Which patients and where: a qualitative study of patient transfers from community hospitals

Mixed Methods Study of the Interfacility Transfer System Utilizing Both Patient-Reported Experiences and Direct Observation of the Transfer Consent Process

BACKGROUND

Interfacility transfer is an integral component of the modern health care system. However, there are no commonly agreed-upon standards for interfacility processes or for patient engagement and shared decision-making in transfer, and little is known about their experience. This study used qualitative methods to better understand the patient and care partner experience with interfacility emergency department (ED)-to-ED transfer.

METHODS

This mixed methods study used two distinct data sources: (1) semistructured interviews of older adult patients and their care partners, performed at bedside in a large, tertiary care hospital (receiving facility) following interfacility transfer, and (2) direct observation of the transfer consent process at two community EDs (referring facilities) in the same health system.

RESULTS

A total of 21 patients and 14 care partners were interviewed. The authors identified several common themes related to perceptions and experiences with interfacility transfer: (1) communication (for example, perceived lack of agency), (2) logistics (for example, wait times), (3) impacts on family (for example, distance from home), (4) uncertainty about the bill (for example, transfer-associated costs), and (5) quality of care (for example, greater trust in tertiary care centers). Direct observations of the transfer consent process for 14 unique patient encounters were also conducted. The research team observed considerable variability in practice patterns among sending clinicians and identified frequent patient-reported issues related to transfer logistics and effective communication, including distractions, lack of privacy, absence of support system, physical pain and/or psychological stress, preferred language, and health literacy.

CONCLUSION

These data suggest several potential areas for improvement in the care of patients requiring interfacility transfer, to increase engagement and allow patients and their care partners to make better-informed decisions most consistent with their goals of care.

Understanding characteristics and trajectories of patients experiencing early death after interhospital transfer

Twenty- to fifty-thousand patients die annually within 72 h of interhospital transfer (early death after transfer; EDAT). The characteristics and trajectories of these patients are ill-defined. In this retrospective cohort study, we characterized EDAT at three representative major referral centers. Primary outcomes included the presence and timing of goals of care (GOC) and/or prognostic discussions. Among 190 medical patients experiencing EDAT, 95 (50.0%) were >65 years, 115 (60.5%) male, and 137 (72.6%) White; 140 (73.7%) patients traveled >50 miles from home, and 174 (91.6%) were referred for specialty care. Whereas GOC were documented pretransfer for 40 patients (21.1%) and unknown for 97 patients (51%); 152 (80.0%) had posttransfer discussions, often within 24 h of death (125; 82.2%). Transfer >50 miles was associated with death ≤24 h after transfer and with posttransfer changes in code status. Further research is needed to evaluate disparities and describe the potential burdens of transfer at end-of-life. Infrequent pretransfer discussions of GOC suggest potential targets for improvement.

Development of a Tool to Measure Potentially Inappropriate Inter-Hospital Transfer (IHT): The POINT Study

BACKGROUND

Although inter-hospital transfer (IHT, the transfer of patients between acute care hospitals) aims at matching patients' care needs to appropriate sites of care, IHT practices are variable leaving some patients vulnerable to risks of discontinuity of care without clear benefit. Identifying which patients may not need IHT can help to prevent inappropriate care and improve patient outcomes.

STUDY OVERVIEW

The POINT Study, "Identification and Prevention of Potentially Inappropriate Inter-Hospital Transfers," is a 5-year study (AHRQ-R01HS028621) that aims to define potentially inappropriate IHT using key stakeholder input, evaluate the incidence and patient safety impact of potentially inappropriate IHT across a nationally representative sample of 18 hospitals, and develop an intervention toolkit to reduce potentially inappropriate IHT. In this paper, we report on the development of a standardized adjudication process to capture potentially inappropriate IHT using results generated from the first 2 years of this project.

DEVELOPMENT OF THE ADJUDICATION TOOL

Development of the adjudication tool to measure potentially inappropriate IHT involved a multi-step process, including (1) conducting focus groups of key stakeholders involved in IHT to generate a consensus definition of "potentially inappropriate IHT;" (2) translating this definition into an adjudication tool for use during retrospective chart review; and (3) conducting rigorous training among all adjudicators to ensure reliability of the adjudication process.

NEXT STEPS

Next steps include launching sites to conduct adjudications with a goal of 1800 total transfer case adjudications across the 18 sites. We will support the adjudication process with monthly tracking and case review meetings among other supports. The results of this work will lead to a foundational understanding of the prevalence, risk factors, and patient safety impact of potentially inappropriate IHT.

Factors associated with delayed referrals of patients with sepsis from primary to tertiary healthcare in Blantyre, Malawi: a qualitative study

BACKGROUND

Sepsis is defined as invasion of pathogens into the blood stream together with the host response to this invasion. Thus, sepsis consists of the systemic inflammatory response syndrome (SIRS)caused by infection. It is a life-threatening condition that requires prompt detection and early definitive medical intervention. Globally, sepsis is common, with an estimated 31.5 million cases per year. Sepsis accounts for a significant in-hospital mortality rate of 17% in high-income countries, while in Malawi, it ranges from 17 to 50%. For Malawi, the trend can be reversed with improvements in patient referral system within the healthcare system. The study sets out to establish factors associate with delay referral of patients with sepsis from primary healthcare to tertiary hospitals and to understand healthcare workers and patients' perspectives on barriers associated with delayed referral of patients with sepsis from primary to tertiary healthcare.

METHODS

A qualitative descriptive study in six health centres within Blantyre District health office. In-depth interviews were conducted with 22 respondents: healthcare providers [n = 12]; patients [n = 10] using semi-structured interview guides. Purposive sampling techniques were used in selecting healthcare providers (health centre in charges) and patients.

RESULTS

The study demonstrating that the main referral pathways for patients with sepsis include community-to-facility and facility-to-facility referrals. Ambulances and personal transport are common transportation mode used during referrals. Primary care facilities face several challenges that delay referrals from primary to tertiary health facility of patients with sepsis, such as lack of referral transport, poor communication, poor road network, shortage of skilled healthcare workers, patient preferences, delayed treatment-seeking action, and ambulances prioritising maternal conditions.

CONCLUSIONS

Patients' delay and failure to access prompt and timely referral services result from the healthcare system's lack of transport, communication problems, bad road networks and shortage of well-trained personnel. Referral delays have deleterious effects on patient-care outcomes.

Appropriately Matching Transport Care Units to Patients in Interhospital Transport Care: Implementation Study

BACKGROUND

In interfacility transport care, a critical challenge exists in accurately matching ambulance response levels to patients' needs, often hindered by limited access to essential patient data at the time of transport requests. Existing systems cannot integrate patient data from sending hospitals' electronic health records (EHRs) into the transfer request process, primarily due to privacy concerns, interoperability challenges, and the sensitive nature of EHR data. We introduce a distributed digital health platform, Interfacility Transport Care (ITC)-InfoChain, designed to solve this problem without compromising EHR security or data privacy.

OBJECTIVE

This study aimed to detail the implementation of ITC-InfoChain, a secure, blockchain-based platform designed to enhance real-time data sharing without compromising data privacy or EHR security.

METHODS

The ITC-InfoChain platform prototype was implemented on Amazon Web Services cloud infrastructure, using Hyperledger Fabric as a permissioned blockchain. Key elements included participant registration, identity management, and patient data collection isolated from the sending hospital's EHR system. The client program submits encrypted patient data to a distributed ledger, accessible to the receiving facility's critical care unit at the time of transport request and emergency medical services (EMS) teams during transport through the PatienTrack web app. Performance was evaluated through key performance indicators such as data transaction times and scalability across transaction loads.

RESULTS

The ITC-InfoChain demonstrated strong performance and scalability. Data transaction times averaged 3.1 seconds for smaller volumes (1-20 transactions) and 6.4 seconds for 100 transactions. Optimized configurations improved processing times to 1.8-1.9 seconds for 400 transactions. These results confirm the platform's capacity to handle high transaction volumes, supporting timely, real-time data access for decision-making during transport requests and patient transfers.

CONCLUSIONS

The ITC-InfoChain platform addresses the challenge of matching appropriate transport units to patient needs by ensuring data privacy, integrity, and real-time data sharing, enhancing the coordination of patient care. The platform's success suggests potential for regional pilots and broader adoption in secure health care systems. Stakeholder resistance due to blockchain unfamiliarity and data privacy concerns remains. Funding has been sought to support a pilot program to address these challenges through targeted education and engagement.

A pilot study: Examining cytoskeleton gene expression profiles in Pakistani children with autism spectrum disorder

BACKGROUND

Finding effective pharmacological interventions to address the complex array of neurodevelopmental disorders is currently an urgent imperative within the scientific community as these conditions present significant challenges for patients and their families, often impacting cognitive, emotional, and social development. In this study, we aimed to explore non-invasive method to diagnose autism spectrum disorders (ASD) within Pakistan children population and to identify clinical drugs for its treatment.

AIMS

The current report outlines a comprehensive bidirectional investigation showcasing the successful utilization of saliva samples to quantify the expression patterns of profilins (PFN1, 2, and 3); and ERM (ezrin, radixin, and moesin) proteins; and additionally moesin pseudogene 1 and moesin pseudogene 1 antisense (MSNP1AS). Subsequently, these expression profiles were employed to forecast interactions between drugs and genes in children diagnosed with ASD.

METHODS

This study sought to delve into the intricate gene expression profiles using qualitative polymerase chain reaction of profilin isoforms (PFN1, 2, and 3) and ERM genes extracted from saliva samples obtained from children diagnosed with ASD. Through this analysis, we aimed to elucidate potential molecular mechanisms underlying ASD pathogenesis, shedding light on novel biomarkers and therapeutic targets for this complex neurological condition. (n = 22). Subsequently, we implemented a diagnostic model utilizing sparse partial least squares discriminant analysis (sPLS-DA) to predict drugs against our genes of interest. Furthermore, connectivity maps were developed to illustrate the predicted associations of 24 drugs with the genes expression.

RESULTS

Our study results showed varied expression profile of cytoskeleton linked genes. Similarly, sPLS-DA model precisely predicted drug to genes response. Sixteen of the examined drugs had significant positive correlations with the expression of the targeted genes whereas eight of the predicted drugs had shown negative correlations.

CONCLUSION

Here we report the role of cytoskeleton linked genes (PFN and ERM) in co-relation to ASD. Furthermore, variable yet significant quantitative expression of these genes successfully predicted drug-gene interactions as shown with the help of connectivity maps that can be used to support the clinical use of these drugs to treat individuals with ASD in future studies.

Information exchange, responsibilities and expectation management in interhospital transfers: a qualitative study of hospital medicine physicians and advanced practice providers

INTRODUCTION

The transfer of patients between hospitals, known as interhospital transfer (IHT), is associated with higher rates of mortality, longer lengths of stay and greater resource utilisation compared with admissions from the emergency department. To characterise the IHT process and identify key barriers and facilitators to IHT care, we examined the experiences of physician and advanced practice provider (APP) hospital medicine clinicians who care for IHT patients transferred to their facility.

METHODS

Qualitative descriptive study using semistructured interviews with adult medicine hospitalists from an academic acute care hospital that accepts approximately 4000 IHT patients annually. A combined inductive and deductive coding approach guided thematic analysis.

RESULTS

We interviewed 30 hospitalists with a mean of 5.7 years of experience. Two-thirds of interviewees were physicians and one-third were APPs.They described IHTs as challenging when (1) exchanged information was incomplete, inaccurate, extraneous, and/or untimely, (2) uncertainty impacted care responsibilities and (3) healthcare team members and patients had differing care expectations. As a result, participants described patient safety issues such as delays in care and inappropriate triage of patients due to incomplete communication of clinical status changes.Recommended improvement strategies include (1) dedicated individuals performing IHT tasks to improve consistency of information exchanged and relationships with transferring clinicians, (2) standardised scripts and documentation, (3) bidirectional communication, (4) interdisciplinary training and (5) shared understanding of care needs and expectations.

CONCLUSIONS

Physicians and APP hospital medicine clinicians at an accepting hospital found information exchange, care responsibilities and expectation management challenging in IHT. In turn, hospitalists perceived a negative impact on IHT patient care and safety. Highly reliable and timely information transfer, standardisation of IHT processes and clear interdisciplinary communication may facilitate improved care for IHT patients.

Multi-Institution Survey of Accepting Physicians' Perception of Appropriate Reasons for Interhospital Transfer: A Mixed-Methods Evaluation

OBJECTIVES

There is a lack of evidence-based guidelines to direct best practices in interhospital transfers (IHTs). We aimed to identify frontline physicians' current and ideal reasons for accepting IHT patients to inform future IHT research and guidelines.

METHODS

We conducted a cross-sectional survey of hospitalist physicians across 11 geographically diverse hospitals. The survey asked respondents how frequently they currently consider and should consider various factors when triaging IHT requests. Responses were dichotomized into "highly considered" and "less considered" factors. Frequencies of the "highly considered" factors (current and ideal) were analyzed. Write-in responses were coded into themes within a priori domains in a qualitative analysis.

RESULTS

Of the 666 hospitalists surveyed, 238 (36%) responded. Respondents most frequently identified the need for specialty procedural and nonprocedural care and bed capacity as factors that should be considered when triaging IHT patients in current and ideal practice, whereas the least frequently considered factors were COVID-related care, insurance/financial considerations, and patient/family preference. More experienced respondents considered patient/family preference more frequently in current and ideal practice compared with less experienced respondents (33% versus 11% [ P = 0.0001] and 26% versus 9% [ P = 0.01], respectively). Qualitative analysis identified several themes in the domains of Criteria for Acceptance, Threshold for Acceptance, and Indications for Physician-to-Physician Communication.

CONCLUSIONS

This geographically diverse sample of hospitalist physicians responsible for accepting IHT patients showed general agreement between primary factors that are currently and that should be considered for IHT acceptance, with greatest weight placed on patients' need for specialty care.

Patient and Hospital Characteristics Associated With the Interhospital Transfer of Adult Patients With Sepsis

IMPORTANCE

The interhospital transfer (IHT) of patients with sepsis to higher-capability hospitals may improve outcomes. Little is known about patient and hospital factors associated with sepsis IHT.

OBJECTIVES

We evaluated patterns of hospitalization and IHT and determined patient and hospital factors associated with the IHT of adult patients with sepsis.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

A total of 349,938 adult patients with sepsis at 329 nonfederal hospitals in California, 2018-2019.

MAIN OUTCOMES AND MEASURES

We evaluated patterns of admission and outward IHT between low sepsis-, intermediate sepsis-, and high sepsis-capability hospitals. We estimated odds of IHT using generalized estimating equations logistic regression with bootstrap stepwise variable selection.

RESULTS

Among the cohort, 223,202 (66.4%) were initially hospitalized at high-capability hospitals and 10,870 (3.1%) underwent IHT. Nearly all transfers (98.2%) from low-capability hospitals were received at higher-capability hospitals. Younger age (< 65 yr) (adjusted odds ratio [aOR] 1.54; 95% CI, 1.40-1.69) and increasing organ dysfunction (aOR 1.22; 95% CI, 1.19-1.25) were associated with higher IHT odds, as were admission to low-capability (aOR 2.79; 95% CI, 2.33-3.35) or public hospitals (aOR 1.35; 95% CI, 1.09-1.66). Female sex (aOR 0.88; 95% CI, 0.84-0.91), Medicaid insurance (aOR 0.59; 95% CI, 0.53-0.66), home to admitting hospital distance less than or equal to 10 miles (aOR 0.92; 95% CI, 0.87-0.97) and do-not-resuscitate orders (aOR 0.48; 95% CI, 0.45-0.52) were associated with lower IHT odds, as was admission to a teaching hospital (aOR 0.83; 95% CI, 0.72-0.96).

CONCLUSIONS AND RELEVANCE

Most patients with sepsis are initially hospitalized at high-capability hospitals. The IHT rate for sepsis is low and more likely to originate from low-capability and public hospitals than from high-capability and for-profit hospitals. Transferred patients with sepsis are more likely to be younger, male, sicker, with private medical insurance, and less likely to have care limitation orders. Future studies should evaluate the comparative benefits of IHT from low-capability hospitals.

Inter-hospital Transfer Decision-making During the COVID-19 Pandemic: a Qualitative Study

BACKGROUND

Inter-hospital patient transfers to hospitals with greater resource availability and expertise may improve clinical outcomes. However, there is little guidance regarding how patient transfer requests should be prioritized when hospital resources become scarce.

OBJECTIVE

To understand the experiences of healthcare workers involved in the process of accepting inter-hospital patient transfers during a pandemic surge and determine factors impacting inter-hospital patient transfer decision-making.

DESIGN

We conducted a qualitative study consisting of semi-structured interviews between October 2021 and February 2022.

PARTICIPANTS

Eligible participants were physicians, nurses, and non-clinician administrators involved in the process of accepting inter-hospital patient transfers. Participants were recruited using maximum variation sampling.

APPROACH

Semi-structured interviews were conducted with healthcare workers across Michigan.

KEY RESULTS

Twenty-one participants from 15 hospitals were interviewed (45.5% of eligible hospitals). About half (52.4%) of participants were physicians, 38.1% were nurses, and 9.5% were non-clinician administrators. Three domains of themes impacting patient transfer decision-making emerged: decision-maker, patient, and environmental factors. Decision-makers described a lack of guidance for transfer decision-making. Patient factors included severity of illness, predicted chance of survival, need for specialized care, and patient preferences for medical care. Decision-making occurred within the context of environmental factors including scarce resources at accepting and requesting hospitals, organizational changes to transfer processes, and alternatives to patient transfer including use of virtual care. Participants described substantial moral distress related to transfer triaging.

CONCLUSIONS

A lack of guidance in transfer processes may result in considerable variation in the patients who are accepted for inter-hospital transfer and in substantial moral distress among decision-makers involved in the transfer process. Our findings identify potential organizational changes to improve the inter-hospital transfer process and alleviate the moral distress experienced by decision-makers.

Hospital factors that influence ICU admission decision-making: a qualitative study of eight hospitals

PURPOSE

Some hospitals in the United States (US) use intensive care 20 times more than others. Since intensive care is lifesaving for some but potentially harmful for others, there is a need to understand factors that influence how intensive care unit (ICU) admission decisions are made.

METHODS

A qualitative analysis of eight US hospitals was conducted with semi-structured, one-on-one interviews supplemented by site visits and clinical observations.

RESULTS

A total of 87 participants (24 nurses, 52 physicians, and 11 other staff) were interviewed, and 40 h were spent observing ICU operations across the eight hospitals. Four hospital-level factors were identified that influenced ICU admission decision-making. First, availability of intermediate care led to reallocation of patients who might otherwise be sent to an ICU. Second, participants stressed the importance of ICU nurse availability as a key modifier of ICU capacity. Patients cared for by experienced general care physicians and nurses were less likely to receive ICU care. Third, smaller or rural hospitals opted for longer emergency department patient-stays over ICU admission to expedite interhospital transfer of critically ill patients. Fourth, lack of clarity in ICU admission policies led clinicians to feel pressured to use ICU care for patients who might otherwise not have received it.

CONCLUSION

Health care systems should evaluate their use of ICU care and establish institutional patterns that ensure ICU admission decisions are patient-centered but also account for resources and constraints particular to each hospital.

Racial and ethnic disparities in interhospital transfer for complex emergency general surgical disease across the United States

BACKGROUND

Differential access to specialty surgical care can drive health care disparities, and interhospital transfer (IHT) is one mechanism through which access barriers can be realized for vulnerable populations. The association between race/ethnicity and IHT for patients presenting with complex emergency general surgery (EGS) disease is understudied.

METHODS

Using the 2019 Nationwide Emergency Department Sample, we identified patients 18 years and older with 1 of 13 complex EGS diseases based on International Classification of Diseases, Tenth Revision , diagnosis codes. The primary outcome was IHT. A series of weighted logistic regression models was created to determine the association of race/ethnicity with the primary outcome while controlling for patient and hospital characteristics.

RESULTS

Of 387,610 weighted patient encounters from 989 hospitals, 59,395 patients (15.3%) underwent IHT. Compared with non-Hispanic White patients, rates of IHT were significantly lower for non-Hispanic Black (15% vs. 17%; unadjusted odds ratio (uOR) [95% confidence interval (CI)], 0.58 [0.49-0.68]; p < 0.001), Hispanic/Latinx (HL) (9.0% vs. 17%; uOR [95% CI], 0.48 [0.43-0.54]; p < 0.001), Asian/Pacific Islander (Asian/PI) (11% vs. 17%; uOR [95% CI], 0.84 [0.78-0.91]; p < 0.001), and other race/ethnicity (12% vs. 17%; uOR [95% CI], 0.68 [0.57-0.81]; p < 0.001) patients. In multivariable models, the adjusted odds of IHT remained significantly lower for HL (adjusted odds ratio [95% CI], 0.76 [0.72-0.83]; p < 0.001) and Asian/PI patients (adjusted odds ratio [95% CI], 0.73 [0.62-0.86]; p < 0.001) but not for non-Hispanic Black and other race/ethnicity patients ( p > 0.05).

CONCLUSION

In a nationally representative sample of emergency departments across the United States, patients of minority race/ethnicity presenting with complex EGS disease were less likely to undergo IHT when compared with non-Hispanic White patients. Disparities persisted for HL and Asian/PI patients when controlling for comorbid conditions, hospital and residential geography, neighborhood socioeconomic status, and insurance; these patients may face unique barriers in accessing surgical care.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

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.

Nonurgent Pediatric Interhospital Transfers: A Narrative Enquiry of Nurses' Experiences in Australia

INTRODUCTION

This study aimed to explore nonurgent pediatric interhospital transfers through the lens of nurses' experiences and perceptions when undertaking these transfers.

METHODS

Using a narrative inquiry approach, data were collected via semistructured interviews with registered nurses (N = 7) who had experience undertaking patient transfers between nonurgent low-acuity and urgent high-acuity hospital settings.

RESULTS

Findings established the following 8 themes: ensuring transfer preparation for risk mitigation, practicing confident advocacy, being accountable for risk mitigation of the deteriorating patient during transfer, maintaining standardized procedure, using training and mentorship to support confidence, maintaining interhospital and intrahospital relationships, recognizing the significance of transfer on families, and acknowledging the burden of transfer and delay.

DISCUSSION

By exploring the stories and experiences of emergency nurses who undertake pediatric interhospital transfers, a deep investigation of the risks and challenges has been described, an area often underrepresented in the literature. Findings from this study highlight important learnings for pediatric interhospital transfer that add value to the wider body of evidence.

Documenting surgical triage in rural surgical networks: Formalising existing structures

OBJECTIVE

It is essential that the embedded process of rural case selection be highlighted and documented to provide reassurance of rigour across rural surgical services supported by generalist surgeons, general practitioners with enhanced surgical skills and general practitioner anaesthetists. This enables feedback and improves the triage and case selection process to ensure the highest quality outcomes. Therefore, this research aims to explore participants' rational criteria for decision making around rural case selection.

DESIGN

Participants participated in a series of semi-structured in-depth interviews which were coded and underwent thematic analysis.

SETTING

Six community hospitals in British Columbia, Canada.

PARTICIPANTS

General practitioners with enhanced surgical skills, general practitioner anaesthetists, local maternity care providers, and specialists.

RESULTS

Based on participant accounts, rural surgical and obstetrical decision-making processes for local patient selection or regional referral had five major components: (1) Clinical Factors, (2) Physician Factors, (3) Patient Factors, (4) Consensus Between Providers and (5) the Availability of Local Resources.

CONCLUSION

Decision-making processes around rural surgical and obstetrical patient selection are complex and require comprehensive understanding of local capacity and resources. Current policies and guidelines fail to consider the varying capacities of each rural site and should be hospital specific.

"Our Hands Are Tied Until Your Doctor Gets Here": Nursing Perspectives on Inter-hospital Transfers

BACKGROUND

The transfer of patients between hospitals (inter-hospital transfer, or IHT) is a common occurrence for patients, but guidelines to ensure safe and effective IHTs are lacking. Poor IHTs result in higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Nurses are often the first point of contact for IHT patients and can provide valuable insights on key challenges to IHT processes.

OBJECTIVE

To characterize the experiences of inpatient floor-level bedside nurses caring for IHT patients and identify care coordination challenges and solutions.

DESIGN/PARTICIPANTS/APPROACH

Qualitative study using semi-structured focus groups and interviews conducted from October 2019 to July 2020 with 21 inpatient floor-level nurses caring for adult medicine patients at an academic hospital. Nurses were recruited using a purposive convenience sampling approach. A combined inductive and deductive coding approach guided by thematic analysis was used for data analysis.

KEY RESULTS

Results from this study are mapped to the Agency for Healthcare Research and Quality Care Coordination Measurement Framework domains of communication, assessing needs and goals, and negotiating accountability. The following key themes characterize nurses' experiences with IHT related to these domains: (1) challenges with information exchange and team communication during IHT, (2) environmental and information preparation needed to anticipate transfers, and (3) determining responsibility and care plans after the IHT patient has arrived at the accepting facility.

CONCLUSIONS

Nurses described the absence of standardized processes to coordinate care before or at the time of patient arrival. Challenges to communication and coordination during IHTs negatively impacted patient care and nursing professional satisfaction. To streamline care for IHT patients and reduce nursing stress, future IHT interventions should include standardized handoff reports, timely identification and easy access to admitting clinicians, and timely clinician evaluation and orders.

Opportunities for Restructuring Hospital Transfer Networks for Pediatric Asthma

OBJECTIVE

To describe the current system of pediatric asthma care and identify potential options for unloading tertiary centers.

METHODS

Retrospective, cross-sectional study using 2014 inpatient and emergency department all-encounter administrative datasets from Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York. Study participants included children <18 with primary diagnosis of asthma.

RESULTS

There were 174,239 encounters for pediatric asthma, with 26,316 admissions and 3101 transfers. About 94.4% of transfers were admitted, with median stay length 2 days (interquartile range [IQR] 1.0-3.0). About 637 hospitals saw pediatric asthma, but 58.7% never admitted these patients. Fifty-four hospitals (8.5%) regularly received transfers; these hospitals were broadly capable pediatric centers (mean pediatric hospital capability indices = 0.82, IQR: 0.64-0.89). Two hundred nine facilities (32.8%) did not regularly receive transfers but were highly capable of caring for pediatric asthma (mean condition-specific capability = 0.92, IQR: 0.85-1.00). Median distance from transferring hospitals to the nearest pediatric center was 25.7 miles (IQR: 6.45-50.15) vs 18.0 miles (IQR: 8.35-29.25) to the nearest potential receiving hospital. Mean cost of a 2-day asthma admission in receiving hospitals was $3927 (IQR: $3083-$4894) versus $3427 (IQR: $2485-$4102) in potential receivers.

CONCLUSIONS

While nearly all acute care hospitals encounter children with asthma, more than half never admit them. Children are primarily transferred to a small subset of specialized centers, despite the existence, in many regions, of closer community hospitals with high pediatric asthma capability. In settings with long transfer distances and tertiary center crowding, a tiered system of hospital care for pediatric asthma may be feasible.

Patient and Physician Experience with Interhospital Transfer: A Qualitative Study

OBJECTIVES

Although existing data suggest marked variability in interhospital transfer (IHT), little is known about specific factors that may impact the quality and safety of this care transition. We aimed to explore transferred patients' and involved physicians' experience with IHT to better understand the components of the transfer continuum and identify potential targets for improvement.

METHODS

We performed a qualitative study using individual interviews of adult patients recently transferred to cardiology, general medicine, and oncology services at a tertiary care academic medical center, as well as their transferring physician, accepting attending physician, and accepting/admitting resident physician. We conducted a thematic analysis, using an inductive approach and an a priori framework from pre-established domains.

RESULTS

Participants included 10 hospitalized adults (6 cardiology, 2 general medicine, and 2 oncology), 9 accepting attending physicians, 12 accepting and/or admitting resident physicians, and 5 transferring physicians (N = 36). Emergent themes demonstrated that participants held a shared understanding of the reason for transfer (most commonly access to more specialized care), and relayed a general dissatisfaction regarding the timing and lack of advanced notification of transfer. We also found distinct differences in IHT experience by stakeholder group: physician participants relayed discontent with intrahospital chains of communication and interhospital information exchange, and patient participants focused more readily on the physical aspects of IHT.

CONCLUSIONS

This study offers insight into IHT from the perspective of those most affected by this process, thereby identifying potential targets in addressing the quality and safety of this transition.

Making sense of the French public hospital system: a network-based approach to hospital clustering using unsupervised learning methods

BACKGROUND

Hospitals in the public and private sectors tend to join larger organizations to form hospital groups. This increasingly frequent mode of functioning raises the question of how countries should organize their health system, according to the interactions already present between their hospitals. The objective of this study was to identify distinctive profiles of French hospitals according to their characteristics and their role in the French hospital network.

METHODS

Data were extracted from the national hospital database for year 2016. The database was restricted to public hospitals that practiced medicine, surgery or obstetrics. Hospitals profiles were determined using the k-means method. The variables entered in the clustering algorithm were: the number of stays, the effective diversity of hospital activity, and a network-based mobility indicator (proportion of stays followed by another stay in a different hospital of the same Regional Hospital Group within 90 days).

RESULTS

Three hospital groups were identified by the clustering algorithm. The first group was constituted of 34 large hospitals (median 82,100 annual stays, interquartile range 69,004 - 117,774) with a very diverse activity. The second group contained medium-sized hospitals (with a median of 258 beds, interquartile range 164 - 377). The third group featured less diversity regarding the type of stay (with a mean of 8 effective activity domains, standard deviation 2.73), a smaller size and a higher proportion of patients that subsequently visited other hospitals (11%). The most frequent type of patient mobility occurred from the hospitals in group 2 to the hospitals in group 1 (29%). The reverse direction was less frequent (19%).

CONCLUSIONS

The French hospital network is organized around three categories of public hospitals, with an unbalanced and disassortative patient flow. This type of organization has implications for hospital planning and infectious diseases control.

Bed management in psychiatry: ensuring that the patient perspective is not forgotten

Bed management and the transfer of patients is an area of clinical care that is frequently overlooked. Often, the lack of discussion leads to the patient perspective being ignored and to transfers to new hospitals without appropriate handovers, both to the detriment of patient outcomes. This article reflects on the real-world consequences of the bed management systems used within the UK's National Health Service (NHS), using the example of a patient in psychiatric services.

Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions

Importance

Although patients with emergency general surgery (EGS) conditions frequently undergo interhospital transfers, the transfer patterns and associated factors are not well understood.

Objective

To examine whether patients with EGS conditions are consistently directed to hospitals with more resources and better outcomes.

Design, Setting, and Participants

This cohort study performed a network analysis of interhospital transfers among adults with EGS conditions from January 1 to December 31, 2016. The analysis used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in 8 states. A total of 728 hospitals involving 85 415 transfers of 80 307 patients were included. Patients were eligible for inclusion if they were 18 years or older and had an acute care hospital encounter with a diagnosis of an EGS condition as defined by the American Association for the Surgery of Trauma. Data were analyzed from January 1, 2020, to June 17, 2021.

Exposures

Hospital-level measures of size (total bed capacity), resources (intensive care unit [ICU] bed capacity, teaching status, trauma center designation, and presence of trauma and/or surgical critical care fellowships), EGS volume (annual EGS encounters), and EGS outcomes (risk-adjusted failure to rescue and in-hospital mortality).

Main Outcomes and Measures

The main outcome was hospital-level centrality ratio, defined as the normalized number of incoming transfers divided by the number of outgoing transfers. A higher centrality ratio indicated more incoming transfers per outgoing transfer. Multivariable regression analysis was used to test the hypothesis that a higher hospital centrality ratio would be associated with more resources, higher volume, and better outcomes.

Results

Among 80 307 total patients, the median age was 63 years (interquartile range [IQR], 50-75 years); 52.1% of patients were male and 78.8% were White. The median number of outgoing and incoming transfers per hospital were 106 (IQR, 61-157) and 36 (IQR, 8-137), respectively. A higher log-transformed centrality ratio was associated with more resources, such as higher ICU capacity (eg, >25 beds vs 0-10 beds: β = 1.67 [95% CI, 1.16-2.17]; P < .001), and higher EGS volume (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.78 [95% CI, 0-1.57]; P = .01). However, a higher log-transformed centrality ratio was not associated with better outcomes, such as lower in-hospital mortality (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.30 [95% CI, -0.09 to 0.68]; P = .83) and lower failure to rescue (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = -0.50 [95% CI, -1.13 to 0.12]; P = .27).

Conclusions and Relevance

In this study, EGS transfers were directed to high-volume hospitals with more resources but were not necessarily directed to hospitals with better clinical outcomes. Optimizing transfer destination in the interhospital transfer network has the potential to improve EGS outcomes.

The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016-2018

BACKGROUND

Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea.

METHODS

This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016-2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups.

RESULTS

We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054).

CONCLUSION

The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the first-transfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.

Racial/Ethnic Disparities in Interhospital Transfer for Conditions With a Mortality Benefit to Transfer Among Patients With Medicare

IMPORTANCE

Interhospital transfer (IHT) of patients is a common occurrence in modern health care. Racial/ethnic disparities are prevalent throughout US health care, but their presence in IHT is not well characterized.

OBJECTIVE

To determine if there are racial/ethnic disparities in IHT for medical diagnoses for which IHT is associated with a mortality benefit.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis used 2013 data from the Center for Medicare & Medicaid Services 100% Master Beneficiary Summary and Inpatient Claims merged with 2013 American Hospital Association data. Individuals with Medicare aged 65 years or older continuously enrolled in Medicare Part A and B with an inpatient hospitalization claim in 2013 for primary diagnosis of acute myocardial infarction, stroke, sepsis, or respiratory diseases were included. Data analysis occurred from November 2019 through July 2020.

EXPOSURES

Race/ethnicity.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was IHT. For the primary analysis, a series of logistic regression models were created to estimate the adjusted odds of IHT for Black and Hispanic patients compared with White patients, controlling for patient clinical and demographic variables and incorporating hospital fixed effects. In secondary analyses, subgroup analyses were conducted by diagnosis, hospital teaching status, and hospitalization to hospitals in the top decile of Black and Hispanic patient proportion.

RESULTS

Among 899 557 patients, 734 958 patients were White (81.7%), 84 544 patients were Black (9.4%), and 47 588 patients were Hispanic (5.3%); there were 418 683 men (46.5%), and 306 215 patients (34.0%) were older than 84 years. The mean (SD) age was 76.8 (7.5) years. Among all patients, 20 171 White patients (2.7%), 1913 Black patients (2.3%), and 1062 Hispanic patients (2.2%) underwent IHT. After controlling for patient variables and hospital fixed effects, Black patients had a persistently lower odds of IHT (adjusted odds ratio, 0.87; 95% CI, 0.81-0.92; P < .001), while Hispanic patients had higher odds of IHT (adjusted odds ratio, 1.14; 95% CI, 1.05-1.24; P = .002) compared with White patients.

CONCLUSIONS AND RELEVANCE

This national evaluation of IHT among patients hospitalized with diagnoses previously found to have mortality benefit with transfer found that, compared with White patients, Black patients had persistently lower adjusted odds of transfer after accounting for patient and hospital characteristics and measured across various hospital settings. Meanwhile, Hispanic patients had higher adjusted odds of transfer. This research highlights the need for the development of strategies to mitigate disparate transfer practices by patient race/ethnicity.

More than a Database: Understanding Community Resource Referrals within a Socio-Technical Systems Framework

Addressing patients' social determinants of health via community resource referrals has historically been the primary domain of social workers and information and referral specialists; however, community resource referral platforms have recently entered the market. We lack an account of the process of community resource referrals and the role of technologies within it. Using sociotechnical systems theory, we analyze data from 12 focus groups (n=102) with healthcare providers, and community organization staff and volunteers in Metropolitan Detroit to describe the process of community resource referral. Findings reveal a deeply sociotechnical process including the following steps: assessing patients' social needs; choosing appropriate referral sources; and facilitating connections. We characterize the importance of knowledge and skills, personal relationships, interorganizational networks, and data sources such as service directories in the referral process. Findings suggest that digital platforms may augment referral functions, but should not be seen to replace interpersonal work, relationships, and interorganizational networks.

Optimizing Safety for Surgical Patients Undergoing Interhospital Transfer

Interhospital transfers play a key role in ensuring that patients receive necessary care. However, patients who are transferred between hospitals are a vulnerable population, and outcomes of transferred patients are suboptimal. Despite the critical nature of interhospital transfers, only limited effort has been dedicated to standardization and improvement of the transfer process. Studying and adapting quality improvement efforts directed at other transitions of care, particularly those that cross between different facilities and care teams "such as the transition from hospital to home or extended care facilities" may improve the care of surgical patients transferred between acute care institutions.

Identifying Racial/Ethnic Disparities in Interhospital Transfer: an Observational Study

BACKGROUND

Interhospital transfer (IHT) is often performed to provide patients with specialized care. Racial/ethnic disparities in IHT have been suggested but are not well-characterized.

OBJECTIVE

To evaluate the association between race/ethnicity and IHT.

DESIGN

Cross-sectional analysis of 2016 National Inpatient Sample data.

PATIENTS

Patients aged ≥ 18 years old with common medical diagnoses at transfer, including acute myocardial infarction, congestive heart failure, arrhythmia, stroke, sepsis, pneumonia, and gastrointestinal bleed.

MAIN MEASURES

We performed a series of logistic regression models to estimate adjusted odds of transfer by race/ethnicity controlling for patient demographics, clinical variables, and hospital characteristics and to identify potential mediators. In secondary analyses, we estimated adjusted odds of transfer among patients at community hospitals (those more likely to transfer patients) and performed subgroup analyses by region and primary medical diagnosis.

KEY RESULTS

Of 5,774,175 weighted hospital admissions, 199,015 (4.5%) underwent IHT, including 4.7% of White patients, compared with 3.9% of Black patients and 3.8% of Hispanic patients. Black (OR 0.83, 95% CI 0.78-0.89) and Hispanic (OR 0.81, 95% CI 0.75-0.87) patients had lower crude odds of transfer compared with White patients, but this became non-significant after adjusting for hospital-level characteristics. In secondary analyses among patients hospitalized at community hospitals, Hispanic patients had lower adjusted odds of transfer (aOR 0.89, 95% CI 0.79-0.98). Disparities in IHT by race/ethnicity varied by region and medical diagnosis.

CONCLUSIONS

Black and Hispanic patients had lower odds of IHT, largely explained by a higher likelihood of being hospitalized at urban teaching hospitals. Racial/ethnic disparities in transfer were demonstrated at community hospitals, in certain geographic regions and among patients with specific diseases.

Care Intensity During Transport to the Critical Care Resuscitation Unit: Transport Clinician's Role

OBJECTIVE

Patients are often transferred between hospitals for a higher level of care. Critically ill patients require high-intensity care after transfer, but their care intensity during transport is unknown. We studied transport clinicians' management for patients who had time-sensitive or critical illnesses and were transferred to a critical care resuscitation unit (CCRU) at a quaternary academic center.

METHODS

We prospectively surveyed transport clinicians who brought interhospital transport patients to the CCRU between March 1, 2019, and January 8, 2020. The primary outcome was care intensity during transport, which was defined as new interventions rendered by transport clinicians.

RESULTS

We analyzed 852 surveys. Seventy-four percent of transports occurred by ground, and 54% originated from emergency departments. Up to 19% of patients received 2 or more interventions, whereas 29% received at least 1 intervention during transport. Ventilator management occurred in 25% of cases. When adjusting for known confounders, respiratory failure or acute respiratory distress syndrome, air transport, and contacting the CCRU attending physicians en route were associated with a higher likelihood of an intervention during transport.

CONCLUSION

Transport clinicians provided new interventions in 48% of patients being transferred to the CCRU. Patients with respiratory failure or acute respiratory distress syndrome and those transported by helicopter emergency medical services were more likely to receive interventions en route.

Dealing with the Sick Rural Surgery Patient in Need of Transfer

Care for rural and urban surgical patients is increasingly more complex due to advancing knowledge and technology. Interhospital transfers occur in approximately 10% of index encounters at rural hospitals secondary to mismatch of patient needs and local resources. Due to the recent expansion of air transport to rural areas, distance and geography are less of a barrier. The interhospital transfer process is understudied and far from standardized. Interhospital transfer status is associated with increase in mortality, complications, length of stay, and costs. The cost, price to patients, and safety of air ambulance transports cannot be ignored.

The Impact of Interhospital Transfers on Surgical Quality Metrics for Academic Medical Centers

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.

Developing an Interfacility Transfer Handoff Intervention: Applying the Person-Based Approach Method

OBJECTIVE

To develop an interfacility transfer handoff intervention by applying the person-based approach method.

METHODS

We conducted a qualitative study that used nominal group technique (NGT) and focus groups to apply the person-based approach for intervention development. NGT methods were used to determine prioritized pediatric transfer handoff elements to design the initial intervention prototype. Five focus group sessions were then held to solicit feedback on the intervention, perceptions on implementing the intervention, and outcomes for evaluating the intervention. Data were analyzed by using content analysis. Iterative improvements were made to the intervention prototype as data emerged.

RESULTS

Forty-two clinical providers in total participated in NGT and focus group sessions, including physicians, advanced practitioners, nurses, and a respiratory therapist. The initial intervention prototype was a handoff mnemonic tool, "SHARING" (short introduction, how the patient appeared, action taken, responses and results, interpretation, next steps, gather documents). Perceived benefits of the intervention included clarifying handoff expectations, reducing handoff deficits, supporting less experienced clinical providers, and setting the stage for ongoing effective communication. Outcomes perceived to be meaningful were related to triage appropriateness, workflow and use, and communication and information sharing. The final version of the intervention consisted of a SHARING reference card and a SHARING electronic medical record note template.

CONCLUSIONS

Using qualitative methods to apply the person-based approach to intervention development, we developed a transfer handoff intervention. Future research is needed to examine impacts of this tool; outcomes can include those identified as meaningful by participants in our present study.

Impact of Patient-Level Characteristics on In-hospital Mortality After Interhospital Transfer to Medicine Services: an Observational Study

BACKGROUND

National administrative datasets have demonstrated increased risk-adjusted mortality among patients undergoing interhospital transfer (IHT) compared to patients admitted through the emergency department (ED).

OBJECTIVE

To investigate the impact of patient-level data not available in larger administrative datasets on the association between IHT status and in-hospital mortality.

DESIGN

Retrospective cohort study with logistic regression analyses to examine the association between IHT status and in-hospital mortality, controlling for covariates that were potential confounders. Model 1: IHT status, admit service. Model 2: model 1 and patient demographics. Model 3: model 2 and disease-specific conditions. Model 4: model 3 and vital signs and laboratory data.

PARTICIPANTS

Nine thousand three hundred twenty-eight adults admitted to Medicine services.

MAIN MEASURES

Interhospital transfer status, coded as an unordered categorical variable (IHT vs ED vs clinic), was the independent variable. The primary outcome was in-hospital mortality. Secondary outcomes included unadjusted length of stay and total cost.

KEY RESULTS

IHT patients accounted for 180 out of 484 (37%) in-hospital deaths, despite accounting for only 17% of total admissions. Unadjusted mean length of stay was 8.4 days vs 5.6 days (p < 0.0001) and mean total cost was $22,647 vs $12,968 (p < 0.0001) for patients admitted via IHT vs ED respectively. The odds ratios (OR) for in-hospital mortality for patients admitted via IHT compared to the ED were as follows: model 1 OR, 2.06 (95% CI 1.66-2.56, p < 0.0001); model 2 OR, 2.07 (95% CI 1.66-2.58, p < 0.0001); model 3 OR, 2.07 (95% CI 1.63-2.61, p < 0.0001); model 4 OR, 1.70 (95% CI 1.31-2.19, p < 0.0001). The AUCs of the models were as follows: model 1, 0.74; model 2, 0.76; model 3, 0.83; model 4, 0.88, consistent with a good prediction model.

CONCLUSIONS

Patient-level characteristics affect the association between IHT and in-hospital mortality. After adjusting for patient-level clinical characteristics, IHT status remains associated with in-hospital mortality.

Transitions of Care: The Presence of Written Interfacility Transfer Guidelines and Agreements for Pediatric Patients

OBJECTIVE

Every year, emergency medical services agencies transport approximately 150,000 pediatric patients between hospitals. During these transitions of care, patient safety may be affected and contribute to adverse events when important clinical information is missing, incomplete, or inaccurate. Written interfacility transfer policies are one way to standardize procedures and facilitate communication between the hospitals leading to improved patient safety and satisfaction for children and families.

METHODS

We assessed the presence and components of written interfacility transfer guidelines and agreements for pediatric patients via a survey sent to US hospital emergency department (ED) nurse managers during 2010 and 2013.

RESULTS

Although there was an increase in the presence of written interfacility transfer guidelines and agreements, a third of hospitals did not have either by 2013, and only 50% had guidelines with all recommended pediatric components. Hospitals with medium and low ED pediatric patient volumes were less likely to have written guidelines or agreements compared with hospitals with high volume. Hospitals with advanced pediatric resources, such as a pediatric emergency care coordinator or EDs designated approved for pediatrics, were more likely to have guidelines or agreements than less resourced hospitals.

CONCLUSIONS

Although there was improvement over time, opportunities exist for increasing the presence of written interfacility transfer guidelines as well as agreements for pediatric patients. Further studies are needed to demonstrate whether improved delivery of patient care is associated with the presence of written interfacility transfer guidelines and agreements and to identify other elements in the process to ensure optimal pediatric patient care.

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.

The Critical Care Resuscitation Unit Transfers More Patients From Emergency Departments Faster and Is Associated With Improved Outcomes

BACKGROUND

Transfer delays of critically ill patients from other hospitals' emergency departments (EDs) to an appropriate referral hospital's intensive care unit (ICU) are associated with poor outcomes.

OBJECTIVES

We hypothesized that an innovative Critical Care Resuscitation Unit (CCRU) would be associated with improved outcomes by reducing transfer times to a quaternary care center and times to interventions for ED patients with critical illnesses.

METHODS

This pre-post analysis compared 3 groups of patients: a CCRU group (patients transferred to the CCRU during its first year [July 2013 to June 2014]), a 2011-Control group (patients transferred to any ICU between July 2011 and June 2012), and a 2013-Control group (patients transferred to other ICUs between July 2013 and June 2014). The primary outcome was time from transfer request to ICU arrival. Secondary outcomes were the interval between ICU arrival to the operating room and in-hospital mortality.

RESULTS

We analyzed 1565 patients (644 in the CCRU, 574 in the 2011-Control, and 347 in 2013-Control groups). The median time from transfer request to ICU arrival for CCRU patients was 108 min (interquartile range [IQR] 74-166 min) compared with 158 min (IQR 111-252 min) for the 2011-Control and 185 min (IQR 122-283 min) for the 2013-Control groups (p < 0.01). The median arrival-to-urgent operation for the CCRU group was 220 min (IQR 120-429 min) versus 439 min (IQR 290-645 min) and 356 min (IQR 268-575 min; p < 0.026) for the 2011-Control and 2013-Control groups, respectively. After adjustment with clinical factors, transfer to the CCRU was associated with lower mortality (odds ratio 0.64 [95% confidence interval 0.44-0.93], p = 0.019) in multivariable logistic regression.

CONCLUSION

The CCRU, which decreased time from outside ED's transfer request to referral ICU arrival, was associated with lower mortality likelihood. Resuscitation units analogous to the CCRU, which transfer resource-intensive patients from EDs faster, may improve patient outcomes.

Inter-hospital transfer and patient outcomes: a retrospective cohort study

BACKGROUND

Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied.

OBJECTIVE

To evaluate the association between IHT and healthcare utilisation and clinical outcomes.

DESIGN

Retrospective cohort.

SETTING

CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data.

PARTICIPANTS

Beneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories.

MAIN OUTCOME MEASURES

Cost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients.

RESULTS

The final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease).

CONCLUSIONS

In this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients' disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.

Interhospital Transfer: Transfer Processes and Patient Outcomes

Though often undertaken to provide patients with specialized care, interhospital transfer (IHT) is associated with worse outcomes for select patients. Certain aspects of the transfer process have been suggested as contributors to these outcomes. We performed a retrospective cohort study including patients ≥ 18 years who underwent IHT to a tertiary care hospital between January 2005 and September 2013. We examined the association between "weekend" transfer, "nighttime" transfer, "time delay" between transfer acceptance and arrival, and admission team "busyness" on the day of transfer, and patient outcomes, including transfer to the intensive care unit (ICU) within 48 hours and 30-day mortality. We utilized multivariable logistic regression models, adjusting for patient characteristics. Secondary analyses examined detailed timing of transfer and evaluated 30-day mortality stratified by service of transfer. Among the 24,352 patients who underwent IHT, the nighttime transfer was associated with increased adjusted odds of ICU transfer (odds ratio [OR] 1.54; 95% CI 1.38, 1.72) and 30-day mortality (OR 1.16; 95% CI 1.01, 1.35). Secondary analyses confirmed the association between nighttime transfer and ICU transfer throughout the week and demonstrated that Sunday (and trend towards Friday) night transfers had increased 30-day mortality, as compared with Monday daytime transfer. Stratified analyses demonstrated a significant association between transfer characteristics and adjusted odds of 30-day mortality among cardiothoracic and gastrointestinal surgical service transfers. Our findings suggest high acuity patients have worse outcomes during off-peak times of transfer and during times of high care team workload. Further study is needed to identify underlying reasons to explain these associations and devise potential solutions.

The Impact of an Acute Care Surgical Service on the Quality and Efficiency of Care Outcome Indicators for Patients with General Surgical Emergencies

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.

A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage

GOAL

Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers' perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage.

MATERIALS AND METHODS

We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method.

FINDINGS

The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers' questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions.

CONCLUSIONS

The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians' voices.

Physician Perspectives on Interhospital Transfers

OBJECTIVE

The transfer of patients between acute care hospitals (interhospital transfer [IHT]) is a common but nonstandardized process leading to variable quality and safety. The goal of this study was to survey accepting physicians regarding problems encountered in the transfer process.

METHODS

A cross-sectional survey of residents and inpatient attendings from internal medicine, neurology, and surgery services at a large tertiary care referral hospital was undertaken to identify problematic aspects of the IHT process as perceived by accepting frontline providers. The frequency that specific scenarios were encountered in caring for transferred patients and whether these processes impacted patient safety were determined using 5- and 3-point Likert scales, respectively. The frequency of responses to each question were measured using proportions.

RESULTS

Approximately 51% of the 284 physicians surveyed responded. Pertinent findings included the following: physician subject surveys found that transferred patients sometimes, frequently, or always arrived without requiring specialized care in 56% of responses, arrived with unrealistic expectations of care in 77.2% of responses, arrived more than 24 hours after accepted for transfer in 80.1% of responses, and arrived without necessary transfer records in 86.9% of responses. Most respondents felt that lack of availability of transfer records and the time of day of arrival frequently posed a risk to transferred patients (57.2% and 53.1%, respectively). Response variation was noted between resident and attending physician respondents.

CONCLUSIONS

Expectations of care, delays and timing of transfer, and information exchange at time of transfer were identified as all too common problems in IHT, which creates a risk for patient safety. These areas are important targets for investigation and the development of interventions to improve patient safety.

Factors associated with the inter-facility transfer of inpatients in Sichuan province, China

BACKGROUND

The overuse of tertiary hospitals and underuse of primary care facilities has been one of the key reasons leading to fast health expenditure increase and health service utilization inequity in China. Recent health care reform in China tries to enforce a patient transfer system to make the health services utilization more efficient. This study examined the pattern and associated factors of inter-facility transfer of inpatients in Sichuan province of Western China.

METHODS

Patient discharge records (n = 1,490,695) from 604 general hospitals during the period of April to June 2015 in Sichuan were extracted from the front page of the medical records system with individual information on demographics, insurance coverage, diagnoses, hospitals admitted and discharge type. We calculated the percentage of inpatients transferring to other health facilities, the Inter-Facility Transfer Rate (IFTR) with adjustment for Charlson Comorbidity Index (CCI). Multi-level logistic regression models were established to identify factors associated with IFTRs.

RESULTS

A small number of tertiary hospitals (n = 75, 12.41%) shared 51.71% (n = 770,823) of all admitted cases while a large number of primary/unrated hospitals (n = 321, 53.15%) shared only 8.15%. The overall CCI-adjusted IFTR was 2.08% with 3.73% among secondary hospitals, 1.87% among tertiary hospitals and 1.30% among primary/unrated hospitals. Uninsured patients (OR = 1.13) and those with a lower level of insurance entitlements (OR = 1.12 for the New Rural Cooperative Medical Scheme and the Basic Medical Insurance for Urban Residents) were more likely to experience inter-facility transfer than those with a higher level of insurance entitlements (the Basic Medical Insurance for Urban Employees).

CONCLUSION

The level of IFTR in general hospitals in Sichuan is low, which is associated with the level of hospitals and insurance entitlements. Further studies are needed to better understand how patients and health care providers respond to different insurance policies and make decisions on inter-facility transfer.

Hospitals Strengthened Relationships With Close Partners After Joining Accountable Care Organizations

The strategies that hospitals participating in Medicare Accountable Care Organizations (ACOs) use to achieve quality and cost containment goals are poorly understood. One possibility is that participating hospitals could try to influence where their patients receive care. To test this hypothesis, we examined whether a hospital's participation in a Medicare ACO was associated with changes in its patterns of patient sharing with other hospitals. Between 2010 and 2014, patient sharing across hospitals increased 23.3%. After controlling for hospital and regional factors, patient sharing increased 4.4% more at ACO hospitals than non-ACO hospitals (p = .001 for difference). This increase occurred disproportionately among hospitals with which ACO hospitals already shared a high proportion of their patients prior to participation, and among hospitals in ACOs characterized as physician-hospital collaborations. The increased sharing of patients among closely affiliated hospitals may serve to achieve ACO quality and cost containment goals through increased interorganizational coordination.

Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis

IMPORTANCE

Hospital care for children is becoming more concentrated, with interhospital transfer occurring more frequently even for common conditions. Condition-specific analysis is required to determine the value, costs, and consequences of this trend.

OBJECTIVES

To describe the capabilities of transferring and receiving hospitals and to determine how often children transferred after an initial diagnosis of abdominal pain or appendicitis require higher levels of care.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort analysis using the 2 most recent available inpatient and emergency department administrative data sets from all acute care hospitals in California from 2010 to 2011 and Florida, Massachusetts, and New York from 2013 to 2014. Data were analyzed between February and June 2018. All patients younger than 18 years with a primary diagnosis of abdominal pain or appendicitis who underwent an interhospital transfer and whose care could be matched through unique identifiers were included.

MAIN OUTCOMES AND MEASURES

Outcomes after hospital transfers, classified into encounters with major surgical procedures, imaging diagnostics, and no major procedures. Pediatric Hospital Capability Index of transferring and receiving hospitals.

RESULTS

There were 465 143 pediatric hospital encounters for abdominal pain and appendicitis, including 53 517 inpatient admissions and 15 275 transfers. Among them, 4469 could be matched to encounters in receiving hospitals. The median (interquartile range) age of this cohort was 10 (7-14) years, with 54.8% female (2449 patients), 40.9% male (1830 patients), and 4.3% unreported sex (190 patients). The increase in capability at the receiving hospital compared with the transferring hospital was large (median [interquartile range] change in Pediatric Hospital Capability Index score, 0.70 [0.54-0.82]), with 9.2% of hospitals (57) with very high capability (Pediatric Hospital Capability Index score >0.77) receiving 80.8% of the total transfers (3610). Diagnostic imaging was undertaken in the care of 710 transferred patients (15.9%) and invasive procedures were performed in 2421 patients (54.2%), including 2153 appendectomies. No imaging or surgery was required in the care of 1338 transfers (29.9%).

CONCLUSIONS AND RELEVANCE

In this study, interfacility transfers of patients with appendicitis and abdominal pain were concentrated toward high-capability hospitals, and about 30% of patients were released without apparent intervention. These findings suggest an opportunity for improving care and decreasing cost through better interfacility coordination, such as standardized management protocols and telemedicine with high-capability hospitals. Further research is needed to identify similar opportunities among other common conditions.

Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies

Critically ill patients may be exposed to unique safety threats as a result of the complexity of interhospital and intrahospital transitions involving the emergency department (ED). Real-time surveys were administered to clinicians in the ED and neuroscience intensive care unit of a tertiary health care system to assess perceptions of handoff safety and quality in transitions involving critically ill neurologic patients. In all, 115 clinical surveys were conducted among 26 patient transfers. Among all clinician types, 1 in 5 respondents felt the handoff process was inadequate. Risks to patient safety during the transfer process were reported by 1 in 3 of respondents. Perceived risks were reported more frequently by nurses (44%) than physicians/advanced practice providers (28%). Real-time survey methodology appears to be a feasible and valuable, albeit resource intensive, tool to identify safety risks, expose barriers to communication, and reveal challenges not captured by traditional approaches to inform multidisciplinary quality improvement efforts.

Interhospital Transfer and Receipt of Specialty Procedures

The practice of transferring patients between acute care hospitals is variable and largely nonstandardized. Although often-cited reasons for transfer include providing patients access to specialty services only available at the receiving institution, little is known about whether and when patients receive such specialty care during the transfer continuum. We performed a retrospective analysis using 2013 100% Master Beneficiary Summary and Inpatient claims files from Centers for Medicare and Medicaid Services. Beneficiaries were included if they were aged =65 years, continuously enrolled in Medicare A and B, with an acute care hospitalization claim, and transferred to another acute care hospital with a primary diagnosis of acute myocardial infarction, gastrointestinal bleed, renal failure, or hip fracture/dislocation. Associated specialty procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification) were identified for each diagnosis. We performed descriptive analyses to compare receipt of specialty procedural services between transferring and receiving hospitals, stratified by diagnosis. Across the 19,613 included beneficiaries, receipt of associated specialty procedures was more common at the receiving than the transferring hospital, with the exception of patients with a diagnosis of gastrointestinal bleed. Depending on primary diagnosis, between 32.4% and 89.1% of patients did not receive any associated specialty procedure at the receiving hospital. Our results demonstrate variable receipt of specialty procedural care across the transfer continuum, implying the likelihood of alternate drivers of interhospital transfer other than solely receipt of specialty procedural care.