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McDougall G, Loubani O. Interfacility transfer of the critically ill: Transfer status does not influence survival. J Crit Care 2024; 82:154813. [PMID: 38636357 DOI: 10.1016/j.jcrc.2024.154813] [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: 12/08/2023] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE To estimate differences in case-mix adjusted hospital mortality between adult ICU patients who are transferred during their ICU-stay and those who are not. METHODS 19,260 visits to 12 ICUs in Nova Scotia (NS), Canada April 2018-September 2023 were analyzed. Data were obtained from the NS Provincial ICU database. Generalized additive models (GAMs) were used to estimate differences in case-mix adjusted hospital mortality between patients who underwent transfer and those who did not. RESULTS 1040/19,260 (5%) ICU visits involved interfacility-transfer. No difference in hospital mortality was identified between transferred and non-transferred patients by GAM (OR, 0.99, 95% CI, 0.82 to 1.19; p = 0.91). No mortality difference was observed between patients undergoing a single transfer versus multiple (OR, 0.87; 95% CI, 0.45 to -1.69; p = 0.68). A GAM including the categories no transfer, one transfer, and multiple transfers identified a difference in hospital mortality for patients that underwent multiple transfers compared to non-transferred patients (OR, 0.68; 95% CI, 0.46 to 1.00, p = 0.05), but no difference was identified in a post-hoc matched cohort sensitivity analysis (OR, 0.68; 95% CI, 0.46 to 1.01, p = 0.05). CONCLUSION The transfer of critically ill patients between ICUs in Nova Scotia did not impact case-mix adjusted hospital mortality.
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Affiliation(s)
- Garrett McDougall
- Department of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Osama Loubani
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada.
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van der Zee DJ, Maruster L, Buijs P, Aerts-Veenstra M, Hatenboer J, Buskens E. Implications of interhospital patient transfers for emergency medical services transportation systems in the Netherlands: a retrospective study. BMJ Open 2024; 14:e077181. [PMID: 38871665 DOI: 10.1136/bmjopen-2023-077181] [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: 06/15/2024] Open
Abstract
OBJECTIVES Interhospital patient transfers have become routine. Known drivers are access to specialty care and non-clinical reasons, such as limited capacity. While emergency medical services (EMS) providers act as main patient transfer operators, the impact of interhospital transfers on EMS service demand and fleet management remains understudied. This study aims to identify patterns in regional interhospital patient transfer volumes and their spatial distribution, and to discuss their potential implications for EMS service demand and fleet management. DESIGN A retrospective study was performed analysing EMS transport data from the province of Drenthe in the Netherlands between 2013 and 2019 and public hospital listings. Yearly volume changes in urgent and planned interhospital transfers were quantified. Further network analysis, including geomapping, was used to study how transfer volumes and their spatial distribution relate to hospital specialisation, and servicing multihospital systems. Organisational data were considered for relating transfer patterns to fleet changes. SETTING EMS in the province of Drenthe, the Netherlands, 492 167 inhabitants. PARTICIPANTS Analyses are based on routinely collected patient data from EMS records, entailing all 248 114 transports (137 168 patients) of the Drenthe EMS provider (2013-2019). From these interhospital transports were selected (24 311 transports). RESULTS Interhospital transfers represented a considerable (9.8%) and increasing share of transports (from 8.6% in 2013 to 11.3% in 2019). Most transfers were related to multihospital systems (47.3%, 11 509 transports), resulting in a considerable growth of planned EMS transports (from 2093 in 2013 to 3511 in 2019). Geomapping suggests increasing transfer distances and diminishing resource efficiencies due to lacking follow-up rides. Organisational data clarify how EMS fleets were adjusted by expanding resources and reorganising fleet operation. CONCLUSIONS Emerging interhospital network transfers play an important role in EMS service demand. Increased interhospital transport volumes and geographical spread require a redesign of current EMS fleets and management along regional lines.
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Affiliation(s)
- Durk-Jouke van der Zee
- Department of Operations, University of Groningen, Faculty of Economics and Business, Groningen, The Netherlands
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Laura Maruster
- Department of Operations, University of Groningen, Faculty of Economics and Business, Groningen, The Netherlands
| | - Paul Buijs
- Department of Operations, University of Groningen, Faculty of Economics and Business, Groningen, The Netherlands
| | - Marjolein Aerts-Veenstra
- Department of Operations, University of Groningen, Faculty of Economics and Business, Groningen, The Netherlands
| | - Jaap Hatenboer
- Ambulancezorg, University Medical Center Groningen, Tynaarlo, The Netherlands
| | - Erik Buskens
- Department of Operations, University of Groningen, Faculty of Economics and Business, Groningen, The Netherlands
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
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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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4
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Thanamyooran A, Nallbani M, Vinson AJ, Clark DA, Fok PT, Goldstein J, More KM, Swain J, Wiemer H, Tennankore KK. Predictors of Urgent Dialysis Following Ambulance Transport to the Emergency Department in Patients Treated With Maintenance Hemodialysis. Can J Kidney Health Dis 2023; 10:20543581221149707. [PMID: 36700056 PMCID: PMC9869220 DOI: 10.1177/20543581221149707] [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: 07/28/2022] [Accepted: 12/04/2022] [Indexed: 01/19/2023] Open
Abstract
Background Patients receiving maintenance hemodialysis frequently require ambulance transport to the emergency department (ambulance-ED transport). Identifying predictors of outcomes after ambulance-ED transport, especially the need for timely dialysis, is important to health care providers. Objective The purpose of this study was to derive a risk-prediction model for urgent dialysis after ambulance-ED transport. Design Observational cohort study. Setting and Patients All ambulance-ED transports among incident and prevalent patients receiving maintenance hemodialysis affiliated with a regional dialysis program (catchment area of approximately 750 000 individuals) from 2014 to 2018. Measurements Patients' vital signs (systolic blood pressure, oxygen saturation, respiratory rate, and heart rate) at the time of paramedic transport and time since last dialysis were utilized as predictors for the outcome of interest. The primary outcome was urgent dialysis (defined as dialysis in a monitored setting within 24 hours of ED arrival or dialysis within 24 hours with the first ED patient blood potassium level >6.5 mmol/L) for an unscheduled indication. Secondary outcomes included, hospitalization, hospital length of stay, and in-hospital mortality. Methods A logistic regression model to predict outcomes of urgent dialysis. Discrimination and calibration were assessed using the C-statistic and Hosmer-Lemeshow test. Results Among 878 ED visits, 63 (7.2%) required urgent dialysis. Hypoxemia (odds ratio [OR]: 4.04, 95% confidence interval [CI]: 1.75-9.33) and time from last dialysis of 24 to 48 hours (OR: 3.43, 95% CI: 1.05-11.9) and >48 hours (OR: 9.22, 95% CI: 3.37-25.23) were strongly associated with urgent dialysis. A risk-prediction model incorporating patients' vital signs and time from last dialysis had good discrimination (C-statistic 0.8217) and calibration (Hosmer-Lemeshow goodness of fit P value .8899). Urgent dialysis patients were more likely to be hospitalized (63% vs 34%), but there were no differences in inpatient mortality or length of stay. Limitations Missing data, requires external validation. Conclusion We derived a risk-prediction model for urgent dialysis that may better guide appropriate transport and care for patients requiring ambulance-ED transport.
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Affiliation(s)
| | | | - Amanda J. Vinson
- Nova Scotia Health, Halifax, Canada,Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - David A. Clark
- Nova Scotia Health, Halifax, Canada,Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Patrick T. Fok
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Judah Goldstein
- Emergency Health Services, Dartmouth, NS, Canada,Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Keigan M. More
- Nova Scotia Health, Halifax, Canada,Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Janel Swain
- Emergency Health Services, Dartmouth, NS, Canada,Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Hana Wiemer
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Karthik K Tennankore
- Nova Scotia Health, Halifax, Canada,Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada,Karthik K. Tennankore, Nova Scotia Health, Room 5082, 5th Floor Dickson Building, Victoria General Hospital, 5820 University Avenue, Halifax, NS B3H 1V8, Canada.
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5
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Abstract
OBJECTIVES To assess recent advances in interfacility critical care transport. DATA SOURCES PubMed English language publications plus chapters and professional organization publications. STUDY SELECTION Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients. DATA EXTRACTION Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport. DATA SYNTHESIS The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis. CONCLUSIONS Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.
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Pan A, Peddle M, Auger P, Parfeniuk D, MacDonald RD. Interfacility transport of mechanically ventilated patients with suspected COVID-19 in the prone position. PREHOSP EMERG CARE 2022; 27:287-292. [PMID: 35103581 DOI: 10.1080/10903127.2022.2036882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
ObjectiveProne positioning during mechanical ventilation in patients with severe respiratory failure is an important intervention with both physiologic and empiric rationale for its use. This study describes a consecutive cohort of patients with severe hypoxemic respiratory failure due to COVID-19 who were transported in the prone position in order to determine the incidence of serious adverse events (SAEs) during transport.MethodsThis retrospective study used prospectively collected data from a provincial air and land critical care transport system where specially trained critical care paramedic crews transported intubated and mechanically ventilated patients with COVID-19 in the prone position. SAEs were determined a priori, and included markers of new hemodynamic or respiratory instability, new resuscitative measures, and equipment or vehicle malfunction. Two authors independently reviewed each patient care record to identify SAEs during transport, and the ability of the crews to successfully manage such events.ResultsFrom April 2020 to June 2021, 127 intubated and mechanically ventilated patients were transported in the prone position. Of these, 117 were transported by land vehicle, 7 by rotor-wing, and 3 by fixed wing aircraft. 67 (52.8%) were vasopressor-dependent, 5 (3.9%) were receiving inhaled vasodilators, 9 (7.1%) were hypoxic (SpO2 <88%), and 3 (2.4%) were hypotensive (SBP <90 or MAP <65 mm Hg) when the transport crew made patient contact at the sending hospital. Of the 122 (96.1%) patients in which a pre-transport PaO2/FiO2 ratio was available, the mean (median; range) was 86.7 (81; 47-144), with 27 patients greater having a ratio greater than 100. The mean (median; range) transport time was 49 (45; 14-176) minutes. There were 19 SAEs in 18 (14.2%) patients during transport, the most common of which was new hypoxia requiring ventilator adjustments (15 of 18 patients). All SAEs were successfully managed by the transport crews. No patient experienced tracheal tube obstruction, unintentional extubation, cardiac arrest, or died during transport.ConclusionPatients with severe hypoxemic respiratory failure due to COVID-19 can safely be transported in the prone position by specially trained critical care paramedic crews.
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Affiliation(s)
- Andy Pan
- Ornge Transport Medicine, Mississauga, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Division of Critical Care Medicine, Department of Medicine, Montfort Hospital, Ottawa, Ontario Canada
| | - Michael Peddle
- Ornge Transport Medicine, Mississauga, Ontario, Canada.,Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Patrick Auger
- Ornge Transport Medicine, Mississauga, Ontario, Canada.,Algonquin College, Ottawa, Ontario, Canada
| | | | - Russell D MacDonald
- Ornge Transport Medicine, Mississauga, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Attending Staff, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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7
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Elkbuli A, Boserup B, Sen-Crowe B, Autrey C, McKenney M. Interfacility transfers and the prevalence of dead on arrival among trauma populations transferred to ACS -verified trauma centers: A nationwide analysis of the ACS-TQIP dataset. Am J Emerg Med 2022; 57:202-206. [PMID: 35074259 DOI: 10.1016/j.ajem.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/01/2022] [Accepted: 01/08/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.
| | - Brad Boserup
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Brendon Sen-Crowe
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Cody Autrey
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; University of South Florida, Tampa, FL, USA
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8
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Abstract
The role of air medical and land-based critical care transport services is not always clear amongst traditional emergency medical service providers or hospital-based health care practitioners. Some of this is historical, when air medical services were in their infancy and their role within the broader health care system was limited. Despite their evolution within the regionalized health care system, some myths remain regarding air medical services in Canada. The goal is to clarify several commonly held but erroneous beliefs regarding the role, impact, and practices in air medical transport.
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Rali P, Sacher D, Rivera-Lebron B, Rosovsky R, Elwing JM, Berkowitz J, Mina B, Dalal B, Davis GA, Dudzinski DM, Duval A, Ichinose E, Kabrhel C, Kapoor A, Lio KU, Lookstein R, McDaniel M, Melamed R, Naydenov S, Sokolow S, Rosenfield K, Tapson V, Bossone E, Keeling B, Channick R, Ross CB. Interhospital Transfer of Patients With Acute Pulmonary Embolism (PE): Challenges and Opportunities. Chest 2021; 160:1844-1852. [PMID: 34273391 DOI: 10.1016/j.chest.2021.07.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/23/2021] [Accepted: 07/02/2021] [Indexed: 01/07/2023] Open
Abstract
Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.
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Affiliation(s)
- Parth Rali
- Temple University Hospital, Philadelphia, PA.
| | | | | | - Rachel Rosovsky
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jean M Elwing
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | - Bhavinkumar Dalal
- Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | | | | | | | | | | | | | - Ka U Lio
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | | | | | | | | | | | | | | | | | | | - Charles B Ross
- Piedmont Heart Institute, Piedmont Atlanta Hospital, Atlanta, GA
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Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine. Crit Care Med 2021; 50:37-49. [PMID: 34259453 DOI: 10.1097/ccm.0000000000005147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions. DATA SOURCES AND STUDY SELECTION Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product. DATA EXTRACTION AND SYNTHESIS The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations. CONCLUSIONS Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.
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Freedland AR, Muller RL, Hoyo C, Turner EL, Moorman PG, Faria EF, Carvalhal GF, Reis RB, Mauad EC, Carvalho AL, Freedland SJ. Implications of Regionalizing Care in the Developing World: Impact of Distance to Referral Center on Compliance to Biopsy Recommendations in a Brazilian Prostate Cancer Screening Cohort. Prostate Cancer 2021; 2021:6614838. [PMID: 34239732 PMCID: PMC8241493 DOI: 10.1155/2021/6614838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/09/2021] [Indexed: 11/18/2022] Open
Abstract
Given growing specialization in medical care, optimal care may require regionalization, which may create access barriers. We tested this within a large prostate cancer (PC) screening program in Brazil. In 2004-2007, Barretos Cancer Hospital prospectively screened men for PC throughout rural Brazil. Men with abnormal screen were referred for follow-up and possible biopsy. We tested the link between distance from screening site to Barretos Cancer Hospital and risk of noncompliance with showing up for biopsy, PC on biopsy and, among those with PC, PC grade using crude and multivariable logistic regression analysis. Among 10,467 men undergoing initial screen, median distance was 257 km (IQR: 135-718 km). On crude and multivariable analyses, farther distance was significantly linked with biopsy noncompliance (OR/100 km: 0.83, P < 0.001). Among men who lived within 150 km of Barretos Cancer Hospital, distance was unrelated to compliance (OR/100 km: 1.09, P=0.87). There was no association between distance and PC risk or PC grade (all P > 0.25). In Brazil, where distances to referral centers can be large, greater distance was related to reduced biopsy compliance in a PC screening cohort. Among men who lived within 150 km, distance was unrelated to compliance. Care regionalization may reduce access when distances are large.
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Affiliation(s)
- Alexis R. Freedland
- Department of Epidemiology, UCI School of Medicine, University of California, Irvine, CA, USA
| | - Roberto L. Muller
- Division of Urology, Center of Oncologic Research, Florianopolis, Santa Catarina, Brazil
| | - Cathrine Hoyo
- Department of Biological Sciences, North Carolina State University, Raleigh, NC, USA
| | - Elizabeth L. Turner
- Global Health Institute, Duke University, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University Graduate School, Durham, NC, USA
| | - Patricia G. Moorman
- Department of Community and Family Medicine, Cancer Control and Population Sciences, Duke Cancer Institute, Durham, NC, USA
| | - Eliney F. Faria
- Division of Urologic Oncology and Laparoscopy, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | | | - Rodolfo B. Reis
- Division of Urology, Ribeirao Preto Medical School of Sao Paulo University (USP), Ribeirao Preto, São Paulo, Brazil
| | - Edmundo C. Mauad
- Department of Preventative Medicine, Barretos Cancer Hospital and Pio XII Foundation, Barretos, São Paulo, Brazil
| | - Andre L. Carvalho
- Research Support Center, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Stephen J. Freedland
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Nadig NR, Sterba KR, Simpson AN, Ruggiero KJ, Hough CT, Goodwin AJ, White K, Ford DW. Psychological Outcomes in Family Members of Patients With Acute Respiratory Failure: Does Inter-ICU Transfer Play a Role? Chest 2021; 160:890-898. [PMID: 33753046 DOI: 10.1016/j.chest.2021.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/18/2020] [Accepted: 03/13/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Family members of patients admitted to the ICU experience a constellation of sequelae described as postintensive care syndrome-family. The influence that an inter-ICU transfer has on psychological outcomes is unknown. RESEARCH QUESTION Is inter-ICU transfer associated with poor psychological outcomes in families of patients with acute respiratory failure? STUDY DESIGN AND METHODS Cross-sectional observational study of 82 families of patients admitted to adult ICUs (tertiary hospital). Data included demographics, admission source, and outcomes. Admission source was classified as inter-ICU transfer (n = 39) for patients admitted to the ICU from other hospitals and direct admit (n = 43) for patients admitted from the ED or the operating room of the same hospital. We used quantitative surveys to evaluate psychological distress (Hospital Anxiety and Depression Scale [HADS]) and posttraumatic stress (Post-Traumatic Stress Scale; PTSS) and examined clinical, family, and satisfaction factors associated with psychological outcomes. RESULTS Families of transferred patients travelled longer distances (mean ± SD, 109 ± 106 miles) compared with those of patients directly admitted (mean ± SD, 65 ± 156 miles; P ≤ .0001). Transferred patients predominantly were admitted to the neuro-ICU (64%), had a longer length of stay (direct admits: mean ± SD, 12.7 ± 9.3 days; transferred patients: mean ± SD, 17.6 ± 9.3 days; P < .01), and a higher number of ventilator days (direct admits: mean ± SD, 6.9 ± 8.6 days; transferred: mean ± SD, 10.6 ± 9.0 days; P < .01). Additionally, they were less likely to be discharged home (direct admits, 63%; transferred, 33%; P = .08). In a fully adjusted model of psychological distress and posttraumatic stress, family members of transferred patients were found to have a 1.74-point (95% CI, -1.08 to 5.29; P = .30) higher HADS score and a 5.19-point (95% CI, 0.35-10.03; P = .03) higher PTSS score than those of directly admitted family members. INTERPRETATION In this exploratory study, posttraumatic stress measured by the PTSS was higher in the transferred families, but these findings will need to be replicated to infer clinical significance.
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Affiliation(s)
- Nandita R Nadig
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC.
| | - Katherine R Sterba
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Annie N Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC
| | - Kenneth J Ruggiero
- College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Catherine T Hough
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Andrew J Goodwin
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - Kyle White
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - Dee W Ford
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC
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13
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Can a screening tool safely identify low risk cardiac patients to be transported with primary care flight paramedics? CAN J EMERG MED 2020; 22:S38-S44. [PMID: 33084556 DOI: 10.1017/cem.2019.459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES We aimed to determine the rate of adverse events during interfacility transport of cardiac patients identified as low risk by a consensus-derived screening tool and transported by primary care flight paramedics (PCP(f)). METHODS We conducted a health records review of adult patients diagnosed with a cardiac condition who were identified as low risk by the screening tool and transported by PCP(f). We excluded patients transported by an advanced care crew, those accompanied by a clinical escort from hospital, and those transported from a scene call, by rotary wing or ground vehicle. We recorded patient and transportation parameters using a piloted-standardized collection tool. We defined adverse events during transport a priori. We report descriptive statistics using mean (standard deviation), [range], (percentage). RESULTS We included 400 patients: mean age 66.9 years old, 66.5% male. Mean transport duration was 136.2 (74.9) minutes. Most common comorbidities were hypertension (50.3%) and coronary artery disease (39.5%). Most transports originated out of Northern Ontario and were for cardiac catheterization (61.8%) or coronary artery bypass grafting (26.8%). Overall, the adverse event rate was low (0.3%), with no serious event such as cardiac arrest, death, or airway intervention. CONCLUSIONS A screening tool can identify cardiac patients at low risk for clinical deterioration during air-medical transport. We believe patients screened with this tool can be transported safely by a PCP(f) crew, leading to potentially significant resource savings.
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Roussas A, Masjedi A, Hanna K, Zeeshan M, Kulvatunyou N, Gries L, Tang A, Joseph B. Number and Type of Complications Associated With Failure to Rescue in Trauma Patients. J Surg Res 2020; 254:41-48. [PMID: 32408029 DOI: 10.1016/j.jss.2020.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/28/2020] [Accepted: 04/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Failure to rescue (FTR) is becoming a ubiquitous metric of quality care. The aim of our study is to determine the type and number of complications associated with FTR after trauma. METHODS We reviewed the Trauma Quality Improvement Program including patients who developed complications after admission. Patients were divided as the following: "FTR" if the patient died or "rescued" if the patient did not die. Logistic regression was used to ascertain the effect of the type and number of complications on FTR. RESULTS A total of 25,754 patients were included with 972 identified as FTR. Logistic regression identified sepsis (odds ratio [OR] = 6.61 [4.72-9.27]), pneumonia (OR = 2.79 [2.15-3.64]), acute respiratory distress syndrome (OR = 4.6 [3.17-6.69]), and cardiovascular complications (OR = 24.22 [19.39-30.26]) as predictors of FTR. The odds ratio of FTR increased by 8.8 for every single increase in the number of complications. CONCLUSIONS Specific types of complications increase the odds of FTR. The overall complication burden will also increase the odds of FTR linearly. LEVEL OF EVIDENCE Level III Prognostic.
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Affiliation(s)
- Adam Roussas
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Aaron Masjedi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Kamil Hanna
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Lynn Gries
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
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Heincelman M, Gebregziabher M, Kirkland E, Schumann SO, Schreiner A, Warr P, Zhang J, Mauldin PD, Moran WP, Rockey DC. Impact of Patient-Level Characteristics on In-hospital Mortality After Interhospital Transfer to Medicine Services: an Observational Study. J Gen Intern Med 2020; 35:1127-1134. [PMID: 31965521 PMCID: PMC7174524 DOI: 10.1007/s11606-020-05659-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 12/30/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND National administrative datasets have demonstrated increased risk-adjusted mortality among patients undergoing interhospital transfer (IHT) compared to patients admitted through the emergency department (ED). OBJECTIVE To investigate the impact of patient-level data not available in larger administrative datasets on the association between IHT status and in-hospital mortality. DESIGN Retrospective cohort study with logistic regression analyses to examine the association between IHT status and in-hospital mortality, controlling for covariates that were potential confounders. Model 1: IHT status, admit service. Model 2: model 1 and patient demographics. Model 3: model 2 and disease-specific conditions. Model 4: model 3 and vital signs and laboratory data. PARTICIPANTS Nine thousand three hundred twenty-eight adults admitted to Medicine services. MAIN MEASURES Interhospital transfer status, coded as an unordered categorical variable (IHT vs ED vs clinic), was the independent variable. The primary outcome was in-hospital mortality. Secondary outcomes included unadjusted length of stay and total cost. KEY RESULTS IHT patients accounted for 180 out of 484 (37%) in-hospital deaths, despite accounting for only 17% of total admissions. Unadjusted mean length of stay was 8.4 days vs 5.6 days (p < 0.0001) and mean total cost was $22,647 vs $12,968 (p < 0.0001) for patients admitted via IHT vs ED respectively. The odds ratios (OR) for in-hospital mortality for patients admitted via IHT compared to the ED were as follows: model 1 OR, 2.06 (95% CI 1.66-2.56, p < 0.0001); model 2 OR, 2.07 (95% CI 1.66-2.58, p < 0.0001); model 3 OR, 2.07 (95% CI 1.63-2.61, p < 0.0001); model 4 OR, 1.70 (95% CI 1.31-2.19, p < 0.0001). The AUCs of the models were as follows: model 1, 0.74; model 2, 0.76; model 3, 0.83; model 4, 0.88, consistent with a good prediction model. CONCLUSIONS Patient-level characteristics affect the association between IHT and in-hospital mortality. After adjusting for patient-level clinical characteristics, IHT status remains associated with in-hospital mortality.
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Affiliation(s)
- Marc Heincelman
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA.
| | - Mulugeta Gebregziabher
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Elizabeth Kirkland
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Samuel O Schumann
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Andrew Schreiner
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Phillip Warr
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Don C Rockey
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
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Abstract
OBJECTIVES Prior studies investigating hospital mechanical ventilation volume-outcome associations have had conflicting findings. Volume-outcome relationships within contemporary mechanical ventilation practices are unclear. We sought to determine associations between hospital mechanical ventilation volume and patient outcomes. DESIGN Retrospective cohort study. SETTING The California Patient Discharge Database 2016. PATIENTS Adult nonsurgical patients receiving mechanical ventilation. INTERVENTIONS The primary outcome was hospital death with secondary outcomes of tracheostomy and 30-day readmission. We used multivariable generalized estimating equations to determine the association between patient outcomes and hospital mechanical ventilation volume quartile. MEASUREMENTS AND MAIN RESULTS We identified 51,689 patients across 274 hospitals who required mechanical ventilation in California in 2016. 38.2% of patients died in the hospital with 4.4% receiving a tracheostomy. Among survivors, 29.5% required readmission within 30 days of discharge. Patients admitted to high versus low volume hospitals had higher odds of death (quartile 4 vs quartile 1 adjusted odds ratio, 1.40; 95% CI, 1.17-1.68) and tracheostomy (quartile 4 vs quartile 1 adjusted odds ratio, 1.58; 95% CI, 1.21-2.06). However, odds of 30-day readmission among survivors was lower at high versus low volume hospitals (quartile 4 vs quartile 1 adjusted odds ratio, 0.77; 95% CI, 0.67-0.89). Higher hospital mechanical ventilation volume was weakly correlated with higher hospital risk-adjusted mortality rates (ρ = 0.16; p = 0.008). These moderately strong observations were supported by multiple sensitivity analyses. CONCLUSIONS Contrary to previous studies, we observed worse patient outcomes at higher mechanical ventilation volume hospitals. In the setting of increasing use of mechanical ventilation and changes in mechanical ventilation practices, multiple mechanisms of worse outcomes including resource strain are possible. Future studies investigating differences in processes of care between high and low volume hospitals are necessary.
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Ostermann M, Vincent JL. How much centralization of critical care services in the era of telemedicine? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:423. [PMID: 31878965 PMCID: PMC6933622 DOI: 10.1186/s13054-019-2705-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 12/16/2019] [Indexed: 11/14/2022]
Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
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Low SYY, Lim EHL, Loh LE, Mok YH, Siow YN, Ng LP, Seow WT, Kirollos RW, Low DCY. Use of an Offsite Intraoperative MRI Operating Theater for Pediatric Brain Tumor Surgery: Experience from a Singapore Children's Hospital. World Neurosurg 2019; 135:e28-e35. [PMID: 31655229 DOI: 10.1016/j.wneu.2019.10.083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Intraoperative magnetic resonance imaging (iMRI) has been recognized as a useful adjunct for brain tumor surgery in pediatric patients. There is minimal data on the use of an offsite intraoperative magnetic resonance imaging operating theater (iMRI OT), whereby vehicle transfer of patients is involved. The primary aim of this study is to validate the feasibility of perioperative patient transfer to use an offsite iMRI OT for patients with pediatric brain tumor. Secondary objectives include the assessment of tumor resection efficacy and perioperative outcomes in our patient cohort. METHODS This is a retrospective, single-institution clinical study of prospectively collected data from Singapore's largest children hospital. Variables of interest include issues encountered during interhospital transfer, achievement of surgical aims, length of stay in hospital, and postoperative complications. Our findings were compared with results of related studies published in the literature. RESULTS From January 1, 2009 to December 31, 2018, a total of 35 pediatric operative cases were performed in our offsite iMRI OT. Within this cohort, 24 of these were brain tumor surgery cases. For all the patients in this study, use of the iMRI OT influenced intraoperative decisions. Average ambulance transport time from parent hospital to the iMRI OT was 30.5 minutes, and from iMRI OT back to the parent hospital after surgery was 27.7 minutes. The average length of hospitalization stay was 7.9 days per patient. There were no ferromagnetic accidents during perioperative iMRI scanning and no airway/hemodynamic incidents in patients encountered during interhospital transfer. CONCLUSIONS In our local context, the use of interhospital transfers for access to iMRI OT is a safe and feasible option in ensuring good patient outcomes for a select group of patients with pediatric brain tumors.
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Affiliation(s)
- Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore.
| | - Evangeline H L Lim
- Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Lik Eng Loh
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Yew Nam Siow
- Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore
| | - Ramez W Kirollos
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore
| | - David C Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore
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Hossain T, Ghazipura M, Dichter JR. Intensive Care Role in Disaster Management Critical Care Clinics. Crit Care Clin 2019; 35:535-550. [PMID: 31445603 DOI: 10.1016/j.ccc.2019.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The "daily disasters" within the ebb and flow of routine critical care provide a foundation of preparedness for the less-frequent, larger events that affect most health care organizations at some time. Although large disasters can overwhelm, those who strengthen processes and habits through daily practice will be the best prepared to manage them.
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Affiliation(s)
- Tanzib Hossain
- New York University Langone Medical Center, 462 First Avenue, 7N24, New York, NY 10016, USA
| | - Marya Ghazipura
- Department of Population Health, New York University Langone Medical Center, 330 East 39th Street, Suite 26B, New York, NY 10016, USA
| | - Jeffrey R Dichter
- Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, MMC 276, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
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Abstract
OBJECTIVE Real-time audiovisual consultation (telemedicine) has been proven feasible and is a promising alternative to interfacility transfer. We sought to describe caregiver perceptions of the decision to transfer his or her child to a pediatric emergency department and the potential use of telemedicine as an alternative to transfer. METHODS Semistructured interviews of caregivers of patients transferred to a pediatric emergency department. Purposive sampling was used to recruit caregivers of patients who were transferred from varying distances and different times of the day. Interviews were conducted in person or on the phone by a trained interviewer. Interviews were recorded, transcribed, and analyzed using modified grounded theory. RESULTS Twenty-three caregivers were interviewed. Sixteen (70%) were mothers; 57% of patients were transported from hospitals outside of the city limits. Most caregivers reported transfer for a specific resource need, such as a pediatric subspecialist. Generally, caregivers felt that the decision to transfer was made unilaterally by the treating physician, although most reported feeling comfortable with the decision. Almost no one had heard about telemedicine; after hearing a brief description, most were receptive to the idea. Caregivers surmised that telemedicine could reduce the risks and cost associated with transfer. However, many felt telemedicine would not be applicable to their particular situation. CONCLUSIONS In this sample, caregivers were comfortable with the decision to transfer their child and identified potential benefits of telemedicine as either an adjunct to or replacement of transfer. As hospitals use advanced technology, providers should consider families' opinions about risks and out-of-pocket costs and tailoring explanations to address individual situations.
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Pannu J, Sanghavi D, Sheley T, Schroeder DR, Kashyap R, Marquez A, Daniels CE, Brown DR, Caples SM. Impact of Telemedicine Monitoring of Community ICUs on Interhospital Transfers. Crit Care Med 2017; 45:1344-1351. [PMID: 28481753 PMCID: PMC5511079 DOI: 10.1097/ccm.0000000000002487] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To study the effects of tele-ICU monitoring on interhospital transfers from community-based ICUs to the quaternary care hospital at Mayo Clinic, Rochester, MN. DESIGN This is a retrospective review of data on interhospital transfers comparing trends prior to tele-ICU implementation to those following implementation. SETTING Tele-ICU programs are increasingly utilized to fill resource gaps in caring for critically ill patients. How such programs impact population and bed management within a healthcare system are not known. Mayo Clinic serves as quaternary referral care center for hospitals in the region within the Mayo Clinic Health System. In August 2013, we implemented tele-ICU monitoring at six Mayo Clinic Health System hospital ICUs. SUBJECTS All adult ICU admissions during the study period (preimplementation phase: January 1, 2012, to December 31, 2012; and postimplementation phase: January 1, 2014, to December 31, 2014) in any of the six specified community ICUs were included in the study. MEASUREMENTS AND MAIN RESULTS Interhospital transfers significantly increased post institution of tele-ICU (p = 0.040) and was attributed primarily to transfer from less specialized ICUs (p = 0.037) as compared with more resource-intensive ICUs (p = 0.88). However, for such patient transfers, there were no significant differences before and after severity of illness scores, ICU mortality, or inhospital mortality. CONCLUSION In a regional healthcare system, implementation of a tele-ICU program is associated with an increase in interhospital transfers from less resourced ICUs to the referral center, a trend that is not readily explained by increased severity of illness.
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Affiliation(s)
- Jasleen Pannu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Devang Sanghavi
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Todd Sheley
- Mayo Clinic Health System-Reporting and Analytics Team, LaCrosse, WI
| | | | - Rahul Kashyap
- Division of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Alberto Marquez
- Division of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Craig E. Daniels
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Sean M. Caples
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Strauch U, Bergmans DCJJ, Habers J, Jansen J, Winkens B, Veldman DJ, Roekaerts PMHJ, Beckers SK. QUIT EMR trial: a prospective, observational, multicentre study to evaluate quality and 24 hours post-transport morbidity of interhospital transportation of critically ill patients: study protocol. BMJ Open 2017; 7:e012861. [PMID: 28283485 PMCID: PMC5353331 DOI: 10.1136/bmjopen-2016-012861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION It is widely accepted that transportation of critically ill patients is high risk. Unfortunately, however, there are currently no evidence-based criteria with which to determine the quality of various interhospital transport systems and their impact on the outcomes for patients. We aim to rectify this by assessing 2 scores which were developed in our hospital in a prospective, observational study. Primarily, we will be examining the Quality of interhospital critical care transportation in the Euregion Meuse-Rhine (QUIT EMR) score, which focuses on the quality of the transport system, and secondarily the SEMROS (Simplified EMR outcome score) which detects changes in the patient's clinical condition in the 24 hours following their transportation. METHODS AND ANALYSIS A web-based application will be used to document around 150 pretransport, intratransport and post-transport items of each patient case.To be included, patients must be at least 18-years of age and should have been supervised by a physician during an interhospital transport which was started in the study region.The quality of the QUIT EMR score will be assessed by comparing 3 predefined levels of transport facilities: the high, medium and low standards. Subsequently, SEMROS will be used to determine the effect of transport quality on the morbidity 24 hours after transportation.It is estimated that there will be roughly 3000 appropriate cases suitable for inclusion in this study per year. Cases shall be collected from 1 April 2015 until 31 December 2017. ETHICS AND DISSEMINATION This trial was approved by the Ethics committees of the university hospitals of Maastricht (Netherlands) and Aachen (Germany). The study results will be published in a peer reviewed journal. Results of this study will determine if a prospective randomised trial involving patients of various categories being randomly assigned to different levels of transportation system shall be conducted. TRIAL REGISTRATION NUMBER NTR4937.
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Affiliation(s)
- Ulrich Strauch
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joachim Habers
- Emergency Medical Service district of Aachen, Aachen, Germany
| | - Jochen Jansen
- Emergency Medical Service South Limburg, Geleen, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands
| | - Dirk J Veldman
- Maastricht University, MEMIC Center for Data and Information Management, Maastricht, The Netherlands
| | - Paul M H J Roekaerts
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
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Frequency, Composition, and Predictors of In-Transit Critical Events During Pediatric Critical Care Transport. Pediatr Crit Care Med 2016; 17:984-991. [PMID: 27505717 DOI: 10.1097/pcc.0000000000000919] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Transport of pediatric patients is common due to healthcare regionalization. We set out to determine the frequency of in-transit critical events during pediatric critical care transport and identify factors associated with these events. DESIGN Retrospective cohort study using administrative and clinical data. SETTING Single pediatric critical care transport provider in Ontario, Canada. PATIENTS All pediatric care transports between January 1, 2005, and December 31, 2010. MEASUREMENTS AND MAIN RESULTS The primary outcome was in-transit critical events, defined by an adaptation of a recent consensus definition. In-transit critical events occurred in 1,094 (12.3%) of 8,889 transports. Hypotension (3.6%), tachycardia (3.7%), and bradycardia (3.3%) were the most common critical events. Crews performed medical interventions in 194 transports (2.2%). The frequency and makeup of critical events varied across patient age groups. Age, pretransport mechanical ventilation, pretransport cardiovascular instability, transport duration, scene calls, and paramedic crew level were independently associated with increased risk of in-transit critical events in multivariate analysis. A Transport Pediatric Early Warning Score of 7 or greater predicted in-transit critical events with high specificity but low sensitivity (92.0% and 20.0%, respectively), but was not superior of the combination of pretransport mechanical ventilation and pretransport cardiovascular instability (sensitivity and specificity of 12.6% and 97.4%, respectively). Removal of early warning signs from the definition resulted in critical event rates comparable to those published in adults and improved predictive performance. CONCLUSIONS Using new consensus definitions of transport-related critical events, we found critical events occurred in almost one in eight transports, and were strongly associated with pretransport cardiovascular instability. Transport Pediatric Early Warning Score was poorly predictive of in-transit critical events, and was not superior to the presence of pretransport mechanical ventilation and cardiovascular instability. Future prospective studies are required to elucidate the optimal matching of transport resources to patients, in particular those with both pretransport cardiovascular instability and mechanical ventilation.
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Abstract
STUDY DESIGN Retrospective review of an administrative database. OBJECTIVE To observe New York statewide trends in lumbar spine surgery and to compare utilization of fusion according to hospital size and patient population. SUMMARY OF BACKGROUND DATA Over the last 30 years, studies have indicated increasing rates of spinal fusion procedures performed each year in the United States. There is no study investigating potential variability in this trend according to hospital volume. METHODS New York Statewide Planning and Research Cooperative System (SPARCS) administrative data were used to identify 228,882 lumbar spine surgery patients. New York State hospitals were categorized as low-, medium-, or high-volume and descriptive statistics were used to determine trends in spinal fusion. RESULTS The number of fusions per year increased 55% from 2005 to 2014. The ratio of fusion to nonfusion surgery increased from 0.88 to 2.67 at high-volume, from 0.84 to 2.30 at medium- volume, and from 0.66 to 1.52 at low-volume hospitals. In 2014, 22% of spine surgery patients at low-volume hospitals were either African Americans or Hispanics compared with 12% and 14% at high- and medium-volume hospitals, respectively. At high-volume hospitals, 33% of patients were privately insured and 3% had Medicare compared with 30% and 6% at low-volume hospitals. CONCLUSION The annual number of lumbar spinal fusions continues to increase, especially at high- and medium-volume hospitals. The percentage of patients treated surgically for lumbar spinal stenosis that undergoes fusion ranges from 53.2 to 66.4% depending on hospital volume. Individual surgeon opinion, patient disease characteristics, and socioeconomic factors may affect surgical decision making. Caucasians and private insurance patients most often receive care at high-volume hospitals. Minorities and patients with Medicaid are over-represented at low-volume centers where fusions are less often performed. Accessibility to care at high-volume centers remains a major concern for these vulnerable populations. LEVEL OF EVIDENCE 3.
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Volume-Mortality Relationships during Hospitalization with Severe Sepsis Exist Only at Low Case Volumes. Ann Am Thorac Soc 2016; 12:1177-84. [PMID: 26086787 DOI: 10.1513/annalsats.201406-287oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Volume-outcome associations have been demonstrated in conditions with high morbidity and mortality; however, the existing literature regarding such associations in sepsis is not definitive. OBJECTIVES To test the hypothesis that annual hospital severe sepsis case volume is associated with mortality during admissions with severe sepsis in teaching and nonteaching hospitals. METHODS This work was a retrospective cohort study of administrative data from the South Carolina State Inpatient Database using multivariate logistic regression and case mix adjustment. MEASUREMENTS AND MAIN RESULTS In the calendar year 2010, 9,815 patients were admitted with severe sepsis or septic shock. Hospitals were stratified into low- (0-75 cases/yr, n = 26), intermediate- (76-300 cases/yr, n = 19), and high (>300 cases/yr, n = 12) -volume tertiles. Patients admitted to hospitals with a low annual case volume for sepsis had higher adjusted odds of dying before discharge (odds ratio, 1.56; 95% confidence interval, 1.25-1.94) compared with patients admitted to high-volume hospitals. Hospitalization at intermediate-volume hospitals was not associated with a difference in mortality (odds ratio, 0.99; 95% confidence interval, 0.90-1.09) compared with high-volume hospitals. There was no difference between the mortality rates of intermediate- and high-volume hospitals at different severity of illness quartiles. Hospital length of stay differed significantly by hospital case volume (low = 8.0, intermediate = 12.7, high = 14.9 [d]; P < 0.0001). CONCLUSIONS Hospitals with low annual sepsis case volume are associated with higher mortality rates, whereas hospitals with intermediate sepsis case volumes are associated with similar mortality rates compared with hospitals with high case volumes.
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MacDonald RD, Allendes F. Intra-aortic Balloon Pump-Dependent Patient Transports by Critical Care Paramedics. Air Med J 2016; 35:231-4. [PMID: 27393759 DOI: 10.1016/j.amj.2015.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/21/2015] [Accepted: 12/30/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Transport of intra-aortic balloon pump (IABP)-dependent patients between hospitals is increasingly common. The transports are typically time-sensitive and require personnel familiar with IABP operation and management of a potentially unstable patient. This study examined transports performed by specially trained critical care paramedics in a large air medical and land critical care transport service. METHODS This retrospective, descriptive review prospectively collected data for IABP-dependent patient transports in Ontario, Canada in a 10-year interval beginning September 2003. Call records and patient care reports were reviewed to capture demographic, patient care, adverse events, and transport-related data. Adverse events, including resuscitation medication, procedure, and patient instability, were independently reviewed by 2 investigators. RESULTS There were 162 IABP-dependent patients transported. Seventy-one were performed by land critical care transport vehicles, 60 by helicopter, and 31 by fixed wing aircraft. The mean patient age was 63.7 ± 13.8 years; the majority (72.2%) were men. Fifty-nine patients (36.4%) were inotrope or vasopressor dependent, and 46 (28.4%) were intubated and mechanically ventilated. The most common indications for IABP insertion were acute myocardial infarction requiring prompt surgical intervention (n = 70), bridge to definitive care (n = 41), and cardiogenic shock (n = 37). The mean transport time was 92.7 ± 79.4 minutes. There were 48 adverse events in 35 patients, most commonly hypotension (systolic blood pressure < 90 mm Hg, n = 18) and tachyarrhythmia requiring therapy (n = 12). There were 3 IABP-related events and 3 cases in which the transport vehicle was inoperable resulting in a transport delay. One patient with cardiogenic shock died before departing the sending hospital. Paramedics managed all events without assistance from other health care personnel. CONCLUSION Specially trained critical care flight paramedics can safely transport potentially unstable IABP-dependent patients to definitive cardiac surgical care.
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Affiliation(s)
- Russell D MacDonald
- Ornge Transport Medicine, Mississauga, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
| | - Felipe Allendes
- Department of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
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Yu TH, Chung KP, Wei CJ, Chien KL, Hou YC. Do the Preferences of Healthcare Provider Selection Vary among Rural and Urban Patients with Different Income and Cause Different Outcome? PLoS One 2016; 11:e0152776. [PMID: 27054711 PMCID: PMC4824465 DOI: 10.1371/journal.pone.0152776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 03/19/2016] [Indexed: 11/18/2022] Open
Abstract
Background Equal access to healthcare facilities and high-level quality of care are important strategies to eliminate the disparity in outcome of care. However, the existing literature regarding how urban or rural dwelling patients with different income level select healthcare providers is insufficient. The purposes of this study were to examine whether differences of healthcare provider selection exist among urban and rural coronary artery bypass surgery (CABG) patients with different income level. If so, we further investigated the associated impact on mortality. Methods A retrospective, multilevel study design was conducted using claims data from 2007–2011 Taiwan’s Universal Health Insurance Scheme. Healthcare providers’ performance and patients’ travelling distance to hospitals were used to define the patterns of healthcare provider selection. Baron and Kenny’s procedures for mediation effect were conducted. Results There were 10,108 CABG surgeries included in this study. The results showed that urban dwelling and higher income patients were prone to receive care from better-performance providers. The travelling distances of urban dwelling patients was 15 KM shorter, especially when they received better-performance provider’s care. The results also showed that the difference of healthcare provider selection and mortality rate existed between rural and urban dwelling patients with different income levels. After the procedure of mediation effect testing, the results showed that the healthcare provider selection partially mediated the relationships between patients’ residential areas with different income levels and 30-day mortality. Conclusion Preferences of healthcare provider selection vary among rural and urban patients with different income, and such differences partially mediated the outcome of care. Health authorities should pay attention to this issue, and propose appropriate solutions to eliminate the disparity in outcome of CABG care.
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Affiliation(s)
- Tsung-Hsien Yu
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Kuo-Piao Chung
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Chung-Jen Wei
- Department of Public Health, Fu-Jen Catholic University, Taipei, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Chang Hou
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
- Department of Chinese Medicine, Tao-Yuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
- Department of Bioscience Technology, Chuan-Yuan Christian University, Taoyuan, Taiwan
- * E-mail:
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Merali Z, Sharma S, MacDonald RD, Massicotte EM. Emergent and Urgent Transfers to Neurosurgical Centers in Ontario. PREHOSP EMERG CARE 2015; 20:245-53. [PMID: 26529260 DOI: 10.3109/10903127.2015.1086847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Critically ill neurosurgical patients require expedient access to neurosurgical centers (NC) to improve outcome. In regionalized health systems patients are often initially evaluated at a non-neurosurgical center (NNC) and are subsequently transferred to a NC using air or ground vehicles. We sought to identify barriers to accessing a NC for critically ill patients by analyzing interfacility transfer times and referral patterns in the province of Ontario. A retrospective observational analysis was undertaken. The cohort included patients in Ontario with emergent and urgent neurologic pathologies who underwent transfer from a NNC to NC between January 1, 2011 and December 31, 2013. Timing, clinical, and geographic data were collected for each transfer. We identified 1103 emergent/urgent transfers. The median transfer time to a NC was 3.4 h (IQR -2.2, 3.8) and varied by the geographic region of origin. A total of 17% of the patients bypassed a closer NC during transfer to their destination NC. Transfers that bypassed a closer NC travelled further (101 miles vs. 296 miles, p < 0.001), took longer (3.1 h vs. 3.9 h, p < 0.001), and in some regions were associated with a higher risk of in-transit clinical decline (3.0% vs. 8.3%, p < 0.05) when compared with transfers that ended at the closest NC. Regionalization of neurosurgical services in Ontario has led to heavy reliance upon patient transfers to maintain continuity of care. Access to a NC varied across the province, which may represent regional differences in neurosurgical bed availability, resource limitations at smaller NCs, or environmental factors. Our descriptions of referral patterns and transport times can guide health system planning in Ontario and similar jurisdictions in the United States and Canada.
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Bronson WH, Lindsay D, Lajam C, Iorio R, Caplan A, Bosco J. Ethics of Provider Risk Factor Modification in Total Joint Arthroplasty. J Bone Joint Surg Am 2015; 97:1635-9. [PMID: 26446971 DOI: 10.2106/jbjs.o.00564] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Wesley H Bronson
- NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003. E-mail address for J. Bosco:
| | - David Lindsay
- NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003. E-mail address for J. Bosco:
| | - Claudette Lajam
- NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003. E-mail address for J. Bosco:
| | - Richard Iorio
- NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003. E-mail address for J. Bosco:
| | - Arthur Caplan
- NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003. E-mail address for J. Bosco:
| | - Joseph Bosco
- NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003. E-mail address for J. Bosco:
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Strauch U, Bergmans DCJJ, Winkens B, Roekaerts PMHJ. Short-term outcomes and mortality after interhospital intensive care transportation: an observational prospective cohort study of 368 consecutive transports with a mobile intensive care unit. BMJ Open 2015; 5:e006801. [PMID: 25922097 PMCID: PMC4420937 DOI: 10.1136/bmjopen-2014-006801] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To evaluate short-term outcomes and mortality after interhospital transportation of intensive care patients performed by a mobile intensive care unit (MICU). SETTING This study was performed in the tertiary care process of interhospital transportation using the local MICU system in the South East of the Netherlands. PARTICIPANTS Between March 2009 and December 2011, all transports of adult patients being performed by the local MICU centre have been documented; data on 42 variables, including a 24 h follow-up Sequential Organ Failure Assessment (SOFA) score of 368 consecutive interhospital transports of intensive care patients, were recorded. In 24 cases, the follow-up SOFA score was missing, so 344 data sets were included. INTERVENTIONS No interventions have been done. PRIMARY/SECONDARY OUTCOME MEASURES Primary outcome measures were the mean SOFA score before and 24 h after transport, and the 24 h post-transport mortality. Moreover, the differences between the groups of 24 h post-transport survivors and non-survivors have been analysed. RESULTS The mean SOFA score before transport was 8.8 for the whole population and 8.6 for those patients who were alive 24 h after transport, with a mean SOFA score of 8.4 after transport. The adverse events rate was 6.4%. Fourteen patients (4.1%) died within 24 h after transport. Patients in this group had a higher SOFA score, lower pH, higher age and more additional medical support devices than those patients in the survivor group. CONCLUSIONS The non-significant decrease in the post-transport SOFA score and the lack of an association between transport and 24 h post-transport mortality indicates that in the study setting, interhospital transportation of intensive care patients performed by a MICU system was not associated with a clinically relevant deterioration of the patient.
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Affiliation(s)
- Ulrich Strauch
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
| | - Paul M H J Roekaerts
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
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Singh JM, MacDonald RD, Ahghari M. Post-medication Hypotension after Administration of Sedatives and Opioids during Critical Care Transport. PREHOSP EMERG CARE 2015; 19:464-74. [PMID: 25658022 DOI: 10.3109/10903127.2014.995848] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Identification of modifiable risk factors for hypotension during critical care transport is important to optimize patient preparation, crew training, and patient safety. We set out to determine the incidence of hemodynamic deterioration after administration of opioids or sedatives during critical care transport, and identify patient- and transport-level predictors. METHODS We assembled a retrospective cohort of adults undergoing urgent critical care transport between January 1, 2005, and December 31, 2010. The primary outcome was post-medication hypotension, defined by new hypotension or new vasopressor within 10 minutes of medication administration. RESULTS Opioids or sedatives were administered 28,592 times in 8,328 patient transports, with 159 episodes of post-medication hypotension (0.6% of all medication administrations). Mechanical ventilation (adjusted odds ratio [OR] 4.9; 95% confidence interval [95%CI] 2.7-8.9), baseline vasopressor requirement (adjusted OR 2.1; 95%CI 1.3-3.4), transport duration (adjusted OR 1.5; 95%CI 1.1-2.2) per log unit increment of duration), surgical diagnosis (adjusted OR 4.1; 95%CI 1.6-10.7 compared to trauma), and ACP crew level (adjusted OR 2.4 compared to baseline of CCP; 95%CI 1.5-3.8) were all associated with an increased odds of post-medication hypotension. ACP crew level remained associated with increased post-medication hypotension in a sensitivity analysis of 1,242 propensity-matched pairs (crude OR for ACP vs. CCP 3.0; 95%CI 1.4-6.5). CONCLUSIONS Post-medication hypotension occurred once in every 160 drug administrations and was associated with mechanical ventilation, baseline hemodynamic instability, transport duration, surgical diagnosis, and ACP crew. These findings provide targets for improvements in patient preparation, crew training, and clinical practices.
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Reimer AP, Daly BJ. Ethical considerations for conducting a randomized controlled trial in transport. Air Med J 2014; 33:274-9. [PMID: 25441519 DOI: 10.1016/j.amj.2014.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 05/13/2014] [Accepted: 06/21/2014] [Indexed: 01/20/2023]
Abstract
Although recent studies support the rapid transfer of patients experiencing time-sensitive emergencies, limited data exist to support the use of air transport for nonurgent patient transfers. The nature of medical transport and the heterogeneity of patients who are transferred present unique challenges in designing and conducting clinical research trials that could contribute to the evidence-based decision making for patient care and transport. The current regulatory framework presents several barriers to conducting such research in the medical transport setting. We present a hypothetic study that randomizes patients to either ground or air transport as an exemplar. We discuss informed consent, risk, and the impracticality of conducting community consultations in a medical transport setting. Finally, recommendations for potential changes to current regulations are presented. These are directed at facilitating the conduct of emergency research through a system of oversight that integrates characteristics of quality improvement and health services research.
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Abstract
INTRODUCTION Timely transfer of patients among facilities within a regionalized critical-care system remains a large obstacle to effective patient care. For medical transport systems where dispatchers are responsible for planning these interfacility transfers, accurate estimates of interfacility transfer times play a large role in planning and resource-allocation decisions. However, the impact of adverse weather conditions on transfer times is not well understood. HYPOTHESIS/PROBLEM Precipitation negatively impacts driving conditions and can decrease free-flow speeds and increase travel times. The objective of this research was to quantify and model the effects of different precipitation types on land travel times for interfacility patient transfers. It was hypothesized that the effects of precipitation would accumulate as the distance of the transfer increased, and they would differ based on the type of precipitation. METHODS Urgent and emergent interfacility transfers carried out by the medical transport system in Ontario from 2005 through 2011 were linked to Environment Canada's (Gatineau, Quebec, Canada) climate data. Two linear models were built to estimate travel times based on precipitation type and driving distance: one for transfers between cities (intercity) and another for transfers within a city (intracity). RESULTS Precipitation affected both transfer types. For intercity transfers, the magnitude of the delays increased as driving distance increased. For median-distance intercity transfers (48 km), snow produced delays of approximately 9.1% (3.1 minutes), while rain produced delays of 8.4% (2.9 minutes). For intracity transfers, the magnitude of delays attributed to precipitation did not depend on distance driven. Transfers in rain were 8.6% longer (1.7 minutes) compared to no precipitation, whereas only statistically marginal effects were observed for snow. CONCLUSION Precipitation increases the duration of interfacility land ambulance travel times by eight percent to ten percent. For transfers between cities, snow is associated with the longest delays (versus rain), but for transfers within a single city, rain is associated with the longest delays.
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Suntharalingam G, Handy J, Walsh A. Regionalisation of critical care: can we sustain an intensive care unit in every hospital? Anaesthesia 2014; 69:1069-73. [PMID: 25204233 DOI: 10.1111/anae.12810] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- G Suntharalingam
- Northwick Park and Central Middlesex Hospitals, North West London Hospitals NHS Trust, London, UK.
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Singh JM, MacDonald RD, Ahghari M. Critical events during land-based interfacility transport. Ann Emerg Med 2014; 64:9-15.e2. [PMID: 24412668 DOI: 10.1016/j.annemergmed.2013.12.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 11/24/2013] [Accepted: 12/05/2013] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE The risks associated with urgent land-based transport of critically ill patients are not well known and have important implications for patient safety, care delivery, and policy development. We seek to determine the incidence of in-transit critical events and associated patient- and transport-level factors. METHODS We conducted a retrospective cohort study using clinical and administrative data. We included adults undergoing urgent land-based critical care transport by a dedicated transport provider between January 1, 2005, and December 31, 2010. The primary outcome was in-transit critical event, defined by adverse events or resuscitative procedures. RESULTS In-transit critical events were observed in 333 (6.5%) of 5,144 urgent land transports. New hypotension (4.4%) or new vasopressors (1.6%) were the most common critical events, with fewer respiratory events (1.3%). Advanced care paramedics had a higher rate compared with critical care paramedics (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1 to 2.2), especially for patients with baseline hemodynamic instability. In multivariate analysis, mechanical ventilation (adjusted OR 1.7; 95% CI 1.3 to 2.2), baseline hemodynamic instability (adjusted OR 3.7; 95% CI 2.8 to 4.9), out-of-hospital duration (adjusted OR 3.6; 95% CI 2.9 to 4.5 per log-fold increase in time), and neurologic diagnosis (adjusted OR 0.5; 95% CI 0.3 to 0.7 compared with that of medical patients) were associated with critical events. CONCLUSION Critical events occurred in approximately 1 in 15 transports and were associated with mechanical ventilation, hemodynamic instability, and transport duration, and were less frequent in neurologic patients. The finding that hypotension is common and predicted by pretransport hemodynamic instability has implications for the preparation and management of this patient group.
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Affiliation(s)
- Jeffrey M Singh
- Division of Critical Care Medicine, University Health Network, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Russell D MacDonald
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Ornge Transport Medicine, Mississauga, Ontario, Canada
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Sethi D, Subramanian S. When place and time matter: How to conduct safe inter-hospital transfer of patients. Saudi J Anaesth 2014; 8:104-13. [PMID: 24665250 PMCID: PMC3950432 DOI: 10.4103/1658-354x.125964] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inter-hospital transfer (IHT) of patients is often needed for diagnostic or therapeutic interventions. However, the transfer process carries its own risks as a poorly and hastily conducted transfer could lead to adverse events. In this article, we have reviewed literature on the key elements of IHT process including pre-transfer patient stabilization. We have also discussed various modes of transfer, physiological effects of transfer, possible adverse events and how to avoid or mitigate these. Even critically ill-patients can be transported safely by experienced and trained personnel using appropriate equipment. The patient must be maximally stabilized prior to transfer though complete optimization may be possible only at the receiving hospital. Ground or air transport may be employed depending on the urgency, feasibility and availability. Meticulous pre-transfer check and adherence to standard protocols during the transfer will help keep the entire process smooth and event free. The transport team should be trained to anticipate and manage any possible adverse events, medical or technical, during the transfer. Coordination between the referring and receiving hospitals would facilitate prompt transfer to the definitive destination avoiding delay at the emergency or casualty. Documentation of the transfer process and transfer of medical record and investigation reports are important for maintaining continuity of medical care and for medico-legal purposes.
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Affiliation(s)
- Divya Sethi
- Department of Anesthesiology, Employees’ State Insurance Cooperation, Postgraduate Institute of Medical Sciences and Research, Indraprastha University, New Delhi, India
| | - Shalini Subramanian
- Department of Anesthesiology, Employees’ State Insurance Cooperation, Postgraduate Institute of Medical Sciences and Research, Indraprastha University, New Delhi, India
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Pecha Kucha Cauldron Presentations. J Intensive Care Soc 2014. [DOI: 10.1177/17511437140151s103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Sangalli F, Patroniti N, Pesenti A. Structure of an ECMO Network for Respiratory Support. ECMO-EXTRACORPOREAL LIFE SUPPORT IN ADULTS 2014. [PMCID: PMC7120892 DOI: 10.1007/978-88-470-5427-1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In adult patients with respiratory failure refractory to conventional treatment, ECMO represents a potentially lifesaving option, and the CESAR trial indeed indicated that significantly more patients with severe ARDS survived without severe disability if they were transferred to a single ECMO center compared with patients who were managed conventionally at remote hospitals. During the 2009 influenza A (H1N1) pandemic, the Italian Ministry of Health instituted a national network of selected ICU centers, the Extracorporeal Membrane Oxygenation Network (ECMOnet). The Italian network was set up to centralize all potentially severe patients in a limited number of tertiary hospitals to provide advanced treatment options including ECMO and identify predictors of mortality in order to define the best timing of ECMO institution. The institution of the Italian ECMO network allowed a high survival rate of patients with severe ARDS due to H1N1 infection treated by ECMO, providing effective and safe centralization and creating an important organization platform to face future possible epidemics with high demand for critical care services and specialized respiratory support.
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Affiliation(s)
- Fabio Sangalli
- Department of Anaesthesia and Intensive Care Medicine, San Gerardo Hospital, Monza (MB), Italy
| | - Nicolò Patroniti
- Department of Health Sciences Medicine, University of Milano-Bicocca, San Gerardo Hospital, Monza (MB), Italy
| | - Antonio Pesenti
- Health Science Departement, Università Milano Bicocca Facoltà Medicina e Chirurgia, Monza (MB), Italy
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Thompson LM, Armfield NR, Slater A, Mattke C, Foster M, Smith AC. The availability, spatial accessibility, service utilisation and retrieval cost of paediatric intensive care services for children in rural, regional and remote Queensland: study protocol. BMC Health Serv Res 2013; 13:163. [PMID: 23638680 PMCID: PMC3750370 DOI: 10.1186/1472-6963-13-163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 04/24/2013] [Indexed: 11/25/2022] Open
Abstract
Background Specialist health services are often organised on a regionalised basis whereby clinical resources and expertise are concentrated in areas of high population. Through a high volume caseload, regionalised facilities may provide improved clinical outcomes for patients. In some cases, regionalisation may be the only economically viable way to organise specialist care. While regionalisation may have benefits, it may also disadvantage some population groups, particularly in circumstances where distance and time are impediments to access. Queensland is a large Australian state with a distributed population. Providing equitable access to specialist healthcare services to the population is challenging. Specialist care for critically ill or injured children is provided by the Queensland Paediatric Intensive Care Service which comprises two tertiary paediatric intensive care units. The two units are located 6 km (3.7 miles) apart by road in the state capital of Brisbane and provide state-wide telephone advice and specialist retrieval services. Services also extend into the northern area of the adjacent state of New South Wales. In some cases children may be managed locally in adult intensive care units in regional hospitals. The aim of this study is to describe the effect of geography and service organisation for children who need intensive care services but who present outside of metropolitan centres in Queensland. Methods/design Using health services and population data, the availability and spatial accessibility to paediatric intensive care services will be analysed. Retrieval utilisation and the associated costs to the health service will be analysed to provide an indication of service utilisation by non-metropolitan patients. Discussion While the regionalisation or centralisation of specialist services is recognised as an economical way to provide specialist health services, the extent to which these models serve critically ill children who live some distance from tertiary care has not been described. This study will provide new information on the effect of the regionalisation of specialist healthcare for critically ill children in Queensland and will have relevance to other regionalised health services. This study, which is focussed on describing the organisation, supply and demands on the health service, will provide the foundation for future work to explore clinical outcomes for non-metropolitan children who require intensive care.
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Impact of interhospital transfer on complications and outcome after intracranial hemorrhage. Neurocrit Care 2013; 17:324-33. [PMID: 22311233 DOI: 10.1007/s12028-012-9679-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Interhospital transfer of patients with intracranial hemorrhage can offer improved care, but may be associated with complications. METHODS A prospective single-center study was conducted between 2/2008 and 6/2010 of patients with subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and subdural hemorrhage (SDH), admitted to the neuro-ICU at a tertiary-care academic hospital. Admission demographics, complications and 3-month functional outcomes were compared between directly admitted and transferred patients. The effect of transfer time on complications and outcomes was assessed. RESULTS Of 257 total patients, 120 (47%) were transferred and 137 (53%) were directly admitted. About 86 (34%) had SAH, 80 (31%) had ICH and 91 (35%) had SDH. The median transfer time was 190 min (46-1,446). Transferred patients were significantly less educated, less likely to be insured and more frequently had SAH as a diagnosis than directly admitted patients (all P < 0.05), though admission neurological and cognitive status was similar. Complications did not differ between transferred and directly admitted patients; however, among transferred patients, longer transfer time was associated with aneurysm rebleed (7.3 vs. 1.8%, P = 0.007) and tracheostomy (20 vs. 17.5%, P = 0.013). In multivariate analysis, after adjusting for other predictors, transferred patients had worse cognitive outcome at 3-months (adjusted OR 12.4, 95% CI 1.2-125.2, P = 0.033) compared to direct admits, though there were no differences in death, disability or length of stay (LOS). CONCLUSIONS Transferred patients had similar rates of death, disability and LOS as directly admitted patients, though worse 3-month cognitive outcomes. Prolonged time to interhospital transfer was associated with an increased risk of aneurysm rerupture and tracheostomy.
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Abstract
PURPOSE OF REVIEW Interest in international comparisons of critical illness is growing, but the utility of these studies is questionable. This review examines the challenges of international comparisons and highlights areas in which international data provide information relevant to clinical practice and resource allocation. RECENT FINDINGS International comparisons of ICU resources demonstrate that definitions of critical illness and ICU beds vary due to differences in ability to provide organ support and variable staffing. Despite these limitations, recent international data provide key information to understand the pros and cons of different availability of ICU beds on patient flow and outcomes, and also highlight the need to ensure long-term follow-up due to heterogeneity in discharge practices for critically ill patients. With increasing emphasis on curbing costs of healthcare, systems that deliver lower cost care provide data on alternative options, such as regionalization, flexible allocation of beds, and bed rationing. SUMMARY Differences in provision of critical care can be leveraged to inform decisions on allocation of ICU beds, improve interpretation of clinical outcomes, and assess ways to decrease costs of care. International definitions of key components of critical care are needed to facilitate research and ensure rigorous comparisons.
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Affiliation(s)
- Meghan Prin
- Department of Anesthesiology, Columbia University, New York, NY, USA
| | - Hannah Wunsch
- Department of Anesthesiology, Columbia University, New York, NY, USA
- Department of Epidemiology, Columbia University, New York, NY, USA
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"A rose is a rose is a rose … except when it's not."--with apologies to gertrude stein. Crit Care Med 2011; 39:2571-2. [PMID: 22005233 DOI: 10.1097/ccm.0b013e31822a5e14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Patroniti N, Zangrillo A, Pappalardo F, Peris A, Cianchi G, Braschi A, Iotti GA, Arcadipane A, Panarello G, Ranieri VM, Terragni P, Antonelli M, Gattinoni L, Oleari F, Pesenti A. The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks. Intensive Care Med 2011; 37:1447-57. [PMID: 21732167 PMCID: PMC7080128 DOI: 10.1007/s00134-011-2301-6] [Citation(s) in RCA: 255] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 06/03/2011] [Indexed: 12/27/2022]
Abstract
PURPOSE In view of the expected 2009 influenza A(H1N1) pandemic, the Italian Health Authorities set up a national referral network of selected intensive care units (ICU) able to provide advanced respiratory care up to extracorporeal membrane oxygenation (ECMO) for patients with acute respiratory distress syndrome (ARDS). We describe the organization and results of the network, known as ECMOnet. METHODS The network consisted of 14 ICUs with ECMO capability and a national call center. The network was set up to centralize all severe patients to the ECMOnet centers assuring safe transfer. An ad hoc committee defined criteria for both patient transfer and ECMO institutions. RESULTS Between August 2009 and March 2010, 153 critically ill patients (53% referred from other hospitals) were admitted to the ECMOnet ICU with suspected H1N1. Sixty patients (48 of the referred patients, 49 with confirmed H1N1 diagnosis) received ECMO according to ECMOnet criteria. All referred patients were successfully transferred to the ECMOnet centers; 28 were transferred while on ECMO. Survival to hospital discharge in patients receiving ECMO was 68%. Survival of patients receiving ECMO within 7 days from the onset of mechanical ventilation was 77%. The length of mechanical ventilation prior to ECMO was an independent predictor of mortality. CONCLUSIONS A network organization based on preemptive patient centralization allowed a high survival rate and provided effective and safe referral of patients with severe H1N1-suspected ARDS.
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Affiliation(s)
- Nicolò Patroniti
- Department of Experimental Medicine, University of Milan-Bicocca, Via Pergolesi 33, 20052 Monza, Italy.
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Parry-Jones J, Szakmany T, Findlay G, Shah S. A Respiratory Centre and Network Model for the Management of Severe Hypoxaemic Respiratory Failure. J Intensive Care Soc 2011. [DOI: 10.1177/175114371101200218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Jack Parry-Jones
- South East Wales Critical Care Network, Intensive Care Consultant, Aneurin Bevan Health Board, Royal Gwent Hospital, Newport
| | | | - George Findlay
- University Hospital of Wales, Cardiff and Vale University Health Board
| | - Sanjoy Shah
- University Hospital of Wales, Cardiff and Vale University Health Board
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Trojanowski J, MacDonald RD. Safe transport of patients with acute coronary syndrome or cardiogenic shock by skilled air medical crews. PREHOSP EMERG CARE 2011; 15:240-5. [PMID: 21226552 DOI: 10.3109/10903127.2010.541978] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Acute coronary syndrome (ACS) is a spectrum of disease that includes unstable angina (UA), non?ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock is a severe complication of an ACS. Evidence suggests that emergent primary coronary intervention is the treatment of choice for patients with acute STEMI, and patients who have hemodynamic instability or suffer a major complication of therapy also require emergent intervention. These patients may require emergent interfacility transfer for this intervention. OBJECTIVE This study examined ACS patient transfers to determine the incidence of adverse events (AEs) during transfer in a large transport medicine service. METHODS This was a retrospective review of prospectively collected data for air medical transfer of ACS or cardiogenic shock patients in Ontario, Canada, from January 2005 to June 2007. Call records and patient care reports were screened for AE identifiers, including resuscitation medication and procedure and unstable cardiac rhythms. Each chart with an AE was independently reviewed by two investigators, with consensus in cases of disagreement, to determine the incidence and type of AE. RESULTS During the study period, there were 2,258 transfers for which the patient had a primary diagnosis of ACS or cardiogenic shock. The mean age was 62 years (range 24-91 years), and 68% of the patients were male. Investigators identified one or more AEs that occurred during 127 (5.6%) patient transfers, with hypotension (n = 80), increasing chest pain (n = 52), and arrhythmia (n = 18) as the three most common AEs. There was one death in flight. Management of the AEs was within the scope of practice of transport personnel in all but one case. CONCLUSION The incidence of AEs in air medical transport of ACS patients is low. Air medical crews can safely transport this potentially unstable patient population.
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Affiliation(s)
- Jan Trojanowski
- Division of Emergency Medicine, Faculty of Medicine, University of Western Ontario, London, Canada
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