The Effect of Treatment Delays Associated with Inpatient Inter-hospital Transfer from Peripheral to Tertiary Hospitals for the Surgical Treatment of Cardiology Patients

Impact of inter-hospital transfer on outcomes of urgent cholecystectomy

BACKGROUND

This study used a national cohort to characterize the impact of inter-hospital transfer status on outcomes following nonelective cholecystectomy for cholecystitis.

METHODS

Nonelective cholecystectomies were identified using the 2016-2019 National Inpatient Sample. Multivariable models adjusting for patient and hospital characteristics were utilized to assess outcomes of interest.

RESULTS

Of an estimated 530,696 patients, 5.3% were transferred. Transferred patients were older, more often male, and more likely to report income in the 0^th-25th percentile, compared to others. After adjustment, transfer was associated with increased odds of infectious complications (AOR 1.31, 95%CI 1.06-1.60) and non-home discharge (AOR 1.59, 95%CI 1.45-1.74), but not mortality. Transfer was linked to a $600 cost decrement at the operating hospital (95%CI -$880-330).

CONCLUSIONS

Transfer status is associated with greater postoperative infection, but not mortality. Given that disparities may play a role in transfer decisions, more work must be done to identify transfer drivers and improve patient outcomes.

The association between preoperative length of hospital stay and deep sternal wound infection: A scoping review

BACKGROUND

Deep sternal wound infection (DSWI) is a serious complication of cardiac surgery, associated with a significantly longer hospital stay, an increased mortality, and an almost doubling of treatment costs. The preoperative length of hospital stay has been suggested in a small number of studies as a modifiable risk factor yet is not included in surgical site infection prevention guidelines. The aim of this scoping review was to review the existing evidence on the association between preoperative length of hospital stay and DSWI, and to identify established risk factors for DSWI.

METHODS

A literature search of six electronic databases yielded 2297 results. Titles concerning risk factors for DSWI, sternal or surgical wound infection, or poststernotomy complications were included. Abstracts relating to preoperative length of stay as a risk factor for DSWI proceeded to full article review. Articles regarding paediatric surgery, DSWI management or unavailable in English were excluded.

RESULTS

The review identified 11 observational cohort studies. DSWI prevalence was between 0.9% and 6.8%. Preoperative length of stay ranged from 0-15.5 days and was found to be associated with DSWI in all studies. Preoperative length of stay and DSWI were inconsistently defined. Other risk factors for DSWI included diabetes, obesity, respiratory disease, heart failure, renal impairment, complex surgery, and reoperation (p < 0.05).

CONCLUSION

In this scoping review, an association between preoperative length of stay and the development of DSWI following cardiac surgery was identified. Thus, preoperative length of stay as a modifiable risk factor for DSWI should be considered for inclusion in cardiothoracic surgical infection prevention guidelines.

Impact of interhospital transfer on clinical outcomes and resource use after cardiac operations: Insights from a national cohort

BACKGROUND

Interhospital transfer is a common clinical practice that has been associated with poor patient outcomes in small series. We aimed to evaluate the impact of transfer status on cardiac surgery patients in a national cohort.

METHODS

Patients undergoing nonelective coronary artery bypass grafting, valve replacement or repair, or a combination were identified using the 2010 to 2017 Nationwide Readmissions Database. Patients were stratified by transfer status and outcomes were evaluated using adjusted multivariable linear and logistic models.

RESULTS

Of an estimated 1,023,315 patients, 170,319 (16.6%) were transfers. Transfer was independently associated with increased complications, index hospitalization duration of stay, costs, early (30 day), and intermediate (31-90 day) readmission. Among transferred patients, transfer to a high-volume center predicted reduced odds of mortality (adjusted odds ratio: 0.64, P < .001). Additionally, transfers were less likely to be readmitted back to the index hospital (80.7% vs 44.9%, P < .001).

CONCLUSION

Transfer status is a significant independent predictor of increased complications, length of stay, cost, and readmission among nonelective cardiac surgery patients. Notably, transfer to higher volume facilities appears to increase odds of survival. Our findings are important when considering the risks involved in the management of transferred patients.

Impact of transfer status on real-world outcomes in nonelective cardiac surgery

OBJECTIVE

Transfer from hospital to hospital for cardiac surgery represents a large portion of some clinical practices. Previous literature in other surgical fields has shown worse outcomes for transferred patients. We hypothesized that transferred patients would be higher risk and demonstrate worse outcomes than those admitted through the emergency department.

METHODS

All patients undergoing cardiac operations with a Society of Thoracic Surgeons Predicted Risk of Mortality were evaluated from a multicenter, statewide Society of Thoracic Surgeons database. Only patients requiring admission before surgery were included. Patients were stratified by admission through the emergency department or in transfer. Transfers were further stratified by the cardiothoracic surgery capabilities at the referring center.

RESULTS

A total of 13,094 patients met the inclusion criteria of admission before surgery. This included 7582 (57.9%) transfers, of which 502 (6.6%) were referred from cardiac centers. Compared with emergency department admissions, transfers had increased hospital costs despite lower operative risk (Predicted Risk of Mortality 1.5% vs 1.6%, P < .01) and equivalent postoperative morbidity (15.6% vs 15.3% P = .63). In risk-adjusted analysis, transfer status was not independently associated with worse outcomes. Patients transferred from centers that perform cardiac surgery are higher risk than general transfers (Predicted Risk of Mortality 2.5% vs 1.5, P < .01), but specialized care results in excellent risk-adjusted outcomes (observed/expected: mortality 0.81; morbidity or mortality 0.90).

CONCLUSIONS

Transfer patients have similar rates of postoperative complications but increased resource use compared with patients admitted through the emergency department. Patients transferred from centers that perform cardiac surgery represent a particularly high-risk subgroup.