Mortality of interhospital transfers originating from an emergency department in Perth, Western Australia

Factors influencing interhospital transfer delays in emergency general surgery: a systematic review and narrative synthesis

BACKGROUND

Emergency general surgery is an emerging public health issue globally, with substantial healthcare burden. Interhospital transfer of critically unwell surgical patients has been the mainstay of bridging gaps in surgical coverage in regional and rural locations, despite evidence of greater morbidity and mortality. Delays in transfer invariably occurs and compounds the situation. Our aim was to examine the factors influencing interhospital transfer delays in emergency general surgical patients.

METHODS

A systematic search of PubMED and EmBase, was performed by two researchers from 2020 to 23rd Feb 2021, for English articles related to interhospital transfer delays in emergency general surgical patients, with an age of >16. Articles were critically appraised and data were extracted into a pre-specified data extraction form. No data was suitable for statistical analysis and a narrative synthesis was performed instead.

RESULTS

Six relevant articles were identified from the search. All studies were retrospective cohort studies with moderate to high risk of bias. Lack of consultant surgeon input, after hours transfer, need for intensive care bed and poor transfer documentation may have a role in interhospital transfer delays. Patients with public health insurance, multiple comorbidities and non-emergency medical conditions experience longer transfer request time and may be at risk of precipitating interhospital transfer delays. Transfer delays are seen in transfers over longer distances.

CONCLUSION

There is a paucity of knowledge on what and how factors influence interhospital transfer delays in emergency general surgical patients. Well-designed prospective cohort studies are required to bridge this knowledge gap.

The importance of the partnership between the public and private healthcare institutions to improve interhospital patient transfers

Purpose

The purpose of this study/paper is to identify the importance of the partnership between the public and private health-care institutions to improve interhospital patient transfers. Scientific research and statistical data show the increased number of interhospital transportation services; therefore, timely and qualified patient transportation between different health-care institutions must be considered, the activity that directly and significantly impacts the patient’s health status and overall quality of the health-care services. The successful patient transportation from the smaller hospitals to the health-care institutions with advanced intensive care or urgent care units can be enhanced through the partnership between private and public health-care institutions.

Design/methodology/approach

The methodology included quantitative method, statistical data analysis and theoretical data generalization. Both primary and secondary data were collected and analyzed during the research. Expert quantification was performed using the survey research method. The survey was conducted in Lithuania. The respondents were selected to be the general managers of the health-care and urgent care institutions, the chief doctors of the reanimation and intensive care department also the chief doctors of the emergency department.

Findings

Because of the centralization and regionalization of health-care services, the number of patients transferred between hospitals by the emergency medical services (EMS) and personal health-care institutions has increased. University hospitals are not sufficiently prepared to accept an increasing flow of patients in accordance with the Ministry of Health orders. Not all regional or district hospitals have the right to provide such assistance, which increases transportation time and costs as well as requires additional human resources. The five EMS categories could be used to improve the patient transfer between different levels of health-care institutions. To increase partnership between private and public health-care organizations, incentives should be provided for the development of private health-care organizations, as well as encouraging actions should be taken to increase the demand for private health-care services by Lithuanian patients.

Practical implications

Five EMS categories identified in this paper could be used to ensure a smooth mechanism for the patient transfer between different levels of the personal health-care institutions. The proposed categories should also be used in the pre-stationary emergency phase (for reducing the interhospital patient transportation amount).

Social implications

Properly organized secondary and tertiary interhospital patient transfers influence the availability and quality of the EMS and reduce inequalities in the provided services and social exclusion.

Originality/value

This paper presents the classification of the interhospital transfer issues, determines the main reasons for the patient interhospital transfer, creates the model for the EMS patient process flows and defines five EMS categories for the assessment of patient conditions. Therefore, the research conducted and the results obtained have both theoretical and social-practical value.

Prognostic factors for short-term patient mortality following interhospital transfers

Introduction:

The data on short-term mortality among patients following interhospital transfers remain uncertain in the literature, and particularly in Turkey. The aim of this study was to determine the characteristics of interhospital transfer patients and to investigate the factors associated with 72-h mortality.

Methods:

All interhospital transfer patients aged 16 years and above from a secondary care public hospital were evaluated retrospectively for the period January to December 2018. A total of 34 variables, including age, gender, date of transfer, referring unit, diagnosis, reason for transfer, transfer destination, waiting and transfer time, vitals, the Glasgow Coma Scale, the presence of intubation, cardiopulmonary resuscitation before transfer, and the use of vasopressor medication, were included in the univariate analysis. The factors associated with short-term mortality were identified by multivariate regression analysis.

Results:

During the 1-year study period, 1216 interhospital transfers were performed. A total of 116 (9.5%) patients died within 72 h following interhospital transfer. Among all the transfers, the median age was 62 (interquartile range, 39–76) years. According to the multivariate analysis, vasopressor use (odds ratio, 3.55; 95% confidence interval: 1.32–9.52), age (odds ratio, 1.01; 95% confidence interval: 1.00–1.03), pulse (odds ratio, 1.01; 95% confidence interval: 1.00–1.02), and diastolic blood pressure (odds ratio, 0.97; 95% confidence interval: 0.95–0.99) were predictive of 72-h mortality following interhospital transfer.

Conclusion:

Nearly 10% of all the transfers from the secondary care public hospital resulted in mortality within 72 h. Vasopressor use, advanced age, lower diastolic blood pressure, and tachycardia were the most important factors associated with short-term mortality.

Comparison between urban and rural mortality in patients with acute myocardial infarction: a nationwide longitudinal cohort study in South Korea

OBJECTIVES

This study investigated the risk associated with interhospital transfer of patients with acute myocardial infarction (AMI) and clinical outcomes according to the location of the patient' residence.

DESIGN

A nationwide longitudinal cohort.

SETTING

National Health Insurance Service database of South Korea.

PARTICIPANTS

This study included 69 899 patients with AMI who visited an emergency centre from 2013 to 2015, as per the Korea National Health Insurance Service database.

PRIMARY OUTCOME MEASURE

The clinical outcome of a patient with AMI was defined as mortality within 7 days, 30 days and 1 year.

RESULTS

Clinical outcomes were analysed and compared with respect to the location of the patient's residence and occurrence of interhospital transfer. We concluded that the HR of mortality within 7 days was 1.49 times higher (95% CI 1.18 to 1.87) in rural patients than in urban patients not subjected to interhospital transfer and 1.90 times higher (95% CI 1.13 to 3.19) in transferred rural patients than in non-transferred urban patients.

CONCLUSIONS

To reduce health inequality in rural areas, a healthcare policy considering regional characteristics, rather than a central government-led, catch-all approach to healthcare policy, must be formulated. Additionally, a local medical emergency delivery system, based on allocation of roles between different medical facilities in the region, must be established.

Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013

BACKGROUND

In 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning.

METHODS

A state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique.

FINDINGS

There were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most 'crowded' ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing.

CONCLUSIONS

The FHR had a consistent effect on 'flow' measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia.