Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury

A Telemedicine Solution to Minimize Unnecessary Emergency Department Transfers for Low-acuity Pediatric Orthopaedic Patients: A Model for Cost Minimization

INTRODUCTION

Unnecessary emergency department (ED) transfers represent a notable source of excess costs and misutilization of healthcare resources, particularly with management of acute pediatric musculoskeletal injuries. This study used institutional data to create a model investigating the expected costs of a formal peer-to-peer telemedicine intervention designed to triage pediatric orthopaedic transfers, which we hypothesized would decrease healthcare costs by minimizing unwarranted ED-to-ED transfers.

METHODS

In this retrospective modeling analysis, 350 pediatric orthopaedic trauma patients transferred to two in-network referral hospitals from outside facilities were identified and stratified into three groups representing how patients theoretically optimally could have been treated. Group 1 patients required ambulance transfer, group 2 patients required ED-level care but no ambulance transfer, and group 3 patients did not require ED-level care. Base case estimates for the proportions of patients in each group, probability of ambulance transport, and direct costs of care for each patient were derived from the database. A decision tree was developed to evaluate the expected costs of two triaging strategies: (1) transfer everyone or (2) triage first using e-consultation. Probabilistic sensitivity analyses were used to determine how the results of the decision analysis varied across ranges of cost and probability estimates.

RESULTS

In the base case analysis, the telemedicine triage strategy was cheaper than the transfer-all strategy ($4,858 versus $6,610). In a 2-way sensitivity analysis comparing cost of a telemedicine visit and proportion of telemedicine triaged patients requiring ambulance transport, the telemedicine triage strategy remained cheaper than the transfer-all strategy across almost all possibilities for both variables. Additional potential benefits of triage before transfer, such as decreased length of time to completion of ED visit, cost to the family, and patient comfort and satisfaction, were not incorporated into this analysis. The potential for misdiagnosis related to telehealth and its potential costs were not included.

DISCUSSION

We revealed substantial cost savings for the healthcare system from implementing a telehealth platform for peer-to-peer consultation when considering patient transfer for musculoskeletal trauma. Initial peer-to-peer e-consultations cost less than reflexive ambulance transfer in most situations.

LEVEL OF EVIDENCE

Economic Level II.

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

INTRODUCTION

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

OBJECTIVE

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

DESIGN

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

FINDINGS

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

DISCUSSION AND CONCLUSION

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

Process improvement using telemedicine consultation to prevent unnecessary interfacility transfers for low-severity blunt head trauma

OBJECTIVE

Mild traumatic brain injuries (MTBI) associated with intracranial haemorrhage are commonly transferred to tertiary care centres. Recent studies have shown that transfers for low-severity traumatic brain injuries may be unnecessary. Trauma systems can be overwhelmed by low acuity patients justifying standardisation of MTBI transfers. We sought to evaluate the impact of telemedicine services on mitigating unnecessary transfers for those presenting with low-severity blunt head trauma after sustaining a ground level fall (GLF).

METHOD

A process improvement plan was developed by a task force of transfer centre (TC) administrators, emergency department physicians (EDP), trauma surgeons and neurosurgeons (NS) to facilitate the requesting EDP and the NS on-call to converse directly to mitigate unnecessary transfers. Consecutive retrospective chart review was performed on neurosurgical transfer requests between 1 January 2021 and 31 January 2022. A comparison of transfers preintervention and postintervention (1 January 2021 to 12 September 2021)/(13 September 2021 to 31 January 2022) was performed.

RESULTS

The TC received 1091 neurological-based transfer requests during the study period (preintervention group: 406 neurosurgical requests; postintervention group: 353 neurosurgical requests). After consultation with the NS on-call, the number of MTBI patients remaining at their respective ED's with no neurological degradation more than doubled from 15 in the preintervention group to 37 in the postintervention group.

CONCLUSION

TC-mediated telemedicine conversations between the NS and the referring EDP can prevent unnecessary transfers for stable MTBI patients sustaining a GLF if needed. Outlying EDPs should be educated on this process to increase efficacy.

Air ambulance retrievals of patients with suspected appendicitis and acute abdominal pain: The patients' journeys, referral pathways and appendectomy outcomes using linked data in Central Queensland, Australia

INTRODUCTION

Acute appendicitis is the most common cause of acute abdominal pain presentations to the ED and common air ambulance transfer.

AIMS

describe how linked data can be used to explore patients' journeys, referral pathways and request-to-activation responsiveness of patients' appendectomy outcomes (minor vs major complexity).

METHODS

Data sources were linked: aeromedical, hospital and death. Request-to-activation intervals showed strong right-tailed skewness. Quantile regression examined whether the longest request-to-activation intervals were associated with appendicitis complexity in patients who underwent an appendectomy.

RESULTS

There were 684 patients in three referral pathways based on hospital capability levels. In total, 5.6 % patients were discharged from ED. 83.3 % of all rural origins entered via the ED. 3.8 % of appendicitis patients were triaged to tertiary hospitals. Appendectomy patients with major complexity outcomes were less likely to have longer request-to-activation wait times & had longer lengths of stay than patients with minor complexity outcomes.

CONCLUSIONS

Linked data highlighted four aspects of a functioning referral system: appendectomy outcomes of major complexity were less likely to have longer request-to-activation intervals compared to minor (sicker patients were identified); few were discharged from EDs (validated transfer); few were triaged to tertiary hospitals (appropriate level for need), and no deaths relating to appendectomy.

Association of the Affordable Care Act Medicaid Expansion With Secondary Overtriage among Young Adult Trauma Patients

BACKGROUND

Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers.

METHODS

Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles.

RESULTS

Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage.

CONCLUSIONS

In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.

Social network analysis of nationwide interhospital emergency department transfers in Taiwan

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

Interfacility Emergency Department Transfer for Midface Fractures in the United States

PURPOSE

Interfacility hospital transfer for isolated midfacial fractures is common but rarely clinically necessary. The purpose of this study was to generate nationally representative estimates regarding the incidence, risk factors, and cost of transfer for isolated midface fractures.

METHODS

This was a retrospective cohort study using the Nationwide Emergency Department Sample 2018 to identify patients with isolated midface fractures. The primary predictor variable was hospital trauma center designation (Level I, Level II, Level III, and nontrauma center). The primary outcome variable was hospital transfer. Total emergency department (ED) charges were also assessed. Covariates were demographic, medical, injury-related, and hospital characteristics. Descriptive, bivariate, and multiple logistic regression statistics were used to evaluate the incidence and predictors of interfacility transfer.

RESULTS

During the study period, there were 161,022 ED encounters with a midface fracture as primary diagnosis, of which 5,680 were transferred (3.53%). In an unadjusted analysis, evaluation at a nontrauma center, level III trauma center, nonteaching hospital, and numerous demographic, medical, and injury-related variables were associated with transfer (P ≤ .001). In the adjusted model, the strongest independent predictors for hospital transfer were evaluation at a nontrauma center (odds ratio [OR] = 16.2, 95% confidence interval [CI] = 13.6-19.4), level III trauma center (OR = 13.4, 95% CI = 11.1-16.1) or level II trauma center (OR = 3.25, 95% CI = 2.66-3.98), any Le Fort fracture (OR = 12.0, 95% CI = 10.4-14.0), orbital floor fracture (OR = 3.73, 95% CI = 3.48-4.00), history of cerebrovascular event (OR = 2.74, 95% CI = 2.18-3.45), and cervical spine injury (OR = 5.87, 95% CI = 4.79-7.20) (P ≤ .001). The average ED charge per encounter was $7,206 ± 9,294 for a total nationwide charge of approximately 1.16 billion dollars. Transferred subjects had total ED charges of $97 million, not including additional charges at the recipient hospital.

CONCLUSION

Isolated midface fractures are transferred infrequently, but given the high incidence have substantial healthcare costs. Predictors of transfer were mixed rather than clustered within one variable type, although it is likely that transfers are driven in part by lack of access to maxillofacial specialists given the predominance of hospital covariates. Programs evaluating necessity of transfer and facilitating specialist evaluation in the outpatient setting may reduce healthcare expenditures for these injuries.

Evaluation of factors associated with interhospital transfers to pediatric and adult tertiary level of care: A study of acute neurological disease cases

INTRODUCTION

Patient referrals to tertiary level of care neurological services are often potentially avoidable and result in inferior clinical outcomes. To decrease transfer burden, stakeholders should acquire a comprehensive perception of specialty referral process dynamics. We identified associations between patient sociodemographic data, disease category and hospital characteristics and avoidable transfers, and differentiated factors underscoring informed decision making as essential care management aspects.

MATERIALS AND METHODS

We completed a retrospective observational study. The inclusion criteria were pediatric and adult patients with neurological diagnosis referred to our tertiary care hospital. The primary outcome was potentially avoidable transfers, which included patients discharged after 24 hours from admission without requiring neurosurgery, neuro-intervention, or specialized diagnostic methodologies and consult in non-neurologic specialties during their hospital stay. Variables included demographics, disease category, health insurance and referring hospital characteristics.

RESULTS

Patient referrals resulted in 1615 potentially avoidable transfers. A direct correlation between increasing referral trends and unwarranted transfers was observed for dementia, spondylosis and trauma conversely, migraine, neuro-ophthalmic disease and seizure disorders showed an increase in unwarranted transfers with decreasing referral trends. The age group over 90 years (OR, 3.71), seizure disorders (OR, 4.16), migraine (OR, 12.50) and neuro-ophthalmic disease (OR, 25.31) significantly associated with higher probability of avoidable transfers. Disparities between pediatric and adult transfer cases were identified for discrete diagnoses. Hospital teaching status but not hospital size showed significant associations with potentially avoidable transfers.

CONCLUSIONS

Neurological dysfunctions with overlapping clinical symptomatology in ageing patients have higher probability of unwarranted transfers. In pediatric patients, disease categories with complex symptomatology requiring sophisticated workup show greater likelihood of unwarranted transfers. Future transfer avoidance recommendations include implementation of measures that assist astute disorder assessment at the referring hospital such as specialized diagnostic modalities and teleconsultation. Additional moderators include after-hours specialty expertise provision and advanced directives education.

Frequency and Predictors of Trauma Transfer Futility to a Rural Level I Trauma Center

INTRODUCTION

Transfer of trauma patients whose injuries are deemed unsurvivable, often results in early death or transition to comfort care and could be considered misuse of health care resources. This is particularly true where tertiary care resources are limited. Identifying riskfactors for and predicting futile transfers could reduce this impact and help to optimize triage and management.

METHODS

A retrospective study of interfacility trauma transfers to a single rural Level I rauma center from 2014 to 2019. Futility was defined as death, hospice, or declaration of comfort measures within 48 h of transfer without procedural or radiographic intervention at the accepting center. Multiple logistic regressions identified independent predictors of futile transfers. The predictive power of Mechanism,Glasgow coma scale, Age, and Arterial pressure (MGAP), an injury severity score based on Mechanism, Glasgow coma scale, Age, and systolic blood Pressure, were evaluated.

RESULTS

Of the 3368 trauma transfers, 37 (1.1%) met criteria as futile. Futile transfers occurred among patients who were significantly older with falls as the most common mechanism. Age, Glasgow coma scale, systolic blood Pressure and Injury Severity Score were significant (P < 0.05) independent predictors of futile transfer. MGAP had a high predictive power area under the receiver operating characteristic (AUROC 0.864, 95% confidence interval 0.803-0.925) for futility.

CONCLUSIONS

A small proportion (1.1%) of transfers to a rural Level I trauma center met criteria for futility. Predictive tools, such as MGAP scoring, can provide objective criteria for evaluation of transfer necessity and prompt care pathways that involve pre-transfer communications, telemedicine, and/or patient centered goals of care discussions. Such tools could be used in conjunction with a more granular assessment regarding potential operational barriers to reduce futile transfers and to enhance optimization of resource utilization in low-resource service areas.

Secondary overtriage of isolated facial trauma

DESIGN

Retrospective chart review.

SETTING

Academic, tertiary care, level I trauma center in a rural state.

BACKGROUND

Unnecessary transfer of certain facial trauma patients results in a burden of time, money, and other resources on both the patient and healthcare system; identification and development of outpatient treatment pathways for these patients is a significant opportunity for cost savings.

OBJECTIVES

To investigate the treatment and disposition of un-complicated, stable, isolated facial trauma injuries transferred from outside hospitals and determine the significance of secondary overtriage.

METHODS

Retrospective chart review utilizing our institutional trauma database, including patients transferred to our emergency department between January 2012 and December 2017. Patients were identified by ICD9 or ICD10 codes and only those with isolated facial trauma were included.

RESULTS

We identified 538 isolated facial trauma patients who were transferred to our institution during the study period. The majority of those patients were transferred via ground ambulance for an average of 76 miles. Overall, 82% of patients (N = 440) were discharged directly from our institution's emergency department. Almost 30% of patients did not require any formal treatment for their injuries; the potential savings associated with elimination of these unnecessary transfers was estimated to be between $388,605 and $771,372.

CONCLUSIONS

We identified a high rate of patients with stable, isolated facial trauma that could potentially be evaluated and treated without emergent transfer. The minimization of these unnecessary transfers represents a significant opportunity for cost and resource utilization savings.

LEVEL OF EVIDENCE

2b- Economic and Cost Analysis.

Interfacility Transfers for Isolated Craniomaxillofacial Trauma: Perspectives of the Facial Trauma Surgeon

STUDY DESIGN

Secondary overtriage is a burden to the medical system. Unnecessary transfers overload trauma centers, occupy emergency transfer resources, and delay definitive patient care. Craniomaxillofacial (CMF) trauma, especially in isolation, is a frequent culprit.

OBJECTIVE

The aim of this study is to assess the perspectives of facial trauma surgeons regarding the interfacility transfer of patients with isolated CMF trauma.

METHODS

A 31-item survey was developed using Likert-type scale and open-ended response systems. Internal consistency testing among facial trauma surgeons yielded a Cronbach's α calculation of .75. The survey was distributed anonymously to the American Society of Maxillofacial Surgeons, the North American Division of AO Craniomaxillofacial, and the American Academy of Facial Plastic and Reconstructive Surgery. Statistical significance in response plurality was determined by nonoverlapping 99.9% confidence intervals (P < .001). Sum totals were reported as means with standard deviations and z scores with P values of less than .05 considered significant.

RESULTS

The survey yielded 196 responses. Seventy-seven percent of respondents did not believe that most isolated CMF transfers required emergency surgery and roughly half (49%) thought that most emergency transfers were unnecessary. Fifty-four percent of respondents agreed that most patients transferred could have been referred for outpatient management and 87% thought that transfer guidelines could help decrease unnecessary transfers. Twenty-seven percent of respondents had no pre-transfer communication with the referring facility. Perspectives on the transfer of specific fracture patterns and their presentations were also collected.

CONCLUSION

Most facial trauma surgeons in this study believe that emergent transfer for isolated CMF trauma is frequently unnecessary. Such injuries rarely require emergent surgery and can frequently be managed in the outpatient setting without activating emergency transfer services. The fracture-specific data collected are a representation of the national, multidisciplinary opinion of facial trauma surgeons and correlate with previously published data on which specific types of facial fractures are most often transferred unnecessarily. The results of this study can serve as the foundation for interfacility transfer guidelines, which may provide a valuable resource in triaging transfers and decreasing associated health-care costs.

Association of insurance status with potentially avoidable transfers to an academic emergency department: A retrospective observational study

BACKGROUND

Interfacility transfers between emergency department (EDs) are common and at times unnecessary. We sought to examine the role of health insurance status with potentially avoidable transfers.

METHODS

We conducted a retrospective observational analysis using hospital electronic administrative data of all interfacility ED-to-ED transfers to a single, quaternary care adult ED in 2018. We defined a potentially avoidable transfer as an ED-to-ED transfer in which the patient did not receive a procedure from a specialist at the receiving hospital and was discharged from the ED or the receiving hospital within 24 hours of arrival. We constructed a multivariable logistic regression model to examine whether insurance status was associated with potentially avoidable transfers among all ED-to-ED transfers adjusting for patient demographics, severity, mode of arrival, clinical condition, and rurality.

RESULTS

Among 7508 transfers, 1862 (25%) were potentially avoidable and were more likely to be uninsured (20% vs 9%). In the multivariable analysis, among ED-to-ED transfers for adults aged 18-64 years old who were uninsured (vs any insurance) were significantly more likely to be potentially avoidable (adjusted odds ratio [aOR] 2.1 [1.7, 2.4]) and there is a significant interaction with age. Potentially avoidable transfers increased with younger age, male sex, black (vs white), small rural classification (vs urban), and arrival by ground ambulance (vs flight).

CONCLUSIONS

Potentially avoidable transfers comprised 1 in 4 transfers. Patients who lack insurance were more than twice as likely to be classified as potentially avoidable even after evaluating for confounders and interactions. This effect was most pronounced among younger patients. Further research is needed to explore why uninsured patients are disproportionately more likely to experience potentially avoidable transfers.

Telemedicine Facilitation of Transfer Coordination From Emergency Departments

STUDY OBJECTIVE

Interhospital transfers are costly to patients and to the health care system. The use of telemedicine may enable more efficient systems by decreasing transfers or diverting transfers from crowded referral emergency departments (EDs) to alternative appropriate facilities. Our primary objective is to describe the prevalence of telemedicine for transfer coordination among US EDs, the ways in which it is used, and characteristics of EDs that use telemedicine for transfer coordination.

METHODS

We used the 2016 National Emergency Department Inventory-USA survey to identify telemedicine-using EDs. We then surveyed all EDs using telemedicine for transfer coordination and a sample of EDs using telemedicine for other clinical applications. We used a multivariable logistic regression model to identify characteristics independently associated with use of telemedicine for transfer coordination.

RESULTS

Of the 5,375 EDs open in 2016, 4,507 responded to National Emergency Department Inventory-USA (84%). Only 146 EDs used telemedicine for transfer coordination; of these, 79 (54%) used telemedicine to assist with clinical care for local admission, 117 (80%) to assist with care before transfer, and 92 (63%) for arranging transfer to a different hospital. Among telemedicine-using EDs, lower ED annual visit volume (odds ratio 5.87, 95% CI 2.79 to 12.36) was independently associated with use of telemedicine for transfer coordination.

CONCLUSION

Although telemedicine has potential to improve efficiency of regional emergency care systems, it is infrequently used for coordination of transfer between EDs. When used, it is most often to assist with clinical care before transfer.

Inter-facility transfer of patients with traumatic intracranial hemorrhage and GCS 14-15: The pilot study of a screening protocol by neurosurgeon to avoid unnecessary transfers

We sought to evaluate feasibility and cost-reduction potential of a pilot screening program involving neurosurgeon tele-consultation for inter-facility transfer decisions in TBI patients with GCS 14–15 and abnormal CT head at a community hospital. The authors performed a retrospective comparative analysis of two patient cohorts during the pilot at a large hospital system from 2015 to 2017. In “screened” patients (n = 85), images and examination were reviewed remotely by a neurosurgeon who made recommendations regarding transfer to a level 1 trauma center. In the “unscreened” group (n = 39), all patients were transferred. Baseline patient characteristics, outcomes, and costs were reviewed. Patient demographics were similar between cohorts. Traumatic subarachnoid hemorrhage was more common in screened patients (29.4% vs 12.8%, P = 0.02). The presence of midline shift >5 mm was comparable between groups. Among screened patients, 5 were transferred (5.8%) and one required evacuation of chronic subdural hematoma. In unscreened patients, 7 required evacuation of subdural hematoma. None of the screened patients who were not transferred deteriorated. Screened patients had significantly reduced average total cost compared to unscreened patients ($2,003 vs. $4,482, P = 0.03) despite similar lengths of stay (2.6 vs. 2.7 days, P = 0.85). In non-surgical patients, costs were less in the screened group ($2,025 vs. $2,939), although statistically insignificant (P = 0.38).

In this pilot study, remote review of images and examination by a neurosurgeon was feasible to avoid unnecessary transfer of patients with traumatic intracranial hemorrhage and GCS 14–15. The true potential in cost-reduction will be realized in system-wide large-scale implementation.

Necessity of trauma referrals to the emergency department

Background:

Patients with traumatic injuries presenting to the emergency department (ED) may be referred to another hospital for further management. Unnecessary referrals can inflate health-care costs and workload, as well as reduce provider and patient satisfaction.

Objectives:

In this study, we determined the proportion of unnecessary trauma referrals and described the characteristics of this patient population.

Methods:

A retrospective chart review was carried out between 1 January and 31 December 2016. Data regarding demographics, diagnosis and clinical course at the ED were collected in standardised forms. A referral was defined as unnecessary if the patient was discharged from the ED without a therapeutic procedure performed.

Results:

There were 121 trauma referrals. The mean age was 39.0±18.3 years old, and 94 (77.7%) patients were male. Seventy-eight (64.5%) of the referrals were from EDs in the same health-care cluster. Overall, 15 (12.3%) referrals were unnecessary, and of these, nine patients had sustained burns or were suffering from smoke inhalation. The length of stay of these unnecessary referrals was 197.0±96.2 minutes. Referring ED outside the health-care cluster was significantly associated with unnecessary referrals (odds ratio=4.42, 95% confidence interval 1.40–13.97, p=0.007).

Conclusion:

More than 1 in 10 trauma referrals were unnecessary. Further collaborative prospective studies with other EDs are needed to elucidate the underlying reasons for such unnecessary referrals so that targeted solutions can be implemented to reduce them in the future.

Navigating telemedicine for facial trauma during the COVID-19 pandemic

Importance

The COVID-19 pandemic is changing how health care providers practice. As some telemedicine and telecommunication support tools have been incorporated into the otolaryngology practice in response to safety and access demands, it is essential to review how these tools and services can help facilitate facial trauma evaluation during a time when clinical resources are limited.

Objective

To review applications of telemedicine for the evaluation of facial trauma to better direct utilization of these methods and technologies during times of limited access to clinical resources such as the COVID-19 pandemic.

Methods

A systematic review was conducted using PubMed, Embase, and Web of Science.

Results

After screening 158 titles and abstracts, we identified 16 eligible studies involving facial trauma evaluation using telemedicine. Telemedicine opportunities for facial trauma evaluation have the potential to be developed in the areas of multidisciplinary remote consultations, facial trauma triage, patient engagement, and postoperative follow-up.

Conclusion

The COVID-19 pandemic is posing obstacles for both providers and patients in the delivery of health care at a time of limited clinical resources. Telemedicine may provide a potential useful tool in the evaluation and triage of facial injuries and patient engagement.

Secondary Overtriage of Trauma Patients: Analysis of Clinical and Geographic Patterns

BACKGROUND

The purpose of a trauma system is to match patients' needs with hospitals' ability to care for them, recognizing that the highest levels of care cannot be provided in all locations. This means that some patients will need to be transferred from a local facility to a higher level of care. Unnecessary transfers are expensive and inconvenient to patients and families. The aim of this study is to analyze the pattern of secondary transfers in a regional trauma system.

METHODS

This is a retrospective analysis. We included patients aged 16 y and older who were transferred to University of Alabama at Birmingham Hospital between 2014 and 2018. We conducted bivariate and multivariate logistic regression analysis to identify clinical and organizational predictors of requiring a critical intervention, early discharge, intensive care unit admission, and mortality. Rather than treating each injury as isolated, we analyzed injury patterns.

RESULTS

A total of3824 patients met the inclusion criteria. Of them, 664 patients (17.4%) required a critical intervention, 635 (16.6%) were discharged within 24 h, 1356 (35.5%) were admitted to the intensive care unit, and 172 (4.0%) patients died. Univariate and multivariate analyses revealed many positive associations, with regard to injury pattern, originating center, and insurance status.

CONCLUSIONS

There are patterns in the data, and further study is required to understand drivers of secondary overtriage, and how we might be able to address this problem. Reducing the number of unnecessary transfers is a difficult task, which will require engagement at all levels of the trauma system.

Trauma transfers to the pediatric emergency department - Is it necessary?

OBJECTIVES:

Pediatric trauma patients presenting to general emergency departments (EDs) may be transferred to pediatric EDs for further management. Unnecessary transfers increase health-care costs, add to workload, and decrease satisfaction. We, therefore, aimed to evaluate the proportion of unnecessary pediatric trauma transfers and describe patient characteristics of these transfers at the pediatric ED.

METHODS:

A retrospective chart review of cases with trauma-related diagnoses was carried out from January to April 2017. Information regarding patient demographics, diagnosis, and clinical progress was collected. A transfer was defined as unnecessary if the patient was discharged from the pediatric ED without any therapeutic procedure performed.

RESULTS:

There were 117 cases of trauma transfers. The mean age was 8.3 ± 4.9 years, and 77 (65.8%) patients were male. Ninety-five (81.2%) transfers were from restructured hospitals. Thirty-one (26.5%) cases were admitted to the hospital. Thirty-four (29.1%) cases were unnecessary transfers. The length of stay in the ED for these transferred cases was 118.4 ± 87.1 min. Referring ED was not significantly associated with discharge (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 0.43–3.83, P = 0.792), discharge without any therapeutic procedure performed (OR: 1.47, 95% CI: 0.50–4.31, P = 0.591), or length of stay (mean difference: 22.3 min, 95% CI: 84.5–39.9, P = 0.471).

CONCLUSION:

About a third of trauma transfers were unnecessary. Further collaborative efforts would be necessary to further define the situation in different health-care settings and exact reasons elucidated so that targeted interventions could be implemented to improve pediatric trauma care.

Predictors of Potentially Unnecessary Transfers to Pediatric Emergency Departments

OBJECTIVES

With soaring US health care costs, identifying areas for reducing cost is prudent. Our objective was to identify the burden of potentially unnecessary pediatric emergency department (ED) transfers and factors associated with these transfers.

METHODS

We performed a retrospective analysis of Pediatric Hospital Information Systems data. We performed a secondary analysis of all patients ≤19 years transferred to 46 Pediatric Hospital Information Systems-participating hospital EDs (January 1, 2013, to December 31, 2014). The primary outcome was the proportion of potentially unnecessary transfers from any ED to a participating ED. Necessary ED-to-ED transfers were defined a priori as transfers with the disposition of death or admission >24 hours or for patients who received sedation, advanced imaging, operating room, or critical care charges.

RESULTS

Of 1 819 804 encounters, 1 698 882 were included. A total of 1 490 213 (87.7%) encounters met our definition for potentially unnecessary transfer. In multivariate analysis, age 1 to 4 years (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.34-1.39), female sex (OR, 1.08; 95% CI, 1.07-1.09), African American race (OR, 1.51; 95% CI, 1.49-1.53), urban residence (OR, 1.75; 95% CI, 1.71-1.78), and weekend transfer (OR, 1.06; 95% CI, 1.05-1.07) were positively associated with potentially unnecessary transfer. Non-Hispanic ethnicity (OR, 0.756; 95% CI, 0.76-0.78), nonminor severity (OR, 0.23; 95% CI, 0.23-0.24), and commercial insurance (OR, 0.86; 95% CI, 0.84-0.87) were negatively associated.

CONCLUSIONS

There are disparities among pediatric ED-to-ED transfers; further research is needed to investigate the cause. Additional research is needed to evaluate how this knowledge could mitigate potentially unnecessary transfers, decrease resource consumption, and limit the burden of these transfers on patients and families.

Secondary Overtriage in Patients with Complicated Mild Traumatic Brain Injury: An Observational Study and Socioeconomic Analysis of 1447 Hospitalizations

BACKGROUND

Secondary overtriage is a problematic phenomenon because it creates unnecessary expense and potentially results in the mismanagement of healthcare resources. The rates of secondary overtriage among patients with complicated mild traumatic brain injury (cmTBI) are unknown.

OBJECTIVE

To determine the rate of secondary overtriage among patients with cmTBI using the institutional trauma registry.

METHODS

An observational study using retrospective analysis of 1447 hospitalizations including all consecutive patients with cmTBI between 2004 and 2013. Data on age, sex, race/ethnicity, insurance status, GCS, Injury Severity Score (ISS), Trauma Injury Severity Score, transfer mode, overall length of stay (LOS), LOS within intensive care unit, and total charges were collected and analyzed.

RESULTS

Overall, the rate of secondary overtriage among patients with cmTBI was 17.2%. These patients tended to be younger (median: 41 vs 60.5 yr; P < .001), have a lower ISS (9 vs 16; P < .001), and were more likely to be discharged home or leave against medical advice.

CONCLUSION

Our findings provide evidence to the growing body of literature suggesting that not all patients with cmTBI need to be transferred to a tertiary care center. In our study, these transfers ultimately incurred a total cost of $13 294 ($1337 transfer cost) per patient.

Interfacility neurosurgical transfers: an analysis of nontraumatic inpatient and emergency department transfers with implications for improvements in care

OBJECTIVE

Interfacility neurosurgical transfers to tertiary care centers are driven by a number of variables, including lack of on-site coverage, limited available technology, insurance factors, and patient preference. The authors sought to assess the timing and necessity of surgery and compared transfers to their institution from emergency departments (ED) and inpatient units at other hospitals.

METHODS

Adult neurosurgical patients who were transferred to a single tertiary care center were analyzed over 12 months. Patients with traumatic injuries or those referred from skilled nursing facilities or rehabilitation centers were excluded.

RESULTS

A total of 504 transferred patients were included, with mean age 55 years (range 19-92 years); 53% of patients were women. Points of origin were ED in 54% cases and inpatient hospital unit in 46%, with a mean distance traveled for most patients of 119 miles. Broad diagnosis categories included brain tumors (n = 142, 28%), vascular lesions, including spontaneous and hypertensive intracerebral hemorrhage (n = 143, 28%), spinal lesions (n = 126, 25%), hydrocephalus (n = 45, 9%), wound complications (n = 29, 6%), and others (n = 19, 4%). Patients transferred from inpatient units had higher rates of surgical intervention (75% vs 57%, p < 0.001), whereas patients transferred from the ED had higher rates of urgent surgery (20% vs 8%, p < 0.001) and shorter mean time to surgery (3 vs 5 days, p < 0.001). Misdiagnosis rates were higher among ED referrals (11% vs 4%, p = 0.008). Across the same timeframe, patients undergoing elective admission (n = 1986) or admission from the authors' own ED (n = 248) had significantly shorter lengths of stay (p < 0.001) and ICU days (p < 0.001) than transferred patients, as well as a significantly lower total cost ($44,412, $46,163, and $72,175, respectively; p < 0.001).

CONCLUSIONS

The authors present their 12-month experience from a single tertiary care center without Level I trauma designation. In this cohort, 65% of patients required surgery, but the rates were higher among inpatient referrals, and misdiagnosis rates were higher among ED transfers. These data suggest that admitting nonemergency patients to local hospitals may improve diagnostic accuracy of patients requiring urgent care, more precisely identify patients in need of transfer, and reduce costs. Referring facilities may lack necessary resources or expertise, and the Emergency Medical Treatment and Active Labor Act (EMTALA) obligates tertiary care centers to accept these patients under those circumstances. Telemedicine and integration of electronic medical records may help guide referring hospitals to pursue additional workup, which may eliminate the need for unnecessary transfer and provide additional cost savings.

Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis

IMPORTANCE

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

OBJECTIVES

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

DESIGN, SETTING, AND PARTICIPANTS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Measuring Emergency Care Survival: The Implications of Risk Adjusting for Race and Poverty

OBJECTIVES

We determined the impact of including race, ethnicity, and poverty in risk adjustment models for emergency care-sensitive conditions mortality that could be used for hospital pay-for-performance initiatives. We hypothesized that adjusting for race, ethnicity, and poverty would bolster rankings for hospitals that cared for a disproportionate share of nonwhite, Hispanic, or poor patients.

METHODS

We performed a cross-sectional analysis of patients admitted from the emergency department to 157 hospitals in Pennsylvania with trauma, sepsis, stroke, cardiac arrest, and ST-elevation myocardial infarction. We used multivariable logistic regression models to predict in-hospital mortality. We determined the predictive accuracy of adding patient race and ethnicity (dichotomized as non-Hispanic white vs. all other Hispanic or nonwhite patients) and poverty (uninsured, on Medicaid, or lowest income quartile zip code vs. all others) to other patient-level covariates. We then ranked each hospital on observed-to-expected mortality, with and without race, ethnicity, and poverty in the model, and examined characteristics of hospitals with large changes between models.

RESULTS

The overall mortality rate among 170,750 inpatients was 6.9%. Mortality was significantly higher for nonwhite and Hispanic patients (adjusted odds ratio [aOR] = 1.27, 95% confidence interval [CI] = 1.19-1.36) and poor patients (aOR = 1.21, 95% CI = 1.12-1.31). Adding race, ethnicity, and poverty to the risk adjustment model resulted in a small increase in C-statistic (0.8260 to 0.8265, p = 0.002). No hospitals moved into or out of the highest-performing decile when adjustment for race, ethnicity, and poverty was added, but the three hospitals that moved out of the lowest-performing decile, relative to other hospitals, had significantly more nonwhite and Hispanic patients (68% vs. 11%, p < 0.001) and poor patients (56% vs. 10%, p < 0.001).

CONCLUSIONS

Sociodemographic risk adjustment of emergency care-sensitive mortality improves apparent performance of some hospitals treating a large number of nonwhite, Hispanic, or poor patients. This may help these hospitals avoid financial penalties in pay-for-performance programs.