients near the end of their acute hospitalization in a comprehensive medical center back to a local community hospital for the completion of their medical care. Demographic, geographic, rurality, procedural, and disease information was compared between case and control groups, then propensity score (PS) matching was performed to create comparable groups to perform analyses.

FINDINGS

Over the 9-year period, 1,056,773 patients meeting inclusion criteria were admitted, of which 430 (0.04%) were back-transferred. After PS matching, LOS was 60% (95% CI: 0.50-0.71) higher and costs were 42% (95% CI: 0.33-0.50) higher in the back-transferred group. Back-transferred cases had 8.34 (95% CI: 3.66-19.0) times the odds of hospice transition and 2.17 (95% CI: 1.37-3.46) the odds of mortality compared to controls. Four percent of back-transfers "failed" with the patient being returned to the larger hospital before discharge.

CONCLUSIONS

Back-transfer is a rare occurrence, and it is associated with longer LOS, higher hospitalization cost, higher mortality, more hospice transfers, and occasional bounce-backs to comprehensive medical centers. Future work should focus more on prospective indications for transfer, the role of end-of-life care, financial impact, and identifying patient populations for whom back-transfer is safest.

Rural Patients With Severe Sepsis or Septic Shock Who Bypass Rural Hospitals Have Increased Mortality: An Instrumental Variables Approach

OBJECTIVE

To identify factors associated with rural sepsis patients' bypassing rural emergency departments to seek emergency care in larger hospitals, and to measure the association between rural hospital bypass and sepsis survival.

DESIGN

Observational cohort study.

SETTING

Emergency departments of a rural Midwestern state.

PATIENTS

All adults treated with severe sepsis or septic shock between 2005 and 2014, using administrative claims data.

INTERVENTIONS

Patients bypassing local rural hospitals to seek care in larger hospitals.

MEASUREMENTS AND MAIN RESULTS

A total of 13,461 patients were included, and only 5.4% (n = 731) bypassed a rural hospital for their emergency department care. Patients who initially chose a top-decile sepsis volume hospital were younger (64.7 vs 72.7 yr; p < 0.001) and were more likely to have commercial insurance (19.6% vs 10.6%; p < 0.001) than those who were seen initially at a local rural hospital. They were also more likely to have significant medical comorbidities, such as liver failure (9.9% vs 4.2%; p < 0.001), metastatic cancer (5.9% vs 3.2%; p < 0.001), and diabetes with complications (25.2% vs 21.6%; p = 0.024). Using an instrumental variables approach, rural hospital bypass was associated with a 5.6% increase (95% CI, 2.2-8.9%) in mortality.

CONCLUSIONS

Most rural patients with sepsis seek care in local emergency departments, but demographic and disease-oriented factors are associated with rural hospital bypass. Rural hospital bypass is independently associated with increased mortality.

Prediction of en-route complications during interfacility transport by outcome predictive scores in ED

OBJECTIVE

The objective was to determine the accuracy of the outcome predictive scores (Modified Early Warning Score [MEWS]; Hypotension, Low Oxygen Saturation, Low Temperature, Abnormal ECG, Loss of Independence [HOTEL] score; and Simple Clinical Score [SCS]) in predicting en-route complications during interfacility transport (IFT) in emergency department.

DESIGN

This was a retrospective cohort study.

METHODS

All IFT cases by ambulances with either nurse-led or physician-led escort, occurring between 1 January 2011 and 31 December 2012, were included. Obstetric and pediatric cases (age < 18 years) were excluded. The condition of patients was quantified by using the predictive scores (MEWS, HOTEL, and SCS) at triage station and on ambulance departure. The accuracy of predictive scores was compared by the receiver operating characteristic (ROC) curves.

RESULTS

A total of 659 cases were included. Seventeen cases had en-route complications (2.6%). The complication rate in physician-escorted transport (2.2%) was similar to that in nurse-escorted transport (2.6%). None of the 57 intubated cases had en-route complications. The area under the ROC curve for MEWS was 0.662 (triage) and 0.479 (departure). The accuracy of MEWS at triage was better than that at departure (P = .049). The area under the ROC curve for HOTEL was 0.613 (triage) and 0.597 (departure), and that for SCS was 0.6 (triage) and 0.568 (departure). In general, the predictive scores at triage were better than those on departure.

CONCLUSION

None of the scores had good accuracy in prediction of en-route complications during IFT. MEWS at triage was among the best one already but was not ideal.

Maximizing efficiency and diagnostic accuracy triage of acute stroke patients: A case-control study

BACKGROUND

Recent data have demonstrated that mechanical thrombectomy (MT) is beneficial for patients presenting within zero to six hours of symptom onset after stroke. However, transferring all patients with possible strokes for endovascular therapy and MT would be inefficient and costly. We conducted a case-control study to identify a subset of the National Institutes of Health Stroke Scale (NIHSS) to identify patients with large-vessel occlusion (LVO) to a high degree of specificity, in order to select those patients for whom transfer is most appropriate.

METHODS

Acute code stroke alerts presenting to a comprehensive stroke center from 2012 to 2013 (779) and corresponding NIHSS were collected. All patients had vascular imaging and 125 demonstrated LVO (cases) and were compared to 272 small-vessel strokes and stroke mimics (controls). Demographics of both groups and modified receiver operating characteristic (ROC) curves were generated for each combination of three NIHSS items to optimize specificity of LVO for those who would benefit from MT.

RESULTS

The average NIHSS of cases was higher than controls (12.5 vs. 6.5, p < 0.0001). The subset of three NIHSS items with the largest modified AUC (optimized for specificity) was maximum "Arm," "Sensory," and "Extinction." Using a cutoff of seven out of a total 10 possible points, the sum score for these items has 90.2% specificity and 16.0% sensitivity for LVO.

CONCLUSION

We present a validated three-question subset of the NIHSS for those who would benefit from MT with a high degree of specificity.