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Hadler RA, Aslakson RA, Hanson LC, Mueller S, Vaughan CE, Kavalieratos D. Interhospital Transfer: A New Frontier for Palliative Care. J Palliat Med 2024. [PMID: 39180436 DOI: 10.1089/jpm.2024.0330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2024] Open
Affiliation(s)
- Rachel A Hadler
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Geriatrics and Extended Care, Atlanta VA Medical Center, Decatur, Georgia, USA
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Rebecca A Aslakson
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Laura C Hanson
- Division of Geriatric Medicine and Palliative Care Program, Department of Medicine, University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Stephanie Mueller
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Camille E Vaughan
- Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Veterans Affairs Birmingham/Atlanta Geriatric Research Education and Clinical Center, Decatur, Georgia, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
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Song JJ, Lee SJ, Song JH, Lee SW, Kim SJ, Han KS. Effect of Inter-Hospital Transfer on Mortality in Patients Admitted through the Emergency Department. J Clin Med 2024; 13:4944. [PMID: 39201085 PMCID: PMC11355088 DOI: 10.3390/jcm13164944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/11/2024] [Accepted: 08/15/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Despite advancements in emergency medical systems, inter-hospital transfer (IHT) remains a critical component. Several studies have analyzed the impact of IHT on patient outcomes. Some studies have reported positive effects, indicating that transfers can improve patient prognosis. However, other studies have suggested that transfers may worsen outcomes. We investigated whether IHT is associated with in-hospital mortality. Methods: This retrospective observational study utilized data on patient outcomes from the National Emergency Department Information System (NEDIS) from 2016 to 2018, focusing on patients admitted to hospitals after visiting the emergency department (ED). The primary outcome was the in-hospital mortality rate. Results: This study included 2,955,476 adult patients admitted to emergency medical centers, with 832,598 (28.2%) undergoing IHT. The in-hospital mortality rate was significantly higher in the transfer group (6.9%) than in the non-transfer group (4.8%). Multiple logistic regression analysis revealed that IHT was an independent predictor of in-hospital mortality (adjusted odds ratio [aOR] 1.114, 95% confidence interval [CI] 1.101-1.128) after adjusting for variables. Sub-analysis indicated that higher severity scores, shorter symptom onset-to-arrival duration, and diagnoses of infectious or respiratory diseases were significantly associated with increased in-hospital mortality among transferred patients. Conclusions: This study identifies IHT as a significant factor associated with increased in-hospital mortality. Additionally, it suggested the need for policies to mitigate the risks associated with IHT, particularly in critically ill patients, those with the acute phase response, and those with infectious, genitourinary, and respiratory diseases.
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Affiliation(s)
| | - Si-Jin Lee
- Emergency Department, College of Medicine, Korea University, 73 Inchon-ro, Seongbuk-gu, Seoul 02841, Republic of Korea; (J.-J.S.); (J.-H.S.); (S.-W.L.); (S.-J.K.)
| | | | | | | | - Kap-Su Han
- Emergency Department, College of Medicine, Korea University, 73 Inchon-ro, Seongbuk-gu, Seoul 02841, Republic of Korea; (J.-J.S.); (J.-H.S.); (S.-W.L.); (S.-J.K.)
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Shannon EM, Fiskio J, Yoon C, Schnipper JL, Mueller SK. Investigating racial and ethnic disparities in interhospital transfer within an academic integrated healthcare system: A matched cohort study. J Hosp Med 2024; 19:702-706. [PMID: 38411292 DOI: 10.1002/jhm.13306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/17/2024] [Accepted: 01/28/2024] [Indexed: 02/28/2024]
Abstract
The presence of racial and ethnic disparities in interhospital transfer (IHT) within integrated healthcare systems has not been fully explored. We matched Black and Latinx patients admitted to community hospitals in our integrated healthcare system between June 2015 and December 2019 to White patients by origin hospital, age, time of year, and disease severity. We performed conditional logistic regression models to determine if race or ethnicity was associated with IHT in one of the tertiary academic medical centers in the system, adjusting for covariates. The sample contained 107,895 admissions (82.6% White, 7.8% Black, and 9.6% Latinx). Transfer rates were 2.2% versus 2.2% after the Black/White match and 1.8% versus 1.8% after the Latinx/White match. After adjusting for covariates, there was no association between race or ethnicity and IHT (Black vs. White odds ratio [OR]: 0.87, 95% confidence interval [CI]: 0.72-1.07; Latinx vs. White OR: 1.05, 95% CI: 0.79-1.40). This may be due to reduced barriers to transfer with an integrated healthcare system.
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Affiliation(s)
- Evan Michael Shannon
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Julie Fiskio
- Mass General Brigham, Boston, Massachusetts, USA
| | - Catherine Yoon
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie K Mueller
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Pagali SR, Ryu AJ, Fischer KM, Parikh RS, Newman JS, Burton MC. Patient Outcomes Compared Between Admissions Coordinated by the Transfer Center and Emergency Department at a U.S. Tertiary Care Hospital. J Patient Saf 2024; 20:352-357. [PMID: 38771223 DOI: 10.1097/pts.0000000000001232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Patient admissions at a U.S. tertiary care hospital occur via the emergency department (ED), or transfer center. We aim to compare the clinical outcomes of patients admitted from the ED to admissions coordinated by the transfer center. METHODS Admissions to Mayo Clinic Hospital, Rochester, MN, between July 2019 to June 2021 were identified in this retrospective study and categorized into two cohorts-transfer center and ED. The two cohorts were then matched for age, sex, admitting service, and Charlson Comorbidity Index. Univariate and multivariate analyses were performed to compare hospital length of stay (LOS), mortality, 30-day mortality, and 30-day readmissions between the two cohorts. RESULTS 73,685 admissions were identified, of which 24,262 (33%) were transfer center admissions. In the matched cohorts (n = 19,093, each), in-hospital mortality (2.4% versus 1.9%), 30-day mortality (5.4% versus 3.9%), 30-day readmission (12.7% versus 7.2%), and LOS (6.4 days versus 5.1 days) were significantly higher ( P < 0.001) among the admissions coordinated by transfer center. A higher palliative care consultation rate (9.4% versus 6.2%, P < 0.001), and a lower proportion of home discharges home (76.2% versus 82.5%, P < 0.001) among transfer center admissions was observed. Similar findings were noted in multivariate analysis, even when adjusting for LOS. CONCLUSIONS Transfer center admissions had higher in-hospital mortality, LOS, 30-day mortality, and 30-day readmission compared to ED admissions. This study also highlights new considerations for palliative care consultation before transfer acceptance, especially to avoid futile transfers. Additional studies analyzing factors behind the outcomes of transfer center admissions are required.
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Affiliation(s)
- Sandeep R Pagali
- From the Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic
| | - Alexander J Ryu
- From the Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic
| | - Karen M Fischer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Riddhi S Parikh
- From the Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic
| | - James S Newman
- From the Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic
| | - M Caroline Burton
- From the Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic
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Watanabe A, Miyamoto Y, Ueyama H, Gotanda H, Tsugawa Y, Kuno T. Percutaneous Microaxial Ventricular Assist Device Versus Intra-Aortic Balloon Pump for Nonacute Myocardial Infarction Cardiogenic Shock. J Am Heart Assoc 2024; 13:e034645. [PMID: 38804220 PMCID: PMC11255633 DOI: 10.1161/jaha.123.034645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/04/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Evidence on the comparative outcomes following percutaneous microaxial ventricular assist devices (pVAD) versus intra-aortic balloon pump for nonacute myocardial infarction cardiogenic shock is limited. METHODS AND RESULTS We included 704 and 2140 Medicare fee-for-service beneficiaries aged 65 to 99 years treated with pVAD and intra-aortic balloon pump, respectively, for nonacute myocardial infarction cardiogenic shock from 2016 to 2020. Patients treated using pVAD compared with those treated using intra-aortic balloon pump were more likely to be concurrently treated with mechanical ventilation, renal replacement therapy, and blood transfusions. We computed propensity scores for undergoing pVAD using patient- and hospital-level factors and performed a matching weight analysis. The use of pVAD was associated with higher 30-day mortality (adjusted odds ratio, 1.92 [95% CI, 1.59-2.33]) but not associated with in-hospital bleeding (adjusted odds ratio, 1.00 [95% CI, 0.81-1.24]), stroke (adjusted odds ratio, 0.91 [95% CI, 0.56-1.47]), sepsis (OR, 0.91 [95% CI, 0.64-1.28]), and length of hospital stay (adjusted mean difference, +0.4 days [95% CI, -1.4 to +2.3]). A quasi-experimental instrumental variable analysis using the cross-sectional institutional practice preferences showed similar patterns, though not statistically significant (adjusted odds ratio, 1.38; 95% CI, 0.28-6.89). CONCLUSIONS Our investigation using the national sample of Medicare beneficiaries showed that the use of pVAD compared with intra-aortic balloon pump was associated with higher mortality in patients with nonacute myocardial infarction cardiogenic shock. Providers should be cautious about the use of pVAD for nonacute myocardial infarction cardiogenic shock, while adequately powered high-quality randomized controlled trials are warranted to determine the clinical effects of pVAD.
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Affiliation(s)
- Atsuyuki Watanabe
- Department of MedicineMount Sinai Beth IsraelIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Yoshihisa Miyamoto
- Division of Nephrology and EndocrinologyThe University of TokyoTokyoJapan
| | - Hiroki Ueyama
- Division of CardiologyEmory University School of MedicineAtlantaGA
| | - Hiroshi Gotanda
- Division of General Internal MedicineCedars‐Sinai Medical CenterLos AngelesCA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services ResearchDavid Geffen School of Medicine at The University of California, Los AngelesLos AngelesCA
- Department of Health Policy and ManagementUCLA Fielding School of Public Health, Los AngelesLos AngelesCA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical CenterAlbert Einstein College of MedicineNew YorkNY
- Division of Cardiology, Jacobi Medical CenterAlbert Einstein College of MedicineNew YorkNY
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Moradi T, Rezaei M, Alavi NM. Delegating care as a double-edged sword for quality of nursing care: a qualitative study. BMC Health Serv Res 2024; 24:592. [PMID: 38715066 PMCID: PMC11075185 DOI: 10.1186/s12913-024-11054-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/29/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Considering the significance of care delegation in enhancing the quality of nursing care and ensuring patient safety, it is imperative to explore nurses' experiences in this domain. As such, this study aimed to explore the experiences of Iranian nurses regarding the delegation of care. METHODS This qualitative study was conducted between 2022 and 2023, employing the content analysis method with a conventional approach. The study utilized purposeful sampling method to select qualified participants. Data collection was carried out through in-depth and semi-structured interviews utilizing open-ended questions. The data analysis process followed the steps proposed by Graneheim and Lundman (2004) and involved the use of MAXQDA version 12 software. To ensure the trustworthiness of the data, the study employed the four rigor indices outlined by Lincoln and Guba (1985). RESULTS In the present study, a total of 15 interviews were conducted with 12 participants, the majority of whom were women. The age range of the participants fell between 25 and 40 years. Through qualitative data analysis, eight subcategories and three main categories of "insourcing of care", "outsourcing of care" and "delegating of care to non-professionals" were identified. Additionally, the overarching theme that emerged from the analysis was "delegation of care, a double-edged sword". CONCLUSIONS The results of the study revealed that the delegation of care occurred through three distinct avenues: to colleagues within the same unit, to colleagues in other units, and to non-professionals. Delegating care was found to have potential benefits, such as reducing the nursing workload and fostering teamwork. However, it was also observed that in certain instances, delegation was not only unhelpful but also led to missed nursing care. Therefore, it is crucial to adhere to standardized principles when delegating care to ensure the maintenance of high-quality nursing care.
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Affiliation(s)
- Tayebeh Moradi
- Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Mahboubeh Rezaei
- Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran.
| | - Negin Masoudi Alavi
- Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran
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Hyder S, Tang R, Huang R, Ludwig A, Scott K, Nadig N. Implementation of an Interdisciplinary Transfer Huddle Intervention for Prolonged Wait Times During Inter-ICU Transfer. Jt Comm J Qual Patient Saf 2024; 50:371-376. [PMID: 38378394 DOI: 10.1016/j.jcjq.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND ICU transfers from a regional to a tertiary-level hospital are initiated typically for a higher level of care. Extended transfer wait times can negatively affect survival, length of stay (LOS), and cost. METHODS In this prospective single-center study, the subjects were adult ICU patients admitted to regional hospitals between January and October 2022, for whom a request was made to transfer to a tertiary-level medical ICU. The authors developed and implemented an interdisciplinary transfer huddle intervention (THI) with the goal of reducing wait times by providing a consistent channel of communication between key stakeholders. The primary outcome was the number of hours elapsed between transfer request and the time of transfer to the tertiary hospital. Secondary outcomes included in-hospital mortality, discharge to home, ICU LOS, and hospital LOS. Data were abstracted from electronic health records and periods before (January to June 2022) and after (June to October 2022) the intervention were compared. Data were analyzed using logistic regression or negative binomial regression, adjusting for patient demographic and clinical characteristics. ICU fellows also completed a daily survey about barriers they perceived to the THI application. RESULTS During the study period, 76 patients were transferred. The THI was completed 75.0% of the time. There were no statistically significant differences in the primary and secondary outcomes before and after the intervention. The top perceived barriers to transfer were lack of physical beds (50.0%) and staffing limitations (37.5%). CONCLUSION The authors successfully developed and implemented a transfer huddle to ensure consistent interdisciplinary communication for patients being transferred between ICUs and identified barriers to such transfer. However, transfer times and patient outcomes were not significantly different after the change. Future studies should consider staffing challenges, hospital capacity, and the role of dedicated transfer teams in in decreasing inter-ICU transfer wait times.
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Liu PPS, Chang HR, Hsu JY, Huang HK, Loh CH, Yeh JI. Association between holiday and weekend admissions and mortality outcomes among patients with acute myocardial infarction receiving percutaneous coronary intervention in Taiwan. Sci Rep 2024; 14:8892. [PMID: 38632335 PMCID: PMC11023946 DOI: 10.1038/s41598-024-59571-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 04/12/2024] [Indexed: 04/19/2024] Open
Abstract
There is a lack of studies that concurrently differentiate the effect of the holiday season from the weekend effect on mortality risk in patients with acute myocardial infarction (AMI). We evaluated the mortality risk among patients admitted with AMI who underwent percutaneous coronary intervention, using data from the Taiwan National Health Insurance Research Database. Adult AMI patients admitted during January and February between 2013 and 2020 were enrolled and classified into the holiday season (using the Chinese New Year holiday seasons as an indicator) (n = 1729), weekend (n = 4725), and weekday (n = 14,583) groups according to the first day of admission. A multivariable logistic regression model was used to assess the risk. With the weekday group or the weekend group as the reference, the holiday season group did not have increased risks of in-hospital mortality (adjusted odds ratio [aOR] 1.15; 95% confidence intervals [CI] 0.93-1.42 or aOR 1.23; 95% CI 0.96-1.56) and 7-day mortality (aOR 1.20; 95% CI 0.90-1.58 or aOR 1.24; 95% CI 0.90-1.70). Stratified and subgroup analyses showed similar trends. We conclude that holiday season-initiated admissions were not associated with higher mortality risks in AMI admission cases than weekday or weekend admissions.
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Affiliation(s)
- Peter Pin-Sung Liu
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
- Center for Healthy Longevity, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Huai-Ren Chang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Cardiology, Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Jin-Yi Hsu
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Huei-Kai Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Chung Yang Rd., Hualien, 97002, Taiwan
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Ching-Hui Loh
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Jih-I Yeh
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan.
- School of Medicine, Tzu Chi University, Hualien, Taiwan.
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Chung Yang Rd., Hualien, 97002, Taiwan.
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Nguyen KT, Lee TM, Mueller SK. Multi-Institution Survey of Accepting Physicians' Perception of Appropriate Reasons for Interhospital Transfer: A Mixed-Methods Evaluation. J Patient Saf 2024; 20:216-221. [PMID: 38345409 DOI: 10.1097/pts.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
OBJECTIVES There is a lack of evidence-based guidelines to direct best practices in interhospital transfers (IHTs). We aimed to identify frontline physicians' current and ideal reasons for accepting IHT patients to inform future IHT research and guidelines. METHODS We conducted a cross-sectional survey of hospitalist physicians across 11 geographically diverse hospitals. The survey asked respondents how frequently they currently consider and should consider various factors when triaging IHT requests. Responses were dichotomized into "highly considered" and "less considered" factors. Frequencies of the "highly considered" factors (current and ideal) were analyzed. Write-in responses were coded into themes within a priori domains in a qualitative analysis. RESULTS Of the 666 hospitalists surveyed, 238 (36%) responded. Respondents most frequently identified the need for specialty procedural and nonprocedural care and bed capacity as factors that should be considered when triaging IHT patients in current and ideal practice, whereas the least frequently considered factors were COVID-related care, insurance/financial considerations, and patient/family preference. More experienced respondents considered patient/family preference more frequently in current and ideal practice compared with less experienced respondents (33% versus 11% [ P = 0.0001] and 26% versus 9% [ P = 0.01], respectively). Qualitative analysis identified several themes in the domains of Criteria for Acceptance, Threshold for Acceptance, and Indications for Physician-to-Physician Communication. CONCLUSIONS This geographically diverse sample of hospitalist physicians responsible for accepting IHT patients showed general agreement between primary factors that are currently and that should be considered for IHT acceptance, with greatest weight placed on patients' need for specialty care.
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Affiliation(s)
- Khanh T Nguyen
- From the Section of Hospital Medicine, University of Chicago, Chicago, Illinois
| | - Tiffany M Lee
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California
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Beauséjour M, Sasseville M, Vigné A, Riendeau S, Gould S, Thorstad K. Inter-Establishment Complex Musculoskeletal Care Pathways in Montreal: Timeline of a Collaboration Involving a Research Team Within a Continuous Quality Improvement Initiative. Health Serv Insights 2024; 17:11786329241237709. [PMID: 38510234 PMCID: PMC10953089 DOI: 10.1177/11786329241237709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 02/09/2024] [Indexed: 03/22/2024] Open
Abstract
Children and adolescents with complex musculoskeletal conditions may receive health care that requires at least 1 transfer between 4 specialized pediatric establishments in the Montreal region (Québec, Canada). This may result in challenges in navigating the system. A collaborative approach, aiming to make the inter-establishment care pathways seamless and to improve the integration of musculoskeletal health services, brought together key stakeholders including a research team. The aim of this paper is to describe the timeline of the collaborative approach's key milestones and activities and, more specifically, to describe the context, process, and outputs of the involvement of researchers in support of a continuous quality improvement project based on an integrated approach. The descriptive timeline was constructed from a qualitative document analysis of the project-related gray literature (n = 80 documents) and was validated and interpreted with key stakeholders. The results showed how the collaborative project was set up and operated, as well as what solutions were developed and implemented. The strategies on how the research team was involved in the integrated approach in addition to its research activities were also described. Conclusions suggest practice recommendations for creating change processes by integrating research, service evaluation and clinical audit into quality improvement projects.
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Affiliation(s)
- Marie Beauséjour
- Université de Sherbrooke – Campus de Longueuil, Longueuil, QC, Canada
- Centre de recherche Charles-Le Moyne (CRCLM), Longueuil, QC, Canada
- CHU Sainte-Justine Research Center, Montréal, QC, Canada
| | - Martin Sasseville
- Université de Sherbrooke – Campus de Longueuil, Longueuil, QC, Canada
- Centre de recherche Charles-Le Moyne (CRCLM), Longueuil, QC, Canada
| | | | | | | | - Kelly Thorstad
- Shriners Hospitals for Children — Canada, Montréal, QC, Canada
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11
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Bromberg GK, Bravard MA, Kobayashi KJ, Moore A. A Novel Role to Manage Capacity and Flow in Hospital Medicine. J Patient Saf 2024; 20:e3-e5. [PMID: 38147059 DOI: 10.1097/pts.0000000000001195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Affiliation(s)
| | | | - Kimiyoshi J Kobayashi
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
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12
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Villarreal JV, Hussien DG, Panchbhavi VK, Jupiter DC. Predisposing Factors for 30-Day Complications Following Leg Amputation. Foot Ankle Spec 2024; 17:49-57. [PMID: 33771044 DOI: 10.1177/19386400211001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although amputation rates, morbidity, and mortality have been established for select populations, the impact of general demographic factors on postoperative surgical complications remains little studied. METHODS The American College of Surgeons' National Surgical Quality Improvement Program database was searched for leg amputations from 2012 to 2017 using CPT codes 27881, 27882, 27884, and 27886, identifying 4162 patients. A total of 29 demographic variables with 4 complications (surgical infection, additional service, and deep-vein thrombosis [DVT], and sepsis) were analyzed. RESULTS Preoperative open, contaminated, or dirty/infected wounds; longer intraoperative times; development of sepsis prior to surgery; and admission of patients from home or another hospital influenced postoperative infection rates. Preoperative open, infected, or dirty/infected wounds; height; weight; total length of hospital stay; and ethnicity affected postoperative additional service incidence. Preoperative congestive heart failure, large decreases in body weight, and total length of hospital stay influenced postoperative DVT rates. Preoperative functional heath status, total length of hospital stay, amputations conducted as emergency cases, preoperative acute renal failure, open or infected wounds, sepsis, and contaminated or dirty/infected wounds affected postoperative sepsis rates. BACKGROUND Conclusion. Understanding these risk factors may allow providers to anticipate and address higher rates of complications in certain patient populations. LEVEL OF EVIDENCE Level III: Prognostic.
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Affiliation(s)
- Joseph V Villarreal
- the School of Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Doha G Hussien
- the School of Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Vinod K Panchbhavi
- the Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
| | - Daniel C Jupiter
- the Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
- the Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, Galveston, Texas
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Lee AHY, Mayes KD, Marsh R, Toledo-Cornell C, Goralnick E, Wilson M, Sanchez LD, Bukhman A, Baymon D, Im D, Chen PC. Analysis of health inequities in transfers of admitted patients from an academic emergency department to partner community hospital. Am J Emerg Med 2024; 75:143-147. [PMID: 37950982 DOI: 10.1016/j.ajem.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/19/2023] [Accepted: 11/01/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Many academic medical centers (AMC) transfer patients who require admission but not tertiary care to partner community hospitals from their emergency departments (ED). These transfers alleviate ED boarding but may worsen existing healthcare disparities. We assessed whether disparities exist in the transfer of patients from one AMC ED to a community hospital General Medical Service. METHODS We performed a retrospective cohort study on all patients screened for transfer between April 1 and December 31, 2021. During the screening process, the treating ED physician determines whether the patient meets standardized clinical criteria and a patient coordinator requests patient consent. We collected patient demographics data from the electronic health record and performed logistic regression at each stage of the transfer process to analyze how individual characteristics impact the odds of proceeding with transfer. RESULTS 5558 patients were screened and 596 (11%) ultimately transferred. 1999 (36%) patients were Black or Hispanic, 698 (12%) had a preferred language other than English, and 956 (17%) were on Medicaid or uninsured. A greater proportion of Black and Hispanic patients were deemed eligible for interhospital transfer compared to White patients and a greater proportion of Hispanic patients completed transfer to the community hospital (p < 0.017 after Bonferroni correction). After accounting for other demographic variables, patients older than 50 (OR 1.21, 95% CI 1.04-1.40), with a preferred language other than English (OR 1.27, 95% CI 1.00-1.62), and from a priority neighborhood (OR 1.38, 95% CI 1.18-1.61) were more likely to be eligible for transfer, while patients who were male (OR 1.50, 95% CI 1.10-2.05) and younger than 50 (OR 1.85, 95% CI 1.20-2.78) were more likely to consent to transfer (p < 0.05). CONCLUSION Health disparities exist in the screening process for our interfacility transfer program. Further investigation into why these disparities exist and mitigation strategies should be undertaken.
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Affiliation(s)
- Andy Hung-Yi Lee
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA; Department of Emergency Medicine, UCLA Ronald Reagan Medical Center, 757 Westwood Plaza, Los Angeles, CA, USA.
| | - Katherine Dickerson Mayes
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Regan Marsh
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Christina Toledo-Cornell
- Harvard Medical School, 25 Shattuck St., Boston, MA, USA; Department of Internal Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA
| | - Eric Goralnick
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Michael Wilson
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Leon D Sanchez
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA; Department of Emergency Medicine, Brigham and Women's Faulkner's Hospital, 1153 Centre St, Jamaica Plain, MA, USA
| | - Alice Bukhman
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA; Department of Emergency Medicine, Brigham and Women's Faulkner's Hospital, 1153 Centre St, Jamaica Plain, MA, USA
| | - Damarcus Baymon
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Dana Im
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
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14
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Bhatnagar A, Mackman S, Van Arendonk KJ, Thalji SZ. Associations between Hospital Setting and Outcomes after Pediatric Appendectomy. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1908. [PMID: 38136110 PMCID: PMC10741462 DOI: 10.3390/children10121908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/02/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023]
Abstract
Prior studies of associations between hospital location and outcomes for pediatric appendectomy have not adjusted for significant differences in patient and treatment patterns between settings. This was a cross-sectional analysis of pediatric appendectomies in the 2016 Kids' Inpatient Database (KID). Weighted multiple linear and logistic regression models compared hospital location (urban or rural) and academic status against total admission cost (TAC), length of stay (LOS), and postoperative complications. Patients were stratified by laparoscopic (LA) or open (OA) appendectomy. Among 54,836 patients, 39,454 (73%) were performed at an urban academic center, 11,642 (21%) were performed at an urban non-academic center, and 3740 (7%) were performed at a rural center. LA was utilized for 49,011 (89%) of all 54,386 patients: 36,049 (91%) of 39,454 patients at urban academic hospitals, 10,191 (87%) of 11,642 patients at urban non-academic centers, and 2771 (74%) of 3740 patients at rural centers (p < 0.001). On adjusted analysis, urban academic centers were associated with an 18% decreased TAC (95% CI -0.193--0.165; p < 0.001) despite an 11% increased LOS (95% CI 0.087-0.134; p < 0.001) compared to rural centers. Urban academic centers were associated with a decreased odds of complication among patients who underwent LA (OR 0.787, 95% CI 0.650-0.952) but not after OA. After adjusting for relevant patient and disease-related factors, urban academic centers were associated with lower costs despite longer lengths of stay compared to rural centers. Urban academic centers utilized LA more frequently and were associated with decreased odds of postoperative complications after LA.
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Affiliation(s)
| | - Sean Mackman
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| | - Kyle J. Van Arendonk
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Sam Z. Thalji
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
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15
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Mueller SK, Garabedian P, Goralnick E, Bates DW, Samal L. Advancing health information during interhospital transfer: An interrupted time series. J Hosp Med 2023; 18:1063-1071. [PMID: 37846028 DOI: 10.1002/jhm.13221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Although the transfer of patients between acute care hospitals (interhospital transfer, IHT) is common, health information exchange (HIE) during IHT remains inadequate, with fragmented communication and unreliable access to clinical information. This study aims to design, implement, and rigorously evaluate the implementation of a HIE platform to improve data access during IHT. METHODS AND ANALYSIS Study subjects include patients aged >18 transferred to the medical, cardiology, oncology, or intensive care unit (ICU) services at an 800-bed quaternary care hospital; and healthcare workers involved in their care. The first aim of this study is to optimize clinician workflow, data visualization, and interoperability through user-centered design sessions for HIE platform development. The second aim is to evaluate the impact of the intervention on clinician-reported medical errors among 500 pre- and 500 postintervention IHT patients using interrupted time series methodology, adjusting for confounding variables and temporal trends. The third aim is to evaluate intervention fidelity, use and perceived usability of the platform, and barriers and facilitators of implementation from interprofessional stakeholder input, using mixed-methods evaluation. The fourth aim is to consolidate key findings to create a toolkit for spread and sustainability. ETHICS AND DISSEMINATION We will track patient safety endpoints and clinician workflow burdens and ensure the protection of patient data throughout the study. We will disseminate our findings via the creation of a toolkit for spread and sustainability, partnering with our funder (AHRQ) for dissemination, and communicating our results via abstracts and publications.
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Affiliation(s)
- Stephanie K Mueller
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Eric Goralnick
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lipika Samal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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16
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Roos J, Loy T, Ploeger MM, Weinhold L, Schmid M, Mewes M, Prangenberg C, Gathen M. It is (not) always on Friday: inter-hospital patient transfers in orthopedic and trauma surgery. Eur J Trauma Emerg Surg 2023; 49:2605-2613. [PMID: 37599307 PMCID: PMC10728266 DOI: 10.1007/s00068-023-02335-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND While inter-hospital transfers for patients who have suffered major trauma have been well investigated, patient flows for other injured patients, or cases with orthopedic complications, are rarely described. This study aims to analyze the affected collective and to show possible reasons, patterns, and pitfalls to optimize the process in future. MATERIALS AND METHODS In a prospective cohort study, all consecutive transfers to a Level I trauma center in Germany were documented and assessed. Patients suffering a major trauma were excluded. Data on the primary treating hospital, patient characteristics, and differences between emergency and elective surgery were analyzed. RESULTS A total of 227 patients were included; 162 were injured, while 65 had suffered a complication after elective orthopedic surgery or had a complex orthopedic pathology. The most common diagnoses leading to transfer were pathologies of the extremities (n = 62), pathologies of the spine (n = 50), and infections (n = 18). The main reasons stated by the transferring hospitals were a lack of expertise (137 cases) and a lack of capacity (43 cases). There was a significantly higher rate of transfers due to trauma (n = 162) than for orthopedic patients (n = 65), p < 0.0001. CONCLUSION There is currently no structured procedure or algorithm for transferring patients in orthopedics and trauma surgery.
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Affiliation(s)
- Jonas Roos
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Thomas Loy
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Milena M Ploeger
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Leonie Weinhold
- Institute for Medical Biometrics, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometrics, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Moritz Mewes
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christian Prangenberg
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Martin Gathen
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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17
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Biru GD, Derebe MA, Workie DL. Joint modeling of longitudinal changes of pulse rate and body temperature with time to recovery of pneumonia patients under treatment: a prospective cohort study. BMC Infect Dis 2023; 23:682. [PMID: 37828463 PMCID: PMC10571452 DOI: 10.1186/s12879-023-08646-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Pneumonia is the leading infectious cause of mortality worldwide and one of the most common lower respiratory tract infections that is contributing significantly to the burden of antibiotic consumption. The study aims to identify the determinants of the progress of pulse rate, body temperature and time to recovery of pneumonia patients. METHOD A prospective cohort study design was used from Felege Hiwot referral hospital on 214 sampled pneumonia patients from March 01, 2022 up to May 31, 2022. The Kaplan-Meier survival estimate and Log-Rank test was used to compare the survival time. Joint model of bivariate longitudinal and time to event model was used to identify factors of longitudinal change of pulse rate and body temperature with time to recovery jointly. RESULT As the follow up time of pneumonia patient's increase by one hour the average longitudinal change of pulse rate and body temperature were decreased by 0.4236 bpm and 0.0119 [Formula: see text]. The average longitudinal change of pulse rate and body temperature of patients who lived in rural was 1.4602 bpm and 0.1550 [Formula: see text] times less as compared to urban residence. Patients who had dangerous signs are significantly increased the average longitudinal change of pulse rate and body temperature by 2.042 bpm and 0.6031 [Formula: see text] as compared to patients who had no dangerous signs. A patient from rural residence was 1.1336 times more likely to experience the event of recovery as compared to urban residence. The estimated values of the association parameter for pulse rate and body temperature were -0.4236 bpm and -0.0119 respectively, which means pulse rate and body temperature were negatively related with patients recovery time. CONCLUSION Pulse rate and body temperature significantly affect the time to the first recovery of pneumonia patients who are receiving treatment. Age, residence, danger sign, comorbidity, baseline symptom and visiting time were the joint determinant factors for the longitudinal change of pulse rate, body temperature and time to recovery of pneumonia patients. The joint model approach provides precise dynamic predictions, widespread information about the disease transitions, and better knowledge of disease etiology.
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Affiliation(s)
- Getu Dessie Biru
- Department of Statistics, Dembi Dolo University, Debretabor University, Ethiopia
| | - Muluwerk Ayele Derebe
- Department of Statistics, College of Science, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Demeke Lakew Workie
- Department of Statistics, College of Science, Bahir Dar University, Bahir Dar, Ethiopia
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18
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Mendelsohn E, Honeyford K, Brittin A, Mercuri L, Klaber RE, Expert P, Costelloe C. The impact of atypical intrahospital transfers on patient outcomes: a mixed methods study. Sci Rep 2023; 13:15417. [PMID: 37723183 PMCID: PMC10507077 DOI: 10.1038/s41598-023-41966-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 09/04/2023] [Indexed: 09/20/2023] Open
Abstract
The architectural design of hospitals worldwide is centred around individual departments, which require the movement of patients between wards. However, patients do not always take the simplest route from admission to discharge, but can experience convoluted movement patterns, particularly when bed availability is low. Few studies have explored the impact of these rarer, atypical trajectories. Using a mixed-method explanatory sequential study design, we firstly used three continuous years of electronic health record data prior to the Covid-19 pandemic, from 55,152 patients admitted to a London hospital network to define the ward specialities by patient type using the Herfindahl-Hirschman index. We explored the impact of 'regular transfers' between pairs of wards with shared specialities, 'atypical transfers' between pairs of wards with no shared specialities and 'site transfers' between pairs of wards in different hospital site locations, on length of stay, 30-day readmission and mortality. Secondly, to understand the possible reasons behind atypical transfers we conducted three focus groups and three in-depth interviews with site nurse practitioners and bed managers within the same hospital network. We found that at least one atypical transfer was experienced by 12.9% of patients. Each atypical transfer is associated with a larger increase in length of stay, 2.84 days (95% CI 2.56-3.12), compared to regular transfers, 1.92 days (95% CI 1.82-2.03). No association was found between odds of mortality, or 30-day readmission and atypical transfers after adjusting for confounders. Atypical transfers appear to be driven by complex patient conditions, a lack of hospital capacity, the need to reach specific services and facilities, and more exceptionally, rare events such as major incidents. Our work provides an important first step in identifying unusual patient movement and its impacts on key patient outcomes using a system-wide, data-driven approach. The broader impact of moving patients between hospital wards, and possible downstream effects should be considered in hospital policy and service planning.
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Affiliation(s)
| | | | | | - Luca Mercuri
- Information Communications and Technology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Robert Edward Klaber
- Department of Paediatrics, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Academic Centre for Paediatrics and Child Health, Imperial College London, London, UK
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Ndebwanimana V, Beeman A, Gallaer A, Uwamahoro C, Uwamahoro D, Ritz C, Lewis S, Hoyt SD, Jean Paul N, Gonsalves-Domond G, Odoom E, Vital M, Martin KD. "EM Doc On Call:" A Pilot Study to Improve Interhospital Transfers in Rwanda. Prehosp Disaster Med 2023; 38:456-462. [PMID: 37340758 PMCID: PMC10445112 DOI: 10.1017/s1049023x23005927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/03/2023] [Accepted: 05/06/2023] [Indexed: 06/22/2023]
Abstract
INTRODUCTION Treatment of seriously ill patients is often complicated by prolonged or complex transfers between hospitals in sub-Saharan Africa. Difficulties or inefficiency in these transfers can lead to poor outcomes for patients. "On-call" triage systems have been utilized to facilitate communication between facilities and to avoid poor outcomes associated with patient transfer. This study attempts to examine the effects of a pilot study to implement such a system in Rwanda. METHODS Data collection occurred prospectively in two stages, pre-intervention and intervention, in the emergency department (ED) at Kigali University Teaching Hospital (CHUK). All patients transferred during the pre-determined timeframe were enrolled. Data were collected by ED research staff via a standardized form. Statistical analysis was performed using STATA version 15.0. Differences in characteristics were assessed using χ2 or Fisher's exact tests for categorical variables and independent sample t-tests for normally distributed continuous variables. RESULTS During the "on call" physician intervention, the indication for transfer was significantly more likely to be for critical care (P <.001), transfer times were faster (P <.001), patients were more likely to be displaying emergency signs (P <.001), and vital signs were more likely to be collected prior to transport (P <.001) when compared to the pre-interventional phase. CONCLUSION The "[Emergency Medicine] EM Doc On Call" intervention was associated with improved timely interhospital transfer and clinical documentation in Rwanda. While these data are not definitive due to multiple limitations, it is extremely promising and worthy of further study.
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Affiliation(s)
- Vincent Ndebwanimana
- Accident and Emergency, Kigali University Teaching Hospital, Kigali, Rwanda
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Aly Beeman
- Warren Alpert Medical School at Brown University, Providence, Rhode IslandUSA
| | - Alexander Gallaer
- Department of Emergency Medicine, University of Utah, Salt Lake City, UtahUSA
| | - Chantal Uwamahoro
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Doris Uwamahoro
- Accident and Emergency, Kigali University Teaching Hospital, Kigali, Rwanda
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Cody Ritz
- MD/MPH Program, Drexel University College of Medicine, Philadelphia, PennsylvaniaUSA
| | - Samuel Lewis
- Department of Emergency Medicine, University of Washington, Seattle, WashingtonUSA
| | - Savanna Dayne Hoyt
- Northeast Ohio Medical University College of Medicine, Rootstown, OhioUSA
| | - Nzabandora Jean Paul
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | | | - Enyonam Odoom
- Warren Alpert Medical School at Brown University, Providence, Rhode IslandUSA
| | - Mutijima Vital
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Kyle Denison Martin
- Warren Alpert Medical School at Brown University, Providence, Rhode IslandUSA
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20
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Harlan EA, Mubarak E, Firn J, Goold SD, Shuman AG. Inter-hospital Transfer Decision-making During the COVID-19 Pandemic: a Qualitative Study. J Gen Intern Med 2023; 38:2568-2576. [PMID: 37254008 PMCID: PMC10228431 DOI: 10.1007/s11606-023-08237-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 05/09/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Inter-hospital patient transfers to hospitals with greater resource availability and expertise may improve clinical outcomes. However, there is little guidance regarding how patient transfer requests should be prioritized when hospital resources become scarce. OBJECTIVE To understand the experiences of healthcare workers involved in the process of accepting inter-hospital patient transfers during a pandemic surge and determine factors impacting inter-hospital patient transfer decision-making. DESIGN We conducted a qualitative study consisting of semi-structured interviews between October 2021 and February 2022. PARTICIPANTS Eligible participants were physicians, nurses, and non-clinician administrators involved in the process of accepting inter-hospital patient transfers. Participants were recruited using maximum variation sampling. APPROACH Semi-structured interviews were conducted with healthcare workers across Michigan. KEY RESULTS Twenty-one participants from 15 hospitals were interviewed (45.5% of eligible hospitals). About half (52.4%) of participants were physicians, 38.1% were nurses, and 9.5% were non-clinician administrators. Three domains of themes impacting patient transfer decision-making emerged: decision-maker, patient, and environmental factors. Decision-makers described a lack of guidance for transfer decision-making. Patient factors included severity of illness, predicted chance of survival, need for specialized care, and patient preferences for medical care. Decision-making occurred within the context of environmental factors including scarce resources at accepting and requesting hospitals, organizational changes to transfer processes, and alternatives to patient transfer including use of virtual care. Participants described substantial moral distress related to transfer triaging. CONCLUSIONS A lack of guidance in transfer processes may result in considerable variation in the patients who are accepted for inter-hospital transfer and in substantial moral distress among decision-makers involved in the transfer process. Our findings identify potential organizational changes to improve the inter-hospital transfer process and alleviate the moral distress experienced by decision-makers.
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Affiliation(s)
- Emily A Harlan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA.
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA.
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.
| | - Eman Mubarak
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Janice Firn
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Susan D Goold
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Andrew G Shuman
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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21
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Clark CJ, Adler R, Xiang L, Shah SK, Cooper Z, Kim DH, Lin KJ, Hsu J, Lipsitz S, Weissman JS. Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: A large multi-institutional comparative cohort study. Am J Surg 2023; 226:108-114. [PMID: 37031040 PMCID: PMC10330079 DOI: 10.1016/j.amjsurg.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/22/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Alzheimer's Disease and Related Dementias (ADRD) may result in poor surgical outcomes. The current study aims to characterize the risk of ADRD on outcomes for patients undergoing colorectal surgery. METHODS Colorectal surgery patients with and without ADRD from 2007 to 2017 were identified using electronic health record-linked Medicare claims data from two large health systems. Unadjusted and adjusted analyses were performed to evaluate postoperative outcomes. RESULTS 5926 patients (median age 74) underwent colorectal surgery of whom 4.8% (n = 285) had ADRD. ADRD patients were more likely to undergo emergent operations (27.7% vs. 13.6%, p < 0.001) and be discharged to a facility (49.8% vs 28.9%, p < 0.001). After multi-variable adjustment, ADRD patients were more likely to have complications (61.1% vs 48.3%, p < 0.001) and required longer hospitalization (7.1 vs 6.1 days, p = 0.001). CONCLUSIONS The diagnosis of ADRD is an independent risk factor for prolonged hospitalization and postoperative complications after colorectal surgery.
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Affiliation(s)
- Clancy J Clark
- Division of Surgical Oncology, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA.
| | - Rachel Adler
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Samir K Shah
- Division of Vascular Surgery, Department of General Surgery, University of Florida, Gainesville, FL, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John Hsu
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
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22
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Fuchs A, Huber M, Riva T, Becker S, Albrecht R, Greif R, Pietsch U. Factors influencing on-scene time in a physician-staffed helicopter emergency medical service (HEMS): a retrospective observational study. Scand J Trauma Resusc Emerg Med 2023; 31:20. [PMID: 37060088 PMCID: PMC10105469 DOI: 10.1186/s13049-023-01085-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/06/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND For helicopter emergency service systems (HEMS), the prehospital time consists of response time, on-scene time and transport time. Little is known about the factors that influence on-scene time or about differences between adult and paediatric missions in a physician-staffed HEMS. METHODS We analysed the HEMS electronic database of Swiss Air-Rescue from 01-01-2011 to 31-12-2021 (N = 110,331). We included primary missions and excluded missions with National Advisory Committee for Aeronautics score (NACA) score 0 or 7, resulting in 68,333 missions for analysis. The primary endpoint 'on-scene time' was defined as first physical contact with the patient until take-off to the hospital. A multivariable linear regression model was computed to examine the association of diagnosis, type and number of interventions and monitoring, and patient's characteristics with the primary endpoint. RESULTS The prehospital time and on-scene time of the missions studied were, respectively, 50.6 [IQR: 41.0-62.0] minutes and 21.0 [IQR: 15.0-28.6] minutes. Helicopter hoist operations, resuscitation, airway management, critical interventions, remote location, night-time, and paediatric patients were associated with longer on-scene times. CONCLUSIONS Compared to adult patients, the adjusted on-scene time for paediatric patients was longer. Besides the strong impact of a helicopter hoist operation on on-scene time, the dominant factors contributing to on-scene time are the type and number of interventions and monitoring: improving individual interventions or performing them in parallel may offer great potential for reducing on-scene time. However, multiple clinical interventions and monitoring interact and are not single interventions. Compared to the impact of interventions, non-modifiable factors, such as NACA score, type of diagnosis and age, make only a minor contribution to overall on-scene time.
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Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
- Swiss Air-Rescue (Rega), Zurich, Switzerland.
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | | | - Roland Albrecht
- Swiss Air-Rescue (Rega), Zurich, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Robert Greif
- University of Bern, Bern, Switzerland
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
- European Resuscitation Council (ERC) Research NET, Niel, Belgium
| | - Urs Pietsch
- Swiss Air-Rescue (Rega), Zurich, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Cini C, Neto AS, Burrell A, Udy A. Inter-hospital transfer and clinical outcomes for people with COVID-19 admitted to intensive care units in Australia: an observational cohort study. Med J Aust 2023. [PMID: 37037671 DOI: 10.5694/mja2.51917] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVES To examine the association between inter-hospital transfer and in-hospital mortality among people with coronavirus disease 2019 (COVID-19) admitted to intensive care units (ICUs) in Australia. DESIGN Retrospective cohort study; analysis of data collected for the Short Period Incidence Study of Severe Acute Respiratory Illness (SPRINT-SARI) Australia study. SETTING, PARTICIPANTS People with COVID-19 admitted to 63 ICUs, 1 January 2020 - 1 April 2022. MAIN OUTCOME MEASURES Primary outcome: in-hospital mortality; secondary outcomes: ICU and hospital lengths of stay and frequency of selected complications. RESULTS Of 5207 people with records in the SPRINT-SARI Australia database at 1 April 2022, 328 (6.3%) had been transferred between hospitals, 305 (93%) during the third pandemic wave. Compared with patients not transferred, their median age was lower (53 years; interquartile range [IQR], 45-61 years v 60 years; IQR, 46-70 years), their median body mass index higher (32.5 [IQR, 27.2-39.0] kg/m2 v 30.1 [IQR, 25.7-35.7] kg/m2 ), and fewer had received a COVID-19 vaccine (22% v 44.9%); their median APACHE II scores were similar (14.0; IQR, 12.0-18.0 v 14.0; IQR, 10.0-19.0). Bacterial pneumonia (64.7% v 29.0%) and bacteraemia (27% v 8%) were more frequent in transferred patients, as was the need for more intensive ICU interventions, including invasive mechanical ventilation (71.2% v 38.1%) and extra-corporeal membrane oxygenation (26% v 1.7%). Crude ICU (19% v 14.9%) and in-hospital mortality (19% v 18.4%) were similar for patients who were or were not transferred; median lengths of ICU (20.0 [IQR, 11.2-40.3] days v 4.6 [IQR, 2.1-10.1] days) and hospital stay (29.7 [IQR, 18.1-49.6] days v 12.3 [IQR, 7.3-21.0] days) were longer for transferred patients. In the multivariable regression analysis, in-hospital mortality risk was lower for transferred patients (risk difference [RD], -5.0 percentage points; 95% confidence interval [CI] -10 to -0.03 percentage points), but not in the propensity score-adjusted analysis (RD, -3.4 [95% CI, -8.9 to 2.1] percentage points). CONCLUSIONS Among people with COVID-19 admitted to ICUs, patients transferred from another hospital required more intense interventions and remained in hospital longer, but were not at greater risk of dying in hospital than the patients who were not transferred.
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Affiliation(s)
| | - Ary S Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
- Austin Hospital, Melbourne, VIC
| | - Aidan Burrell
- Alfred Health, Melbourne, VIC
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
| | - Andrew Udy
- Alfred Health, Melbourne, VIC
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
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Suen CG, Wood AJ, Burke JF, Betjemann JP, Guterman EL. Hospital EEG Capability and Associations With Interhospital Transfer in Status Epilepticus. Neurol Clin Pract 2023; 13:e200143. [PMID: 37064585 PMCID: PMC10101704 DOI: 10.1212/cpj.0000000000200143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/06/2023] [Indexed: 03/18/2023]
Abstract
Background and Objectives EEG is widely recommended for status epilepticus (SE) management. However, EEG access and use across the United States is poorly characterized. We aimed to evaluate changes in inpatient EEG access over time and whether availability of EEG is associated with interhospital transfers for patients hospitalized with SE. Methods We performed a cross-sectional study using data available in the National Inpatient Sample data set from 2012 to 2018. We identified hospitals that used continuous or routine EEG during at least 1 seizure-related hospitalization in a given year using ICD-9 and ICD-10 procedure codes and defined these hospitals as EEG capable. We examined annual change in the proportion of hospitals that were EEG capable during the study period, compared characteristics of hospitals that were EEG capable with those that were not, and fit multivariable logistic regression models to determine whether hospital EEG capability was associated with likelihood of interhospital transfer. Results Among 4,550 hospitals in 2018, 1,241 (27.3%) were EEG capable. Of these, 1,188 hospitals (95.7%) were in urban settings. From 2012 to 2018, the proportion of hospitals that were EEG capable increased in urban settings (30.5%-41.1%, Mann-Kendall [M-K] test p < 0.001) and decreased in rural settings (4.0%-3.2%, M-K p = 0.026). Among 130,580 patients hospitalized with SE, 80,725 (61.8%) presented directly to an EEG-capable hospital. However, EEG use during hospitalization varied from 8% to 98%. Initial admission to a hospital without EEG capability was associated with 22% increased likelihood of interhospital transfer (adjusted RR 1.22, [95% CI, 1.09-1.37]; p < 0.01). Among those hospitalized at an EEG-capable hospital, patients admitted to hospitals in the lowest quintile of EEG volume were more than 2 times more likely to undergo interhospital transfer (adjusted RR 2.22, [95% CI 1.65-2.93]; p < 0.001). Discussion A minority of hospitals are EEG capable yet care for most patients with SE. Inpatient EEG use, however, varies widely among EEG-capable hospitals, and lack of inpatient EEG access is associated with interhospital transfer. Given the high incidence and cost of SE, there is a need to better understand the importance and use of EEG in this patient population to further organize inpatient epilepsy systems of care to optimize outcomes.
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Affiliation(s)
- Catherine G Suen
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - Andrew J Wood
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - James F Burke
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - John P Betjemann
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - Elan L Guterman
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
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Mitra B, Law A, Mathew J, Crabtree A, Mertin H, Underhill A, Noonan M, Hunter P, Smit DV. Telehealth consultation before inter-hospital transfer after falls in a subacute hospital (the PREVENT-2 study). Emerg Med Australas 2023; 35:306-311. [PMID: 36358005 DOI: 10.1111/1742-6723.14130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Inter-hospital transfers are increasingly common due to the regionalisation of healthcare, but are associated with patient discomfort, high costs and adverse events. The aim of the present study was to evaluate the effectiveness of a trauma outreach service for preventing inter-hospital transfers to a major trauma centre. METHODS This was an observational pre- and post-intervention study over a 12-month period from 1 October 2020 to 30 September 2021. Eligible patients sustained a fall at Caulfield Hospital, a subacute care hospital specialising in community services, rehabilitation, geriatric medicine and aged mental health. The intervention was delivery of site-specific education at Caulfield Hospital and a trauma outreach service by specialist trauma clinicians at The Alfred Hospital who provided remote assessment, assisted with clinical management decisions and advised on appropriateness of transfer. RESULTS The present study included 160 patients in the pre-intervention phase and 203 after the intervention. The primary outcome of transfer occurred in 19 (11.9%) patients in the pre-intervention phase and 4 (2.0%) in the post-intervention phase (P < 0.001). In the subgroup of patients without pelvis or long bone fractures, pre-intervention transfer occurred for 17 (10.9%) patients and post-intervention transfer occurred for 4 (2.0%) patients (P < 0.001). CT imaging was performed for 54 (33.8%) patients in the pre-intervention and 45 (22.2%) patients in the post-intervention group (P = 0.014). CONCLUSIONS Telehealth consultation with a trauma specialist was associated with significant reduction of inter-hospital transfers, and significant reduction of CT imaging. This supports continuation of the service with scope for expansion and evaluation of patient-centred outcomes.
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Affiliation(s)
- Biswadev Mitra
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Amelia Law
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph Mathew
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Amelia Crabtree
- Health of Older People Unit, Caulfield Hospital, Melbourne, Victoria, Australia
| | - Helen Mertin
- Health of Older People Unit, Caulfield Hospital, Melbourne, Victoria, Australia
| | - Andrew Underhill
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Noonan
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter Hunter
- Health of Older People Unit, Caulfield Hospital, Melbourne, Victoria, Australia
| | - De Villiers Smit
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
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Chen KC, Wen SH. Impact of interhospital transfer on emergency department timeliness of care and in-hospital outcomes of adult non-trauma patients. Heliyon 2023; 9:e13393. [PMID: 36814609 PMCID: PMC9939607 DOI: 10.1016/j.heliyon.2023.e13393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 01/28/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Background Patients who present to the emergency department (ED) from interhospital transfer (IHT) and non-IHT are known to have differences in various clinical outcomes including mortality. The ED timeliness of care is an effective indicator of the quality of ED care and operational efficiency. The impact of IHT on ED timeliness of care remains unclear. We evaluated the association between IHT and ED timeliness of care or in-hospital outcomes in adult non-trauma patients. Methods Data of consecutive hospital admission of adult non-trauma patients who visited the ED of a medical center from January 2018 to Jun 2020 were retrospectively analyzed. The patients were divided into IHT and non-IHT cohorts. Various data were recorded. The ED length of stay (LOS) was measured as the outcome of ED timeliness of care, while hospital LOS and in-hospital death were measured as the in-hospital outcomes. Multiple regression analyses were performed using unmatched and propensity-matched cohorts. In the later analyses, both groups were propensity matched for sex, age, and other covariates that showed significant differences between two groups to achieve a 1:4 balanced cohort. Results Data on 1856 IHT patients and 16295 non-IHT patients were analyzed. IHT was associated with a shorter ED LOS, longer hospital LOS, and higher odds of in-hospital death compared with non-IHT in unmatched and propensity-matched analyses. The shorter ED LOS was due to the slightly longer interval of arrival to ED physicians (∼1 min) and considerably shorter intervals of ED physicians to decision (∼120 min) and decision to departure (∼105 min). Risk stratification revealed that IHT was associated with a shorter ED LOS in patients with all levels (1-5) of Taiwan Triage and Acuity Scale (TTAS) and associated with longer hospital LOS and higher odds of in-hospital death in patients with TTAS level ≥3. Conclusions IHT was associated with a shorter ED LOS, longer hospital LOS, and higher odds of in-hospital death in adult non-trauma patients compared with non-IHT. The expedited ED timeliness of care in the IHT cohort was due to considerably shorter intervals of both ED physicians to decision and decision to disposition.
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Affiliation(s)
- Kun-Chuan Chen
- Department of Emergency Medicine, Hualien Tzu Chi Hospital, Hualien City, Taiwan,Institute of Medical Sciences, Tzu Chi University, Hualien City, Taiwan
| | - Shu-Hui Wen
- Institute of Medical Sciences, Tzu Chi University, Hualien City, Taiwan,Department of Public Health, College of Medicine, Tzu Chi University, Hualien City, Taiwan,Corresponding author. Institute of Medical Sciences, Tzu Chi University, Hualien City, Taiwan.
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Burke LG, Burke RC, Orav EJ, Duggan CE, Figueroa JF, Jha AK. Association of Academic Medical Center Presence With Clinical Outcomes at Neighboring Community Hospitals Among Medicare Beneficiaries. JAMA Netw Open 2023; 6:e2254559. [PMID: 36723939 PMCID: PMC9892959 DOI: 10.1001/jamanetworkopen.2022.54559] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Studies suggest that academic medical centers (AMCs) have better outcomes than nonteaching hospitals. However, whether AMCs have spillover benefits for patients treated at neighboring community hospitals is unknown. OBJECTIVE To examine whether market-level AMC presence is associated with outcomes for patients treated at nonteaching hospitals within the same markets. DESIGN, SETTING, AND PARTICIPANTS This retrospective, population-based cohort study assessed traditional Medicare beneficiaries aged 65 years and older discharged from US acute care hospitals between 2015 and 2017 (100% sample). Data were analyzed from August 2021 to December 2022. EXPOSURES The primary exposure was market-level AMC presence. Health care markets (ie, hospital referral regions) were categorized by AMC presence (percentage of hospitalizations at AMCs) as follows: no presence (0%), low presence (>0% to 20%), moderate presence (>20% to 35%), and high presence (>35%). MAIN OUTCOMES AND MEASURES The primary outcomes were 30-day and 90-day mortality and healthy days at home (HDAH), a composite outcome reflecting mortality and time spent in facility-based health care settings. RESULTS There were 22 509 824 total hospitalizations, with 18 865 229 (83.8%) at non-AMCs. The median (IQR) age of patients was 78 (71-85) years, and 12 568 230 hospitalizations (55.8%) were among women. Of 306 hospital referral regions, 191 (62.4%) had no AMCs, 61 (19.9%) had 1 AMC, and 55 (17.6%) had 2 or more AMCs. Markets characteristics differed significantly by category of AMC presence, including mean population, median income, proportion of White residents, and physicians per population. Compared with markets with no AMC presence, receiving care at a non-AMC in a market with greater AMC presence was associated with lower 30-day mortality (9.5% vs 10.1%; absolute difference, -0.7%; 95% CI, -1.0% to -0.4%; P < .001) and 90-day mortality (16.1% vs 16.9%; absolute difference, -0.8%; 95% CI, -1.2% to -0.4%; P < .001) and more HDAH at 30 days (16.49 vs 16.12 HDAH; absolute difference, 0.38 HDAH; 95% CI, 0.11 to 0.64 HDAH; P = .005) and 90 days (61.08 vs 59.83 HDAH; absolute difference, 1.25 HDAH; 95% CI, 0.58 to 1.92 HDAH; P < .001), after adjustment. There was no association between market-level AMC presence and mortality for patients treated at AMCs themselves. CONCLUSIONS AND RELEVANCE AMCs may have spillover effects on outcomes for patients treated at non-AMCs, suggesting that they have a broader impact than is traditionally recognized. These associations are greatest in markets with the highest AMC presence and persist to 90 days.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ashish K. Jha
- Brown University School of Public Health, Providence, Rhode Island
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Downer T, Halsall R, Cole R, Thomas C, Kearney L. Nonurgent Pediatric Interhospital Transfers: A Narrative Enquiry of Nurses' Experiences in Australia. J Emerg Nurs 2023:S0099-1767(22)00347-6. [PMID: 36709078 DOI: 10.1016/j.jen.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This study aimed to explore nonurgent pediatric interhospital transfers through the lens of nurses' experiences and perceptions when undertaking these transfers. METHODS Using a narrative inquiry approach, data were collected via semistructured interviews with registered nurses (N = 7) who had experience undertaking patient transfers between nonurgent low-acuity and urgent high-acuity hospital settings. RESULTS Findings established the following 8 themes: ensuring transfer preparation for risk mitigation, practicing confident advocacy, being accountable for risk mitigation of the deteriorating patient during transfer, maintaining standardized procedure, using training and mentorship to support confidence, maintaining interhospital and intrahospital relationships, recognizing the significance of transfer on families, and acknowledging the burden of transfer and delay. DISCUSSION By exploring the stories and experiences of emergency nurses who undertake pediatric interhospital transfers, a deep investigation of the risks and challenges has been described, an area often underrepresented in the literature. Findings from this study highlight important learnings for pediatric interhospital transfer that add value to the wider body of evidence.
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Alagoz E, Saucke M, Arroyo N, Ingraham A. Communication During Interhospital Transfers of Emergency General Surgery Patients: A Qualitative Study of Challenges and Opportunities. J Patient Saf 2022; 18:711-716. [PMID: 36170588 PMCID: PMC9523144 DOI: 10.1097/pts.0000000000000979] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Transferred emergency general surgery (EGS) patients experience worse outcomes than directly admitted patients. Improving communication during transfers may improve patient care. We sought to understand the nature of and challenges to communication between referring (RP) and accepting (AP) providers transferring EGS patients from the transfer center nurse's (TCN) perspective. METHODS Guided by the Relational Coordination Framework, we interviewed 17 TCNs at an academic medical center regarding (in)efficient and (in)effective communication between RPs and APs. In-person interviews were recorded, transcribed, and managed in NVivo. Four researchers developed a codebook, cocoded transcripts, and met regularly to build consensus and discuss emergent themes. We used data matrices to perform constant comparisons and arrive at higher-level concepts. RESULTS Challenges to ideal communication centered on the appropriateness and completeness of information, efficiency of the conversation, and degree of consensus. Transfer center nurses described that RPs provided incomplete information because of a lack of necessary infrastructure, personnel, or technical knowledge; competing clinical demands; or a fear of the transfer request being rejected. Inefficient communication resulted from RPs being unfamiliar with the information APs expected and the lack of a structured process to share information. Communication also failed when providers disagreed about the necessity of the transfer. Accepting providers diffused tension and facilitated communication by embracing the role of a "coach," negotiating "wait-and-see" agreements, and providing explanations of why transfers were unnecessary. CONCLUSIONS Transfer center nurses described numerous challenges to provider communication. Opportunities for improvement include sharing appropriate and complete information, ensuring efficient communication, and reaching consensus about the course of action.
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Affiliation(s)
- Esra Alagoz
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Megan Saucke
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Natalia Arroyo
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Angela Ingraham
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
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Han JS, Yuan E, Bonney PA, Lin M, Reckamp K, Ding L, Zada G, Mack WJ, Attenello FJ. Interhospital transfer of patients with malignant brain tumors undergoing resection is associated with routine discharge. Clin Neurol Neurosurg 2022; 221:107372. [DOI: 10.1016/j.clineuro.2022.107372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 07/17/2022] [Indexed: 11/26/2022]
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Liu LJW, Crispo JAG, Bach P, Ansell DR, Thibault D, Willis AW, Cragg JJ. Amphetamine-related care in the USA, 2003-2014: cross-sectional analyses examining inpatient trends and factors associated with hospitalisation outcomes. BMJ Open 2022; 12:e059898. [PMID: 36127119 PMCID: PMC9490607 DOI: 10.1136/bmjopen-2021-059898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 08/15/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Although amphetamine use is a growing health problem in the USA, there are limited data on amphetamine-related hospitalisations. The primary objective of our study was to examine trends in amphetamine-related hospitalisations in the USA between 2003 and 2014, including by age and sex. Our secondary objectives were to examine whether demographic, clinical and care setting characteristics were associated with select outcomes of amphetamine-related hospitalisations, including in-hospital mortality, prolonged length of stay and leaving against medical advice. DESIGN, SETTING AND PARTICIPANTS Using the 2003-2014 National Inpatient Sample, we estimated the rate of amphetamine-related hospitalisations for each year in the USA among individuals 18+ years of age, stratified by age and sex. Subgroup analyses examined hospitalisations due to amphetamine causes. Unconditional logistic regression modelling was used to estimate the adjusted odds of admission outcomes for sociodemographic, clinical and hospital indicators. PRIMARY AND SECONDARY OUTCOMES Our primary outcome was amphetamine-related hospitalisations between 2003 and 2014; secondary outcomes included in-hospital mortality, prolonged length of stay and leaving against medical advice. RESULTS Amphetamine-related hospitalisation rates increased from 27 to 69 per 100 000 population between 2003 and 2014. Annual rates were consistently greater among younger (18-44 years) individuals and men. Regional differences were observed, with admission to Western hospitals being associated with increased mortality (adjusted OR, AOR 5.07, 95% CI 1.22 to 21.04) and shorter (0-2 days) lengths of stay (AOR 0.70, 95% CI 0.58 to 0.83) compared with Northeast admissions. Males (AOR 1.26, 95% CI 1.15 to 1.38; compared with females) and self-pay (AOR 2.30, 95% CI 1.90 to 2.79; compared with private insurance) were associated with leaving against medical advice. CONCLUSIONS Increasing rates of amphetamine-related hospitalisation risk being overshadowed by other public health crises. Regional amphetamine interventions may offer the greatest population health benefits. Future studies should examine long-term outcomes among patients hospitalised for amphetamine-related causes.
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Affiliation(s)
- Lisa J W Liu
- Collaboration for Outcomes Research and Evaluation (CORE), The University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - James A G Crispo
- Collaboration for Outcomes Research and Evaluation (CORE), The University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, Canada
- Human Sciences Division, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Paxton Bach
- Department of Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Dominique R Ansell
- Emergency Department, Health Sciences North, Sudbury, Ontario, Canada
- Clinical Sciences Division, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Dylan Thibault
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Allison W Willis
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jacquelyn J Cragg
- Collaboration for Outcomes Research and Evaluation (CORE), The University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
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Franklin BJ, Mueller SK, Bates DW, Gandhi TK, Morris CA, Goralnick E. Use of Hospital Capacity Command Centers to Improve Patient Flow and Safety: A Scoping Review. J Patient Saf 2022; 18:e912-e921. [PMID: 35435429 DOI: 10.1097/pts.0000000000000976] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Delayed emergency department (ED) and hospital patient throughput is recognized as a critical threat to patient safety. Increasingly, hospitals are investing significantly in deploying command centers, long used in airlines and the military, to proactively manage hospital-wide patient flow. This scoping review characterizes the evidence related to hospital capacity command centers (CCCs) and synthesizes current data regarding their implementation. METHODS As no consensus definition exists for CCCs, we characterized them as units (i) involving interdisciplinary, permanently colocated teams, (ii) using real-time data, and (iii) managing 2 or more patient flow functions (e.g., bed management, transfers, discharge planning, etc.), to distinguish CCCs from transfer centers. We undertook a scoping review of the medical and gray literature published through April 2019 related to CCCs meeting these criteria. RESULTS We identified 8 eligible articles (including 4 peer-reviewed studies) describing 7 CCCs of varying designs. The most common CCC outcome measures related to transfer volume (n = 5) and ED boarding (n = 4). Several CCCs also monitored patient-level clinical parameters. Although all articles reported performance improvements, heterogeneity in CCC design and evidence quality currently restricts generalizability of findings. CONCLUSIONS Numerous anecdotal accounts suggest that CCCs are being widely deployed in an effort to improve hospital patient flow and safety, yet peer-reviewed evidence regarding their design and effectiveness is in its earliest stages. The costs, objectives, and growing deployment of CCCs merit an investment in rigorous research to better measure their processes and outcomes. We propose a standard definition, conceptual framework, research priorities, and reporting standards to guide future investigation of CCCs.
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Mo C, Cheng Y, Pan J, Tan K, Zhang X, Xu J. Association between hospital characteristics and 30-day mortality of patients hospitalized for acute myocardial infarction in Sichuan, China. J Evid Based Med 2022; 15:236-244. [PMID: 36018065 DOI: 10.1111/jebm.12491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/27/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Because acute myocardial infarction (AMI) is a major cause of death, China faces the challenge of improving its quality of care. This study provides context-specific evidence of association between 30-day mortality and hospital characteristics in China to extend the understanding of hospitalized AMI patients. METHODS We conducted a retrospective cohort study of 67,619 hospitalized AMI patients at 372 tertiary and secondary hospitals in Sichuan, China, between January 1, 2018 and December 31, 2020. Using a hierarchical logistic regression model to control risk factors, we explored relationships among 30-day mortality, hospital level, AMI volume, and percutaneous coronary intervention (PCI) timeliness. Locally weighted scatterplot smoothing was used to observe the trends of 30-day mortality with increased AMI volume and PCI timeliness. RESULTS After risk factor adjustment, the 30-day mortality model demonstrated that a lower hospital level and smaller AMI volume were associated with higher 30-day mortality (medium-volume: OR = 1.511, 95% CI (1.195, 1.910); small-volume: OR = 1.636, 95% CI (1.277, 2.096); other tertiary: OR = 1.190, 95% CI (1.037, 1.365); secondary: OR = 1.524, 95% CI (1.289, 1.800)). Similarly, 30-day mortality was higher for patients at hospitals with a low PCI timeliness (low timeliness: OR = 1.318, 95% CI (1.079, 1.610)). Scatterplot smoothing showed hospital 30-day mortality first reduced quickly and gradually stabilized with increased AMI volume and PCI timeliness. CONCLUSION Patients admitted to tertiary grade A hospitals, large-volume hospitals, and high- or medium-timeliness hospitals were more likely to survive at 30 days. Policymakers should focus on improving the outcomes at hospitals without these characteristics.
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Affiliation(s)
- Chunmei Mo
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Yongzhong Cheng
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Jingping Pan
- Health Information Center of Sichuan Province, Chengdu, P.R. China
| | - Kun Tan
- Health Information Center of Sichuan Province, Chengdu, P.R. China
| | - Xueli Zhang
- Health Information Center of Sichuan Province, Chengdu, P.R. China
| | - Jiuping Xu
- Business School, Sichuan University, Chengdu, P.R. China
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Ku NW, Tsai CL, Chen SC, Huang CH, Fang CC, Shun SC. Bed-to-Bed Transfer Program Among Patients Who Need Hospitalization in a Crowded Emergency Department in Taiwan. Int J Health Policy Manag 2022; 11:1844-1851. [PMID: 34634877 PMCID: PMC9808224 DOI: 10.34172/ijhpm.2021.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/18/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Emergency department (ED) crowding is a universal issue. In Taiwan, patients with common medical problems prefer to visit ED of medical centers, resulting in overcrowding. Thus, a bed-to-bed transfer program has been implemented since 2014. However, there was few studies that compared clinical outcomes among patients who choose to stay in medical centers to those being transferred to regional hospitals. The aim of this study was to explore the transfer rate, delineate the factors related to patient transfer, and clarify the influence upon the program outcomes. METHODS A retrospective cohort study was conducted using demographic and clinical disease factors from the patient electronic referral system, electronic medical records (EMRs) of a medical center in Taipei, and response to referrals from regional hospitals. The study included adult patients who were assessed as appropriate for transfer in 2016. We analyzed the outcomes (length of stay and mortality rate) between the referrals were accepted and refused using propensity score matching. RESULTS Of the 1759 patients eligible for transfer to regional hospitals, 420 patients (24%) accepted the referral. Medical records were obtained from the regional hospitals for 283 patients (67%). After propensity score matching, the results showed that interhospital transfer resulted in similar median total length of stay (8.7 days in the medical center vs 7.9 days in regional hospitals; P=.245). In-hospital mortality was low for both groups (3.1% in the medical center vs 1.3% in regional hospitals; P=.344). CONCLUSION Transfer from an overcrowded ED in a medical center to regional hospitals in eligible patients results in non-significant outcome of total length of stay. With the caveat of an underpowered sample, we did not find statistically significant differences in in-hospital mortality. This healthcare delivery model may be used in other cities facing similar problems of ED overcrowding.
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Affiliation(s)
- Nai-Wen Ku
- School of Nursing, National Taiwan University, Taipei, Taiwan
- Department of Emergency, National Taiwan University Hospital, Taipei, Taiwan
| | - Chu-Lin Tsai
- Department of Emergency, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shyr-Chyr Chen
- Department of Emergency, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Chung Fang
- Department of Emergency, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shiow-Ching Shun
- Institute of Clinical Nursing, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Watters DA, Brown WA. Promoting good practice before, during and after transfers. ANZ J Surg 2022; 92:1296-1297. [PMID: 35688640 DOI: 10.1111/ans.17744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
Affiliation(s)
- David A Watters
- Victorian Perioperative Consultative Council, Victoria, Australia.,School of Medicine and Health Sciences, Deakin University, Geelong, Victoria, Australia.,Barwon Health, Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - Wendy A Brown
- Victorian Perioperative Consultative Council, Victoria, Australia.,Monash University Department of Surgery, Alfred Health, Melbourne, Victoria, Australia
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Murshed I, Gupta AK, Kovoor JG, Maddern GJ. Surgical inter-hospital transfers: life saver or resource drainer? ANZ J Surg 2022; 92:1300-1301. [PMID: 35688641 PMCID: PMC9328366 DOI: 10.1111/ans.17786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/03/2022] [Accepted: 05/05/2022] [Indexed: 01/17/2023]
Affiliation(s)
- Ishraq Murshed
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Department of Cardiothoracic Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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Pomponio MK, Khan IS, Evans LT, Simmons NE, Ball PA, Ryken TC, Hong J. Association between interhospital transfer and increased in-hospital mortality in patients with spinal epidural abscesses. Spine J 2022; 22:921-926. [PMID: 35017053 DOI: 10.1016/j.spinee.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/30/2021] [Accepted: 01/03/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal epidural abscess (SEA) is an uncommon yet serious infection, associated with significant morbidity and mortality. Patients diagnosed with SEA often require surgical interventions or critical care services that are not available at community hospitals and are therefore transferred to tertiary care centers. Little is known about the effects of interhospital transfer on acute outcomes for patients with SEA. PURPOSE To study the effects of interhospital transfer on acute outcomes for patients with SEA. STUDY DESIGN Cross sectional analysis using the 2009 to 2017 National Inpatient Sample (NIS). PATIENT SAMPLE Using the 2009 to 2017 NIS, we identified cases of SEA using ICD, Ninth, or Tenth Revision diagnosis codes 324.1 & G06.1. OUTCOME MEASURES Our primary endpoint was in hospital mortality. METHODS The association between interhospital transfer and inpatient mortality was assessed using multivariable logistic regression to adjust for potential covariates. Patient and hospital factors associated with interhospital transfer were assessed in a secondary analysis. RESULTS A total of 21.5% of patient with SEA were treated after transfer from another hospital. After adjusting for covariates, those who presented after transfer had higher odds of death during hospitalization (OR: 1.51, 95% CI 1.27-1.78, p<.001). Transferred patients were significantly more likely to live in rural communities (11.4 % vs. 5.3 % for nontransferred patients). CONCLUSIONS Interhospital transfer, which occurred more frequently in patients from rural hospitals, was associated with death even after controlling for disease severity. Addressing healthcare delivery disparities across the US, including across the rural-urban spectrum, will require better understanding of the observed increased mortality of interhospital transfer as a preventable source of in-hospital mortality for SEA.
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Affiliation(s)
- Maria K Pomponio
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road Hanover, NH 03755, USA
| | - Imad S Khan
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Linton T Evans
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Nathan E Simmons
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Perry A Ball
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Timothy C Ryken
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Jennifer Hong
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
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Zachrison KS, Amati V, Schwamm LH, Yan Z, Nielsen V, Christie A, Reeves MJ, Sauser JP, Lomi A, Onnela JP. Influence of Hospital Characteristics on Hospital Transfer Destinations for Patients With Stroke. Circ Cardiovasc Qual Outcomes 2022; 15:e008269. [PMID: 35369714 DOI: 10.1161/circoutcomes.121.008269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients with stroke are frequently transferred between hospitals. This may have implications on the quality of care received by patients; however, it is not well understood how the characteristics of sending and receiving hospitals affect the likelihood of a transfer event. Our objective was to identify hospital characteristics associated with sending and receiving patients with stroke. METHODS Using a comprehensive statewide administrative dataset, including all 78 Massachusetts hospitals, we identified all transfers of patients with ischemic stroke between October 2007 and September 2015 for this observational study. Hospital variables included reputation (US News and World Report ranking), capability (stroke center status, annual stroke volume, and trauma center designation), and institutional affiliation. We included network variables to control for the structure of hospital-to-hospital transfers. We used relational event modeling to account for complex temporal and relational dependencies associated with transfers. This method decomposes a series of patient transfers into a sequence of decisions characterized by transfer initiations and destinations, modeling them using a discrete-choice framework. RESULTS Among 73 114 ischemic stroke admissions there were 7189 (9.8%) transfers during the study period. After accounting for travel time between hospitals and structural network characteristics, factors associated with increased likelihood of being a receiving hospital (in descending order of relative effect size) included shared hospital affiliation (5.8× higher), teaching hospital status (4.2× higher), stroke center status (4.3× and 3.8× higher when of the same or higher status), and hospitals of the same or higher reputational ranking (1.5× higher). CONCLUSIONS After accounting for distance and structural network characteristics, in descending order of importance, shared hospital affiliation, hospital capabilities, and hospital reputation were important factor in determining transfer destination of patients with stroke. This study provides a starting point for future research exploring how relational coordination between hospitals may ensure optimized allocation of patients with stroke for maximal patient benefit.
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Affiliation(s)
- Kori S Zachrison
- Departments of Emergency Medicine (K.S.Z.), Massachusetts General Hospital, Boston.,Harvard Medical School (K.S.Z., L.H.S.), Boston, MA
| | - Viviana Amati
- Social Networks Lab of the Department of Humanities, Social, and Political Sciences, ETH Zurich, Switzerland (V.A.)
| | - Lee H Schwamm
- Neurology (L.H.S., Z.Y.), Massachusetts General Hospital, Boston.,Harvard Medical School (K.S.Z., L.H.S.), Boston, MA
| | - Zhiyu Yan
- Neurology (L.H.S., Z.Y.), Massachusetts General Hospital, Boston
| | - Victoria Nielsen
- Massachusetts Department of Public Health, Boston, MA (V.N., A.C.)
| | - Anita Christie
- Massachusetts Department of Public Health, Boston, MA (V.N., A.C.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics of Michigan State University, East Lansing (M.J.R.)
| | - Joseph P Sauser
- Hankamer School of Business at Baylor University, Waco, TX (J.P.S.)
| | - Alessandro Lomi
- Faculty of Economics of the University of Italian Switzerland, Lugano, Switzerland (A.L.)
| | - Jukka-Pekka Onnela
- Department of Biostatistics at the Harvard T.H. Chan School of Public Health, Boston, MA (J.P.O.)
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Reddan T, Halligan T, Corness J. An audit of inter‐hospital transfers of children with abdominal pain and their associated medical imaging findings. SONOGRAPHY 2021. [DOI: 10.1002/sono.12291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Tristan Reddan
- Medical Imaging and Nuclear Medicine Queensland Children's Hospital South Brisbane Australia
- School of Clinical Sciences Queensland University of Technology Brisbane Australia
| | - Toni Halligan
- Allied Health Professions' Office Queensland Queensland Health Herston Australia
| | - Jonathan Corness
- Medical Imaging and Nuclear Medicine Queensland Children's Hospital South Brisbane Australia
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Paajanen J, Mäkinen L, Suikkila A, Rehell M, Javanainen M, Lindahl A, Kekäläinen E, Kurkela S, Halmesmäki K, Anttila VJ, Lamminmäki S. Isolation precautions cause minor delays in diagnostics and treatment of non-COVID patients. Infect Prev Pract 2021; 3:100178. [PMID: 34642658 PMCID: PMC8492011 DOI: 10.1016/j.infpip.2021.100178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 09/29/2021] [Indexed: 11/26/2022] Open
Abstract
Background Isolation precautions are essential prevent spread of COVID-19 infection but may have a negative impact on inpatient care. The impact of these measures on non-COVID-19 patients remains largely unexplored. Aim This study aimed to investigate diagnostic and treatment delays related to isolation precautions, the associated patient outcome, and the predisposing risk factors for delays. Methods This observational study was conducted in seven Helsinki region hospitals during the first wave of the COVID-19 pandemic in Finland. The study used data on all non-COVID-19 inpatients, who were initially isolated due to suspected COVID-19, to estimate whether isolation precautions resulted in diagnostic or treatment delays. Results Out of 683 non-COVID-19 patients, 33 (4.8%) had delays related to isolation precautions. Clinical condition deteriorated non-fatally in seven (1.0%) patients. The following events were associated with an increased risk of treatment or a diagnostic delay: more than three ward transfers (P = 0.025); referral to an incorrect speciality in the emergency department (P = 0.004); more than three SARS-CoV-2 RT-PCR tests performed (P = 0.022); and where cancer was the final diagnosis (P = 0.018). In contrast, lower respiratory tract symptoms (P = 0.013) decreased the risk. Conclusions The use of isolation precautions for patients who did not have COVID-19 had minor negative effects on patient outcomes. The present study underlines the importance of targeting diagnostic efforts to patients with unspecified symptoms and to those with a negative SARS-CoV-2 test result. Thorough investigations to achieve an accurate diagnosis improves the prognosis of patients and facilitates appropriate targeting of hospital resources.
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Affiliation(s)
- J. Paajanen
- Department of Pulmonary Medicine, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland
- Corresponding author. Address: Department of Pulmonary Medicine, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland. Tel.: +358 9 4711.
| | - L.K. Mäkinen
- Department of Pulmonary Medicine, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland
| | - A. Suikkila
- Department of Otorhinolaryngology, Head and Neck Surgery, Head and Neck Center, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland
| | - M. Rehell
- Department of Otorhinolaryngology, Head and Neck Surgery, Head and Neck Center, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland
| | - M. Javanainen
- Meilahti University Hospital, Adnominal Center, HUS, Haartmaninkatu 4, Helsinki P.O. Box 340, FIN-00029, Helsinki, Finland
| | - A. Lindahl
- Department of Pulmonary Medicine, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland
| | - E. Kekäläinen
- HUS Diagnostic Center, HUSLAB, Clinical Microbiology, University of Helsinki and Helsinki University Hospital, Finland
- Translational Immunology Research Program, University of Helsinki, Finland
| | - S. Kurkela
- HUS Diagnostic Center, HUSLAB, Clinical Microbiology, University of Helsinki and Helsinki University Hospital, Finland
| | - K. Halmesmäki
- Department of Vascular Surgery, Abdominal Center, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland
| | - V.-J. Anttila
- Department of Infectious Diseases, Inflammatory Center, University of Helsinki and Helsinki University Hospital, HUS, 00029, Finland
| | - S. Lamminmäki
- Department of Otorhinolaryngology, Head and Neck Surgery, Head and Neck Center, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland
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Functional outcomes following an in-hospital cardiac arrest: A retrospective cohort study. Aust Crit Care 2021; 35:424-429. [PMID: 34454801 DOI: 10.1016/j.aucc.2021.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/24/2021] [Accepted: 07/21/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/PURPOSE Whilst much is known about the survival outcomes of patients that suffer an in-hospital cardiac arrest (IHCA) in Australia very little is known about the functional outcomes of survivors. This study aimed to describe the functional outcomes of a cohort of patients that suffered an in-hospital cardiac arrest (IHCA) and survived to hospital discharge in a regional Australian hospital. METHODS This is a single-centre retrospective observational cohort study conducted in a regional Australian hospital. All adult patients that had an IHCA in the study hospital between 1 Jan 2017 and 31 Dec 2019 and survived to hospital discharge were included in the study. Functional outcomes were reported using the Modified Rankin Scale (mRS), a six-point scale for which increasing scores represent increasing disability. Scores were assigned through a retrospective review of medical notes. RESULTS Overall, 102 adult patients had an IHCA during the study period, of whom 50 survived to hospital discharge. The median age of survivors was 68 years, and a third had a shockable initial arrest rhythm. Of survivors, 47 were able to be assigned both mRS scores. At discharge, 81% of patients achieved a favourable functional outcome (mRS 0-3 or equivalent function at discharge equal to admission). CONCLUSIONS Most survivors to hospital discharge following an IHCA have a favourable functional outcome and are discharged home. Although these results are promising, larger studies across multiple hospitals are required to further inform what is known about functional outcomes in Australian IHCA survivors.
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Kim MS, Choi SH, Bae JW, Lee J, Kim H, Lee WK. Did inter-hospital transfer reduce mortality in patients with acute myocardial infarction in the real world? A nationwide patient cohort study. PLoS One 2021; 16:e0255839. [PMID: 34352024 PMCID: PMC8341481 DOI: 10.1371/journal.pone.0255839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/24/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Inter-hospital transfer (IHT) and primary percutaneous coronary intervention (PCI) are preferred over onsite thrombolysis when provided expeditiously. On the other hand, its benefit has not been evaluated in a real-world situation. This study examined the effects of IHT on the short- and long-term mortality in patients with acute myocardial infarction (AMI) and compared the reperfusion treatments and resources between the referring and receiving hospitals. METHODS Patients newly diagnosed with AMI and admitted to hospital were selected from the national health insurance database from 2004 to 2018. The 30-day and one-year mortality in the transferred and non-transferred patients were estimated and compared using stabilized inverse probability of treatment weighting to account for confounding bias. RESULTS Of the 258,291 participants, 10,158 were transferred to one or more hospitals. IHT was more likely to occur to older or more comorbid people, patients in rural areas, and those whose insurance was medical aid. The 30-day and one-year mortality of the non-IHT group was 9.7% and 15.8%, respectively, whereas the figure was 11.4% and 20.5% in the IHT group. After balancing the baseline characteristics, the transferred patients were 1.12 (95% CI: 1.06-1.20) and 1.25 (95% CI: 1.20-1.31) times more likely to die during the subsequent 30 days and one year, respectively, than those treated solely at the presenting hospital. In ST-segment elevation myocardial infarction (STEMI), the hazard ratios of the 30-day and 1-year mortality were 1.14 (95% CI: 0.97-1.35) and 1.31 (95% CI: 1.15-1.49) in the transferred patients after balancing cardiogenic shock and cardiac arrest. On-site thrombolysis was rarely performed in the referring hospitals. CONCLUSION Patients transferred for the treatment of AMI experienced higher short- and long-term mortality. Therefore, onsite thrombolysis and the estimated time delay to PCI should be considered in regional hospitals to reduce mortality with the organization of STEMI treatment networks.
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Affiliation(s)
- Mi-Sook Kim
- Division of Clinical Epidemiology, Medical Research Collaborating Center, Biomedical Research Institution, Seoul National University Hospital, Seoul, Korea
| | - Seong Huan Choi
- Department of Cardiology, Inha University Hospital, School of Medicine, Inha University, Incheon, Korea
| | - Jang-Whan Bae
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joongyub Lee
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeongsu Kim
- Department of Preventive Medicine, School of Medicine, Konkuk University, Seoul, Korea
| | - Won Kyung Lee
- Department of Prevention and Management, Inha University Hospital, School of Medicine, Inha University, Incheon, Korea
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Reichheld A, Yang J, Sokol-Hessner L, Quinn G. Defining Best Practices for Interhospital Transfers. J Healthc Qual 2021; 43:214-224. [PMID: 33596008 DOI: 10.1097/jhq.0000000000000293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Interhospital transfers (IHT) are important yet high-risk transitions in care. Variable IHT processes and a lack of clarity around best practice may contribute to risk. To define the best practice principles for IHTs and identify improvement opportunities in the transfer process to our hospital's Cardiology services. METHODS Through literature review, interviews with experts and key stakeholders, a survey of health care professionals at our institution, and a failure modes effect analysis, we identified themes in IHT best practices and improvement opportunities. RESULTS We identified six critical elements of IHT: (1) initiation of transfer request; (2) the management of transfer request and information exchange; (3) updates between transfer acceptance and patient transport; (4) transport; (5) patient admission and information availability; and (6) measurement, evaluation, and feedback. Improvement opportunities were found in all elements. CONCLUSIONS The standardization of these six critical elements may improve the safety of IHTs.
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Kim YJ, Hong JS, Hong SI, Kim JS, Seo DW, Ahn R, Jeong J, Lee SW, Moon S, Kim WY. The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016-2018. J Korean Med Sci 2021; 36:e172. [PMID: 34184436 PMCID: PMC8239427 DOI: 10.3346/jkms.2021.36.e172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/31/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. METHODS This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016-2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. RESULTS We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). CONCLUSION The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the first-transfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.
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Affiliation(s)
- Youn Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Seok Hong
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seok In Hong
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - June Sung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ryeok Ahn
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jinwoo Jeong
- Department of Emergency Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Sung Woo Lee
- Department of Emergency Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sungwoo Moon
- National Emergency Medical Center, National Medical Center, Seoul, Korea
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Baig SH, Gorth DJ, Yoo EJ. Critical Care Utilization and Outcomes of Interhospital Medical Transfers at Lower Risk of Death. J Intensive Care Med 2021; 37:679-685. [PMID: 34080443 DOI: 10.1177/08850666211022613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate utilization and mortality outcomes of interhospital transferred critically-ill medical patients with lower predicted risk of hospital mortality. MATERIALS & METHODS Multisite retrospective cohort analysis of patients with Acute Physiology and Chronic Health Evaluation (APACHE) IV-a predicted mortality of ≤20% from 335 ICUs in 208 hospitals in the Philips eICU database between 2014-2015. Differences in length-of-stay (LOS) and mortality between transferred and local patients were evaluated using negative binomial logistic regression and logistic regression, respectively. Stratified analyses were conducted for subgroups of predicted mortality: 0%-5%, 6%-10%, 11%-15%, and 16%-20%. RESULTS Transfers had a higher risk of longer ICU and hospital LOS across all risk strata (IRR 1.12; 95% CI 1.09-1.16, P < 0.001 and IRR 1.11; 95% CI 1.07-1.14, P < 0.001 respectively). Mortality was higher among transfers, largely driven by the 6%-10% mortality risk strata (OR 1.30; 95% CI 1.09-1.54, P = 0.003). CONCLUSIONS Interhospital transfer of critically-ill medical patients with lower illness severity is associated with higher ICU and hospital utilization and increased mortality. Better understanding of factors driving patient selection for and characteristics of interhospital transfer for this population will have an impact on ICU resource utilization, care efficiency, and hospital quality.
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Affiliation(s)
- Saqib H Baig
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, PA, USA
| | - Deborah J Gorth
- Sidney Kimmel Medical College, Thomas Jefferson University, PA, USA
| | - Erika J Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, PA, USA
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Justice SA, Sewell DK, Miller AC, Simmering JE, Polgreen PM. Inferring patient transfer networks between healthcare facilities. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2021. [DOI: 10.1007/s10742-021-00249-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Tanaka S, Kunie K, Takemura Y, Ichikawa N, Kida R. Exploring nurses' clinical reasons for bed transfers in acute care wards: An observational study. J Nurs Manag 2021; 29:2297-2306. [PMID: 33930232 DOI: 10.1111/jonm.13352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 12/01/2022]
Abstract
AIMS To investigate the number of bed transfers (patient transfers within the same ward) and their reasons in acute care wards of mid-sized hospitals with multibed and private rooms. BACKGROUND Bed transfers, even when necessary, are burdensome for patients; however, the reasons for bed transfers in various types of rooms remain unclear. METHODS An observational study was conducted in seven wards in three hospitals in Japan. Nurses completed a questionnaire regarding each bed transfer, which elicited the reasons for the transfer. We classified transfer patterns based on the functions of the patients' rooms and the number of beds in each room and analysed scores. RESULTS Overall, 560 responses were analysed. The average number of bed transfers per day was 2.7. In total, 43% of bed transfers were conducted for patients aged over 70. The most frequent bed transfer pattern was 'transfer between patient rooms with the same number of beds', and the most frequent reason was 'patient did not need that bed'. CONCLUSIONS Unnecessary bed transfers could be reduced by ward designs that reflect nurses' clinical judgement. IMPLICATIONS FOR NURSING MANAGEMENT Monitoring data for the reason regarding bed transfer contributes to hospital planning and decreases unnecessary bed transfers.
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Affiliation(s)
- Shingo Tanaka
- Department of Nursing Administration, Division of Health Sciences and Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Keiko Kunie
- Department of Nursing Administration, School of Nursing, Tokyo Women's Medical University, Tokyo, Japan
| | - Yukie Takemura
- Department of Nursing Administration, Division of Health Sciences and Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Naoko Ichikawa
- Department of Nursing Administration, Division of Health Sciences and Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Ryohei Kida
- Department of Nursing Administration, Division of Health Sciences and Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Shannon EM, Zheng J, Orav EJ, Schnipper JL, Mueller SK. Racial/Ethnic Disparities in Interhospital Transfer for Conditions With a Mortality Benefit to Transfer Among Patients With Medicare. JAMA Netw Open 2021; 4:e213474. [PMID: 33769508 PMCID: PMC7998076 DOI: 10.1001/jamanetworkopen.2021.3474] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
IMPORTANCE Interhospital transfer (IHT) of patients is a common occurrence in modern health care. Racial/ethnic disparities are prevalent throughout US health care, but their presence in IHT is not well characterized. OBJECTIVE To determine if there are racial/ethnic disparities in IHT for medical diagnoses for which IHT is associated with a mortality benefit. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis used 2013 data from the Center for Medicare & Medicaid Services 100% Master Beneficiary Summary and Inpatient Claims merged with 2013 American Hospital Association data. Individuals with Medicare aged 65 years or older continuously enrolled in Medicare Part A and B with an inpatient hospitalization claim in 2013 for primary diagnosis of acute myocardial infarction, stroke, sepsis, or respiratory diseases were included. Data analysis occurred from November 2019 through July 2020. EXPOSURES Race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome of interest was IHT. For the primary analysis, a series of logistic regression models were created to estimate the adjusted odds of IHT for Black and Hispanic patients compared with White patients, controlling for patient clinical and demographic variables and incorporating hospital fixed effects. In secondary analyses, subgroup analyses were conducted by diagnosis, hospital teaching status, and hospitalization to hospitals in the top decile of Black and Hispanic patient proportion. RESULTS Among 899 557 patients, 734 958 patients were White (81.7%), 84 544 patients were Black (9.4%), and 47 588 patients were Hispanic (5.3%); there were 418 683 men (46.5%), and 306 215 patients (34.0%) were older than 84 years. The mean (SD) age was 76.8 (7.5) years. Among all patients, 20 171 White patients (2.7%), 1913 Black patients (2.3%), and 1062 Hispanic patients (2.2%) underwent IHT. After controlling for patient variables and hospital fixed effects, Black patients had a persistently lower odds of IHT (adjusted odds ratio, 0.87; 95% CI, 0.81-0.92; P < .001), while Hispanic patients had higher odds of IHT (adjusted odds ratio, 1.14; 95% CI, 1.05-1.24; P = .002) compared with White patients. CONCLUSIONS AND RELEVANCE This national evaluation of IHT among patients hospitalized with diagnoses previously found to have mortality benefit with transfer found that, compared with White patients, Black patients had persistently lower adjusted odds of transfer after accounting for patient and hospital characteristics and measured across various hospital settings. Meanwhile, Hispanic patients had higher adjusted odds of transfer. This research highlights the need for the development of strategies to mitigate disparate transfer practices by patient race/ethnicity.
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Affiliation(s)
- Evan Michael Shannon
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jie Zheng
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jeffrey L. Schnipper
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stephanie K. Mueller
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
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Altieri Dunn SC, Bellon JE, Bilderback A, Borrebach JD, Hodges JC, Wisniewski MK, Harinstein ME, Minnier TE, Nelson JB, Hall DE. SafeNET: Initial development and validation of a real-time tool for predicting mortality risk at the time of hospital transfer to a higher level of care. PLoS One 2021; 16:e0246669. [PMID: 33556123 PMCID: PMC7870086 DOI: 10.1371/journal.pone.0246669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/24/2021] [Indexed: 01/31/2023] Open
Abstract
Background Processes for transferring patients to higher acuity facilities lack a standardized approach to prognostication, increasing the risk for low value care that imposes significant burdens on patients and their families with unclear benefits. We sought to develop a rapid and feasible tool for predicting mortality using variables readily available at the time of hospital transfer. Methods and findings All work was carried out at a single, large, multi-hospital integrated healthcare system. We used a retrospective cohort for model development consisting of patients aged 18 years or older transferred into the healthcare system from another hospital, hospice, skilled nursing or other healthcare facility with an admission priority of direct emergency admit. The cohort was randomly divided into training and test sets to develop first a 54-variable, and then a 14-variable gradient boosting model to predict the primary outcome of all cause in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and transition to comfort measures only or hospice care. For model validation, we used a prospective cohort consisting of all patients transferred to a single, tertiary care hospital from one of the 3 referring hospitals, excluding patients transferred for myocardial infarction or maternal labor and delivery. Prospective validation was performed by using a web-based tool to calculate the risk of mortality at the time of transfer. Observed outcomes were compared to predicted outcomes to assess model performance. The development cohort included 20,985 patients with 1,937 (9.2%) in-hospital mortalities, 2,884 (13.7%) 30-day mortalities, and 3,899 (18.6%) 90-day mortalities. The 14-variable gradient boosting model effectively predicted in-hospital, 30-day and 90-day mortality (c = 0.903 [95% CI:0.891–0.916]), c = 0.877 [95% CI:0.864–0.890]), and c = 0.869 [95% CI:0.857–0.881], respectively). The tool was proven feasible and valid for bedside implementation in a prospective cohort of 679 sequentially transferred patients for whom the bedside nurse calculated a SafeNET score at the time of transfer, taking only 4–5 minutes per patient with discrimination consistent with the development sample for in-hospital, 30-day and 90-day mortality (c = 0.836 [95%CI: 0.751–0.921], 0.815 [95% CI: 0.730–0.900], and 0.794 [95% CI: 0.725–0.864], respectively). Conclusions The SafeNET algorithm is feasible and valid for real-time, bedside mortality risk prediction at the time of hospital transfer. Work is ongoing to build pathways triggered by this score that direct needed resources to the patients at greatest risk of poor outcomes.
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Affiliation(s)
| | - Johanna E. Bellon
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Andrew Bilderback
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | | | - Jacob C. Hodges
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Mary Kay Wisniewski
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Matthew E. Harinstein
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Tamra E. Minnier
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Joel B. Nelson
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Daniel E. Hall
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
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50
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Badal BD, Kruger AJ, Hart PA, Lara L, Papachristou GI, Mumtaz K, Hussan H, Conwell DL, Hinton A, Krishna SG. Predictors of hospital transfer and associated risks of mortality in acute pancreatitis. Pancreatology 2021; 21:25-30. [PMID: 33341342 DOI: 10.1016/j.pan.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 11/03/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is limited research in prognosticators of hospital transfer in acute pancreatitis (AP). Hence, we sought to determine the predictors of hospital transfer from small/medium-sized hospitals and outcomes following transfer to large acute-care hospitals. METHODS Using the 2010-2013 Nationwide Inpatient Sample (NIS), patients ≥18 years of age with a primary diagnosis of AP were identified. Hospital size was classified using standard NIS Definitions. Multivariable analyses were performed for predictors of "transfer-out" from small/medium-sized hospitals and mortality in large acute-care hospitals. RESULTS Among 381,818 patients admitted with AP to small/medium-sized hospitals, 13,947 (4%) were transferred out to another acute-care hospital. Multivariable analysis revealed that older patients (OR = 1.04; 95%CI 1.03-1.06), men (OR = 1.15; 95%CI 1.06-1.24), lower income quartiles (OR = 1.54; 95%CI 1.35-1.76), admission to a non-teaching hospital (OR = 3.38; 95%CI 3.00-3.80), gallstone pancreatitis (OR = 3.32; 95%CI 2.90-3.79), pancreatic surgery (OR = 3.14; 95%CI 1.76-5.58), and severe AP (OR = 3.07; 95%CI 2.78-3.38) were predictors of "transfer-out". ERCP (OR = 0.53; 95%CI 0.43-0.66) and cholecystectomy (OR = 0.14; 95%CI 0.12-0.18) were associated with decreased odds of "transfer-out". Among 507,619 patients admitted with AP to large hospitals, 31,058 (6.1%) were "transferred-in" from other hospitals. The mortality rate for patients "transferred-in" was higher than those directly admitted (2.54% vs. 0.91%, p < 0.001). Multivariable analysis revealed that being "transferred-in" from other hospitals was an independent predictor of mortality (OR = 1.47; 95% CI 1.22-1.77). CONCLUSIONS Patients with AP transferred into large acute-care hospitals had a higher mortality than those directly admitted likely secondary to more severe disease. Early implementation of published clinical guidelines, triage, and prompt transfer of high-risk patients may potentially offset these negative outcomes.
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Affiliation(s)
- Bryan D Badal
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Andrew J Kruger
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Luis Lara
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Georgious I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Hisham Hussan
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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