Interhospital Transfer Delays Appropriate Treatment for Patients With Severe Sepsis and Septic Shock: A Retrospective Cohort Study

Pitfalls in the Treatment of Sepsis

Sepsis is a challenging, dynamic, pathophysiology requiring expertise in diagnosis and management. Controversy exists as to the most sensitive early indicators of sepsis and sepsis severity. Patients presenting to the emergency department often lack complete history or clinical data that would point to optimal management. Awareness of these potential knowledge gaps is important for the emergency provider managing the septic patient. Specific areas of management including the initiation and management of mechanical ventilation, the appropriate disposition of the patient, and consideration of transfer to higher levels of care are reviewed.

Out-of-Hospital ICU Transfers to an Oncological Referral Center: Characteristics, Resource Utilization, and Patient Outcomes

OBJECTIVE:

To determine resource utilization and outcomes of out-of-hospital transfer patients admitted to the intensive care unit (ICU) of a cancer referral center.

DESIGN:

Single-center cohort.

SETTING:

A tertiary oncological center.

PATIENTS:

Patients older than 18 years transferred to our ICU from an outside hospital between January 2013 and December 2015.

MEASUREMENTS AND MAIN RESULTS:

A total of 2127 (90.3%) were emergency department (ED) ICU admissions and 228 (9.7%) out-of-hospital transfers. The ICU length of stay (LOS) was longer in the out-of-hospital transfers when compared to all other ED ICU admissions ( P = .001); however, ICU and hospital mortality were similar between both groups. The majority of patients were transferred for a higher level of care (77.2%); there was no difference in the amount of interventions performed, ICU LOS, and ICU mortality between nonhigher level-of-care and higher level-of-care patients. Factors associated with an ICU LOS ≥10days were a higher Sequential Organ Failure Assessment (SOFA) score, weekend admissions, presence of shock, need for mechanical ventilation, and acute kidney injury on admission or during ICU stay ( P < .008). The ICU mortality of transferred patients was 17.5% and associated risk factors were older age, higher SOFA score on admission, use of mechanical ventilation and vasopressors during ICU stay, and renal failure on admission ( P < .0001). Data related to the transfer such as LOS at the outside facility, time of transfer, delay in transfer, and longer distance traveled were not associated with increased LOS or mortality in our study.

CONCLUSION:

Organ failure severity on admission, and not transfer-related factors, continues to be the best predictor of outcomes of critically ill patients with cancer when transferred from other facilities to the ICU. Our data suggest that transferring critically ill patients with cancer to a specialized center does not lead to worse outcomes or increased resource utilization when compared to patients admitted from the ED.

Interhospital transfers of the critically ill: Time spent at referring institutions influences survival

OBJECTIVE

To determine if the length of stay at a referring institution intensive care unit (ICU) before transfer to a tertiary/quaternary care facility is a risk factor for mortality.

DESIGN

We performed a retrospective chart review of patients transferred to our ICU from referring institution ICUs over a 3-year period. Logistical regression analysis was performed to determine which factors were independently associated with increased mortality. The primary outcomes were ICU and hospital mortality.

MAIN RESULTS

A total of 1248 patients were included in our study. Length of stay at the referring institution was an independent risk factor for both ICU and hospital mortality (P<.0001), with increasing lengths of stay correlating with increased mortality. Each additional day at the referring institution was associated with a 1.04 increase in likelihood of ICU mortality (95% confidence interval, 1.02-1.06; P =0.001) and a 1.029 (95% confidence interval, 1.01-1.05; P .005) increase in likelihood of hospital mortality.

CONCLUSIONS

Length of stay at the referring institution before transfer is a risk factor for worse outcomes, with longer stays associated with increased likelihood of mortality. Further studies delineating which factors most affect length of stay at referring institutions, though a difficult task, should be pursued.

[Telemedicine in the ICU - the possibilities and limitations of an innovation]

BACKGROUND

Intensive care medicine is challenged by demographic changes and an increasing number of patient combined with existing shortage of doctors. Telemedicine is a promising approach to ensure patient care in the coming years. Due to a shortage of intensive care physicians in the USA, comprehensive telemedicine coverage has already been established. To date, 11 % of all hospitals are supported by a telemedicine center. The beneficial impact in terms of quality of care, patient safety and economic factors has been confirmed in numerous multicenter studies.

RESULTS

In the largest multicenter study by Lilly et al., including 107,432 critically ill patients in the intervention group, telemedicine interventions led to a reduced ICU and hospital mortality. In addition, tele-consulting significantly reduced the ICU- and hospital length of stay. These findings were further supported by following studies and metaanalysis, which confirmed these results. The incidence of ventilator-associated pneumonia and catheter-associated infections was significantly reduced, when compared to the preintervention group. Furthermore, patient safety and treatment outcomes were improved by increased guideline adherence. Last, the telemedicine intervention significantly decreased the overall treatment costs. These positive results were reproducible even in larger and academic hospitals. At the same time it should be pointed out that a transfer to other health care systems should be considered cautiously in the context of different local infrastructure and culture. Finally, it has to be investigated to what extent the results can be transferred to the health-care situation in Germany.

CONCLUSION

Previous data demonstrated that telemedical support can improve the outcome in critically ill patients, both during hospitalization as well as in the long-term result until the discharge home. Telemedicine is neither a magic bullet nor a replacement for a physician. Instead it is a new type of medical cooperation to further improve the outcomes of critically ill patients.

Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: An instrumental variables approach

PURPOSE

The objective of this study was to evaluate the impact of regionalization on sepsis survival, to describe the role of inter-hospital transfer in rural sepsis care, and to measure the cost of inter-hospital transfer in a predominantly rural state.

MATERIALS AND METHODS

Observational case-control study using statewide administrative claims data from 2005 to 2014 in a predominantly rural Midwestern state. Mortality and marginal costs were estimated with multivariable generalized estimating equations models and with instrumental variables models.

RESULTS

A total of 18 246 patients were included, of which 59% were transferred between hospitals. Transferred patients had higher mortality and longer hospital length-of-stay than non-transferred patients. Using a multivariable generalized estimating equations (GEE) model to adjust for potentially confounding factors, inter-hospital transfer was associated with increased mortality (aOR 1.7, 95% CI 1.5-1.9). Using an instrumental variables model, transfer was associated with a 9.2% increased risk of death. Transfer was associated with additional costs of $6897 (95% CI $5769-8024). Even when limiting to only those patients who received care in the largest hospitals, transfer was still associated with $5167 (95% CI $3696-6638) in additional cost.

CONCLUSIONS

The majority of rural sepsis patients are transferred, and these transferred patients have higher mortality and significantly increased cost of care.