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McKissic D, Riley T, Billimoria Z, Mastroianni R, Kotler A, Bhatti A, Feltner J, Baker C, Umoren RA, Gray MM. A Description of Medications and Intravenous Fluids Used During Neonatal Transport by a Regional Pediatric Critical Care Team. Air Med J 2024; 43:236-240. [PMID: 38821705 DOI: 10.1016/j.amj.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 12/13/2023] [Accepted: 12/26/2023] [Indexed: 06/02/2024]
Abstract
OBJECTIVE This study aimed to describe the type and frequency of enteral and parenteral fluids and medications used during the transport of neonates by a regional pediatric critical care transport team. METHODS We performed a retrospective analysis of neonates transported by a regional neonatal transport team affiliated with a level IV neonatal intensive care unit within a large care network between 2020 and 2021. Demographic and clinical data were collected from the electronic medical record. Standard frequency tabulation and summary statistics were used to report demographics, transport characteristics, and fluid and medication use; results were then stratified by preterm (37 weeks) and term births. RESULTS In the 628 included transports, more term than preterm infants received at least 1 fluid or medication (53% vs. 43%, respectively). The most commonly administered medications were antibiotics (ampicillin and gentamicin), prostaglandin, and opiates (morphine sulfate and fentanyl). In addition, term infants received more analgesic medications, antimicrobials, and prostaglandin, whereas preterm infants received total parenteral nutrition more often. There were over 38 different medications provided on the transports studied. CONCLUSION This study of a single transport team revealed that a wide variety of medications and fluids were used in the transport of neonates, with term infants receiving more medications than preterm infants. These data could be used by transport teams in making or updating their standardized medication lists or in creating simulations.
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Affiliation(s)
- Devin McKissic
- Division of Neonatology, University of Washington School of Medicine, Seattle, WA.
| | - Taylor Riley
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Zeenia Billimoria
- Division of Neonatology, University of Washington School of Medicine, Seattle, WA
| | - Rossella Mastroianni
- Division of Neonatology, University of Washington School of Medicine, Seattle, WA
| | | | | | - John Feltner
- Division of Neonatology, University of Washington School of Medicine, Seattle, WA
| | - Chris Baker
- Critical Care Transport Service, Seattle Children's Hospital, Seattle, WA
| | - Rachel A Umoren
- Division of Neonatology, University of Washington School of Medicine, Seattle, WA
| | - Megan M Gray
- Division of Neonatology, University of Washington School of Medicine, Seattle, WA
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Willis N, Gagnon K, Wong K, McGowan M, Nolan B. Use of Fixed Wing Modified Scene Air Ambulance Responses for Injured Patients in Northern Ontario: A Pilot Study. Air Med J 2024; 43:177-182. [PMID: 38490785 DOI: 10.1016/j.amj.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Timely access to a lead trauma hospital (LTH) saves lives; however, the vast geography of Northern Ontario creates a barrier to equitable access to an LTH. Paramedics in Ontario follow the field trauma triage standard (FTTS) to identify which patients should be directly brought to an LTH. A pilot project was launched using a fixed wing modified scene response (MSR) to transport patients from Northern Ontario who met the FTTS directly to an LTH. This study aimed to 1) explore the impact of the fixed wing MSR pilot program on the time to LTH arrival for injured patients in Northern Ontario compared with the traditional interfacility transfer (IFT) process and 2) determine the frequency and specific FTTS criteria that were fulfilled. METHODS This was a retrospective cohort study of injured patients in Northern Ontario who were emergently transported to an LTH by the provincial air ambulance service between January 2016 and October 2021. Electronic patient care records were manually reviewed, and patient cases were grouped by their sending and receiving facilities to evaluate time differences between MSR and IFT. RESULTS For same-distance transports, the average time from injury to trauma center arrival was reduced with MSR (292.8 minutes) compared with IFT (507.8 minutes), with a mean difference of 130.3 minutes. All MSR cases and 90% of IFT cases met at least 1 FTTS criterion. CONCLUSION Fixed wing MSR improves access to timely definitive care for injured patients in Northern Ontario, and all patients transported in this pilot project met the trauma bypass criteria.
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Affiliation(s)
- Nicole Willis
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | | | - Kealin Wong
- Department of Emergency Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Melissa McGowan
- Department of Emergency Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Brodie Nolan
- Ornge, Mississauga, Ontario, Canada; Department of Emergency Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Oami T, Abe T, Nakada TA, Imaeda T, Aizimu T, Takahashi N, Yamao Y, Nakagawa S, Ogura H, Shime N, Umemura Y, Matsushima A, Fushimi K. Association between hospital spending and in-hospital mortality of patients with sepsis based on a Japanese nationwide medical claims database study. Heliyon 2024; 10:e23480. [PMID: 38170111 PMCID: PMC10758802 DOI: 10.1016/j.heliyon.2023.e23480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
Background The effect of hospital spending on the mortality rate of patients with sepsis has not yet been fully elucidated. We hypothesized that hospitals that consume more medical resources would have lower mortality rates among patients with sepsis. Methods This retrospective study used administrative data from 2010 to 2017. The enrolled hospitals were divided into quartiles based on average daily medical cost per sepsis case. The primary and secondary outcomes were the average in-hospital mortality rate of patients with sepsis and the effective cost per survivor among the enrolled hospitals, respectively. A multiple regression model was used to determine the significance of the differences among hospital categories to adjust for baseline imbalances. Results Among 997 hospitals enrolled in this study, the crude in-hospital mortality rates were 15.7% and 13.2% in the lowest and highest quartiles of hospital spending, respectively. After adjusting for confounding factors, the highest hospital spending group demonstrated a significantly lower in-hospital mortality rate than the lowest hospital spending group (coefficient = -0.025, 95% confidence interval [CI] -0.034 to -0.015; p < 0.0001). Similarly, the highest hospital spending group was associated with a significantly higher effective cost per survivor than the lowest hospital spending group (coefficient = 77.7, 95% CI 73.1 to 82.3; p < 0.0001). In subgroup analyses, hospitals with a small or medium number of beds demonstrated a consistent pattern with the primary test, whereas those with a large number of beds or academic affiliations displayed no association. Conclusions Using a nationwide Japanese medical claims database, this study indicated that hospitals with greater expenditures were associated with a superior survival rate and a higher effective cost per survivor in patients with sepsis than those with lower expenditures. In contrast, no correlations between hospital spending and mortality were observed in hospitals with a large number of beds or academic affiliations.
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Affiliation(s)
- Takehiko Oami
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Toshikazu Abe
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taro Imaeda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tuerxun Aizimu
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasuo Yamao
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Nakagawa
- Department of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Asako Matsushima
- Department of Emergency and Critical Care, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Tokyo, Japan
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Safavi KC, Koehler A, Mathews N, McKenzie R, Stone C, Masson PR, Hu M, Dunn PF. Impact of a Repatriation Program Between Quaternary and Community Hospitals. Jt Comm J Qual Patient Saf 2023; 49:592-598. [PMID: 37612179 DOI: 10.1016/j.jcjq.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Capacity challenges at quaternary hospitals cause delays or denials in patient transfers from community hospitals that can compromise quality and safety. Repatriation is an innovative approach to increase capacity at the quaternary hospital by transferring a patient back to their originating community hospital after the quaternary portion of their care is completed. METHODS A repatriation program was implemented at a large quaternary care teaching hospital over a one-year period (2020 to 2021). The authors characterized the rate of successful repatriation and associated patient characteristics, determined the impact on quaternary hospital capacity in terms of bed days saved, and estimated the resultant number of backfilled admissions that could be accommodated. The research team also monitored the rate of readmissions for repatriations back to the quaternary hospital. RESULTS Overall, 215 repatriations were attempted, and 103 (47.5%) were successful. The most common diagnoses were sepsis (13, 12.6%), stroke (12, 11.7%), intracranial bleed (10, 9.7%), gastrointestinal perforation/obstruction (9, 8.7%), and trauma (9, 8.7%). The median length of stay at the quaternary hospital was 13 days (interquartile range [IQR] 7-20) and 12 days (IQR 4-26) at the community hospital. There were 2,842 bed days saved at the quaternary hospital, with a backfill opportunity of 431 admissions. The readmission rate to the quaternary hospital was 1.9%. CONCLUSION By dynamically matching patient need with hospital capability at different phases of the patient's care, Repatriation can save bed days at the quaternary hospital, creating capacity to improve access for patients needing timely transfer. The low observed readmission rate suggests that repatriation is safe.
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Greene A, Dion PM, Nolan B, Trachter R, Vu E, Trojanowski J. Overcoming distance: an exploration of current practices of government and charity-funded critical care transport and retrieval organizations. Scand J Trauma Resusc Emerg Med 2023; 31:52. [PMID: 37789319 PMCID: PMC10548638 DOI: 10.1186/s13049-023-01125-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/26/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND For critically ill and injured patients, timely access to definitive care is associated with a reduction in avoidable mortality. Access to definitive care is significantly affected by geographic remoteness. To overcome this disparity, a robust critical care transport (CCT) or retrieval system is essential to support the equity of care and overcome the tyranny of distance. While critical care transport or retrieval systems have evolved over the years, there is no universally accepted system or standard, which has led to considerable variation in practices. The objective of this mixed-methods study was to identify and explore the current clinical, operational, and educational practices of government and charity-funded critical care transport and retrieval organizations operating across access- and weather- challenged geography. METHODS This study utilized a mixed-methods approach comprising a rapid review of the literature and semi-structured interviews with identified subject matter experts (SME). RESULTS A total of 44 articles and 14 interviews with SMEs from six different countries, 12 different services/systems, and seven operational roles, including clinicians (physician, paramedic, and nurse), educator, quality improvement, clinical governance, clinical informatics and research, operations manager, and medical director were included in the narrative analysis. The study identified several themes including deployment, crew composition, selection and education, clinical governance, quality assurance and quality improvement and research. CONCLUSION This mixed-methods study underscores the paucity of literature describing current clinical, operational, and educational practices of government or charity-funded CCT or retrieval programs operating across access- and weather- challenged geography. While many common themes were identified including clearly defined mission profiles, use of dedicated or specialized transport teams, central coordination, rigorous selection processes, service-sponsored graduate education, and strong clinical governance, there is little consensus and considerable variation in current practices. Further research is needed to identify and harmonize best practices within the CCT and retrieval environments.
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Affiliation(s)
- Adam Greene
- British Columbia Emergency Health Services, Provincial Health Services Authority, Victoria, BC, Canada.
- School of Medicine, Cardiff University, Cardiff, Wales, UK.
| | - Pierre-Marc Dion
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brodie Nolan
- Department of Emergency Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rob Trachter
- Department of Emergency Medicine, Nanaimo Regional General Hospital, Nanaimo, BC, Canada
| | - Erik Vu
- British Columbia Emergency Health Services, Provincial Health Services Authority, Victoria, BC, Canada
- Division of Emergency Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jan Trojanowski
- British Columbia Emergency Health Services, Provincial Health Services Authority, Victoria, BC, Canada
- Division of Critical Care Medicine, Department of Medicine, Kelowna General Hospital, University of British Columbia, Kelowna, BC, Canada
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Brown L, França UL, McManus ML. Neighborhood Poverty and Distance to Pediatric Hospital Care. Acad Pediatr 2023; 23:1276-1281. [PMID: 36754164 DOI: 10.1016/j.acap.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To describe the relationship between neighborhood poverty and geographic access to pediatric inpatient care. METHODS This is a retrospective, cross-sectional study using 2017-18 hospital and demographic data, as well as geographic data from the 2010 census. Acute care hospitals in 17 states were included, comprising approximately one-third of the national population. The main outcome was distance to capable pediatric hospital care by neighborhood Area Deprivation Index (ADI), both overall and by urbanicity. RESULTS Median distance to pediatric hospital care increased linearly with poverty across ADI national deciles (Pearson coefficient of 0.986; P < .001). The most advantaged neighborhoods were a median of 2.5 miles from the nearest pediatric capable hospital (interquartile range [IQR] 1.2-5.6) while those in the most disadvantaged were a median of 13.8 miles away (IQR 3.3-35.9; P < .001). The nearest hospital admitted children in 51.17% (7927) of advantaged neighborhoods (lowest national ADI quintile) and only 26.02% (3729) of disadvantaged neighborhoods (highest national ADI quintile). The association between poverty and median distance to care was observed in rural, suburban, and urban census block groups (P < .001 for all trends). In suburban neighborhoods, children from the most disadvantaged neighborhoods were 3 times as likely as children from the most advantaged neighborhoods to live more than 20 miles from pediatric inpatient care (27.85%, 456,533 of children from bottom quintile neighborhoods vs 9.24%, 259,787 of children from top quintile neighborhoods, P < .001). CONCLUSIONS Distances to capable pediatric hospital care are greater from poor than affluent neighborhoods. This carries potential implications for disparities in pediatric health outcomes.
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Affiliation(s)
- Lauren Brown
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (L Brown, UL França, and ML McManus), Boston, Mass; Harvard Medical School (L Brown, UL França, and ML McManus), Boston, Mass; Department of Anesthesiology, Mass General Brigham, Brigham and Women's Hospital (L Brown), Boston, Mass.
| | - Urbano L França
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (L Brown, UL França, and ML McManus), Boston, Mass; Harvard Medical School (L Brown, UL França, and ML McManus), Boston, Mass
| | - Michael L McManus
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (L Brown, UL França, and ML McManus), Boston, Mass; Harvard Medical School (L Brown, UL França, and ML McManus), Boston, Mass
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McDaniel CE, Leyenaar JK, Bryan MA, Test M, Sullivan E. Urban-rural disparities in interfacility transfers for children during COVID-19. J Rural Health 2023; 39:611-616. [PMID: 36710077 PMCID: PMC11132630 DOI: 10.1111/jrh.12746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE We aimed to identify temporal trends and differences in urban and rural pediatric interfacility transfers (IFTs) before and during the COVID-19 pandemic. METHODS We conducted a cross-sectional analysis of IFT among children <18 years from January 2019 to June 2022 using the Pediatric Health Information System. The primary outcome was IFTs from general hospitals to referral children's hospitals. The primary exposure was patient rurality, defined by Rural-Urban Commuting Area codes. We categorized IFTs into medical, surgical, and mental health diagnoses and analyzed trends by month. We calculated observed-to-expected (O-E) ratios of pre-pandemic (March 2019-Feb 2020) transfers compared to pandemic year 1 (March 2020-Feb 2021) and year 2 (March 2021-February 2022) using Poisson modeling. FINDINGS Of 419,250 IFTs, 18.8% (n = 78,751) were experienced by rural-residing children. The O-E ratio of IFT in year 1 for urban children was 14.0% (95% confidence interval [CI] 13.8, 14.2) and 14.8% (95% CI 14.4, 15.3) for rural children compared to pre-pandemic (P = .0001). In year 2, transfers rebounded with IFTs for rural-residing children increasing more than urban-residing children (101.7% [95% CI 100.1, 103.4] compared to 90.7% [95% CI 89.0, 90.4], P < .0001). For mental-health indications in year 2, rural transfer ratios were higher than urban, 126.8% (95% CI, 116.7, 137.6) compared to 113.7% (95% CI 109.9, 117.6), P = .0168. CONCLUSIONS Pediatric IFTs decreased dramatically during pandemic year 1. In year 2, while medical and surgical transfers continued to lag pre-pandemic volumes, transfers for mental health indications significantly exceeded pre-pandemic levels, particularly among rural-residing children.
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Affiliation(s)
- Corrie E. McDaniel
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - JoAnna K. Leyenaar
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Mersine A. Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Matthew Test
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Erin Sullivan
- Seattle Children’s Research Institute, Seattle, Washington, USA
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Tu KJ, Wymore C, Tchangalova N, Fuller BM, Mohr NM. The impact of telehealth in sepsis care: A systematic review. J Telemed Telecare 2023:1357633X231170038. [PMID: 37093782 PMCID: PMC11187410 DOI: 10.1177/1357633x231170038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Sepsis is associated with significant mortality. Telehealth may improve the quality of early sepsis care, but the use and impact of telehealth applications for sepsis remain unclear. We aim to describe the telehealth interventions that have been used to facilitate sepsis care, and to summarize the reported effect of telehealth on sepsis outcomes. DATA SOURCES We identified articles reporting telehealth use for sepsis using an English-language search of PubMed, CINAHL Plus (EBSCO), Academic Search Ultimate (EBSCO), APA PsycINFO (EBSCO), Public Health (ProQuest), and Web of Science databases with no restrictions on publication date. STUDY SELECTION Included studies described the use of telehealth as an intervention for treating sepsis. Only comparative effectiveness analyses were included. DATA EXTRACTION AND SYNTHESIS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines, two investigators independently selected articles for inclusion and abstracted data. A random-effects subgroup analysis was conducted on patient survival treated with and without telehealth. RESULTS A total of 15 studies were included, involving 188,418 patients with sepsis. Thirteen studies used observational study designs, and the most common telehealth applications were provider-to-provider telehealth consultation and intensive care unit telehealth. Clinical and methodological heterogeneity was significantly high. Telehealth use was associated with higher survival, especially in settings with low control group survival. The effect of telehealth on other care processes and outcomes were more varied and likely dependent on hospital-level factors. CONCLUSIONS Telehealth has been used in diverse applications for sepsis care, and it may improve patient outcomes in certain contexts. Additional interventional trials and cost-based analyses would clarify the causal role of telehealth in improving sepsis outcomes.
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Affiliation(s)
- Kevin J. Tu
- Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, Maryland
| | - Cole Wymore
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Nedelina Tchangalova
- Research and Academic Services, University of Maryland Libraries, College Park, Maryland
| | - Brian M. Fuller
- Division of Critical Care, Department of Anesthesiology, Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia Critical Care, and Epidemiology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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Cini C, Neto AS, Burrell A, Udy A. Inter-hospital transfer and clinical outcomes for people with COVID-19 admitted to intensive care units in Australia: an observational cohort study. Med J Aust 2023. [PMID: 37037671 DOI: 10.5694/mja2.51917] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVES To examine the association between inter-hospital transfer and in-hospital mortality among people with coronavirus disease 2019 (COVID-19) admitted to intensive care units (ICUs) in Australia. DESIGN Retrospective cohort study; analysis of data collected for the Short Period Incidence Study of Severe Acute Respiratory Illness (SPRINT-SARI) Australia study. SETTING, PARTICIPANTS People with COVID-19 admitted to 63 ICUs, 1 January 2020 - 1 April 2022. MAIN OUTCOME MEASURES Primary outcome: in-hospital mortality; secondary outcomes: ICU and hospital lengths of stay and frequency of selected complications. RESULTS Of 5207 people with records in the SPRINT-SARI Australia database at 1 April 2022, 328 (6.3%) had been transferred between hospitals, 305 (93%) during the third pandemic wave. Compared with patients not transferred, their median age was lower (53 years; interquartile range [IQR], 45-61 years v 60 years; IQR, 46-70 years), their median body mass index higher (32.5 [IQR, 27.2-39.0] kg/m2 v 30.1 [IQR, 25.7-35.7] kg/m2 ), and fewer had received a COVID-19 vaccine (22% v 44.9%); their median APACHE II scores were similar (14.0; IQR, 12.0-18.0 v 14.0; IQR, 10.0-19.0). Bacterial pneumonia (64.7% v 29.0%) and bacteraemia (27% v 8%) were more frequent in transferred patients, as was the need for more intensive ICU interventions, including invasive mechanical ventilation (71.2% v 38.1%) and extra-corporeal membrane oxygenation (26% v 1.7%). Crude ICU (19% v 14.9%) and in-hospital mortality (19% v 18.4%) were similar for patients who were or were not transferred; median lengths of ICU (20.0 [IQR, 11.2-40.3] days v 4.6 [IQR, 2.1-10.1] days) and hospital stay (29.7 [IQR, 18.1-49.6] days v 12.3 [IQR, 7.3-21.0] days) were longer for transferred patients. In the multivariable regression analysis, in-hospital mortality risk was lower for transferred patients (risk difference [RD], -5.0 percentage points; 95% confidence interval [CI] -10 to -0.03 percentage points), but not in the propensity score-adjusted analysis (RD, -3.4 [95% CI, -8.9 to 2.1] percentage points). CONCLUSIONS Among people with COVID-19 admitted to ICUs, patients transferred from another hospital required more intense interventions and remained in hospital longer, but were not at greater risk of dying in hospital than the patients who were not transferred.
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Affiliation(s)
| | - Ary S Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
- Austin Hospital, Melbourne, VIC
| | - Aidan Burrell
- Alfred Health, Melbourne, VIC
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
| | - Andrew Udy
- Alfred Health, Melbourne, VIC
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
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Larsen K, Nolan B, Gomez D. A system in crisis: exploring how recent emergency department closures influence potential access to emergency care in Ontario. CAN J EMERG MED 2023; 25:218-223. [PMID: 36719622 PMCID: PMC9888742 DOI: 10.1007/s43678-023-00460-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/13/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Access to emergency medical care in Ontario has been under stress, mainly due to a lack of human resources (staffing of nurses and doctors). Over the past year, several emergency departments in Ontario have closed. Some of these closures are nightly, while others have closed for weeks at a time, leaving Ontario residents without access to emergency medical care which can lead to poor or more severe outcomes. The purpose of this paper was to examine how closures of ED's in Ontario have influenced potential access to emergency medical care. METHODS We performed population-level geographic information systems (GIS)-based analysis of potential access to ED hospitals in Ontario. The number of people with access to an ED was calculated when all ED's in Ontario were open, then recalculated with the 14 ED closures. Access was defined by ground travel with 30 min, 45 min, and 60 min travel times used for analysis. Differences in the number of people at the census block level who potentially lost access were compiled and examined by census subdivision. RESULTS If all 14 ED's had closed at the same time, there would be 35,808 people at 30 min, 15,018 at 45 min, and 12,131 at 60 min travel times in Ontario who lost access to ED care. Certain areas of the province saw more significant decreases in ED access. At 45 min travel times, nearly 2000 people in Central Frontenac lost access (44% of population), while 7298 people in Cochrane (North Part) lost access (20% of population). CONCLUSIONS ED closures have led to decreases in potential access to emergency care for predominantly rural populations. Health human resource recovery strategies must focus on areas where lack of overlap exists.
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Affiliation(s)
- Kristian Larsen
- School of Population and Public Health, CAREX Canada, University of British Columbia, Vancouver, BC Canada
- Department of Geography and Planning, University of Toronto, Toronto, ON Canada
- Department of Geography and Environmental Studies, Toronto Metropolitan University, Toronto, ON Canada
| | - Brodie Nolan
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
- Department of Emergency Medicine, St. Michael’s Hospital, Toronto, ON Canada
| | - David Gomez
- Department of Surgery, University of Toronto, Toronto, ON Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON Canada
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Mohr NM, Okoro U, Harland KK, Fuller BM, Campbell K, Swanson MB, Wymore C, Faine B, Zepeski A, Parker EA, Mack L, Bell A, DeJong K, Mueller K, Chrischilles E, Carpenter CR, Wallace K, Jones MP, Ward MM. Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study. Ann Emerg Med 2023; 81:1-13. [PMID: 36253295 PMCID: PMC9780149 DOI: 10.1016/j.annemergmed.2022.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/07/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVE To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs). METHODS Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence. RESULTS A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86). CONCLUSION Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA.
| | - Uche Okoro
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Brian M Fuller
- Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO; Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
| | - Kalyn Campbell
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Surgery, Hennepin County Medical Center, Minneapolis, MN
| | - Morgan B Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Cole Wymore
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Brett Faine
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Pharmaceutical Practice, College of Pharmacy, University of Iowa, Iowa City, IA
| | - Anne Zepeski
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Edith A Parker
- Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City, IA
| | - Luke Mack
- Avel eCare, Sioux Falls, SD; Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD
| | | | | | - Keith Mueller
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
| | | | | | - Kelli Wallace
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Michael P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
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12
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Lee H, Lee S, Kim H. Factors affecting the length of stay in the emergency department for critically Ill patients transferred to regional emergency medical center. Nurs Open 2022; 10:3220-3231. [PMID: 36575810 PMCID: PMC10077391 DOI: 10.1002/nop2.1573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/17/2022] [Accepted: 12/10/2022] [Indexed: 12/29/2022] Open
Abstract
AIM To identify the factors affecting Emergency Department Length of Stay for transferred critically ill patients. BACKGROUND The Length of Stay of the transferred patients is an important indicator of Emergency Department service quality; thus, understanding the factors affecting the Emergency Department Length of Stay of transferred critically ill patients is essential. METHODS Using the electronic medical records of 968 transferred critically ill Emergency Department patients of a tertiary hospital in Korea, prediction models for Emergency Department Length of Stay were built using various machine learning algorithms. RESULTS The logistic regression (AUROC 0.85) models showed the best performance, followed by random forest (AUROC 0.83) and Naive Bayes (AUROC 0.83). The logistic regression model indicated that fewer consultations, the highest acuity level, need for an emergency operation or angiography, need for ICU admission, severe emergency disease and fewer diagnoses were the statistically significant predictors for Emergency Department Length of Stay of 6 h or less. CONCLUSIONS The transferred critically ill patients analysed in this study who required immediate or specialized care tended to receive needed care on time at the study site. IMPLICATIONS FOR NURSING MANAGEMENT Understanding the factors affecting the Emergency Department Length of Stay of transferred critically ill patients is crucial for developing strategies to manage the nursing resource of Emergency Department successfully.
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Affiliation(s)
- Hyungbok Lee
- Emergency Nursing Department, Seoul National University Hospital, Seoul, Korea.,College of Nursing, Seoul National University, Seoul, Korea
| | - Sangrim Lee
- Emergency Nursing Department, Seoul National University Hospital, Seoul, Korea.,College of Nursing, Seoul National University, Seoul, Korea
| | - Hyeoneui Kim
- College of Nursing, Seoul National University, Seoul, Korea.,The Research Institute of Nursing Science, Seoul National University, Seoul, Korea
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13
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Characteristics of Patients Who Visited Emergency Department: A Nationwide Population-Based Study in South Korea (2016-2018). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148578. [PMID: 35886425 PMCID: PMC9316116 DOI: 10.3390/ijerph19148578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022]
Abstract
The utilization of the emergency department (ED) has been continuously increasing and has become a burden for ED resources. The aim of this study was to describe the characteristics, outcomes, common diagnoses, and disease classifications of patients who were referred to the ED. This nationwide epidemiologic study examined the data from adult patients (>18 years) who visited EDs from 1 January 2016 to 31 December 2018. Most EDs in Korea provide data from ED patients to the National Emergency Medical Center (NEMC). The disposition of ED patients was classified as discharge, admission, death, and re-transfer. From 2016 to 2018, the proportion of referred patients out of the total ED visits increased from 7.3% to 7.8%. The referred patients were older (61.1 vs. 50.5 years), had worse vital signs, longer ED lengths of stay (409.1 vs. 153.3 min), and higher admission (62.3 vs. 16.9%) and re-transfer rates (4.4 vs. 1.9%) than the direct-visit patients. Among the referred patients in the 3 years, 62.3% were hospitalized, and the most common disease classification was “disease of the digestive system” (19.8%). The most common diagnosis was pneumonia (6.0%), followed by urinary tract infection, gastrointestinal bleeding, and hepatobiliary infection. The number of patients referred to EDs is increasing, and more than 60% of referred patients are hospitalized. Detailed characteristics of these patients will be helpful for improving ED management and the distribution of medical resources.
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14
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Kabil G, Frost SA, Hatcher D, Shetty A, Foster J, McNally S. Early fluid bolus in adults with sepsis in the emergency department: a systematic review, meta-analysis and narrative synthesis. BMC Emerg Med 2022; 22:3. [PMID: 35016638 PMCID: PMC8753824 DOI: 10.1186/s12873-021-00558-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/02/2021] [Indexed: 12/13/2022] Open
Abstract
Background Early intravenous fluids for patients with sepsis presenting with hypoperfusion or shock in the emergency department remains one of the key recommendations of the Surviving Sepsis Campaign guidelines to reduce mortality. However, compliance with the recommendation remains poor. While several interventions have been implemented to improve early fluid administration as part of sepsis protocols, the extent to which they have improved compliance with fluid resuscitation is unknown. The factors associated with the lack of compliance are also poorly understood. Methods We conducted a systematic review, meta-analysis and narrative review to investigate the effectiveness of interventions in emergency departments in improving compliance with early fluid administration and examine the non-interventional facilitators and barriers that may influence appropriate fluid administration in adults with sepsis. We searched MEDLINE Ovid/PubMed, Ovid EMBASE, CINAHL, and SCOPUS databases for studies of any design to April 2021. We synthesised results from the studies reporting effectiveness of interventions in a meta-analysis and conducted a narrative synthesis of studies reporting non-interventional factors. Results We included 31 studies out of the 825 unique articles identified in the systematic review of which 21 were included in the meta-analysis and 11 in the narrative synthesis. In meta-analysis, interventions were associated with a 47% improvement in the rate of compliance [(Random Effects (RE) Relative Risk (RR) = 1.47, 95% Confidence Interval (CI), 1.25–1.74, p-value < 0.01)]; an average 24 min reduction in the time to fluids [RE mean difference = − 24.11(95% CI − 14.09 to − 34.14 min, p value < 0.01)], and patients receiving an additional 575 mL fluids [RE mean difference = 575.40 (95% CI 202.28–1353.08, p value < 0.01)]. The compliance rate of early fluid administration reported in the studies included in the narrative synthesis is 48% [RR = 0.48 (95% CI 0.24–0.72)]. Conclusion Performance improvement interventions improve compliance and time and volume of fluids administered to patients with sepsis in the emergency department. While patient-related factors such as advanced age, co-morbidities, cryptic shock were associated with poor compliance, important organisational factors such as inexperience of clinicians, overcrowding and inter-hospital transfers were also identified. A comprehensive understanding of the facilitators and barriers to early fluid administration is essential to design quality improvement projects. PROSPERO Registration ID CRD42021225417. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00558-5.
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Affiliation(s)
- Gladis Kabil
- Western Sydney University, School of Nursing and Midwifery, Locked bag 1797, Penrith, NSW, 2751, Australia. .,Department of Emergency, Westmead Hospital, Sydney, Australia.
| | - Steven A Frost
- Western Sydney University, School of Nursing and Midwifery, Locked bag 1797, Penrith, NSW, 2751, Australia.,South Western Sydney Nursing and Midwifery Research, Ingham Institute of Applied Medical Research, Sydney, Australia.,University of New South Wales, Sydney, Australia
| | - Deborah Hatcher
- Western Sydney University, School of Nursing and Midwifery, Locked bag 1797, Penrith, NSW, 2751, Australia
| | - Amith Shetty
- Westmead Institute for Medical Research, Westmead, Australia.,NSW Ministry of Health, New South Wales, Australia
| | - Jann Foster
- Western Sydney University, School of Nursing and Midwifery, Locked bag 1797, Penrith, NSW, 2751, Australia
| | - Stephen McNally
- Western Sydney University, School of Nursing and Midwifery, Locked bag 1797, Penrith, NSW, 2751, Australia
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15
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Abstract
OBJECTIVES To describe the geography of pediatric critical care services and the relationship between poverty and distance to these services across the United States. DESIGN Retrospective, cross-sectional study. SETTING Contiguous United States. PATIENTS Children less than 18 years as represented in the 2016 American Community Survey. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pediatric critical care services were geographically concentrated within urban areas, with half of all PICUs located within 9.5 miles of another (interquartile range, 3.4-51.5 miles). Median distances from neighborhoods to the nearest unit increased linearly with Area Deprivation Index (p < 0.001), such that the median distance from the least privileged neighborhoods was nearly three times that of the most privileged neighborhoods (first decile = 7.8 miles [interquartile range, 3.4-15.8 miles] vs tenth decile = 22.6 miles [interquartile range, 4.2-52.5 miles]; p < 0.001). A relationship between neighborhood poverty and distance to a PICU was present across all U.S. regions and within urban/suburban and rural areas. CONCLUSIONS In the United States, the distance to pediatric critical care services increases with poverty. This carries implications for access to care and health outcome disparities.
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Affiliation(s)
- Lauren E Brown
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Urbano L França
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Michael L McManus
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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16
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Myers V, Nolan B. Delays to Initiate Interfacility Transfer for Patients Transported by a Critical Care Transport Organization. Air Med J 2021; 40:436-440. [PMID: 34794785 DOI: 10.1016/j.amj.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The time to initiate an interfacility transfer is an important and understudied cause of delay to definitive management. This study identifies characteristics associated with delays to initiate interfacility transfer of critically ill patients. METHODS We performed a retrospective cohort study of adult patients who underwent interfacility transfer by a provincial critical care transport organization over a 3-year period. The primary outcome was the time to initiate interfacility transfer. Quantile regression explored the impact of patient, environmental, and institutional characteristics. RESULTS In total 11,231 patients were included. Cardiac (+1.45 hours), gastrointestinal (+3.28 hours), respiratory (+4.90 hours), or sepsis (+3.03 hours) reasons for transfer; vasopressor requirements (+2.31 hours); and evening time (+3.67 hours) were associated with longer times to initiate interfacility transfer at the 90th quantile. Neurologic (-1.45 hours), obstetric (-1.56 hours), or trauma (-3.14 hours) reasons for transfer; Glasgow Coma Scale < 8 (-0.98 hours); blood transfusion requirement (-1.47 hours); and smaller sending sites were associated with shorter times to initiate transfer. CONCLUSION The time to initiate interfacility transfer represents a modifiable delay in a patient's transport journey. This study highlights important patient, environmental, and institutional characteristics associated with increased time to initiate transfer. Collaboration between transport organizations and hospitals in developing regional bypass criteria and prearranged transfer agreements may help facilitate timely patient transfer.
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Affiliation(s)
- Victoria Myers
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Brodie Nolan
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Emergency Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Ornge, Toronto, Ontario, Canada
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17
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Interhospital Transfer Outcomes for Critically Ill Patients With Coronavirus Disease 2019 Requiring Mechanical Ventilation. Crit Care Explor 2021; 3:e0559. [PMID: 34729490 PMCID: PMC8553251 DOI: 10.1097/cce.0000000000000559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Supplemental Digital Content is available in the text. Studying interhospital transfer of critically ill patients with coronavirus disease 2019 pneumonia in the spring 2020 surge may help inform future pandemic management.
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18
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Kirby J. Are we overlooking the rural patient journey when it comes to sepsis diagnosis and management? Emerg Med Australas 2021; 33:941-943. [PMID: 34346166 DOI: 10.1111/1742-6723.13838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/29/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022]
Abstract
Surviving Sepsis Campaign guidelines have progressively moved towards faster time-based treatment targets over recent years despite international data consistently showing low protocol adherence. A key stakeholder in Australian healthcare remains overlooked in sepsis research: the under-resourced rural ED. The journey of the rural patient markedly differs to that of the metropolitan patient, involving greater reliance upon patient transfers, reduced staffing and resource inaccessibility, directly impacting on sepsis protocol adherence and patient outcomes. Greater representation of rural patients and EDs in Australian sepsis research is paramount in guiding future sepsis treatment protocols. This perspective piece explores current international sepsis literature, recognising significant barriers to sepsis protocol adherence specific to rural Australian EDs.
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Affiliation(s)
- Jordan Kirby
- Warrnambool Clinical School, School of Medicine, Deakin University, Geelong, Victoria, Australia
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19
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Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine. Crit Care Med 2021; 50:37-49. [PMID: 34259453 DOI: 10.1097/ccm.0000000000005147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions. DATA SOURCES AND STUDY SELECTION Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product. DATA EXTRACTION AND SYNTHESIS The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations. CONCLUSIONS Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.
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20
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Baig SH, Gorth DJ, Yoo EJ. Critical Care Utilization and Outcomes of Interhospital Medical Transfers at Lower Risk of Death. J Intensive Care Med 2021; 37:679-685. [PMID: 34080443 DOI: 10.1177/08850666211022613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate utilization and mortality outcomes of interhospital transferred critically-ill medical patients with lower predicted risk of hospital mortality. MATERIALS & METHODS Multisite retrospective cohort analysis of patients with Acute Physiology and Chronic Health Evaluation (APACHE) IV-a predicted mortality of ≤20% from 335 ICUs in 208 hospitals in the Philips eICU database between 2014-2015. Differences in length-of-stay (LOS) and mortality between transferred and local patients were evaluated using negative binomial logistic regression and logistic regression, respectively. Stratified analyses were conducted for subgroups of predicted mortality: 0%-5%, 6%-10%, 11%-15%, and 16%-20%. RESULTS Transfers had a higher risk of longer ICU and hospital LOS across all risk strata (IRR 1.12; 95% CI 1.09-1.16, P < 0.001 and IRR 1.11; 95% CI 1.07-1.14, P < 0.001 respectively). Mortality was higher among transfers, largely driven by the 6%-10% mortality risk strata (OR 1.30; 95% CI 1.09-1.54, P = 0.003). CONCLUSIONS Interhospital transfer of critically-ill medical patients with lower illness severity is associated with higher ICU and hospital utilization and increased mortality. Better understanding of factors driving patient selection for and characteristics of interhospital transfer for this population will have an impact on ICU resource utilization, care efficiency, and hospital quality.
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Affiliation(s)
- Saqib H Baig
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, PA, USA
| | - Deborah J Gorth
- Sidney Kimmel Medical College, Thomas Jefferson University, PA, USA
| | - Erika J Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, PA, USA
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21
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Wong R, Blachman-Braun R, Mann U, Eng A, Lother S, Patel P. Location of residence and mortality for patients diagnosed with Fournier's gangrene. Can Urol Assoc J 2021; 15:E267-E271. [PMID: 33119500 PMCID: PMC8095282 DOI: 10.5489/cuaj.6749] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Fournier's gangrene (FG) is a necrotizing infection of the genitalia. Time from to surgical intervention is a critical determinant of prognosis. We sought to investigate whether patients from rural locations have worse clinical outcomes given distance from a tertiary center. METHODS The Manitoba Intensive Care Unit (ICU) registry includes patients who have been admitted into ICUs across Manitoba. We identified patients admitted with FG from February 1999 to October 2019. Age, gender, Charlson comorbidity index (CCI), presence of colostomy and scrotal debridement, length of stay (LOS), and mortality outcomes were obtained. Patients were categorized as being rural or urban. RESULTS From 1999-2019, a total of 79 patients were admitted with FG. The median age was 60 years [interquartile range [IQR] 48-67). The mortality rate during hospitalization was 16.5%. There was no statistically significant difference in the number of deaths for patients from urban vs. rural dwellings (9/47 [19.1%] vs. 4/32 [12.5%], p=0.434]. A comparison of the 66 (83.5%) patients that survived and the 13 (16.5%) that died during ICU hospitalization demonstrated no difference in age, gender, CCI, presence of colostomy, and rates of scrotal re-debridement (p>0.05). Multivariable analysis demonstrated that living in a rural area was not associated with increased mortality (odds ratio 0.64, 95% confidence interval 00.16-2.57, p=0.527). CONCLUSIONS Location of residence was not predictive of death from FG. In addition, baseline characteristics such as age, gender, CCI, surgical interventions, or LOS were not found to be associated with mortality.
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Affiliation(s)
- Rachel Wong
- University of Manitoba, Winnipeg, MB, Canada
| | - Ruben Blachman-Braun
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Uday Mann
- University of Alberta, Edmonton, AB, Canada
| | - Amanda Eng
- University of Manitoba, Winnipeg, MB, Canada
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22
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Fisher ND, Bi AS, Aggarwal V, Leucht P, Tejwani NC, McLaurin TM. A Level 1 Trauma Center's response to the COVID-19 pandemic in New York City: a qualitative and quantitative story. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1451-1456. [PMID: 33616766 PMCID: PMC7897731 DOI: 10.1007/s00590-021-02902-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/08/2021] [Indexed: 01/28/2023]
Abstract
Background The purpose of this study is to describe a Level 1 Trauma Center’s orthopedic response to the COVID-19 pandemic, and to compare outcomes of acute fracture patients pre-COVID versus during the COVID-19 pandemic. Methods All inpatient fracture cases performed over a 5-month period were identified and retrospective chart review performed. Patients were divided into pre- and COVID-era groups based on when surgery was performed relative to March 16, 2020 (the date elective operations were ceased), and groups were statistically compared. Patients with a COVID test result were further sub-divided into COVID negative and positive groups, and statistically compared. Statistical analysis was performed using independent t-test for continuous variables and chi-square analysis for categorical variables. Results One hundred and nineteen patients were identified, 38% females with average age of 58 years. Average length of stay was 7 days with average time from injury to surgery of 3 days and average time from admission to surgery of 1.3 days. Overall in-hospital complication rate was 29.4%, and 30-day mortality and readmission rates were 2.5% and 5%, respectively. Sixty-nine patients comprised the pre-COVID group, and 50 in the COVID-era group. There was no significant difference with respect to length of stay, time from injury to surgery, time from admission to surgery, need for post-operative ICU stay, in-hospital complication rate, 30-day mortality rate and 30-day readmission rate. Thirty-four patients had COVID testing, with 24 negative and 10 positive. COVID-positive patients had longer time from injury to surgery (8.5 days vs. 2 days, p = 0.003) and longer time from admission to surgery (2.7 days vs. 1.2 days, p = 0.034). While more COVID-positive patients required ICU admission post-operatively (60% vs. 21%, p = 0.036), there was no difference in overall complication rate. Conclusions Orthopedic care of acute fracture patients was not affected by a global pandemic. The response of our Level 1 Trauma Center’s orthopedic department can guide other hospitals if and when new surges in COVID cases arise, in order to prevent compromising appropriate orthopedic care. Level of evidence Prognostic III.
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Affiliation(s)
- Nina D Fisher
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.
| | - Andrew S Bi
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Vinay Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopedic Surgery, Health and Hospitals, Bellevue, New York, NY, USA
| | - Philipp Leucht
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopedic Surgery, Health and Hospitals, Bellevue, New York, NY, USA
| | - Nirmal C Tejwani
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopedic Surgery, Health and Hospitals, Bellevue, New York, NY, USA
| | - Toni M McLaurin
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopedic Surgery, Health and Hospitals, Bellevue, New York, NY, USA
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23
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Mohr NM, Harland KK, Okoro UE, Fuller BM, Campbell K, Swanson MB, Simpson SQ, Parker EA, Mack LJ, Bell A, DeJong K, Faine B, Zepeski A, Mueller K, Chrischilles E, Carpenter CR, Jones MP, Ward MM. TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study). J Comp Eff Res 2021; 10:77-91. [PMID: 33470848 DOI: 10.2217/cer-2020-0141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure. ClinicalTrials.gov: NCT04441944.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Uche E Okoro
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Brian M Fuller
- Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA.,Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Kalyn Campbell
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Surgery, Hennepin County Medical Center, Minneapolis, MN 55415, USA
| | - Morgan B Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Stephen Q Simpson
- Department of Pulmonary, Critical Care, & Sleep Medicine, University of Kansas, Kansas City, KS 66160, USA.,Biomedical Advanced Research & Development Authority, US Department of Health & Human Services, Washington, DC 20201, USA
| | - Edith A Parker
- Department of Community & Behavioral Health, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Luke J Mack
- Avera eCARE, Sioux Falls, SD 57104, USA.,Department of Family Medicine, University of South Dakota School of Medicine, Sioux Falls, SD 57105, USA
| | | | | | - Brett Faine
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Pharmacy Practice & Science, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA.,Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Department of Health Management & Policy, Iowa City, IA 52242, USA
| | - Anne Zepeski
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Department of Health Management & Policy, Iowa City, IA 52242, USA
| | - Keith Mueller
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Elizabeth Chrischilles
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Michael P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA 52242, USA
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Bischoff T, Sawadsky B, Peddle M, Nolan B. Impact of Prepatching on Paramedic In-Hospital Times for Emergent Interfacility Transfers. PREHOSP EMERG CARE 2020; 25:832-838. [PMID: 33205688 DOI: 10.1080/10903127.2020.1852351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Background: The care required for patients at times necessitates they be transferred to another hospital capable of providing specialized care, a process known as an interfacility transfer. Delays to appropriate care for critically ill patients are associated with increased morbidity and mortality. Improving efficiencies in interfacility transport process can thus expedite the time to critical treatment. Traditionally paramedics would patch to a transport medicine physician (TMP) after initial patient contact to discuss the case and expected management during transport. The concept of prepatch shifts this discussion between the TMP and paramedics prior to initial patient contact. The objective of this study was to assess if prepatching with paramedics prior to arrival at the patient reduced the in-hospital time for emergent interfacility transfers transported by a provincial critical care transport organization. Methods: This was a retrospective cohort study of all emergent, adult interfacility transports for patients transported by a provincial critical care transport organization in Ontario, Canada from January 2016 to December 2019. Quantile regression was used to evaluate the impact of prepatching as well as patient and paramedic characteristics on paramedic in-hospital time. Results: A total of 10,088 patients were included in the study, with 3,606 patients having a prepatch conducted and 6,482 without. Ventilated patients and vasopressor use were associated with higher prepatch rates; with the use of prepatch in these patients increasing over subsequent years of the study. Additionally, patients requiring higher levels of care, including being mechanically ventilated or dependent on vasopressors, were associated with longer in-hospital times. Prepatching reduced in-hospital time by 4 minutes at the 90th quantile across all patients. Conclusion: Prepatching reduced paramedic in-hospital time for emergent interfacility transports. Although the clinical impact of this reduction in time is uncertain, prepatching may serve in facilitating shared mental modeling between paramedics and TMPs which may be beneficial to patient safety and team performance.
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Delayed interhospital transfer of critically ill patients with surgical sepsis. J Trauma Acute Care Surg 2020; 88:169-175. [PMID: 31856021 DOI: 10.1097/ta.0000000000002476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Suboptimal triage of critically ill patients with surgical sepsis may contribute to adverse outcomes. Patients transferred to a tertiary care center after spending 24 hours or longer at an outside facility were compared with patients who had early triage to a tertiary care center with the null hypothesis that management parameters and outcomes would be similar between groups. METHODS This prospective observational cohort study included 308 patients treated for surgical sepsis in a surgical intensive care unit at a tertiary care center. Patients transferred after spending more than 24 hours at an outside facility (n = 69) were compared with patients who were directly admitted or transferred within 24 hours (n = 239). Patient characteristics, management parameters, and outcomes were compared between groups. This study was registered at ClinicalTrials.gov (NCT02276066). RESULTS Average outside facility length of stay in the delayed transfer group was 43 hours. Delayed transfer patients had higher sequential organ failure assessment (7 vs. 5, p = 0.003) and APACHE II scores (19 vs. 16, p = 0.007) on admission. The interval between admission and source control was significantly longer in the delayed transfer group (12.1 hours vs. 1.0 hours, p = 0.009). The incidence of nosocomial infection was significantly higher in the delayed transfer group (41% vs. 23%, p = 0.005). Delayed transfer was independently associated with a 10-day increase in hospital length of stay. Delayed transfer patients were less likely to be discharged home (22% vs. 59%, p < 0.001) and suffered twofold higher in-hospital mortality (14.5% vs. 7.1%, p = 0.056). CONCLUSION Patients with surgical sepsis who spent more than 24 hours at an outside facility prior to transfer had greater initial illness severity, longer intervals between admission and source control, and more nosocomial infections compared with patients who had early triage to a tertiary care center. LEVEL OF EVIDENCE Care management/therapeutic, Level IV; Epidemiologic/prognostic, Level III.
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26
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Connecting the Docs: Telemedicine Support during In-Hospital Cardiac Arrest Resuscitation. Ann Am Thorac Soc 2020; 17:278-279. [PMID: 32108502 DOI: 10.1513/annalsats.201912-884ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Cushing AM, Bucholz E, Michelson KA. Trends in Regionalization of Emergency Care for Common Pediatric Conditions. Pediatrics 2020; 145:peds.2019-2989. [PMID: 32169895 PMCID: PMC7236317 DOI: 10.1542/peds.2019-2989] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND For children who cannot be discharged from the emergency department, definitive care has become less frequent at most hospitals. It is uncertain whether this is true for common conditions that do not require specialty care. We sought to determine how the likelihood of definitive care has changed for 3 common pediatric conditions: asthma, croup, and gastroenteritis. METHODS We used the Nationwide Emergency Department Sample database to study children <18 years old presenting to emergency departments in the United States from 2008 to 2016 with a primary diagnosis of asthma, croup, or gastroenteritis, excluding critically ill patients. The primary outcome was referral rate: the number of patients transferred among all patients who could not be discharged. Analyses were stratified by quartile of annual pediatric volume. We used logistic regression to determine if changes over time in demographics or comorbidities could account for referral rate changes. RESULTS Referral rates increased for each condition in all volume quartiles. Referral rates were greatest in the lowest pediatric volume quartile. Referral rates in the lowest pediatric volume quartile increased for asthma (13.6% per year; 95% confidence interval [CI] 5.6%-22.2%), croup (14.8% per year; 95% CI 2.6%-28.3%), and gastroenteritis (16.4% per year; 95% CI 3.5%-31.0%). Changes over time in patient age, sex, comorbidities, weekend presentation, payer mix, urban-rural location of presentation, or area income did not account for these findings. CONCLUSIONS Increasing referral rates over time suggest decreasing provision of definitive care and regionalization of inpatient care for 3 common, generally straightforward conditions.
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Affiliation(s)
- Anna M Cushing
- Boston Children's Hospital, Boston, Massachusetts; and .,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Emily Bucholz
- Boston Children's Hospital, Boston, Massachusetts; and
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Gupta AK, Stewart SK, Cottell K, McCulloch GAJ, Miller J, Babidge WJ, Maddern GJ. Potentially avoidable issues in urology mortality cases in Australia: identification and improvements. ANZ J Surg 2020; 90:719-724. [PMID: 32106356 DOI: 10.1111/ans.15765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 12/29/2019] [Accepted: 01/29/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study aimed to identify the most common potentially avoidable factors in urology deaths, focusing on the lessons that can be learnt. METHODS This study analysed data from a well-established and comprehensive peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2015, focusing on urology cases with identified areas for improvement in patient management. Of all audited deaths, 11% (79/719) had serious clinical management issues with a total of 109 individual clinical management issues identified. These were categorized based on perioperative stage (preoperative, intraoperative or post-operative), followed by thematic analysis within each stage. RESULTS The study found preoperative issues to be the most common (n = 48), followed by post-operative issues (n = 32) with intraoperative issues less common (n = 13). Communication issues were seen at all three stages (n = 16). Overall, the most common theme was at the preoperative stage; inadequate preoperative assessment (n = 27). More specifically, the most common preoperative assessment issues involved a failure to order necessary preoperative investigations, or to administer necessary preoperative treatment (e.g. prophylactic antibiotics). The most common communication issue was between teams and at handover, often involving failure by junior medical staff to communicate issues to the responsible surgical consultant. CONCLUSION Urological surgical cases with potentially avoidable mortality constitute a small, but important subset of deaths. The analysis of these cases can inform various stakeholders to improve the quality and safety of urological surgical care.
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Affiliation(s)
- Aashray K Gupta
- South Australian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sasha K Stewart
- South Australian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Kimberley Cottell
- South Australian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Glenn A J McCulloch
- South Australian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - John Miller
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Wendy J Babidge
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia.,Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia.,Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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Ilko SA, Vakkalanka JP, Ahmed A, Harland KK, Mohr NM. Central Venous Access Capability and Critical Care Telemedicine Decreases Inter-Hospital Transfer Among Severe Sepsis Patients: A Mixed Methods Design. Crit Care Med 2020; 47:659-667. [PMID: 30730442 DOI: 10.1097/ccm.0000000000003686] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Severe sepsis is a complex, resource intensive, and potentially lethal condition and rural patients have worse outcomes than urban patients. Early identification and treatment are important to improving outcomes. The objective of this study was to identify hospital-specific factors associated with inter-hospital transfer. DESIGN Mixed method study integrating data from a telephone survey and retrospective cohort study of state administrative claims. SETTING AND SUBJECTS Survey of Iowa emergency department administrators between May 2017 and June 2017 and cohort of adults seen in Iowa emergency departments for severe sepsis and septic shock between January 2005 and December 2013. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Multivariable logistic regression was used to identify independent predictors of inter-hospital transfer. We included 114 institutions that provided data (response rate = 99%), and responses were linked to a total of 150,845 visits for severe sepsis/septic shock. In our adjusted model, having the capability to place central venous catheters or having a subscription to a tele-ICU service was independently associated with lower odds of inter-hospital transfer (adjusted odds ratio, 0.69; 95% CI, 0.54-0.86 and adjusted odds ratio, 0.69; 95% CI, 0.54-0.88, respectively). A facility's participation in a sepsis-specific quality improvement initiative was associated with 62% higher odds of transfer (adjusted odds ratio, 1.62; 95% CI, 1.10-2.39). CONCLUSIONS The insertion of central venous catheters and access to a critical care physician during sepsis treatment are important capabilities in hospitals that transfer fewer sepsis patients. In the future, hospital-specific capabilities may be used to identify institutions as regional sepsis centers.
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Affiliation(s)
- Steven A Ilko
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.,Department of Management and Organizations, University of Iowa Tippie College of Business, Iowa City, IA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA.,Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
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Mohr NM, Campbell KD, Swanson MB, Ullrich F, Merchant KA, Ward MM. Provider-to-provider telemedicine improves adherence to sepsis bundle care in community emergency departments. J Telemed Telecare 2020; 27:518-526. [PMID: 31903840 DOI: 10.1177/1357633x19896667] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Sepsis is a life-threatening emergency. Together, early recognition and intervention decreases mortality. Protocol-based resuscitation in the emergency department (ED) has improved survival in sepsis patients, but guideline-adherent care is less common in low-volume EDs. This study examined the association between provider-to-provider telemedicine and adherence with sepsis bundle components in rural community hospitals. METHODS This is a prospective cohort study of adults presenting with sepsis or septic shock in community EDs participating in rural telemedicine networks. The primary outcome was adherence to four sepsis bundle requirements: lactate measurement within 3 hours, blood culture before antibiotics, broad-spectrum antibiotics, and adequate fluid resuscitation. Multivariable generalized estimating equations estimated the association between telemedicine and adherence. RESULTS In this cohort (n = 655), 5.6% of subjects received ED telemedicine consults. The telemedicine group was more likely to be male and have a higher severity of illness. After adjusting for severity and chief complaint, total sepsis bundle adherence was higher in the telemedicine group compared with the non-telemedicine group (aOR 17.27 [95%CI 6.64-44.90], p < 0.001). Telemedicine consultation was associated with higher adherence with three of the individual bundle components: lactate, antibiotics, and fluid resuscitation. DISCUSSION Telemedicine patients were more likely to receive initial blood lactate measurement, timely broad-spectrum antibiotics, and adequate fluid resuscitation. In rural, community EDs, telemedicine may improve sepsis care and potentially reduce disparities in sepsis outcomes at low-volume facilities. Future work should identify specific components of telemedicine-augmented care that improve performance with sepsis quality indicators.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, College of Medicine, University of Iowa, Iowa City, USA.,Department of Anesthesia Division of Critical Care, College of Medicine, University of Iowa, Iowa City, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, USA
| | - Kalyn D Campbell
- Department of Emergency Medicine, College of Medicine, University of Iowa, Iowa City, USA
| | - Morgan B Swanson
- Department of Emergency Medicine, College of Medicine, University of Iowa, Iowa City, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, USA
| | - Fred Ullrich
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
| | - Kimberly A Merchant
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
| | - Marcia M Ward
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
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Double inter-hospital transfer in Sepsis patients presenting to the ED does not worsen mortality compared to single inter-hospital transfer. J Crit Care 2019; 56:49-57. [PMID: 31837601 DOI: 10.1016/j.jcrc.2019.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/13/2019] [Accepted: 11/29/2019] [Indexed: 12/16/2022]
Abstract
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.
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Abe T, Kushimoto S, Tokuda Y, Phillips GS, Rhodes A, Sugiyama T, Komori A, Iriyama H, Ogura H, Fujishima S, Shiraishi A, Saitoh D, Mayumi T, Naito T, Takuma K, Nakada TA, Shiino Y, Tarui T, Hifumi T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Tsuruta R, Hagiwara A, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Gando S. Implementation of earlier antibiotic administration in patients with severe sepsis and septic shock in Japan: a descriptive analysis of a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:360. [PMID: 31744549 PMCID: PMC6862854 DOI: 10.1186/s13054-019-2644-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/09/2019] [Indexed: 12/13/2022]
Abstract
Background Time to antibiotic administration is a key element in sepsis care; however, it is difficult to implement sepsis care bundles. Additionally, sepsis is different from other emergent conditions including acute coronary syndrome, stroke, or trauma. We aimed to describe the association between time to antibiotic administration and outcomes in patients with severe sepsis and septic shock in Japan. Methods This prospective observational study enrolled 1184 adult patients diagnosed with severe sepsis based on the Sepsis-2 criteria and admitted to 59 intensive care units (ICUs) in Japan between January 1, 2016, and March 31, 2017, as the sepsis cohort of the Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis and Trauma (FORECAST) study. We compared the characteristics and in-hospital mortality of patients administered with antibiotics at varying durations after sepsis recognition, i.e., 0–60, 61–120, 121–180, 181–240, 241–360, and 361–1440 min, and estimated the impact of antibiotic timing on risk-adjusted in-hospital mortality using the generalized estimating equation model (GEE) with an exchangeable, within-group correlation matrix, with “hospital” as the grouping variable. Results Data from 1124 patients in 54 hospitals were used for analyses. Of these, 30.5% and 73.9% received antibiotics within 1 h and 3 h, respectively. Overall, the median time to antibiotic administration was 102 min [interquartile range (IQR), 55–189]. Compared with patients diagnosed in the emergency department [90 min (IQR, 48–164 min)], time to antibiotic administration was shortest in patients diagnosed in ICUs [60 min (39–180 min)] and longest in patients transferred from wards [120 min (62–226)]. Overall crude mortality was 23.4%, where patients in the 0–60 min group had the highest mortality (28.0%) and a risk-adjusted mortality rate [28.7% (95% CI 23.3–34.1%)], whereas those in the 61–120 min group had the lowest mortality (20.2%) and risk-adjusted mortality rates [21.6% (95% CI 16.5–26.6%)]. Differences in mortality were noted only between the 0–60 min and 61–120 min groups. Conclusions We could not find any association between earlier antibiotic administration and reduction in in-hospital mortality in patients with severe sepsis.
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Affiliation(s)
- Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan. .,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan. .,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuharu Tokuda
- Department of Medicine, Muribushi Project for Okinawa Residency Programs, Urasoe, Japan
| | - Gary S Phillips
- Department of Biomedical Informatics, Ohio State University, Columbus, OH, USA
| | - Andrew Rhodes
- Department of Intensive Care Medicine, St George's University Hospitals Foundation Trust, London, UK
| | - Takehiro Sugiyama
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.,Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Komori
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Hiroki Iriyama
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshio Naito
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Mpirimbanyi C, Abahuje E, Hirwa AD, Gasakure M, Rwagahirima E, Niyonzima C, Hakizimana AN, Ishimwe E, Ntirenganya F, Rickard J. Defining the Three Delays in Referral of Surgical Emergencies from District Hospitals to University Teaching Hospital of Kigali, Rwanda. World J Surg 2019; 43:1871-1879. [PMID: 30944958 DOI: 10.1007/s00268-019-04991-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Surgical conditions represent up to 30% of the global burden of diseases. The aim of this study was to assess the delays in patients transferred to a tertiary referral hospital from district hospitals (DHs) in Rwanda with emergency general surgery (EGS) conditions. METHODS We performed a prospective review of all EGS patients referred from DH over a 3-month period to assess delays in transfer and accessing care. We then surveyed general practitioners to define their perspective on delays in surgical care. RESULTS Over a 3-month period, there were 86 patients transferred from DH with EGS conditions. The most common diagnoses were bowel obstruction (n = 22, 26%) and trauma (n = 19, 22%). The most common performed operations were laparotomy (n = 21, 24%) and bowel resection (n = 20, 23%). The mortality rate was 12%, and the intensive care unit admission rate was 4%. In transfer to the referral hospital, 5% patients were delayed for financial reasons and 2% due to lack of insurance. After reaching CHUK, 5% patients were delayed due to laboratory and radiology issues. Other delays included no operating theater available (4%) and no surgeon available (1%). Providers' perceptions for not performing surgeries at DH were predominantly the lack of a competent surgical provider or anesthesia staff. CONCLUSION EGS patients represent a broad range of diagnoses. Delays were noted at each step in the referral process with multiple areas for potential improvement. Expanding surgical access at the DH has the potential to decrease delays and thereby improves patient outcomes.
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Affiliation(s)
- Christophe Mpirimbanyi
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda.
| | - Egide Abahuje
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Aime Dieudone Hirwa
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Miguel Gasakure
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Elisee Rwagahirima
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Christian Niyonzima
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | | | - Epiphanie Ishimwe
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Faustin Ntirenganya
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda.,University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jennifer Rickard
- University Teaching Hospital of Kigali, Kigali, Rwanda.,University of Minnesota, Minneapolis, MN, USA
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Immunosuppression and Heterogeneity in the Sepsis Volume-Outcome Relationship. Ann Am Thorac Soc 2019; 15:916-918. [PMID: 30067099 DOI: 10.1513/annalsats.201805-344ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Froehlich A, Tegtmeier RJ, Faine BA, Reece J, Ahmed A, Mohr NM. Opportunities for achieving resuscitation goals during the inter-emergency department transfer of severe sepsis patients by emergency medical services: A case series. J Crit Care 2019; 52:163-165. [PMID: 31078996 DOI: 10.1016/j.jcrc.2019.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/08/2019] [Accepted: 04/17/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aimed to describe the care provide by Emergency Medical Services (EMS) to severe sepsis patients being transferred between acute care hospitals and identify how that care contributes to sepsis care goals. METHODS This was a single-center retrospective cohort study conducted at a 60,000-visit Midwestern academic emergency department, using run reports from 13 ambulance services transferring from 9 hospitals. RESULTS 39 patients were included in the final cohort, transferred by 13 ambulance services from 9 hospitals. Included patients were adults with severe sepsis transferred by ambulance between 2009 and 2014. Thirty-nine patients were included in this cohort. 41% (n = 12) of patients received an adequate fluid bolus of 30 mL/kg (median 42.9 mL/kg crystalloid fluid, IQR 8.0 mL/kg) prior to tertiary care arrival. Seventeen percent (n = 2) of patients completed the adequate bolus during transfer time. Broad-spectrum antibiotics were initiated during transfer in 2 patients. CONCLUSIONS EMS sepsis care during transfer was limited. EMS crews primarily continued treatments previously initiated and did not take additional steps toward resuscitation targets. Data suggests the inter-emergency department transfer period may provide an opportunity to continue working toward treatment targets, though the time is currently underutilized.
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Affiliation(s)
- Adam Froehlich
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, 220 Hawkins Dr, Iowa City, IA 52242, United States.
| | - Ryan J Tegtmeier
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, 220 Hawkins Dr, Iowa City, IA 52242, United States.
| | - Brett A Faine
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, 220 Hawkins Dr, Iowa City, IA 52242, United States; Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, 220 Hawkins Dr, Iowa City, IA 52242, United States.
| | - Jennifer Reece
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, 220 Hawkins Dr, Iowa City, IA 52242, United States.
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, 220 Hawkins Dr, Iowa City, IA 52242, United States.
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, 220 Hawkins Dr, Iowa City, IA 52242, United States; Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, 451 Newton Rd, Iowa City, IA 52242, United States; Department of Epidemiology, University of Iowa College of Public Health, 145 N Riverside Dr, Iowa City, IA 52242, United States.
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Cerebrospinal fluid/blood glucose point-of-care testing ratio for diagnosing bacterial meningitis in a limited medical resource setting. Eur J Emerg Med 2019; 26:145. [PMID: 30801430 DOI: 10.1097/mej.0000000000000558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Deisz R, Rademacher S, Gilger K, Jegen R, Sauerzapfe B, Fitzner C, Stoppe C, Benstoem C, Marx G. Additional Telemedicine Rounds as a Successful Performance-Improvement Strategy for Sepsis Management: Observational Multicenter Study. J Med Internet Res 2019; 21:e11161. [PMID: 30664476 PMCID: PMC6350091 DOI: 10.2196/11161] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/20/2018] [Accepted: 10/08/2018] [Indexed: 01/05/2023] Open
Abstract
Background Sepsis is a major health care problem with high morbidity and mortality rates and affects millions of patients. Telemedicine, defined as the exchange of medical information via electronic communication, improves the outcome of patients with sepsis and decreases the mortality rate and length of stay in the intensive care unit (ICU). Additional telemedicine rounds could be an effective component of performance-improvement programs for sepsis, especially in underserved rural areas and hospitals without ready access to critical care physicians. Objective Our aim was to evaluate the impact of additional daily telemedicine rounds on adherence to sepsis bundles. We hypothesized that additional telemedicine support may increase adherence to sepsis guidelines and improve the detection rates of sepsis and septic shock. Methods We conducted a retrospective, observational, multicenter study between January 2014 and July 2015 with one tele-ICU center and three ICUs in Germany. We implemented telemedicine as part of standard care and collected data continuously during the study. During the daily telemedicine rounds, routine screening for sepsis was conducted and adherence to the Surviving Sepsis Campaign’s 3-hour and 6-hour sepsis bundles were evaluated. Results In total, 1168 patients were included in this study, of which 196 were positive for severe sepsis and septic shock. We found that additional telemedicine rounds improved adherence to the 3-hour (Quarter 1, 35% vs Quarter 6, 76.2%; P=.01) and 6-hour (Quarter 1, 50% vs Quarter 6, 95.2%; P=.001) sepsis bundles. In addition, we noted an increase in adherence to the item “Administration of fluids when hypotension” (Quarter 1, 80% vs Quarter 6, 100%; P=.049) of the 3-hour bundle and the item “Remeasurement of lactate” (Quarter 1, 65% vs Quarter 6, 100%, P=.003) of the 6-hour bundle. The ICU length of stay after diagnosis of severe sepsis and septic shock remained unchanged over the observation period. Due to a higher number of patients with sepsis in Quarter 5 (N=60) than in other quarters, we observed stronger effects of the additional rounds on mortality in this quarter (Quarter 1, 50% vs Quarter 5, 23.33%, P=.046). Conclusions Additional telemedicine rounds are an effective component of and should be included in performance-improvement programs for sepsis management.
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Affiliation(s)
- Robert Deisz
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, University Hospital RWTH Aachen, Aachen, Germany
| | - Susanne Rademacher
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, University Hospital RWTH Aachen, Aachen, Germany
| | - Katrin Gilger
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, University Hospital RWTH Aachen, Aachen, Germany
| | - Rudolf Jegen
- Department of Anaesthesiology, St. Elisabeth Hospital, Jülich, Germany
| | | | - Christina Fitzner
- Department of Medical Statistics, Medical Faculty RWTH Aachen, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, University Hospital RWTH Aachen, Aachen, Germany
| | - Carina Benstoem
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, University Hospital RWTH Aachen, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, University Hospital RWTH Aachen, Aachen, Germany
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Greenwood-Ericksen MB, Rothenberg C, Mohr N, Andrea SD, Slesinger T, Osborn T, Whittle J, Goyal P, Tarrant N, Schuur JD, Yealy DM, Venkatesh A. Urban and Rural Emergency Department Performance on National Quality Metrics for Sepsis Care in the United States. J Rural Health 2018; 35:490-497. [PMID: 30488590 DOI: 10.1111/jrh.12339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The Centers for Medicare and Medicaid Services (CMS) and the American College of Emergency Physicians (ACEP) developed national quality measures for emergency department (ED) sepsis care. Like care for many conditions, meeting sepsis quality metrics can vary between settings. We sought to examine and compare sepsis care quality in rural vs urban hospital-based EDs. METHODS We analyzed data from EDs participating in the national Emergency Quality Network (E-QUAL). We collected preliminary performance data on both the CMS measure (SEP-1) and the ACEP measures via manual chart review. We analyzed SEP-1 data at the hospital level based on existing CMS definitions and analyzed ACEP measure data at the patient level. We report descriptive statistics of performance variation in rural and urban EDs. FINDINGS Rural EDs comprised 58 of the EDs reporting SEP-1 results and 405 rural patient charts in the manual review. Of sites reporting SEP-1 results, 44% were rural and demonstrated better aggregate SEP-1 bundle adherence than urban EDs (79% vs 71%; P = .049). Both urban and rural hospitals reported high levels of compliance with the ACEP recommended initial actions of obtaining lactate and blood cultures, with urban EDs outperforming rural EDs on metrics of IV fluid administration and antibiotics (74% urban vs 60% rural; P ≤ .001; 91% urban vs 84% rural; P ≤ .001, respectively). CONCLUSIONS Sepsis care at both rural and urban EDs often achieves success with national metrics. However, performance on individual components of ED sepsis care demonstrates opportunities for improved processes of care at rural EDs.
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Affiliation(s)
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.,Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Nicholas Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Todd Slesinger
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Tiffany Osborn
- Department of Surgery, Acute and Critical Care Surgery and Department of Medicine, Emergency Medicine, Washington University, St. Louis, Missouri
| | - Jessica Whittle
- Department of Emergency Medicine, UT Chattanooga/Erlanger Health Systems, Chattanooga, Tennessee
| | - Pawan Goyal
- American College of Emergency Physicians, Washington, DC
| | - Nalani Tarrant
- American College of Emergency Physicians, Washington, DC
| | - Jeremiah D Schuur
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Arjun Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.,Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut
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Abstract
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.
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Affiliation(s)
- Urbano L. França
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Michael L. McManus
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Hantrakun V, Somayaji R, Teparrukkul P, Boonsri C, Rudd K, Day NPJ, West TE, Limmathurotsakul D. Clinical epidemiology and outcomes of community acquired infection and sepsis among hospitalized patients in a resource limited setting in Northeast Thailand: A prospective observational study (Ubon-sepsis). PLoS One 2018; 13:e0204509. [PMID: 30256845 PMCID: PMC6157894 DOI: 10.1371/journal.pone.0204509] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 09/10/2018] [Indexed: 12/22/2022] Open
Abstract
Infection and sepsis are leading causes of death worldwide but the epidemiology and outcomes are not well understood in resource-limited settings. We conducted a four-year prospective observational study from March 2013 to February 2017 to examine the clinical epidemiology and outcomes of adults admitted with community-acquired infection in a resource-limited tertiary-care hospital in Ubon Ratchathani province, Northeast Thailand. Hospitalized patients with infection and accompanying systemic manifestations of infection within 24 hours of admission were enrolled. Subjects were classified as having sepsis if they had a modified sequential organ failure assessment (SOFA) score ≥2 at enrollment. This study was registered with ClinicalTrials.gov, number NCT02217592. A total of 4,989 patients were analyzed. Of the cohort, 2,659 (53%) were male and the median age was 57 years (range 18-101). Of these, 1,173 (24%) patients presented primarily to the study hospital, 3,524 (71%) were transferred from 25 district hospitals or 8 smaller hospitals in the province, and 292 (6%) were transferred from one of 30 hospitals in other provinces. Three thousand seven hundred and sixteen (74%) patients were classified as having sepsis. Patients with sepsis had an older age distribution and a greater prevalence of comorbidities compared to patients without sepsis. Twenty eight-day mortality was 21% (765/3,716) in sepsis and 4% (54/1,273) in non-sepsis patients (p<0.001). After adjusting for gender, age, and comorbidities, sepsis on admission (adjusted hazard ratio [HR] 3.30; 95% confidence interval [CI] 2.48-4.41, p<0.001), blood culture positive for pathogenic organisms (adjusted HR 2.21; 95% CI 1.89-2.58, p<0.001) and transfer from other hospitals (adjusted HR 2.18; 95% CI 1.69-2.81, p<0.001) were independently associated with mortality. In conclusion, mortality of community-acquired sepsis in Northeast Thailand is considerable and transferred patients with infection are at increased risk of death. To reduce mortality of sepsis in this and other resource-limited setting, facilitating rapid detection of sepsis in all levels of healthcare facilities, establishing guidelines for transfer of sepsis patients, and initiating sepsis care prior to and during transfer may be beneficial.
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Affiliation(s)
- Viriya Hantrakun
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ranjani Somayaji
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, United States
| | | | | | - Kristina Rudd
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, United States
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom
| | - T. Eoin West
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, United States
| | - Direk Limmathurotsakul
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Fortis S, Sarrazin MV, Beck BF, Panos RJ, Reisinger HS. ICU Telemedicine Reduces Interhospital ICU Transfers in the Veterans Health Administration. Chest 2018; 154:69-76. [DOI: 10.1016/j.chest.2018.04.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/05/2018] [Accepted: 04/02/2018] [Indexed: 11/26/2022] Open
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König V, Kolzter O, Albuszies G, Thölen F. [Factors affecting in-hospital mortality in patients with sepsis: Development of a risk-adjusted model based on administrative data from German hospitals]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2018; 133:30-39. [PMID: 29610028 DOI: 10.1016/j.zefq.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 02/28/2018] [Accepted: 03/01/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Inpatient administrative data from hospitals is already used nationally and internationally in many areas of internal and public quality assurance in healthcare. For sepsis as the principal condition, only a few published approaches are available for Germany. The aim of this investigation is to identify factors influencing hospital mortality by employing appropriate analytical methods in order to improve the internal quality management of sepsis. METHODS The analysis was based on data from 754,727 DRG cases of the CLINOTEL hospital network charged in 2015. The association then included 45 hospitals of all supply levels with the exception of university hospitals (range of beds: 100 to 1,172 per hospital). Cases of sepsis were identified via the ICD codes of their principal diagnosis. Multiple logistic regression analysis was used to determine the factors influencing in-hospital lethality for this population. The model was developed using sociodemographic and other potential variables that could be derived from the DRG data set, and taking into account current literature data. The model obtained was validated with inpatient administrative data of 2016 (51 hospitals, 850,776 DRG cases). RESULTS Following the definition of the inclusion criteria, 5,608 cases of sepsis (2016: 6,384 cases) were identified in 2015. A total of 12 significant and, over both years, stable factors were identified, including age, severity of sepsis, reason for hospital admission and various comorbidities. The AUC value of the model, as a measure of predictability, is above 0.8 (H-L test p>0.05, R2 value=0.27), which is an excellent result. CONCLUSION The CLINOTEL model of risk adjustment for in-hospital lethality can be used to determine the mortality probability of patients with sepsis as principal diagnosis with a very high degree of accuracy, taking into account the case mix. Further studies are needed to confirm whether the model presented here will prove its value in the internal quality assurance of hospitals.
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Affiliation(s)
- Volker König
- CLINOTEL Krankenhausverbund gGmbH, Köln, Deutschland.
| | - Olaf Kolzter
- CLINOTEL Krankenhausverbund gGmbH, Köln, Deutschland
| | - Gerd Albuszies
- Klinik für Anästhesiologie, anästhesiologische Intensivmedizin und perioperative Schmerztherapie, Gesundheits- und Pflegezentrum Rüsselsheim gGmbH, Rüsselsheim, Deutschland
| | - Frank Thölen
- CLINOTEL Krankenhausverbund gGmbH, Köln, Deutschland
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Serum anion gap predicts lactate poorly, but may be used to identify sepsis patients at risk for death: A cohort study. J Crit Care 2018; 44:223-228. [DOI: 10.1016/j.jcrc.2017.10.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/22/2017] [Accepted: 10/28/2017] [Indexed: 01/17/2023]
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Patel JJ, Kurman J, Al-Ghandour E, Thandra K, Mawari S, Graf J, Kovac J, Rein L, Simpson SQ. Predictors of 24-h mortality after inter-hospital transfer to a tertiary medical intensive care unit. J Intensive Care Soc 2018; 19:319-325. [PMID: 30515241 DOI: 10.1177/1751143718765412] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose To identify variables associated with 24-h mortality after inter-hospital transfer. Materials and methods Single center retrospective study of adult patients transferred to a tertiary care medical ICU between 1 January 2010 and 15 April 2014. Demographic, clinical, physiologic, and laboratory data were collected. The Lasso method was used for logistic regression to identify predictors of 24-h mortality after inter-hospital ICU transfer. Results We identified 773 patients. Median age was 58 years (IQR 45-69), 49% were female, 83% Caucasian, and 48% had Medicare. The median length of stay at the transferring facility was 1.0 day (IQR 0-2). Median SOFA score on the day of ICU transfer was 5 (IQR 2-8). Twenty-two (3%) died within 24 h after inter-hospital transfer. SOFA score of 12-16 the day of inter-hospital transfer (odds ratio (OR) 7.77, 95% CI 1.21-66.26, p = 0.037), FiO2 0.8-1.0 on ICU arrival, and cardiac arrest prior to transfer (OR 4.94, 95% CI 1.43-15.96, p = 0.009) were associated with an increased risk for 24-h mortality after inter-hospital transfer. Conclusions Our study identified biologically plausible and potentially modifiable factors associated with 24-h mortality after inter-hospital medical ICU transfer, which may serve to inform patients and families of readiness and risk for mortality after inter-hospital transfer.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jonathan Kurman
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL, USA
| | | | - Krishna Thandra
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Samih Mawari
- John Dingell Veteran's Affairs Medical Center, Detroit, MI, USA
| | - Jeanette Graf
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, WI, USA
| | - Jennifer Kovac
- Department of Emergency Medicine, Medical College of Wisconsin, WI, USA
| | - Lisa Rein
- Institute for Health and Society, Medical College of Wisconsin, WI, USA
| | - Steven Q Simpson
- Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, KS, USA
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Rush B, Tyler PD, Stone DJ, Geisler BP, Walley KR, Celi LA. Outcomes of Ventilated Patients With Sepsis Who Undergo Interhospital Transfer: A Nationwide Linked Analysis. Crit Care Med 2018; 46:e81-e86. [PMID: 29068858 PMCID: PMC5734994 DOI: 10.1097/ccm.0000000000002777] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The outcomes of critically ill patients who undergo interhospital transfer are not well understood. Physicians assume that patients who undergo interhospital transfer will receive more advanced care that may translate into decreased morbidity or mortality relative to a similar patient who is not transferred. However, there is little empirical evidence to support this assumption. We examined country-level U.S. data from the Nationwide Readmissions Database to examine whether, in mechanically ventilated patients with sepsis, interhospital transfer is associated with a mortality benefit. DESIGN Retrospective data analysis using complex survey design regression methods with propensity score matching. SETTING The Nationwide Readmissions Database contains information about hospital admissions from 22 States, accounting for roughly half of U.S. hospitalizations; the database contains linkage numbers so that admissions and transfers for the same patient can be linked across 1 year of follow-up. PATIENTS From the 2013 Nationwide Readmission Database Sample, 14,325,172 hospital admissions were analyzed. There were 61,493 patients with sepsis and on mechanical ventilation. Of these, 1,630 patients (2.7%) were transferred during their hospitalization. A propensity-matched cohort of 1,630 patients who did not undergo interhospital transfer was identified. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The exposure of interest was interhospital transfer to an acute care facility. The primary outcome was hospital mortality; the secondary outcome was hospital length of stay. The propensity score included age, gender, insurance coverage, do not resuscitate status, use of renal replacement therapy, presence of shock, and Elixhauser comorbidities index. After propensity matching, interhospital transfer was not associated with a difference in in-hospital mortality (12.3% interhospital transfer vs 12.7% non-interhospital transfer; p = 0.74). However, interhospital transfer was associated with a longer total hospital length of stay (12.8 d interquartile range, 7.7-21.6 for interhospital transfer vs 9.1 d interquartile range, 5.1-17.0 for non-interhospital transfer; p < 0.01). CONCLUSIONS Patients with sepsis requiring mechanical ventilation who underwent interhospital transfer did not have improved outcomes compared with a cohort with matched characteristics who were not transferred. The study raises questions about the risk-benefit profile of interhospital transfer as an intervention.
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Affiliation(s)
- Barret Rush
- Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, 677 Huntington Ave, Boston, MA 02115
- Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, Canada
| | - Patrick D Tyler
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David J Stone
- Departments of Anesthesiology and Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Benjamin P Geisler
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston MA 02114
| | - Keith R Walley
- Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, Canada
| | - Leo Anthony Celi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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47
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Abstract
IMPORTANCE Timely and efficient access to hospital care is essential for the health and well-being of children. As insurance networks, accountable care organizations, and alternative payment methods evolve, these new systems of care must continue to serve the needs of children. OBJECTIVE To test the hypothesis that the availability of definitive pediatric hospital care is significantly more limited than adult care and is decreasing disproportionately. DESIGN This study used case mix data during fiscal years 2004 through 2014 to measure transfer frequency and identify the site of care completion for all patients seen in acute care hospitals throughout Massachusetts. Patterns of care among children were then compared with patterns of care among adults. Participants were all patients seen in an emergency department or admitted to a hospital from 2004 through 2014, including more than 34 million encounters. MAIN OUTCOMES AND MEASURES Hospital Capability Index and Regionalization Index for all acute care hospitals and all conditions within the Clinical Classifications Software of the Healthcare Cost and Utilization Project. RESULTS Over the study period, the Commonwealth of Massachusetts hospital system was composed of 66 acute care hospitals. After excluding newborns and mental health conditions, there were 34 511 312 encounters, with 25 226 014 emergency department visits and 9 285 298 observation or full admissions. From 2004 through 2014, care for adults and children concentrated among hospitals but much more so for pediatric care. The number of children requiring care in more than one hospital increased 36.2% (from 7190 to 9793). The median (interquartile range [IQR]) Hospital Capability Index, reflecting the likelihood of a hospital completing a patient's care without transfer, decreased 10.8% (from 0.74 [IQR, 0.65-0.81] to 0.66 [IQR, 0.53-0.76]) for adult care and 65.0% (0.20 [IQR, 0.05-0.34] to 0.07 [IQR, 0.01-0.23]) for pediatric care. Almost all of the shift was from nonacademic to academic hospitals. The median Regionalization Index, reflecting the degree to which care for specific conditions is regionalized, was very high for pediatric conditions and further increased from 0.79 (IQR, 0.67-0.91) to 0.87 (IQR, 0.80-0.91). Over the same decade, the mean Regionalization Index for adult conditions was low and increased modestly from 0.25 (IQR, 0.14-0.39) to 0.32 (IQR, 0.19-0.46). Among pediatric conditions, more than 75% were highly regionalized in 2014 compared with fewer than 50% in 2004. CONCLUSIONS AND RELEVANCE Pediatric hospital care has become increasingly concentrated, and many children with common conditions are now less frequently treated in the community. This finding has significant implications for systemwide capacity management and should be specifically accounted for in public health activities, disaster planning, and determinations of network adequacy.
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Affiliation(s)
- Urbano L. França
- Division of Critical Care, Department of Anesthesia, Perioperative, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Michael L. McManus
- Division of Critical Care, Department of Anesthesia, Perioperative, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
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48
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Janz DR, Khan YA, Mooney JL, Semler MW, Rice TW, Johnson JL, deBoisblanc BP. Effect of Interhospital ICU Relocation on Patient Physiology and Clinical Outcomes. J Intensive Care Med 2017; 34:1010-1016. [PMID: 28820040 DOI: 10.1177/0885066617726754] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Relocation of large numbers of critically ill patients between hospitals is sometimes necessary and the risks associated with relocation may be high. In the setting of adherence to an interhospital intensive care unit (ICU) relocation protocol, we aimed to determine whether the interhospital relocation of all ICU patients in a single day is associated with changes in vital signs, device removal, and worse clinical outcomes. We conducted a prospective, observational, cohort study of all critically ill adults admitted to a tertiary medical center's ICUs on the day of a planned hospital relocation and exposed to interhospital ICU relocation compared with unexposed critically ill adults. Changes in vital signs were evaluated by the before-and-after interhospital relocation measurement of vital signs, and clinical outcomes were collected for all patients. A total of 699 patients were admitted to the ICU during the observation period, 24 of whom were exposed to interhospital ICU relocation on a single day. The median interhospital transport duration was 28 minutes (interquartile range: 24-35) and 29% of patients were receiving invasive mechanical ventilation. Patients exposed to interhospital ICU relocation had no significant change in any vital sign measurement and no devices were unintentionally removed. Inhospital mortality was similar (8.3%) to patients not exposed to interhospital ICU relocation (9.2%, P > .99). In the setting of adherence to an ICU relocation protocol, the interhospital ICU relocation of all critically ill adults during a single day is not associated with changes in vital signs, device removal, or worse clinical outcomes.
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Affiliation(s)
- David R Janz
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Yasin A Khan
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Jennifer L Mooney
- Department of Surgery, Section of Trauma/Critical Care Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Matthew W Semler
- Division of Allergy, Department of Medicine, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Todd W Rice
- Division of Allergy, Department of Medicine, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jessica L Johnson
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Bennett P deBoisblanc
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA, USA
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49
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Case Volume-Outcomes Associations Among Patients With Severe Sepsis Who Underwent Interhospital Transfer. Crit Care Med 2017; 45:615-622. [PMID: 28151758 DOI: 10.1097/ccm.0000000000002254] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Case volume-outcome associations bolster arguments to regionalize severe sepsis care, an approach that may necessitate interhospital patient transfers. Although transferred patients may most closely reflect care processes involved with regionalization, associations between sepsis case volume and outcomes among transferred patients are unclear. We investigated case volume-outcome associations among patients with severe sepsis transferred from another hospital. DESIGN Serial cross-sectional study using the Nationwide Inpatient Sample. SETTING United States nonfederal hospitals, years 2003-2011. PATIENTS One hundred forty-one thousand seven hundred seven patients (weighted national estimate of 717,732) with severe sepsis transferred from another acute care hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We examined associations between quintiles of annual hospital severe sepsis case volume for the receiving hospital and in-hospital mortality among transferred patients with severe sepsis. Secondary outcomes included hospital length of stay and total charges. Transferred patients accounted for 13.2% of hospitalized severe sepsis cases. In-hospital mortality was 33.2%, with median length of stay 11 days (interquartile range, 5-22), and median total charge $70,722 (interquartile range, $30,591-$159,013). Patients transferred to highest volume hospitals had higher predicted mortality risk, greater number of acutely dysfunctional organs, and lower adjusted in-hospital mortality when compared with the lowest-volume hospitals (odds ratio, 0.80; 95% CI, 0.67-0.90). In stratified analysis (p < 0.001 for interaction of case volume by organ failure), mortality benefit associated with case volume was limited to patients with single organ dysfunction (n = 48,607, 34.3% of transfers) (odds ratio, 0.66; 95% CI, 0.55-0.80). Treatment at highest volume hospitals was significantly associated with shorter adjusted length of stay (incidence rate ratio, 0.86; 95% CI, 0.75-0.98) but not costs (% charge difference, 95% CI: [-]18.8, [-]37.9 to [+]0.3). CONCLUSIONS Hospital mortality was lowest among patients with severe sepsis who were transferred to high-volume hospitals; however, case volume benefits for transferred patients may be limited to patients with lower illness severity.
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Rural Patients With Severe Sepsis or Septic Shock Who Bypass Rural Hospitals Have Increased Mortality: An Instrumental Variables Approach. Crit Care Med 2017; 45:85-93. [PMID: 27611977 DOI: 10.1097/ccm.0000000000002026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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