Critical Care Utilization and Outcomes of Interhospital Medical Transfers at Lower Risk of Death

A randomised, open-label trial of nebulised unfractionated heparin in patients mechanically ventilated for COVID-19

Nebulised unfractionated heparin (UFH) might reduce time to ventilator separation in patients with COVID-19 by reducing virus infectivity, pulmonary coagulopathy, and inflammation, but clinical trial data are limited. Between 1 July 2020 and 23 March 2022, we conducted, at two hospitals in Victoria, Australia, a randomised, parallel-group, open-label, controlled trial of nebulised UFH. Eligible patients were aged 18 years or more, intubated, under intensive care unit management, had a PaO2 to FIO2 ratio of 300 or less, had acute opacities affecting at least one lung quadrant and attributed to COVID-19, and were polymerase chain reaction-positive for SARS-CoV-2 or had further testing planned. The target sample size was 270, however, the trial was stopped due to slow recruitment. There were 50 enrolments, all of whom were analysed. The median age was 55 (interquartile range (IQR) 46-64) years, 28 (56%) were males, and 46 (92%) had acute respiratory distress syndrome. Twenty-seven (54%) were randomised to nebulised heparin and 23 (46%) to standard care. Nebulised UFH was administered to the heparin group on 6 (IQR 4-10) days; median daily dose of 83 (IQR 75-88) kIU. The primary outcome, time to separation from invasive ventilation to day 28 adjusted for the competing risk of death, was not significantly different between groups but took numerically longer in the nebulised heparin group (12.0, standard deviation (SD) 10.4 days versus 7.4, SD 6.9 days; hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.31 to 1.01, P = 0.052). One patient died by day 28 in each group, fewer than expected. Time to separation from invasive ventilation among survivors to day 28 occurred more quickly than expected in the standard care group and was, without correction for multiple comparisons, significantly slower in the heparin group (11.3, SD 10.0 days, n = 26 versus 6.4, SD 5.2 days, n = 22; HR 0.52, 95% CI 0.30 to 0.92, P = 0.024). Nebulised heparin did not reduce time to ventilator separation in intubated adult patients with COVID-19. The study is limited by the small sample size and potential for sampling bias. Further study is required.

Interhospital transports and mortality in patients with critical COVID-19: a single-centre cohort study

OBJECTIVES

This study aimed to compare mortality rates and length of hospital stay between patients with critical COVID-19 transferred to another hospital due to capacity constraints and those who remained at their initial admission hospital.

DESIGN

Single-centre cohort study.

SETTING AND PARTICIPANTS

665 patients were treated for SARS-CoV-2 at two intensive care units (ICUs) in Stockholm, Sweden, from 1 March 2020 to 30 June 2021. Data on interhospital transfers (IHTs) were retrieved from medical records and patient data management systems according to predefined protocols.

MAIN OUTCOME MEASURES

The outcomes were 30-day and 90-day mortality, days alive and out of ICU. HR with 95% CI were calculated using Cox proportional hazard models with adjustments for age, sex, body mass index, severity of illness, comorbidity, invasive ventilation, treatment limitations and pandemic waves.

RESULTS

Of 665 patients, 133 (20%) were transferred to another hospital. The mortality rate of transferred patients compared with non-transferred patients at 30 days was 19% vs 26% (p=0.13) and at 90 days 26% vs 30% (p=0.43). In the adjusted Cox regression analysis, IHT was associated with a lower mortality risk at 30 days (HR 0.47, 95% CI 0.30 to 0.76) and 90 days (HR 0.52, 95% CI 0.34 to 0.79). However, the number of days alive and out of ICU was significantly lower for the IHT group at 30 days.

CONCLUSION

In our study, IHT due to capacity constraints among critically ill COVID-19 patients was not associated with a higher mortality risk. The suitability for transfer was likely associated with lower mortality, although residual confounding cannot be ruled out. The requirement for invasive ventilation among transferred patients might account for the extended length of ICU stay, rather than the transfer itself. However, the difficulty in studying this issue lies in the fact that while patients are likely exposed to risks during transfer, they are simultaneously the patients stable enough to be transported.

Patient outcomes after interhospital transfer: the impact of early intensive care unit upgrade

BACKGROUND

There is little known about the prevalence and outcomes of medical patients requiring early intensive care unit upgrade (EIU) following interhospital transfer, and previous studies of EIU focus on patients admitted through the emergency room. We aimed to examine the characteristics and risk factors for poor outcome among medical patients undergoing EIU after interhospital transfer.

MATERIALS AND METHODS

The publicly available Medical Information Mart for Intensive Care (MIMIC) IV database (2008-2019) was queried to identify non-surgical patients undergoing interhospital transfer. Patients who subsequently underwent EIU, defined as ICU admission within 24 hours of arrival after interhospital transfer, were compared to those who did not experience EIU for differences in mortality and length-of-stay (LOS.) We used multivariate logistic regression to identify risk factors for hospital death in this population and negative binomial regression to estimate the impact of EIU on hospital LOS.

RESULTS

We identified 5,619 patients who underwent interhospital transfer, of which 339 (6.0%) experienced EIU and 5280 (94.0%) did not. Patients undergoing EIU after interhospital transfer were significantly older (median age 69 vs. 64 years; p = 0.001,) but there was no difference in sex. After risk-adjustment, we found an association between EIU and a higher risk of mortality (aOR 6.9, 95%CI 5.24-9.08). Increased comorbidity burden as measured by Charlson Comorbidity Index (CCI) was linked to higher odds of death (aOR 1.26, 95% CI 1.22-1.31,) as was nonwhite race (aOR 1.69, 95% CI 1.34-2.14). EIU was associated with a longer hospital LOS (IRR 1.40, 95%CI 1.28-1.54).

CONCLUSION

EIU after interhospital transfer is associated with higher mortality and longer LOS. Further study will help identify process features of transfer and patient characteristics contributing to poor outcome after arrival from an outlying facility and guide efforts to mitigate risk and provide equitable care across the transfer continuum.

Effect of Inter-Hospital Transfer on Mortality in Patients Admitted through the Emergency Department

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.

Impact of interhospital transfer status on outcomes of variceal and nonvariceal upper gastrointestinal bleeding: insights from the National Inpatient Sample analysis, 2017 to 2020

Background

Variceal and nonvariceal upper gastrointestinal bleeding (VUGIB and NVUGIB, respectively) require prompt intervention. Existing studies offer limited insight into the impact of interhospital transfers on patients with VUGIB and NVUGIB.

Methods

We conducted a retrospective study using the US National Inpatient Sample database from 2017 to 2020. The outcomes included in-hospital mortality, incidence of complications, procedural performance, and resource utilization.

Results

A total of 28,275 VUGIB and 781,370 NVUGIB adult patients were included. Transferred VUGIB and NVUGIB patients, when compared to nontransferred ones, demonstrated higher inpatient mortality (adjusted odds ratio [AOR] 1.49 and 1.86, P < 0.05). Patients with VUGIB and NVUGIB had a higher likelihood of acute kidney injury requiring dialysis (AOR 3.79 and 1.76, respectively, P = 0.01), vasopressor requirement (AOR 2.13 and 2.37, respectively, P < 0.01), need for mechanical ventilation (AOR 1.73 and 2.02, respectively, P < 0.01), and intensive care unit admission (AOR 1.76 and 2.01, respectively, P < 0.01). Compared to their nontransferred counterparts, transferred VUGIB patients had a higher rate of undergoing transjugular intrahepatic portosystemic shunt (AOR 3.26, 95% CI 1.92-5.54, P < 0.01), while transferred NVUGIB patients had a higher rate of interventional radiology-guided embolization (AOR 2.01, 95% CI 1.73-2.34, P < 0.01) and endoscopic hemostasis (AOR 1.10, 95% CI 1.05-1.15, P < 0.01).

Conclusion

Interhospital transfer is associated with worse clinical outcomes and higher resource utilization for VUGIB and NVUGIB patients.

Unit-to-unit transfer due to shortage of intensive care beds in Sweden 2015-2019 was associated with a lower risk of death but a longer intensive care stay compared to no transfer: a registry study

BACKGROUND

Intensive care unit-to-unit transfer due to temporary shortage of beds is increasing in Sweden. Transportation induces practical hazards, and the change of health care provider may prolong the length of stay in intensive care. We previously showed that the risk of death at 90 days did not differ between patients transferred due to a shortage of beds and non-transferred patients with a similar burden of illness in a tertiary intensive care unit. The aim of this study was to widen the analysis to a nation-wide cohort of critically ill patients transferred to another intensive care unit in Sweden due to shortage of intensive care beds.

METHODS

Retrospective comparison between capacity transferred and non-transferred patients, based on data from the Swedish Intensive Care Registry during a 5-year period before the COVID-19 pandemic. Patients with insufficient data entries or a recurring capacity transfer within 90 days were excluded. To assess the association between capacity transfer and death as well as intensive care stay within 90 days after ICU admission, logistic regression models with step-wise adjustment for SAPS3 score, primary ICD-10 ICU diagnosis and the number of days in the intensive care unit before transfer were applied.

RESULTS

From 161,140 eligible intensive care admissions, 2912 capacity transfers were compared to 135,641 discharges or deaths in the intensive care unit. Ninety days after ICU admission, 28% of transferred and 21% of non-transferred patients were deceased. In the fully adjusted model, capacity transfer was associated with a lower risk of death within 90 days than no transfer; OR (95% CI) 0.71 (0.65-0.69) and the number of days spent in intensive care was longer: 12.4 [95% CI 12.2-12.5] vs 3.3 [3.3-3.3].

CONCLUSIONS

Intensive care unit-to-unit transfer due to shortage of bed capacity as compared to no transfer during a 5-year period preceding the COVID-19 pandemic in Sweden was associated with lower risk of death within 90 days but with longer stay in intensive care.