Identifying causes of delay in interfacility transfer of patients by air ambulance

Potential Access to Emergency General Surgical Care in Ontario

Limited access to timely emergency general surgery (EGS) care is a probable driver of increased mortality and morbidity. Our objective was to estimate the portion of the Ontario population with potential access to 24/7 EGS care. Geographic information system-based network-analysis was used to model 15-, 30-, 45-, 60-, and 90-min land transport catchment areas for hospitals providing EGS care, 24/7 emergency department (ED) access, and/or 24/7 operating room (OR) access. The capabilities of hospitals to provide each service were derived from a prior survey. Population counts were based on 2016 census blocks, and the 2019 road network for Ontario was used to determine speed limits and driving restrictions. Ninety-six percent of the Ontario population (n = 12,933,892) lived within 30-min's driving time to a hospital that provides any EGS care. The availability of 24/7 EDs was somewhat more limited, with 95% (n = 12,821,747) having potential access at 30-min. Potential access to all factors, including 24/7 ORs, was only possible for 93% (n = 12,471,908) of people at 30-min. Populations with potential access were tightly clustered around metropolitan centers. Supplementation of 24/7 OR capabilities, particularly in centers with existing 24/7 ED infrastructure, is most likely to improve access without the need for new hospitals.

Prepatching Reduces Paramedic In-Hospital Time for Emergent Interfacility Transfers of Patients Requiring Mechanical Ventilation or Vasopressors: A Retrospective Cohort Study

OBJECTIVE

Regionalization of specialty medical services may necessitate an interfacility transfer. Prepatching is a model of care adopted by critical care transport organizations to reduce the transfer time to specialty care. In this model, paramedics communicate with a transport medical physician before arrival at the sending hospital to discuss a patient's condition and management plan, allowing paramedics to focus solely on packaging the patient when he or she arrives at the sending hospital. The objective of this study was to assess the impact of prepatching on paramedic in-hospital time for emergent interfacility transfers of patients requiring mechanical ventilation or vasopressor support.

METHODS

This is a retrospective cohort study of all emergent interfacility transfers by Ornge, the provincial critical care transport organization in Ontario, Canada, over a 4-year period. All patients over 18 years old who were either intubated or on vasopressor medications were included in the study population. 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 4,466 emergent interfacility transports were included. Of these, 1,898 were completed with prepatching, and 2,568 were not. Vasopressor use was associated with significantly higher prepatching rates. Overall, prepatching reduced in-hospital time by 9 minutes at the 90th quantile across all patients. Increased in-hospital time was noted for patients on mechanical ventilation, on vasopressor medications, and transported by a fixed wing vehicle by 38, 29, and 49 minutes at the 90th quantile, respectively (P < .05). Conversely, patients transported by a critical care paramedic crew configuration were associated with a 27-minute decrease in in-hospital time at the 90th quantile compared with transport by an advanced care paramedic crew configuration (P < .05).

CONCLUSION

Prepatching reduced paramedic in-hospital time for emergent interfacility transports for patients who were mechanically ventilated or require vasopressors. These results suggest that prepatching can reduce the overall time to definitive care in high-risk patients, potentially improving patient outcomes in critically ill patients.

Characteristics associated with delays in decision to transfer injured patients

Introduction

The regionalized nature of trauma care necessitates interfacility transfer which is vulnerable to delays given its complexity. Little is known about the interval of time a patient spends at the sending hospital prior to when the transfer is initiated—the “decision to transfer” time. This primary objective of the study was to explore the impact of patient, environmental, and institutional characteristics on decision to transfer time.

Methods

This was a retrospective cohort study of injured adult patients who underwent emergent interfacility transfer by a provincial critical care transport organization over a 31-month period. Quantile regression was used to evaluate the impact of patient, environmental, and institutional characteristics on the time to decision to transfer.

Results

A total of 1128 patients were included. The median decision to transfer time was 2.42 h and the median total transport time was 3.12 h. The following variables were associated with an increase in time to decision to transfer at the 90th percentile of time: age >75 (+2.47 h), age 66–75 (+3.70 h), age 56–65 (+1.20 h), transfer between 00:00 and 07:59 (+2.08 h), and transfer in the summer (+2.25 h). The following variables were associated with a decrease in time to decision to transfer at the 90th percentile of time: Glasgow Coma Scale 3–8 (−2.21 h), respiratory rate >30 (−2.01 h), sending site being a community hospital with <100 beds (−4.11 h), or the sending site being a nursing station (−5.66 h).

Conclusion

Time to decision to transfer was a sizable proportion of the patients interfacility transfer. Older patients were associated with a delay in decision to transfer as were patients transferred overnight and in the summer. These findings may be used to support the implementation of geriatric trauma triage guidelines and promote ongoing education and quality improvement initiatives to decrease delay.