Breaking down walls: a qualitative evaluation of perceived emergency department delays for patients transferred with ST-elevation myocardial infarction

Operation of national coordinating service for interhospital transfer from emergency departments: experience and implications from Korea

BACKGROUND

Since 2014, Korea has been operating the National Emergency Medical Situation Room (NEMSR) to provide regional emergency departments (EDs) with coordination services for the interhospital transfer of critically ill patients. The present study aimed to describe the NEMSR's experience and interhospital transfer pattern from EDs nationwide, and investigate the factors related to delayed transfers or transfers that could not be arranged by the NEMSR.

METHODS

This study was a retrospective cross-sectional analysis of the NEMSR's coordination registry from 2017 to 2019. The demographic and hospital characteristics related to emergency transfers were analyzed with hierarchical logistic models.

RESULTS

The NEMSR received a total of 14,003 requests for the arrangement of the interhospital transfers of critically ill patients from 2017 to 2019. Of 10,222 requests included in the analysis, 8297 (81.17%) successful transfers were coordinated by the NEMSR. Transfers were requested mainly due to a shortage of medical staff (59.79%) and ICU beds (30.80%). Delayed transfers were significantly associated with insufficient hospital resources. The larger the bed capacity of the sending hospital, the more difficult it was to coordinate the transfer (odds ratio [OR] for transfer not arranged = 2.04; 95% confidence interval [CI]: 1.48-2.82, ≥ 1000 beds vs. < 300 beds) and the longer the transfer was delayed (OR for delays of more than 44 minutes = 2.08; 95% CI: 1.57-2.76, ≥ 1000 beds vs. < 300 beds).

CONCLUSIONS

The operation of the NEMSR has clinical importance in that it could efficiently coordinate interhospital transfers through a protocolized process and resource information system. The coordination role is significant as information technology in emergency care develops while regional gaps in the distribution of medical resources widen.

Reduction in Interfacility Transfer Response Time after Implementation of an AutoLaunch Protocol

Background: Interfacility transfers (IFTs) are an essential component of healthcare systems to allow movement of patients between facilities. It is essential to limit any delays in patients receiving the care they require at the receiving facility. The primary objective of this study was to assess whether IFT response time was reduced after implementation of an AutoLaunch protocol, in which an ambulance is dispatched to the sending facility prior to acceptance of the patient by the receiving facility. The secondary objective was to describe the frequency and amount of time ambulances had to stage outside the sending facility in situations where the ambulance arrived prior to the patient being accepted by the receiving facility. Methods: This was a retrospective pre-post analysis of patients undergoing IFT for services not available at the sending facility between October 1, 2018 and September 30, 2019, with the AutoLaunch protocol being implemented on March 25, 2019. IFT response time was defined as the time the transfer request was initially made to the time the ambulance arrived at the sending facility. Dispatch call logs and transport records were analyzed before and after implementation of the AutoLaunch protocol to assess for a difference in IFT response time as well as frequency and amount of time ambulances had to stage. Results: Of 1,881 IFTs analyzed, 885 (47.0%) were completed under the traditional protocol and 996 (53.0%) were completed under the AutoLaunch protocol. The median IFT response time under the traditional protocol was 27.5 minutes (interquartile range (IQR): 17.9, 43.3), compared with 19.9 minutes (IQR: 12.8, 28.2) under the AutoLaunch protocol (p < 0.01), representing a 27.6% reduction in response time, or 7.6 minutes saved. Of the 996 AutoLaunch transfers, there were 215 incidents (21.6%) in which the IFT ambulance had to stage, and the median staging time was 10.1 minutes (IQR: 4.9, 24.2). Conclusions: Implementation of our AutoLaunch protocol resulted in a significant reduction in ambulance response time for interfacility transfers. Further studies are needed to assess whether the reduction in response time is associated with improved patient outcomes for certain conditions.

Prehospital Evaluation, ED Management, Transfers, and Management of Inpatient STEMI

ST elevation myocardial infarction diagnoses have reduced in number over the past 10 years; however, associated morbidity and mortality remain high. Societal guidelines focus on early diagnosis and timely access to reperfusion, preferably percutaneous coronary intervention (PCI), with fibrinolytics reserved for those who cannot receive timely PCI. Proposed algorithms recommend emergency department bypass in stable patients with a clear diagnosis to reduced door-to-balloon time. Emergency providers should limit their evaluation, focusing on life-threatening comorbidities, unstable vitals, or contraindications to a catheterization laboratory. In-hospital patients prove diagnostically challenging because they may be unable to express symptoms, and reperfusion strategies can complicate other diagnoses.