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Estrada LV, Barcelona V, Dhingra L, Luchsinger JA, Dick AW, Glance LG, Stone PW. Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents. JAMA Netw Open 2024; 7:e249312. [PMID: 38696169 DOI: 10.1001/jamanetworkopen.2024.9312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
Importance Nursing home (NH) transfers to hospitals are common and have been associated with cognitive decline; approximately 45% of NH hospital transfers are potentially avoidable hospitalizations (PAHs). Objective To determine PAH incidence for historically marginalized NH residents with severe cognitive impairment compared with non-Hispanic White residents. Design, Setting, and Participants This cross-sectional study merged 2018 Centers for Medicaid & Medicare Services datasets and LTCFocus, a public dataset on US NH care, for US NH residents aged 65 years and older who had a hospitalization. Analyses were performed from January to May 2022. Exposure Race and ethnicity of NH residents. Main Outcomes and Measures Racial and ethnic differences in resident-level annual rates of PAHs were estimated for residents with and without severe cognitive impairment (measured using the Cognitive Function Scale), controlling for resident characteristics, comorbidities, dual eligibility, and time at risk. PAHs were defined as NH hospital transfers that resulted from neglectful NH care or for which NH treatment would have been appropriate. Results Of 2 098 385 NH residents nationwide included in the study, 7151 (0.3%) were American Indian or Alaska Native, 39 873 (1.9%) were Asian, 229 112 (10.9%) were Black or African American, 99 304 (4.7%) were Hispanic, 2785 (0.1%) were Native Hawaiian or Pacific Islander, 1 713 670 (81.7%) were White, and 6490 (0.3%) were multiracial; 1 355 143 (64.6%) were female; 128 997 (6.2%) were severely cognitively impaired; and the mean (SD) age was 81.8 (8.7) years. PAH incidence rate ratios (IRRs) were significantly greater for residents with severe cognitive impairment compared with those without. In unadjusted analyses comparing historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment, American Indian or Alaska Native residents had a 49% higher PAH incidence (IRR, 1.49 [95% CI, 1.10-2.01]), Black or African American residents had a 64% higher incidence (IRR, 1.64 [95% CI, 1.48-1.81]), and Hispanic residents had a 45% higher incidence (IRR, 1.45 [95% CI, 1.29-1.62]). Higher incidences persisted for historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment in adjusted analyses. Asian residents had a 24% higher PAH incidence (IRR, 1.24 [95% CI, 1.06-1.45]), Black or African American residents had a 48% higher incidence (IRR, 1.48 [95% CI, 1.36-1.60]), and Hispanic residents had a 27% higher incidence (IRR, 1.27 [95% CI, 1.16-1.39]). Conclusions and Relevance In this cross-sectional study of PAHs, compared with non-Hispanic White NH residents, historically marginalized residents had increased PAH incidence. In the presence of severe cognitive impairment, incidence rates increased significantly compared with rates for residents without severe cognitive impairment. These results suggest that identification of residents with severe cognitive impairment and proper NH care may help prevent further cognitive decline by avoiding PAHs.
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Affiliation(s)
- Leah V Estrada
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - José A Luchsinger
- Departments of Medicine and Epidemiology, Columbia University Irving Medical Center
| | | | - Laurent G Glance
- RAND Corporation, Boston, Massachusetts
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York
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McNair K, Botticello A, Stubblefield MD. Using Performance Status to Identify Risk of Acute Care Transfer in Inpatient Cancer Rehabilitation. Arch Phys Med Rehabil 2024; 105:947-952. [PMID: 38232794 DOI: 10.1016/j.apmr.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/20/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To identify patient factors associated with acute care transfer (ACT) among cancer survivors admitted for inpatient medical rehabilitation. DESIGN An exploratory, observational design was used to analyze retrospective data from electronic medical records. SETTING Data were obtained from 3 separate inpatient rehabilitation hospitals within a private rehabilitation hospital system in the Northeast. PARTICIPANTS Medical records were reviewed and analyzed for a total of 416 patients with a confirmed oncologic diagnosis treated in 1 of the inpatient rehabilitation hospitals between January and December 2020. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The primary outcome measure was the incidence of an ACT. Covariates included the adapted Karnofsky Performance Scale (KPS) for inpatient rehabilitation, demographic information, admission date, re-admission status, discharge destination, and cancer-related variables, such as primary cancer diagnosis and presence/location of metastases. RESULTS One in 5 patients (21.2%) were transferred to acute care. Patients with hematologic cancer had a higher risk of ACT compared with those with central nervous system (CNS) cancer. Lower functional status, measured by the adapted KPS, was associated with a higher likelihood of ACT. Patients with an admission KPS score indicating the need for maximum assistance had the highest transfer rate (59.1%). CONCLUSIONS These findings highlight the medical complexity of this population and increased risk of an interrupted rehabilitation stay. Considering patients' performance status, cancer type, and extent of disease may be important when assessing the appropriateness of IRF admission relative to patient quality of life. Earlier and improved understanding of the patient's prognosis will allow the cancer rehabilitation program to meet the patient's unique needs and facilitate an appropriate discharge to the community in an optimal window of time.
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Affiliation(s)
- Keara McNair
- Kessler Institute for Rehabilitation, West Orange, NJ; Rutgers, Department of Rehabilitation and Movement Sciences, School of Health Professions, Newark, NJ.
| | - Amanda Botticello
- Center for Outcomes and Assessment Research, Kessler Foundation, West Orange, NJ; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ
| | - Michael D Stubblefield
- Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ
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Schumacher S, Mitzlaff B, Mohrmann C, Fiedler KM, Heep A, Beske F, Hoffmann F, Lange M. Characteristics and special challenges of neonatal emergency transports. Early Hum Dev 2024; 192:106012. [PMID: 38648678 DOI: 10.1016/j.earlhumdev.2024.106012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND As a rule, newborns do not require special medical care. If unexpected complications occur peripartum or postpartum, support from and transport to specialised neonatal hospitals might be needed. METHODS In a retrospective study, all transport protocols of a supraregional paediatric‑neonatological maximum care hospital in northwestern Germany from 01.10.2018 through 30.09.2021 were analysed. The particular focus was on transports of newborns (<7 days) and the leading symptoms that led to contact. RESULTS A total of 299 patients were included (average age of 15.4 h, 61.6 % males). The average complete transport time was approximately 2 h. Five leading neonatal diseases (respiratory, infectious, asphyxia, cardiac, haematological) were found to represent the causes of >80 % of transfers. Respiratory adaptation disorders are the main reason for transferring a newborn to a centre, whereas asphyxia is the most severe condition. The various symptoms differ in their time of onset, a factor which must be taken into account in practice. Differences were also found between different types of hospitals: while a large proportion of transports were carried out from maternity hospitals (80.6 %), children transported from children's hospitals were generally more severely ill. DISCUSSION Transfers of neonates, especially from maternity hospitals to neonatal intensive care units due to special neonatal diseases, are not rare. In times of increasingly scarce resources, the effective care of sick or at-risk neonates is essential. For low-population regions, this means professional cooperation between maximum care providers and smaller children's hospitals and maternity-only hospitals.
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Affiliation(s)
- S Schumacher
- Department of Pediatrics, Klinikum Leer, Leer, Germany
| | - B Mitzlaff
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - C Mohrmann
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - K M Fiedler
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - A Heep
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - F Beske
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - F Hoffmann
- Department of Healthcare Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - M Lange
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany.
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Miller LG, McKinnell JA, Singh RD, Gussin GM, Kleinman K, Saavedra R, Mendez J, Catuna TD, Felix J, Chang J, Heim L, Franco R, Tjoa T, Stone ND, Steinberg K, Beecham N, Montgomery J, Walters D, Park S, Tam S, Gohil SK, Robinson PA, Estevez M, Lewis B, Shimabukuro JA, Tchakalian G, Miner A, Torres C, Evans KD, Bittencourt CE, He J, Lee E, Nedelcu C, Lu J, Agrawal S, Sturdevant SG, Peterson E, Huang SS. Decolonization in Nursing Homes to Prevent Infection and Hospitalization. N Engl J Med 2023; 389:1766-1777. [PMID: 37815935 DOI: 10.1056/nejmoa2215254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
BACKGROUND Nursing home residents are at high risk for infection, hospitalization, and colonization with multidrug-resistant organisms. METHODS We performed a cluster-randomized trial of universal decolonization as compared with routine-care bathing in nursing homes. The trial included an 18-month baseline period and an 18-month intervention period. Decolonization entailed the use of chlorhexidine for all routine bathing and showering and administration of nasal povidone-iodine twice daily for the first 5 days after admission and then twice daily for 5 days every other week. The primary outcome was transfer to a hospital due to infection. The secondary outcome was transfer to a hospital for any reason. An intention-to-treat (as-assigned) difference-in-differences analysis was performed for each outcome with the use of generalized linear mixed models to compare the intervention period with the baseline period across trial groups. RESULTS Data were obtained from 28 nursing homes with a total of 28,956 residents. Among the transfers to a hospital in the routine-care group, 62.2% (the mean across facilities) were due to infection during the baseline period and 62.6% were due to infection during the intervention period (risk ratio, 1.00; 95% confidence interval [CI], 0.96 to 1.04). The corresponding values in the decolonization group were 62.9% and 52.2% (risk ratio, 0.83; 95% CI, 0.79 to 0.88), for a difference in risk ratio, as compared with routine care, of 16.6% (95% CI, 11.0 to 21.8; P<0.001). Among the discharges from the nursing home in the routine-care group, transfer to a hospital for any reason accounted for 36.6% during the baseline period and for 39.2% during the intervention period (risk ratio, 1.08; 95% CI, 1.04 to 1.12). The corresponding values in the decolonization group were 35.5% and 32.4% (risk ratio, 0.92; 95% CI, 0.88 to 0.96), for a difference in risk ratio, as compared with routine care, of 14.6% (95% CI, 9.7 to 19.2). The number needed to treat was 9.7 to prevent one infection-related hospitalization and 8.9 to prevent one hospitalization for any reason. CONCLUSIONS In nursing homes, universal decolonization with chlorhexidine and nasal iodophor led to a significantly lower risk of transfer to a hospital due to infection than routine care. (Funded by the Agency for Healthcare Research and Quality; Protect ClinicalTrials.gov number, NCT03118232.).
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Affiliation(s)
- Loren G Miller
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - James A McKinnell
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Raveena D Singh
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Gabrielle M Gussin
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Ken Kleinman
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Raheeb Saavedra
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Job Mendez
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Tabitha D Catuna
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - James Felix
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Justin Chang
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Lauren Heim
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Ryan Franco
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Thomas Tjoa
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Nimalie D Stone
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Karl Steinberg
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Nancy Beecham
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Jocelyn Montgomery
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - DeAnn Walters
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Steven Park
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Steven Tam
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Shruti K Gohil
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Philip A Robinson
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Marlene Estevez
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Brian Lewis
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Julie A Shimabukuro
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Gregory Tchakalian
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Aaron Miner
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Crystal Torres
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Kaye D Evans
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Cassiana E Bittencourt
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Jiayi He
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Eunjung Lee
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Christine Nedelcu
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Julia Lu
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Shalini Agrawal
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - S Gwynn Sturdevant
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Ellena Peterson
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
| | - Susan S Huang
- From the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance (L.G.M., J.A.M., J. Mendez, J.F., R.F., G.T., A.M., C.T.), the Division of Infectious Diseases (R.D.S., G.M.G., R.S., T.D.C., J.C., L.H., T.T., S.P., S.K.G., M.E., B.L., J.H., E.L., C.N., J.L., S.A., S.S.H.) and the Department of Pathology and Laboratory Medicine (J.A.S., K.D.E., C.E.B.), University of California Irvine School of Medicine, Irvine, the Division of Geriatrics and Gerontology, University of California Irvine School of Medicine, Orange (S.T.), the California Association of Health Facilities, Sacramento ( J. Montgomery, D.W.), and Hoag Memorial Hospital, Newport Beach (P.A.R.) - all in California; the Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst (K.K., S.G.S.); the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (N.D.S.); the Society for Post-Acute and Long-Term Care Medicine, Columbia, MD (K.S., E.P.); the National Association of Directors of Nursing Administration in Long-Term Care, Springdale, OH (N.B.); and the Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea (E.L.)
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Alexander M, Lan NSR, Dallo MJ, Briffa TG, Sanfilippo FM, Hooper A, Bartholomew H, Hii L, Hillis GS, McQuillan BM, Dwivedi G, Rankin JM, Ihdayhid AR. Clinical outcomes and health care costs of transferring rural Western Australians for invasive coronary angiography, and a cost-effective alternative care model: a retrospective cross-sectional study. Med J Aust 2023; 219:155-161. [PMID: 37403443 DOI: 10.5694/mja2.52018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/20/2023] [Accepted: 05/10/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVES To examine the severity of coronary artery disease (CAD) in people from rural or remote Western Australia referred for invasive coronary angiography (ICA) in Perth and their subsequent management; to estimate the cost savings were computed tomography coronary angiography (CTCA) offered in rural centres as a first line investigation for people with suspected CAD. DESIGN Retrospective cohort study. SETTING, PARTICIPANTS Adults with stable symptoms in rural and remote WA referred to Perth public tertiary hospitals for ICA evaluation during the 2019 calendar year. MAIN OUTCOME MEASURES Severity and management of CAD (medical management or revascularisation); health care costs by care model (standard care or a proposed alternative model with local CTCA assessment). RESULTS The mean age of the 1017 people from rural and remote WA who underwent ICA in Perth was 62 years (standard deviation, 13 years); 680 were men (66.9%), 245 were Indigenous people (24.1%). Indications for referral were non-ST elevation myocardial infarction (438, 43.1%), chest pain with normal troponin level (394, 38.7%), and other (185, 18.2%). After ICA assessment, 619 people were medically managed (60.9%) and 398 underwent revascularisation (39.1%). None of the 365 patients (35.9%) without obstructed coronaries (< 50% stenosis) underwent revascularisation; nine patients with moderate CAD (50-69% stenosis; 7%) and 389 with severe CAD (≥ 70% stenosis or occluded vessel; 75.5%) underwent revascularisation. Were CTCA used locally to determine the need for referral, 527 referrals could have been averted (53%), the ICA:revascularisation ratio would have improved from 2.6 to 1.6, and 1757 metropolitan hospital bed-days (43% reduction) and $7.3 million in health care costs (36% reduction) would have been saved. CONCLUSION Many rural and remote Western Australians transferred for ICA in Perth have non-obstructive CAD and are medically managed. Providing CTCA as a first line investigation in rural centres could avert half of these transfers and be a cost-effective strategy for risk stratification of people with suspected CAD.
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Affiliation(s)
| | - Nick S R Lan
- Fiona Stanley Hospital, Perth, WA
- The University of Western Australia, Perth, WA
| | | | | | | | - Andrew Hooper
- Medical Royal Flying Doctor Service Western Australia, Perth, WA
| | | | | | - Graham S Hillis
- Royal Perth Hospital, Perth, WA
- The University of Western Australia, Perth, WA
| | - Brendan M McQuillan
- The University of Western Australia, Perth, WA
- Sir Charles Gairdner Hospital, Perth, WA
| | - Girish Dwivedi
- Fiona Stanley Hospital, Perth, WA
- Harry Perkins Institute of Medical Research, Perth, WA
| | | | - Abdul Rahman Ihdayhid
- Fiona Stanley Hospital, Perth, WA
- Harry Perkins Institute of Medical Research, Perth, WA
- Curtin Medical School, Curtin University, Perth, WA
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Stamm B, Royan R, Giurcanu M, Messe SR, Jauch EC, Prabhakaran S. Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke. JAMA 2023; 330:636-649. [PMID: 37581671 PMCID: PMC10427946 DOI: 10.1001/jama.2023.12739] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/22/2023] [Indexed: 08/16/2023]
Abstract
Importance Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED). Objective To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times. Design, Setting, and Participants US registry-based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals. Exposure Patient- and hospital-level characteristics. Main Outcomes and Measures The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy. Results Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (-20.1 minutes; 95% CI, -22.1 to -18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (-66.7 minutes; 95% CI, -68.7 to -64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (-16.8 minutes; 95% CI, -21.0 to -12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times. Conclusions and Relevance In this US registry-based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.
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Affiliation(s)
- Brian Stamm
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Neurology, Northwestern University, Chicago, Illinois
| | - Regina Royan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois
- Assistant Editor, JAMA Network Open
| | - Mihai Giurcanu
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Steven R. Messe
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Edward C. Jauch
- Department of Research, Mountain Area Health Education Center, Asheville, North Carolina
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Antony AR, Champion JD. Predictors of Acute Care Transfers From Skilled Nursing Facilities: Recommendations for Preventing Unnecessary Hospitalization. Res Gerontol Nurs 2022; 15:172-178. [PMID: 35708962 DOI: 10.3928/19404921-20220609-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Preventing acute care transfers from skilled nursing facilities (SNFs) is a challenge secondary to residents' associated debilitated status and comorbidities. Acute care transfers often result in serious complications and unnecessary health care expenditure. Literature implies that approximately two thirds of these acute care transfers could be prevented using proactive interventions. The purpose of the current study was to identify the predictors of acute care transfers for SNF residents in developing relevant prevention strategies. A retrospective chart review using multivariate logistic regression analysis showed increased odds of SNF hospitalization was significantly associated with impaired cognition, chronic obstructive pulmonary disease, and chronic kidney disease, whereas decreased odds of hospitalization was identified among non-Hispanic White residents. Study recommendations include prompt assessment of comorbid symptomatology among SNF residents for the timely management and prevention of unnecessary acute care transfers. [Research in Gerontological Nursing, xx(x), xx-xx.].
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Blanckenberg N, Motala T. Facilitating remote access to specialist medical expertise through the scaled up adoption of a smartphone application: A South African case. S Afr Med J 2022; 112:13504. [PMID: 35139992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND In the context of a shortage of medical specialists, a medical referral app, designed for use on smartphones, was launched in 2014 for use by doctors in the public health service in South Africa. OBJECTIVES As this is a novel intervention, with potential to have an impact on the use of scarce resources, and because not much was known about the use of the app, a descriptive study was undertaken to assess its adoption in Western Cape Government Health (WCGH) facilities. METHODS Usage data of the app in WCGH facilities, in terms of referral and user numbers, were obtained from the date of its introduction in 2014. In addition, all the referrals to WCGH facilities for July 2019, stripped of any identifying data of patients or doctors, were analysed for origin, destination, outcome and response times. Descriptive statistics were used to analyse the data. RESULTS Use of the app grew rapidly from 40 referrals per quarter to 16 437 per quarter after 5 years in use, with a cumulative total of 95 381 referrals. In July 2019, active users of the system included 913 sending doctors and 298 receiving doctors, representing 20 medical specialties. The senders and receivers were representative of every level in the healthcare system, from clinic to tertiary hospital. In July 2019, a total of 5 941 referrals were sent by means of the app to public facilities in Western Cape Province. Of the referrals, 80% were classified as acute and 20% as non-urgent. The referral outcomes included 51% accepted for transfer, 19% accepted for a specialist appointment, and 13% concluded with advice alone without the need for a specialist appointment or patient transfer - this category accounted for 28% of non-urgent referrals and 9% of acute referrals. In 50% of referrals, advice was given to the referring doctor, either as an additional or the only outcome. The median response times were 9 minutes for acute referrals and 19 minutes for non-urgent referrals. CONCLUSIONS This study documents the scale-up of a mobile phone consultation and referral app from pilot phase to significant growth in use across a resource-constrained healthcare system. In a large proportion of cases, advice was given to the referring doctor by means of the app, frequently obviating the need for a specialist appointment or patient transfer. This finding demonstrates that a mobile app has the potential to reduce the need for face-to-face specialist visits, thereby improving the use of scarce medical resources.
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Affiliation(s)
- N Blanckenberg
- Cape Winelands District, Western Cape Government Health, South Africa.
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Baimas-George M, Schiffern L, Yang H, Paton L, Barbat S, Matthews B, Reinke CE. Emergency general surgery transfer to lower acuity facility: The role of right-sizing care in emergency general surgery regionalization. J Trauma Acute Care Surg 2022; 92:38-43. [PMID: 34670959 DOI: 10.1097/ta.0000000000003435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Regionalization of emergency general surgery (EGS) has primarily focused on expediting care of high acuity patients through interfacility transfers. In contrast, triaging low-risk patients to a nondesignated trauma facility has not been evaluated. This study evaluates a 16-month experience of a five-surgeon team triaging EGS patients at a tertiary care, Level I trauma center (TC) to an affiliated community hospital 1.3 miles away. METHODS All EGS patients who presented to the Level I TC emergency department from January 2020 to April 2021 were analyzed. Patients were screened by EGS surgeons covering both facilities for transfer appropriateness including hemodynamics, resource need, and comorbidities. Patients were retrospectively evaluated for disposition, diagnosis, comorbidities, length of stay, surgical intervention, and 30-day mortality and readmission. RESULTS Of 987 patients reviewed, 31.5% were transferred to the affiliated community hospital, 16.1% were discharged home from the emergency department, and 52.4% were admitted to the Level I TC. Common diagnoses were biliary disease (16.8%), bowel obstruction (15.7%), and appendicitis (14.3%). Compared with Level I TC admissions, Charlson Comorbidity Index was lower (1.89 vs. 4.45, p < 0.001) and length of stay was shorter (2.23 days vs. 5.49 days, p < 0.001) for transfers. Transfers had a higher rate of surgery (67.5% vs. 50.1%, p < 0.001) and lower readmission and mortality (8.4% vs. 15.3%, p = 0.004; 0.6% vs. 5.0%, p < 0.001). Reasons not to transfer were emergency evaluation, comorbidity burden, operating room availability, and established care. No transfers required transfer back to higher care (under-triage). Bed days saved at the Level I TC were 693 (591 inpatients). Total operating room minutes saved were 24,008 (16,919, between 7:00 am and 5:00 pm). CONCLUSION Transfer of appropriate patients maintains high quality care and outcomes, while improving operating room and bed capacity and resource utilization at a tertiary care, Level I TC. Emergency general surgery regionalization should consider triage of both high-risk and low-risk patients. LEVEL OF EVIDENCE Prospective comparative cohort study, Level II.
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Affiliation(s)
- Maria Baimas-George
- From the Department of Surgery (M.B.-G., L.S., L.P., S.B., B.M., C.E.R.), Carolinas Medical Center, Charlotte, North Carolina; and Clinical Analytics, Department of Information and Analytics Services (H.Y.), Atrium Health, Charlotte, North Carolina
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Rosen JE, Bulger EM, Cuschieri J. Respiratory events after intensive care unit discharge in trauma patients: Epidemiology, outcomes, and risk factors. J Trauma Acute Care Surg 2022; 92:28-37. [PMID: 34284468 PMCID: PMC8692327 DOI: 10.1097/ta.0000000000003362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Respiratory complications are associated with significant morbidity and mortality in trauma patients. The care transition from the intensive care unit (ICU) to the acute care ward is a vulnerable time for injured patients. There is a lack of knowledge about the epidemiology of respiratory events and their outcomes during this transition. METHODS Retrospective cohort study in a single Level I trauma center of injured patients 18 years and older initially admitted to the ICU from 2015 to 2019 who survived initial transfer to the acute care ward. The primary outcome was occurrence of a respiratory event, defined as escalation in oxygen therapy beyond nasal cannula or facemask for three or more consecutive hours. Secondary outcomes included unplanned intubation for a primary pulmonary cause, adjudicated via manual chart review, as well as in-hospital mortality and length of stay. Multivariable logistic regression was used to examine patient characteristics associated with posttransfer respiratory events. RESULTS There were 6,561 patients that met the inclusion criteria with a mean age of 52.3 years and median Injury Severity Score of 18 (interquartile range, 13-26). Two hundred and sixty-two patients (4.0%) experienced a respiratory event. Respiratory events occurred early after transfer (median, 2 days, interquartile range, 1-5 days), and were associated with high mortality (16% vs. 1.8%, p < 0.001), and ICU readmission rates (52.6% vs. 4.7%, p < 0.001). Increasing age, male sex, severe chest injury, and comorbidities, including preexisting alcohol use disorder, congestive heart failure, and chronic obstructive pulmonary disease, were associated with increased odds of a respiratory event. Fifty-eight patients experienced an unplanned intubation for a primary pulmonary cause, which was associated with an in-hospital mortality of 39.7%. CONCLUSION Respiratory events after transfer to the acute care ward occur close to the time of transfer and are associated with high mortality. Interventions targeted at this critical time are warranted to improve patient outcomes. LEVEL OF EVIDENCE Prognostic and Epidemiological study, level III.
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Affiliation(s)
- Joshua E Rosen
- From the Surgical Outcomes Research Center, Department of Surgery (J.E.R.), University of Washington; Department of Surgery (J.E.R., E.M.B.), Harborview Medical Center, Seattle, Washington; and Department of Surgery (J.C.), University of California San Francisco, San Francisco, California
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11
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Xu Y, Liu S, Wang J. Multiple attribute group decision-making based on interval-valued q-rung orthopair uncertain linguistic power Muirhead mean operators and linguistic scale functions. PLoS One 2021; 16:e0258772. [PMID: 34673796 PMCID: PMC8530323 DOI: 10.1371/journal.pone.0258772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/06/2021] [Indexed: 11/23/2022] Open
Abstract
Fuzzy set theory and its extended form have been widely used in multiple-attribute group decision-making (MAGDM) problems, among which the interval-valued q-rung orthopair fuzzy sets (IVq-ROFSs) got a lot of attention for its ability of capturing information denoted by interval values. Based on the previous studies, to find a better solution for fusing qualitative quantization information with fuzzy numbers, we propose a novel definition of interval-valued q-rung orthopair uncertain linguistic sets (IVq-ROULSs) based on the linguistic scale functions, as well as its corresponding properties, such as operational rules and the comparison method. Furthermore, we utilize the power Muirhead mean operators to construct the information fusion method, and provide a variety of aggregation operators based on the proposed information description environment. A model framework is constructed for solving the MAGDM problem utilizing the proposed method. Finally, we illustrate the performance of the new method and investigate its advantages and superiorities through comparative analysis.
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Affiliation(s)
- Yuan Xu
- School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Shifeng Liu
- School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Jun Wang
- School of Economics and Management, Beijing University of Chemical Technology, Beijing, China
- * E-mail:
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Zachrison KS, Richard JV, Wilcock A, Zubizaretta JR, Schwamm LH, Uscher-Pines L, Mehrotra A. Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks. JAMA Netw Open 2021; 4:e2126612. [PMID: 34554236 PMCID: PMC8461501 DOI: 10.1001/jamanetworkopen.2021.26612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed. OBJECTIVE To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified. EXPOSURES For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics. MAIN OUTCOMES AND MEASURES Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients. RESULTS Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients. CONCLUSIONS AND RELEVANCE This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Jessica V. Richard
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Andrew Wilcock
- Department of Family Medicine, University of Vermont College of Medicine, Burlington
| | - Jose R. Zubizaretta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
| | | | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Ilonzo N, Lee J, James C, Phair J, Ting W, Faries P, Vouyouka A. Sex-based differences in loss of independence after lower extremity bypass surgery. Am J Surg 2021; 223:170-175. [PMID: 34364654 DOI: 10.1016/j.amjsurg.2021.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/22/2021] [Accepted: 07/13/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This study analyzes sex-based differences in the risk of discharge to a nonhome facility (loss of independence) after lower extremity revascularization and resultant outcomes. METHODS Data from the NSQIP database for years 2015-2017 was utilized to assess sex-based differences in loss of independence and associated unplanned readmission and 30-day amputation using chi-square, student t-test, and multivariate logistic regression analyses where appropriate. RESULTS There was increased loss of independence in women (34.9% vs. 26.1 %, p < .01) and associated increase in unplanned readmission (18.4% vs. 13.6 %, p = .01) and length of stay (12.1 days vs 6.5 days, p < .01). Endovascular revascularization was associated with decreased likelihood of loss of independence (OR 0.43, CI 0.36-0.50). CONCLUSION Loss of independence after lower extremity bypass surgery affects women more than men and it is associated with worse postoperative outcomes.
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Affiliation(s)
- Nicole Ilonzo
- Division of Vascular Surgery, Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Jonathan Lee
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA
| | - Crystal James
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA
| | - John Phair
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA
| | - Windsor Ting
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA
| | - Peter Faries
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA
| | - Ageliki Vouyouka
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA.
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Follette C, Halimeh B, Chaparro A, Shi A, Winfield R. Futile trauma transfers: An infrequent but costly component of regionalized trauma care. J Trauma Acute Care Surg 2021; 91:72-76. [PMID: 34144558 DOI: 10.1097/ta.0000000000003139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Appropriate interfacility transfers are a key component of highly functioning trauma systems but transfer of unsalvageable patients can overburden the resources of higher-level centers. We sought to identify the occurrence and associated reasons for futile transfers within our trauma system. METHODS Using prospectively collected data from our system database, a retrospective cohort study was conducted to identify patients who underwent interfacility transfer to our American College of Surgeons level I center. Adult patients from June 2017 to June 2019 who died, had comfort measures implemented, were discharged, or went to hospice care within 48 hours of admission without significant operation, procedure, or radiologic intervention were examined. Futility was defined as resulting in death or hospice discharge within 48 hours of transfer without major operative, endoscopic, or radiologic intervention. RESULTS A total of 1,241 patients transferred to our facility during the study period. Four hundred seven patients had a length of stay less than or equal to 48 hours. Eighteen (1.5%) met the criteria for futility. The most common reason for transfer in the futile population was traumatic brain injury (56%) and need for neurosurgical capabilities (62%). Futile patients had a median age and Injury Severity Score of 75 and 21. The main transportation method was ground 9 (50%) with 8 (44.4%) being transported by helicopter and 1 (5.6%) being transported by both. Combining transport costs with hospital charges, each futile transfer was estimated to cost US $56,396 (interquartile range, 41,889-106,393) with a total cost exceeding US $1.7 million. With an estimated 33,000 interfacility transfers annually for trauma in the United States, the cost of futile transfers to the American trauma system would exceed 27 million dollars each year. CONCLUSION Futile transfers represent a small but costly portion transfer volume. Identification of patients whose conditions preclude the benefit of transfer due to futility and development of appropriate support for referral will significantly improve appropriate allocation of health care resources. LEVEL OF EVIDENCE Economic; Care management, level IV.
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Affiliation(s)
- Craig Follette
- From the Department of Surgery at the University of Kansas Medical Center, Kansas City, Kansas
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Kim YJ, Hong JS, Hong SI, Kim JS, Seo DW, Ahn R, Jeong J, Lee SW, Moon S, Kim WY. The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016-2018. J Korean Med Sci 2021; 36:e172. [PMID: 34184436 PMCID: PMC8239427 DOI: 10.3346/jkms.2021.36.e172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/31/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. METHODS This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016-2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. RESULTS We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). CONCLUSION The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the first-transfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.
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Affiliation(s)
- Youn Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Seok Hong
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seok In Hong
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - June Sung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ryeok Ahn
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jinwoo Jeong
- Department of Emergency Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Sung Woo Lee
- Department of Emergency Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sungwoo Moon
- National Emergency Medical Center, National Medical Center, Seoul, Korea
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Fatima S, Shamim S, Butt AS, Awan S, Riffat S, Tariq M. The discrepancy between admission and discharge diagnoses: Underlying factors and potential clinical outcomes in a low socioeconomic country. PLoS One 2021; 16:e0253316. [PMID: 34129648 PMCID: PMC8205140 DOI: 10.1371/journal.pone.0253316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 06/02/2021] [Indexed: 11/30/2022] Open
Abstract
Objective The discrepancy between admission and discharge diagnosis can lead to possible adverse patient outcomes. There are gaps in integrated studies, and less is understood about its characteristics and effects. Therefore, this study was conducted to determine the frequency, characteristics, and outcomes of diagnostic discrepancies at admission and discharge. Design and data sources This retrospective study reviewed the admitting and discharge diagnoses of adult patients admitted at Aga Khan University Hospital (AKUH), Internal Medicine Department between October 2018 and February 2019. The frequency and outcomes of discrepancies in patient diagnoses were noted among Emergency Department (ED) physician versus admitting physician, admitting physician versus discharge physician, and ED physician versus discharge physician for the full match, partial match, and mismatch diagnoses. The studied outcomes included interdepartmental transfer, Intensive Care Unit (ICU) transfer, in-hospital mortality, readmission within 30 days, and the length of stay. For simplicity, we only analyzed the factors for the discrepancy among ED physicians and discharge physicians. Results Out of 537 admissions, there were 25.3–27.2% admissions with full match diagnoses while 18.6–19.4% and 45.3–47.9% had mismatch and partial match diagnoses respectively. The discrepancy resulted in an increased number of interdepartmental transfers (5–5.8%), ICU transfers (5.6–8.7%), in-hospital mortality (8–11%), and readmissions within 30 days in ED (14.4%-16.7%). A statistically significant difference was observed for the ward’s length of stay with the most prolonged stay in partially matched diagnoses (6.3 ± 5.4 days). Among all the factors that were evaluated for the diagnostic discrepancy, older age, multi-morbidities, level of trainee clerking the patient, review by ED faculty, incomplete history, and delay in investigations at ED were associated with significant discrepant diagnoses. Conclusions Diagnostic discrepancies are a relevant and significant healthcare problem. Fixed patient or physician characteristics do not readily predict diagnostic discrepancies. To reduce the diagnostic discrepancy, emphasis should be given to good history taking and thorough physical examination. Patients with older age and multi-morbidity should receive significant consideration.
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Affiliation(s)
- Samar Fatima
- Department of Medicine, Section of Internal Medicine, Aga Khan University Hospital, Karachi, Pakistan
- * E-mail:
| | - Sara Shamim
- Department of Medicine, Section of Internal Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Amna Subhan Butt
- Section of Gastroenterology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Safia Awan
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Simra Riffat
- Department of Medicine, Section of Internal Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Tariq
- Department of Medicine, Section of Internal Medicine, Aga Khan University Hospital, Karachi, Pakistan
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Carod Pérez C, Carrau E, Sola J, De Alfonso N, Ávila A, Alonso G, Gené E. New health care facilities in the COVID-19 pandemic: health hotels. Emergencias 2021; 33:225-228. [PMID: 33978339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
| | - Elisenda Carrau
- Dirección, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Joan Sola
- Unidad de Hospitalización a Domicilio, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Natalia De Alfonso
- Dirección, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Antonio Ávila
- Gestión de pacientes, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Gilberto Alonso
- Servicio de Urgencias, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Emili Gené
- Servicio de Urgencias, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España. Institut d'Investigació i Innovació Parc Taulí I3PT. Sabadell, Barcelona, España. Universitat Autònoma de Barcelona, Departamento de Medicina, Universitat Internacional de Catalunya, Barcelona, España
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Cooper JG, Ferguson J, Donaldson LA, Black KMM, Livock KJ, Horrill JL, Davidson EM, Scott NW, Lee AJ, Fujisawa T, Lee KK, Anand A, Shah ASV, Mills NL. The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS): A Prospective Cohort Study. Ann Emerg Med 2021; 77:575-588. [PMID: 33926756 DOI: 10.1016/j.annemergmed.2021.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To determine whether risk stratification in the out-of-hospital setting could identify patients with chest pain who are at low and high risk to avoid admission or aid direct transfer to cardiac centers. METHODS Paramedics prospectively enrolled patients with suspected acute coronary syndrome without diagnostic ST-segment elevation on the ECG. The History, ECG, Age and Risk Factors (HEAR) score was recorded contemporaneously, and out-of-hospital samples were obtained to measure cardiac Troponin I (cTnI) level on a point-of-care device, to allow calculation of the History, ECG, Age, Risk Factors, and Troponin (HEART) score. HEAR and HEART scores less than or equal to 3 and greater than or equal to 7 were defined as low and high risk for major adverse cardiac events at 30 days. RESULTS Of 1,054 patients (64 years [SD 15 years]; 42% women), 284 (27%) experienced a major adverse cardiac event at 30 days. The HEAR score was calculated in all patients, with point-of-care cTnI testing available in 357 (34%). A HEAR score less than or equal to 3 identified 32% of patients (334/1,054) as low risk, with a sensitivity of 84.9% (95% confidence interval [CI] 80.7% to 89%), whereas a score greater than or equal to 7 identified just 3% of patients (30/1,054) as high risk, with a specificity of 98.7% (95% CI 97.9% to 99.5%). A point-of-care HEART score less than or equal to 3 identified a similar proportion as low risk (30%), with a sensitivity of 87.0% (95% CI 80.7% to 93.4%), whereas a score greater than or equal to 7 identified 14% as high risk, with a specificity of 94.8% (95% CI 92.0% to 97.5%). CONCLUSION Paramedics can use the HEAR score to discriminate risk, but even when used in combination with out-of-hospital point-of-care cTnI testing, the HEART score does not safely rule out major adverse cardiac events, and only a small proportion of patients are identified as high risk.
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Affiliation(s)
- Jamie G Cooper
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom; Department of Applied Medicine, University of Aberdeen, Aberdeen, United Kingdom.
| | - James Ferguson
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom; Department of Applied Medicine, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Kim M M Black
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Kate J Livock
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Judith L Horrill
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Elaine M Davidson
- Department of Clinical Biochemistry, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Neil W Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, United Kingdom
| | - Amanda J Lee
- Medical Statistics Team, University of Aberdeen, Aberdeen, United Kingdom
| | - Takeshi Fujisawa
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; BHF Cardiovascular Biomarker Laboratory, University of Edinburgh, Edinburgh, United Kingdom
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; BHF Cardiovascular Biomarker Laboratory, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
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Abstract
IMPORTANCE New Centers for Medicare & Medicaid Services waivers created a payment mechanism for hospital at home services. Although it is well established that direct admission to hospital at home from the community as a substitute for hospital care provides superior outcomes and lower cost, the effectiveness of transfer hospital at home-that is, completing hospitalization at home-is unclear. OBJECTIVE To evaluate the outcomes of the transfer component of a Veterans Affairs (VA) Hospital in Home program (T-HIH), taking advantage of natural geographical limitations in a program's service area. DESIGN, SETTING, AND PARTICIPANTS In this quality improvement study, T-HIH was offered to veterans residing in Philadelphia, Pennsylvania, and their outcomes were compared with those of propensity-matched veterans residing in adjacent Camden, New Jersey, who were admitted to the VA hospital from 2012 to 2018. Data analysis was performed from October 2019 to May 2020. INTERVENTION Enrollment in the T-HIH program. MAIN OUTCOMES AND MEASURES The main outcomes were hospital length of stay, 30-day and 90-day readmissions, VA direct costs, combined VA and Medicare costs, mortality, 90-day nursing home use, and days at home after hospital discharge. An intent-to-treat analysis of cost and utilization was performed. RESULTS A total of 405 veterans (mean [SD] age, 66.7 [0.83] years; 399 men [98.5%]) with medically complex conditions, primarily congestive heart failure and chronic obstructive pulmonary disease exacerbations (mean [SD] hierarchical condition categories score, 3.54 [0.16]), were enrolled. Ten participants could not be matched, so analyses were performed for 395 veterans (all of whom were men), 98 in the T-HIH group and 297 in the control group. For patients in the T-HIH group compared with the control group, length of stay was 20% lower (6.1 vs 7.7 days; difference, 1.6 days; 95% CI, -3.77 to 0.61 days), VA costs were 20% lower (-$5910; 95% CI, -$13 049 to $1229), combined VA and Medicare costs were 22% lower (-$7002; 95% CI, -$14 314 to $309), readmission rates were similar (23.7% vs 23.0%), the numbers of nursing home days were significantly fewer (0.92 vs 7.45 days; difference, -6.5 days; 95% CI, -12.1 to -0.96 days; P = .02), and the number of days at home was 18% higher (81.4 vs 68.8 days; difference, 12.6 days; 95% CI, 3.12 to 22.08 days; P = .01). CONCLUSIONS AND RELEVANCE In this study, T-HIH was significantly associated with increased days at home and less nursing home use but was not associated with increased health care system costs.
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Affiliation(s)
- Shubing Cai
- Geriatrics and Extended Care Data Analysis Center, Philadelphia, Pennsylvania
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Orna Intrator
- Geriatrics and Extended Care Data Analysis Center, Philadelphia, Pennsylvania
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Caitlin Chan
- Geriatrics and Extended Care Data Analysis Center, Philadelphia, Pennsylvania
- VA Palo Alto Health Economics Resource Center, Menlo Park, California
| | - Laurence Buxbaum
- Cpl Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia
| | - Mary Ann Haggerty
- Penn Medicine at Home, University of Pennsylvania Health System, Philadelphia
| | - Ciaran S. Phibbs
- Geriatrics and Extended Care Data Analysis Center, Philadelphia, Pennsylvania
- VA Palo Alto Health Economics Resource Center, Menlo Park, California
- Department of Pediatrics (Neonatal Medicine), Stanford University School of Medicine, Stanford, California
| | - Edna Schwab
- Cpl Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia
| | - Bruce Kinosian
- Geriatrics and Extended Care Data Analysis Center, Philadelphia, Pennsylvania
- Cpl Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia
- Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania
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Williamson T, Hodges S, Yang LZ, Lee HJ, Gabr M, Ugiliweneza B, Boakye M, Shaffrey CI, Goodwin CR, Karikari IO, Lad S, Abd-El-Barr M. Impact of US hospital center and interhospital transfer on spinal cord injury management: An analysis of the National Trauma Data Bank. J Trauma Acute Care Surg 2021; 90:1067-1076. [PMID: 34016930 PMCID: PMC8243877 DOI: 10.1097/ta.0000000000003165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) is a serious public health problem. Outcomes are determined by severity of immediate injury, mitigation of secondary downstream effects, and rehabilitation. This study aimed to understand how the center type a patient presents to and whether they are transferred influence management and outcome. METHODS The National Trauma Data Bank was used to identify patients with SCI. The primary objective was to determine association between center type, transfer, and surgical intervention. A secondary objective was to determine association between center type, transfer, and surgical timing. Multivariable logistic regression models were fit on surgical intervention and timing of the surgery as binary variables, adjusting for relevant clinical and demographic variables. RESULTS There were 11,744 incidents of SCI identified. A total of 2,883 patients were transferred to a Level I center and 4,766 presented directly to a level I center. Level I center refers to level I trauma center. Those who were admitted directly to level I centers had a higher odd of receiving a surgery (odds ratio, 1.703; 95% confidence interval, 1.47-1.97; p < 0.001), but there was no significant difference in terms of timing of surgery. Patients transferred into a level I center were also more likely to undergo surgery than those at a level II/III/IV center, although this was not significant (odds ratio, 1.213; 95% confidence interval, 0.099-1.48; p = 0.059). CONCLUSION Patients with traumatic SCI admitted to level I trauma centers were more likely to have surgery, particularly if they were directly admitted to a level I center. This study provides insights into a large US sample and sheds light on opportunities for improving pre hospital care pathways for patients with traumatic SCI, to provide the timely and appropriate care and achieve the best possible outcomes. LEVEL OF EVIDENCE Care management, Level IV.
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Affiliation(s)
| | - Sarah Hodges
- Duke University School of Medicine, Department of Neurosurgery
| | | | - Hui-Jie Lee
- Duke University Department of Biostatistics and Bioinformatics
| | - Mostafa Gabr
- Duke University School of Medicine, Department of Neurosurgery
| | - Beatrice Ugiliweneza
- University of Louisville, Kentucky Spinal Cord Injury Research Center, Department of Neurosurgery, School of Medicine
| | - Maxwell Boakye
- University of Louisville, Kentucky Spinal Cord Injury Research Center, Department of Neurosurgery, School of Medicine
| | | | - C Rory Goodwin
- Duke University School of Medicine, Department of Neurosurgery
| | | | - Shivanand Lad
- Duke University School of Medicine, Department of Neurosurgery
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Temsah MH, Al-Sohime F, Alhaboob A, Al-Eyadhy A, Aljamaan F, Hasan G, Ali S, Ashri A, Nahass AA, Al-Barrak R, Temsah O, Alhasan K, Jamal AA. Adverse events experienced with intrahospital transfer of critically ill patients: A national survey. Medicine (Baltimore) 2021; 100:e25810. [PMID: 33950984 PMCID: PMC8104182 DOI: 10.1097/md.0000000000025810] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Research that focuses on transfers to and from the intensive care unit (ICU) could highlight important patients' safety issues. This study aims to describe healthcare workers' (HCWs) practices involved in patient transfers to or from the ICU.This cross-sectional study was conducted among HCWs during the Saudi Critical Care Society's annual International Conference, April 2017. Responses were assessed using Likert scales and frequencies. Bivariate analysis was used to evaluate the significance of different indicators.Overall, 312 HCWs participated in this study. Regarding transfer to ICUs, the most frequently reported complications were deterioration in respiratory status (51.4%), followed by deterioration in hemodynamic status (46.5%), and missing clinical information (35.5%). Regarding transfers from ICUs to the general ward, the most commonly reported complications were changes in respiratory status (55.6%), followed by incomplete clinical information (37.9%), and change in hemodynamic conditions (29%). The most-used models for communicating transfers were written documents in electronic health records (69.3%) and verbal communication (62.8%). One-fourth of the respondents were not aware of the Situation, Background, Assessment, Recommendation (SBAR) method of patients' handover. Pearson's test of correlation showed that the HCW's perceived satisfaction with their hospital transfer guidelines showed significant negative correlation with their reported transfer-related complications (r = -0.27, P < .010).Hemodynamic and respiratory status deterioration is representing significant adverse events among patients transferred to or from the ICU. Factors controlling the perceived satisfaction of HCWs involved in patients, transfer to and from the ICU need to be addressed, focusing on their compliance to the hospital-wide transfer and handover policies. Quality improvement initiatives could improve patient safety to transfer patients to and from the ICU and minimize the associated adverse events.
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Affiliation(s)
- Mohamad-Hani Temsah
- College of Medicine, King Saud University, Riyadh
- Pediatric Intensive Care Unit, Pediatric Department
| | - Fahad Al-Sohime
- College of Medicine, King Saud University, Riyadh
- Pediatric Intensive Care Unit, Pediatric Department
| | - Ali Alhaboob
- College of Medicine, King Saud University, Riyadh
- Pediatric Intensive Care Unit, Pediatric Department
| | - Ayman Al-Eyadhy
- College of Medicine, King Saud University, Riyadh
- Pediatric Intensive Care Unit, Pediatric Department
| | - Fadi Aljamaan
- College of Medicine, King Saud University, Riyadh
- Critical Care Department, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Gamal Hasan
- Assiut Faculty of Medicine, Assiut University, Assiut, Egypt
- Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Salma Ali
- Pediatric Intensive Care Unit, Pediatric Department
| | - Ahmed Ashri
- Pediatric Intensive Care Unit, Pediatric Department
| | | | | | | | | | - Amr A. Jamal
- College of Medicine, King Saud University, Riyadh
- Family & Community Medicine Department, College of Medicine, King Saud University Medical City
- Evidence-Based Health Care & Knowledge Translation Research Chair, King Saud University, Riyadh, Saudi Arabia
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Kang MG, Kang Y, Kim K, Park HW, Koh JS, Park JR, Hwang SJ, Ahn JH, Park Y, Jeong YH, Kwak CH, Hwang JY. Cardiac mortality benefit of direct admission to percutaneous coronary intervention-capable hospital in acute myocardial infarction: Community registry-based study. Medicine (Baltimore) 2021; 100:e25058. [PMID: 33725894 PMCID: PMC7969221 DOI: 10.1097/md.0000000000025058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 02/12/2021] [Indexed: 01/05/2023] Open
Abstract
Appropriate risk stratification and timely revascularization of acute myocardial infarction (AMI) are available in percutaneous coronary intervention (PCI) - capable hospitals (PCHs). This study evaluated whether direct admission vs inter-hospital transfer influences cardiac mortality in patients with AMI. This study was conducted in the PCH where the patients were able to arrive within an hour. The inclusion criteria were AMI with a symptom onset time within 24 hours and having undergone PCI within 24 hours after admission. The cumulative incidence of cardiac death after percutaneous coronary intervention was evaluated in the direct admission versus inter-hospital transfer groups. Among the 3178 patients, 2165 (68.1%) were admitted via inter-hospital transfer. Patients with ST-segment elevation myocardial infarction (STEMI) in the direct admission group had a reduced symptom onset-to-balloon time (121 minutes, P < .001). With a median period of 28.4 (interquartile range, 12.0-45.6) months, the cumulative incidence of 2-year cardiac death was lower in the direct admission group (NSTEMI, 9.0% vs 11.0%, P = .136; STEMI, 9.7% vs 13.7%, P = .040; AMI, 9.3% vs 12.3%, P = .014, respectively). After the adjustment for clinical variables, inter-hospital transfer was the determinant of cardiac death (hazard ratio, 1.59; 95% confidence interval, 1.08-2.33; P = .016). Direct PCH admission should be recommended for patients with suspected AMI and could be a target for reducing cardiac mortality.
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Affiliation(s)
- Min Gyu Kang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Yoomee Kang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Kyehwan Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Hyun Woong Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Jeong Rang Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Seok-Jae Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
| | - Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Choong Hwan Kwak
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Jin-Yong Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju
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Shannon EM, Zheng J, Orav EJ, Schnipper JL, Mueller SK. Racial/Ethnic Disparities in Interhospital Transfer for Conditions With a Mortality Benefit to Transfer Among Patients With Medicare. JAMA Netw Open 2021; 4:e213474. [PMID: 33769508 PMCID: PMC7998076 DOI: 10.1001/jamanetworkopen.2021.3474] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
IMPORTANCE Interhospital transfer (IHT) of patients is a common occurrence in modern health care. Racial/ethnic disparities are prevalent throughout US health care, but their presence in IHT is not well characterized. OBJECTIVE To determine if there are racial/ethnic disparities in IHT for medical diagnoses for which IHT is associated with a mortality benefit. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis used 2013 data from the Center for Medicare & Medicaid Services 100% Master Beneficiary Summary and Inpatient Claims merged with 2013 American Hospital Association data. Individuals with Medicare aged 65 years or older continuously enrolled in Medicare Part A and B with an inpatient hospitalization claim in 2013 for primary diagnosis of acute myocardial infarction, stroke, sepsis, or respiratory diseases were included. Data analysis occurred from November 2019 through July 2020. EXPOSURES Race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome of interest was IHT. For the primary analysis, a series of logistic regression models were created to estimate the adjusted odds of IHT for Black and Hispanic patients compared with White patients, controlling for patient clinical and demographic variables and incorporating hospital fixed effects. In secondary analyses, subgroup analyses were conducted by diagnosis, hospital teaching status, and hospitalization to hospitals in the top decile of Black and Hispanic patient proportion. RESULTS Among 899 557 patients, 734 958 patients were White (81.7%), 84 544 patients were Black (9.4%), and 47 588 patients were Hispanic (5.3%); there were 418 683 men (46.5%), and 306 215 patients (34.0%) were older than 84 years. The mean (SD) age was 76.8 (7.5) years. Among all patients, 20 171 White patients (2.7%), 1913 Black patients (2.3%), and 1062 Hispanic patients (2.2%) underwent IHT. After controlling for patient variables and hospital fixed effects, Black patients had a persistently lower odds of IHT (adjusted odds ratio, 0.87; 95% CI, 0.81-0.92; P < .001), while Hispanic patients had higher odds of IHT (adjusted odds ratio, 1.14; 95% CI, 1.05-1.24; P = .002) compared with White patients. CONCLUSIONS AND RELEVANCE This national evaluation of IHT among patients hospitalized with diagnoses previously found to have mortality benefit with transfer found that, compared with White patients, Black patients had persistently lower adjusted odds of transfer after accounting for patient and hospital characteristics and measured across various hospital settings. Meanwhile, Hispanic patients had higher adjusted odds of transfer. This research highlights the need for the development of strategies to mitigate disparate transfer practices by patient race/ethnicity.
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Affiliation(s)
- Evan Michael Shannon
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jie Zheng
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jeffrey L. Schnipper
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stephanie K. Mueller
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
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Altieri Dunn SC, Bellon JE, Bilderback A, Borrebach JD, Hodges JC, Wisniewski MK, Harinstein ME, Minnier TE, Nelson JB, Hall DE. SafeNET: Initial development and validation of a real-time tool for predicting mortality risk at the time of hospital transfer to a higher level of care. PLoS One 2021; 16:e0246669. [PMID: 33556123 PMCID: PMC7870086 DOI: 10.1371/journal.pone.0246669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/24/2021] [Indexed: 01/31/2023] Open
Abstract
Background Processes for transferring patients to higher acuity facilities lack a standardized approach to prognostication, increasing the risk for low value care that imposes significant burdens on patients and their families with unclear benefits. We sought to develop a rapid and feasible tool for predicting mortality using variables readily available at the time of hospital transfer. Methods and findings All work was carried out at a single, large, multi-hospital integrated healthcare system. We used a retrospective cohort for model development consisting of patients aged 18 years or older transferred into the healthcare system from another hospital, hospice, skilled nursing or other healthcare facility with an admission priority of direct emergency admit. The cohort was randomly divided into training and test sets to develop first a 54-variable, and then a 14-variable gradient boosting model to predict the primary outcome of all cause in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and transition to comfort measures only or hospice care. For model validation, we used a prospective cohort consisting of all patients transferred to a single, tertiary care hospital from one of the 3 referring hospitals, excluding patients transferred for myocardial infarction or maternal labor and delivery. Prospective validation was performed by using a web-based tool to calculate the risk of mortality at the time of transfer. Observed outcomes were compared to predicted outcomes to assess model performance. The development cohort included 20,985 patients with 1,937 (9.2%) in-hospital mortalities, 2,884 (13.7%) 30-day mortalities, and 3,899 (18.6%) 90-day mortalities. The 14-variable gradient boosting model effectively predicted in-hospital, 30-day and 90-day mortality (c = 0.903 [95% CI:0.891–0.916]), c = 0.877 [95% CI:0.864–0.890]), and c = 0.869 [95% CI:0.857–0.881], respectively). The tool was proven feasible and valid for bedside implementation in a prospective cohort of 679 sequentially transferred patients for whom the bedside nurse calculated a SafeNET score at the time of transfer, taking only 4–5 minutes per patient with discrimination consistent with the development sample for in-hospital, 30-day and 90-day mortality (c = 0.836 [95%CI: 0.751–0.921], 0.815 [95% CI: 0.730–0.900], and 0.794 [95% CI: 0.725–0.864], respectively). Conclusions The SafeNET algorithm is feasible and valid for real-time, bedside mortality risk prediction at the time of hospital transfer. Work is ongoing to build pathways triggered by this score that direct needed resources to the patients at greatest risk of poor outcomes.
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Affiliation(s)
| | - Johanna E. Bellon
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Andrew Bilderback
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | | | - Jacob C. Hodges
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Mary Kay Wisniewski
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Matthew E. Harinstein
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Tamra E. Minnier
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
| | - Joel B. Nelson
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Daniel E. Hall
- The Wolff Center at UPMC, Pittsburgh, Pennsylvania, United States of America
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
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Billig JI, Nasser JS, Cho HE, Chou CH, Chung KC. Association of Interfacility Transfer and Patient and Hospital Characteristics With Thumb Replantation After Traumatic Amputation. JAMA Netw Open 2021; 4:e2036297. [PMID: 33533928 PMCID: PMC7859845 DOI: 10.1001/jamanetworkopen.2020.36297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Given that 40% of hand function is achieved with the thumb, replantation of traumatic thumb injuries is associated with substantial quality-of-life benefits. However, fewer replantations are being performed annually in the US, which has been associated with less surgical expertise and increased risk of future replantation failures. Thus, understanding how interfacility transfers and hospital characteristics are associated with outcomes warrants further investigation. OBJECTIVE To assess the association of interfacility transfer, patient characteristics, and hospital factors with thumb replantation attempts and success. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the US National Trauma Data Bank from 2009 to 2016 for adult patients with isolated traumatic thumb amputation injury who underwent revision amputation or replantation. Data analysis was performed from May 4, 2020, to July 20, 2020. EXPOSURES Interfacility transfer, defined as transfer of a patient from 1 hospital to another to obtain care for traumatic thumb amputation. MAIN OUTCOMES AND MEASURES Replantation attempt and replantation success, defined as having undergone a replantation without a subsequent revision amputation during the same hospitalization. Multilevel logistic regression models were used to assess the associations of interfacility transfer, patient characteristics, and hospital factors with replantation outcomes. RESULTS Of 3670 patients included in this analysis, 3307 (90.1%) were male and 2713 (73.9%) were White; the mean (SD) age was 45.8 (16.5) years. A total of 1881 patients (51.2%) were transferred to another hospital; most of these patients were male (1720 [91.4%]) and White (1420 [75.5%]). After controlling for patient and hospital characteristics, uninsured patients were less likely to have thumb replantation attempted (odds ratio [OR], 0.61; 95% CI, 0.47-0.78) or a successful replantation (OR, 0.64; 95% CI, 0.49-0.84). Interfacility transfer was associated with increased odds of replantation attempt (OR, 1.34; 95% CI, 1.13-1.59), with 13% of the variation at the hospital level. Interfacility transfer was also associated with increased replantation success (OR, 1.23; 95% CI, 1.03-1.47), with 14% of variation at the hospital level. CONCLUSIONS AND RELEVANCE In this cross-sectional study, interfacility transfer and particularly hospital-level variation were associated with increased thumb replantation attempts and successes. These findings suggest a need for creating policies that incentivize hospitals with replantation expertise to provide treatment for traumatic thumb amputations, including promotion of centralization of replantation care.
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Affiliation(s)
- Jessica I. Billig
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor
| | - Jacob S. Nasser
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Hoyune E. Cho
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor
- Department of Plastic Surgery, University of California, Irvine
| | - Ching-Han Chou
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor
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Abstract
Patients' satisfaction with care transitions is low, especially when it comes to understanding their care when discharged home from the hospital. Therefore, a quality improvement effort was initiated with the aim of improving patients' satisfaction with care transitions. Specific goals of the project were to improve communication between healthcare providers and patients, increase patient satisfaction, and enhance patient education by standardizing multidisciplinary discharge planning rounds.
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Affiliation(s)
- Jerilyn Bumpas
- Author Affiliations: Nursing Instructor (Ms Bumpas), Tarleton State University School of Nursing, Stephenville, and ICU Registered Nurse, Lake Granbury Medical Center, Granbury, Texas; and Professor (Dr Copeland), Adult Health Department, University of South Alabama College of Nursing, and Inservice Specialist, University Health Children's and Women's Hospital, Mobile, Alabama
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Scheving WL, Froehler M, Hart K, McNaughton CD, Ward MJ. Inter-facility transfer for patients with acute large vessel occlusion stroke receiving mechanical thrombectomy. Am J Emerg Med 2021; 39:132-136. [PMID: 33039216 PMCID: PMC7736132 DOI: 10.1016/j.ajem.2020.09.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/29/2020] [Accepted: 09/16/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the preferred treatment for large vessel occlusion (LVO) ischemic stroke, and neurological outcome improves with earlier treatment. Patients with LVO frequently require inter-facility transfer to access MT but delays at transferring EDs may worsen neurological outcomes. METHODS We conducted a retrospective observational study to evaluate the association of time spent and transferring EDs with 90-day neurological outcomes among patients who were transferred from an outside ED to the Comprehensive Stroke Center and received MT. Time intervals at transferring EDs were examined descriptively, and multivariable logistic regression modeling was used to examine the association of time spent in the ED with 90-day neurologic outcome (modified Rankin Scale; good ≤2, poor ≥3). RESULTS Among 111 patients transferred to a stroke center for MT between 2013 and 2017, the time between CT scan and the stroke center transfer request was 44 (IQR 27,65) minutes, or 47% of transferring ED total duration. Duration at the transferring ED was not significantly associated with 90-day outcome. Only NIH Stroke Scale at the time of arrival to the stroke center was associated with good 90-day neurological outcome (aOR 0.84, 95%CI 0.77, 0.92, p < 0.0001). CONCLUSIONS Among LVO patients transferred for MT, the total time spent at transferring EDs was not associated with 90-day neurologic outcome in patients with LVO. As therapies and their associated effectiveness improves over time, future investigations should further characterize the time between CT and transfer request to identify targets for process improvement and clinical outcomes.
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Affiliation(s)
- William L Scheving
- University of California at Los Angeles School of Medicine, Department of Emergency Medicine, Los Angeles, CA, USA.
| | - Michael Froehler
- Vanderbilt University Medical Center, Department of Neurology, Nashville, TN, USA.
| | - Kimberly Hart
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN, USA.
| | - Candace D McNaughton
- Vanderbilt University Medical Center, Department of Emergency Medicine. Geriatric Research Education and Clinical Centers (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Michael J Ward
- Vanderbilt University Medical Center, Department of Emergency Medicine. VA Tennessee Valley Healthcare System, 1313 21st Ave. S. Nashville, TN 37232, USA.
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Isaacs DJ, Johnson EJ, Hofmann ER, Rangarajan S, Vinson DR. Primary care physicians comprehensively manage acute pulmonary embolism without higher-level-of-care transfer: A report of two cases. Medicine (Baltimore) 2020; 99:e23031. [PMID: 33157953 PMCID: PMC7647577 DOI: 10.1097/md.0000000000023031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 09/25/2020] [Accepted: 10/06/2020] [Indexed: 12/23/2022] Open
Abstract
RATIONALE The evidence for outpatient pulmonary embolism (PE) management apart from hospitalization is expanding. The availability and ease of direct oral anticoagulants have facilitated this transition. The literature, however, is sparse on the topic of comprehensive management of pulmonary embolism in the primary care clinic setting. As such, the role of the primary care physician in the complete diagnosis, risk stratification for outpatient eligibility, and initiation of treatment is unclear. CASE PRESENTATIONS Case 1: A 33-year-old man with known heterozygous Factor V Leiden mutation and a remote history of deep vein thrombosis presented to his primary care physician's office with 2 days of mild pleuritic chest pain and a dry cough after a recent transcontinental flight. Case 2: A 48-year-old man with a complex medical history including recent transverse myelitis presented to his primary care family physician with dyspnea and pleuritic chest pain for 6 days. DIAGNOSIS Case 1: Computed tomographic pulmonary angiography that same afternoon showed multiple bilateral segmental and subsegmental emboli as well as several small pulmonary infarcts. Case 2: The patient's D-dimer was elevated at 1148 ng/mL. His physician ordered a computed tomographic pulmonary angiography, performed that evening, which showed segmental and subsegmental PE. INTERVENTIONS Both patients were contacted by their respective physicians shortly after their diagnoses and, in shared decision-making, opted for treatment at home with 5 days of enoxaparin followed by dabigatran. OUTCOMES Neither patient developed recurrence nor complications in the subsequent 3 months. LESSONS These cases, stratified as low risk using the American College of Chest Physicians criteria and the PE Severity Index, are among the first in the literature to illustrate comprehensive primary care-based outpatient PE management. Care was provided within an integrated delivery system with ready, timely access to laboratory, advanced radiology, and allied health services. This report sets the stage for investigating the public health implications of comprehensive primary care-based PE management, including cost-savings as well as enhanced patient follow-up and patient satisfaction.
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Affiliation(s)
| | | | - Erik R. Hofmann
- The Permanente Medical Group, Oakland
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento
| | - Suresh Rangarajan
- The Permanente Medical Group, Oakland
- Department of Adult and Family Medicine, Kaiser Permanente Oakland Medical Center, Oakland
| | - David R. Vinson
- The Permanente Medical Group, Oakland
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville
- Kaiser Permanente Northern California Division of Research, Oakland, CA
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Nasr VG, Valencia E, Staffa SJ, Faraoni D, DiNardo JA, Berry JG, Leahy I, Ferrari L. Comprehensive Risk Assessment of Morbidity in Pediatric Patients Undergoing Noncardiac Surgery: An Institutional Experience. Anesth Analg 2020; 131:1607-1615. [PMID: 33079885 DOI: 10.1213/ane.0000000000005157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Utilizing the intrinsic surgical risk (ISR) and the patient's chronic and acute conditions, this study aims to develop and validate a comprehensive predictive model of perioperative morbidity in children undergoing noncardiac surgery. METHODS Following institutional review board (IRB) approval at a tertiary care children's hospital, data for all noncardiac surgical encounters for a derivation dataset from July 2017 to December 2018 including 16,724 cases and for a validation dataset from January 2019 to December 2019 including 9043 cases were collected retrospectively. The primary outcome was a composite morbidity score defined by unplanned transfer to an intensive care unit (ICU), acute respiratory failure requiring intubation, postoperative need for noninvasive or invasive positive pressure ventilation, or cardiac arrest. Internal model validation was performed using 1000 bootstrap resamples, and external validation was performed using the 2019 validation cohort. RESULTS A total of 1519 surgical cases (9.1%) experienced the defined composite morbidity. Using multivariable logistic regression, the Risk Assessment of Morbidity in Pediatric Surgery (RAMPS) score was developed with very good predictive ability in the derivation cohort (area under the curve [AUC] = 0.805; 95% confidence interval [CI], 0.795-0.816), very good internal validity using 1000 bootstrap resamples (bias-corrected Nagelkerke R = 0.21 and Brier score = 0.07), and good external validity (AUC = 0.783; 95% CI, 0.770-0.797). The included variables are age <5 years, critically ill, chronic condition indicator (CCI) ≥3, significant CCI ≥2, and ISR quartile ≥3. The RAMPS score ranges from 0 to 10, with the risk of composite morbidity ranging from 1.8% to 42.7%. CONCLUSIONS The RAMPS score provides the ability to identify a high-risk cohort of pediatric patients using a 5-component tool, and it demonstrated good internal and external validity and generalizability. It also provides an opportunity to improve perioperative planning with the intent of improving both individual-patient outcomes and the appropriate allocation of health care resources.
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Affiliation(s)
- Viviane G Nasr
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eleonore Valencia
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven J Staffa
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - James A DiNardo
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jay G Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Izabela Leahy
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lynne Ferrari
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Allen L, Vogt K, Joos E, van Heest R, Saleh F, Widder S, Hameed M, Parry NG, Minor S, Murphy P. Impact of interhospital transfer on patient outcomes in emergency general surgery. Surgery 2020; 169:455-459. [PMID: 33268072 DOI: 10.1016/j.surg.2020.08.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/12/2020] [Accepted: 08/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Emergency general surgery patients are at an increased risk for morbidity and mortality compared to their elective surgery counterparts. The complex nature of emergency general surgery conditions can challenge community hospitals, which may lack appropriate systems and personnel. Outcomes related to transfer have not been well-established. We aimed to compare postoperative outcomes of patients who were transferred from another hospital to a center with dedicated acute care surgery services with patients admitted directly to the acute care surgery centers. METHODS We performed a secondary analysis of a national, multicenter review of emergency general surgery patients undergoing complex emergency general surgery at 5 centers across Canada. The primary outcome was the development of any complication. The adjusted odds of postoperative complication was assessed using logistic regression, controlling for age, comorbidities, duration of stay before transfer, American Society of Anesthesiologists classification, and booking priority. RESULTS A total of 1,846 patients were included in the study, and 176 (9.5%) were transferred. Of these 21% (n = 37) underwent an operative procedure, and 15% (n = 27) underwent an operation at the transferring center. Transferred patients were more likely to have at least 1 comorbidity (68% vs 57%; P = .004), were classified as greater urgency on arrival (<2 hours booking priority, 43% vs 17%; P < .001), had a greater American Society of Anesthesiologists classification (American Society of Anesthesiologists ≥3 = 81% vs 65%; P < .001), a greater duration of operation (119 vs 110 minutes; P = .004), and were more likely to undergo a second operation (28% vs 14%; P < .001) compared to patients directly admitted to an acute care surgery center. On univariate analysis, transferred patients had greater rates of complications (48% vs 31%; P < .001), mortality (14% vs 7%; P = .005), and admission to the intensive care unit (22% vs 12%; P < .001). Transfer status remained an independent predictor of complication (odds ratio 1.9 [95% confidence interval 1.3-2.7]; P < .001) and intensive care unit admission (odds ratio 1.9 [95% confidence interval 1.2-3.0]; P = .007), but not mortality (odds ratio 1.1 [95% confidence interval 0.6-1.9]; P = .79) on regression analysis. CONCLUSION Complex emergency general surgery patients transferred to acute care surgery centers may have worse outcomes and greater use of resources compared to those admitted directly. This finding has clinically and financially important implications for the design and regionalization of acute care surgery services as well as resource allocation at acute care surgery centers.
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Affiliation(s)
- Laura Allen
- Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Kelly Vogt
- Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Emilie Joos
- Department of General Surgery, University of British Columbia, Vancouver, Canada
| | - Rardi van Heest
- Department of Surgery, William Osler Health System, Brampton, Ontario, Canada
| | - Fady Saleh
- Department of Surgery, University Health Network of Toronto, Ontario, Canada
| | - Sandy Widder
- Department of General Surgery and Critical Care, University of Alberta, Edmonton, Canada
| | - Morad Hameed
- Department of General Surgery, University of British Columbia, Vancouver, Canada
| | - Neil G Parry
- Division of General Surgery, Department of Surgery, Western University, Ontario, Canada; Department of Critical Care Medicine, Western University, Ontario, Canada
| | - Sam Minor
- Department of General Surgery, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Critical Care Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patrick Murphy
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America.
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Haslam NR, Bouamra O, Lawrence T, Moran CG, Lockey DJ. Time to definitive care within major trauma networks in England. BJS Open 2020; 4:963-969. [PMID: 32644299 PMCID: PMC7528529 DOI: 10.1002/bjs5.50316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 05/26/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Significant mortality improvements have been reported following the implementation of English trauma networks. Timely transfer of seriously injured patients to definitive care is a key indicator of trauma network performance. This study evaluated timelines from emergency service (EMS) activation to definitive care between 2013 and 2016. METHODS An observational study was conducted on data collected from the UK national clinical audit of major trauma care of patients with an Injury Severity Score above 15. Outcomes included time from EMS activation to: arrival at a trauma unit (TU) or major trauma centre (MTC); to CT; to urgent surgery; and to death. RESULTS Secondary transfer was associated with increased time to urgent surgery (median 7·23 (i.q.r. 5·48-9·28) h versus 4·37 (3·00-6·57) h for direct transfer to MTC; P < 0·001) and an increased crude mortality rate (19·6 (95 per cent c.i. 16·9 to 22·3) versus 15·7 (14·7 to 16·7) per cent respectively). CT and urgent surgery were performed more quickly in MTCs than in TUs (2·00 (i.q.r. 1·55-2·73) versus 3·15 (2·17-4·63) h and 4·37 (3·00-6·57) versus 5·37 (3·50-7·65) h respectively; P < 0·001). Transfer time and time to CT increased between 2013 and 2016 (P < 0·001). Transfer time, time to CT, and time to urgent surgery varied significantly between regional networks (P < 0·001). CONCLUSION Secondary transfer was associated with significantly delayed imaging, delayed surgery, and increased mortality. Key interventions were performed more quickly in MTCs than in TUs.
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Affiliation(s)
- N. R. Haslam
- Barts and The London School of Anaesthesia, Barts Health NHS TrustLondonUK
| | - O. Bouamra
- Trauma Research and Audit NetworkUniversity of ManchesterSalfordUK
| | - T. Lawrence
- Trauma Research and Audit NetworkUniversity of ManchesterSalfordUK
| | - C. G. Moran
- Trauma and Orthopaedic SurgeryQueen's Medical CentreNottinghamUK
| | - D. J. Lockey
- Centre for Trauma Sciences, Blizard InstituteQueen Mary University of LondonLondonUK
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Kanai Y, Takagi H. Markov chain analysis for the neonatal inpatient flow in a hospital. Health Care Manag Sci 2020; 24:92-116. [PMID: 32997207 DOI: 10.1007/s10729-020-09515-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 07/16/2020] [Indexed: 11/28/2022]
Abstract
Discrete-time Markov chain and queueing-theoretic models are used to quantitatively formulate the flow of neonatal inpatients over several wards in a hospital. Parameters of the models are determined from the operational analysis of the record of the numbers of admission/departure for each ward every day and the order log of patient movement from ward to ward for two years provided by the Medical Information Department of the University of Tsukuba Hospital in Japan. Our formulation is based on the analysis of the precise routes (the route of an inpatient is defined as a sequence of the wards in which he/she stays from admission to discharge) and their length-of-stay (LoS) in days in each ward on their routes for all neonatal inpatients. Our theoretical model calculates the probability distribution for the number of patients staying in each ward per day which agrees well with the corresponding histogram observed for each ward as well as for the whole hospital. The proposed method can be used for the long-term capacity planning of hospital wards with respect to the probabilistic bed utilization.
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Affiliation(s)
- Yuta Kanai
- Tsukuba Institute of Research, 1-7 Takezono, Tsukuba-shi, Ibaraki-ken, 305-0032, Japan
| | - Hideaki Takagi
- University of Tsukuba (Professor Emeritus), 747-3 Serizawa, Chigasaki-shi, Kanagawa-ken, 253-0008, Japan.
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Low PH, Mangat MS, Liew DNS, Wong ASH. Neurosurgical Services in the Northern Zone of Sarawak in Malaysia: The Way Forward Amid the COVID-19 Pandemic. World Neurosurg 2020; 144:e710-e713. [PMID: 32949798 PMCID: PMC7494498 DOI: 10.1016/j.wneu.2020.09.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/03/2022]
Abstract
Background The novel coronavirus disease 2019 (COVID-19) pandemic has set a huge challenge to the delivery of neurosurgical services, including the transfer of patients. We aimed to share our strategy in handling neurosurgical emergencies at a remote center in Borneo island. Our objectives included discussing the logistic and geographic challenges faced during the COVID-19 pandemic. Methods Miri General Hospital is a remote center in Sarawak, Malaysia, serving a population with difficult access to neurosurgical services. Two neurosurgeons were stationed here on a rotational basis every fortnight during the pandemic to handle neurosurgical cases. Patients were triaged depending on their urgent needs for surgery or transfer to a neurosurgical center and managed accordingly. All patients were screened for potential risk of contracting COVID-19 prior to the surgery. Based on this, the level of personal protective equipment required for the health care workers involved was determined. Results During the initial 6 weeks of the Movement Control Order in Malaysia, there were 50 urgent neurosurgical consultations. Twenty patients (40%) required emergency surgery or intervention. There were 9 vascular (45%), 5 trauma (25%), 4 tumor (20%), and 2 hydrocephalus cases (10%). Eighteen patients were operated at Miri General Hospital, among whom 17 (94.4%) survived. Ninety percent of anticipated transfers were avoided. None of the medical staff acquired COVID-19. Conclusions This framework allowed timely intervention for neurosurgical emergencies (within a safe limit), minimized transfer, and enabled uninterrupted neurosurgical services at a remote center with difficult access to neurosurgical care during a pandemic.
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Affiliation(s)
- Peh Hueh Low
- Department of Neurosurgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia.
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Sanjuan Menéndez E, Girón Espot P, Calleja Macho L, Rodríguez-Samaniego MT, Santana Román KE, Rubiera Del Fueyo M. Implementation of a protocol for direct stroke patient transfer and mobilization of a stroke team to reduce times to reperfusion. Emergencias 2020; 31:385-390. [PMID: 31777209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The timing of treatment is a key prognostic factor in stroke. Our hospital implemented a rapid-action time-to-intervention protocol to optimize reperfusion times. The protocol consisted of direct transfer of stroke-code patients to the scanner or angiosuite and mobilization of the stroke team. Our aim was to assess the impact of the protocol on times to reperfusion. We also sought to evaluate the feasibility and safety of including a stroke-team nurse and assess staff satisfaction with the protocol. MATERIAL AND METHODS Descriptive study of patients attended by the hospital stroke team between March 2015 and March 2018. Outcomes were compared to those for the previous period (February 2014 to February 2015). RESULTS Nine hundred three patients were attended under the rapid-action protocol; 502 of them (55.6%) underwent reperfusion. The median (interquartile range) door-to-needle or groin access times were 24 (18-33) minutes for fibrinolysis and 39 (20-75) minutes for thrombectomy. Both times were significantly shorter than in the earlier period (43 [31-66] and 93 [60-150] minutes, respectively; P<.001). Median duration of nurse attendance was 25 (20-32) minutes during the implementation period, and no problems of feasibility or safety appeared during nurse attendance. Twenty staff members (95%) reported that the rapid-action protocol increased their workload but they felt it warranted continued application. CONCLUSION Direct transfer of stroke patients for scanning or to the angiography suite, with nurse attendance, safely reduced reperfusion times.
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Affiliation(s)
| | - Pilar Girón Espot
- Unidad de Ictus, Hospital Universitari Vall d'Hebron, Barcelona, España
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Schuman AD, Syrjamaki JD, Norton EC, Hallstrom BR, Regenbogen SE. Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission. Surgery 2020; 169:341-346. [PMID: 32900495 DOI: 10.1016/j.surg.2020.07.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments. METHODS We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests. RESULTS Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use. CONCLUSION Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.
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Affiliation(s)
- Ari D Schuman
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX
| | - John D Syrjamaki
- Michigan Value Collaborative, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - Brian R Hallstrom
- Department of Orthopedic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Scott E Regenbogen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
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Tran A, Taljaard M, Abdulaziz KE, Matar M, Lampron J, Steyerberg EW, Vaillancourt C. Early identification of the need for major intervention in patients with traumatic hemorrhage: development and internal validation of a simple bleeding score. Can J Surg 2020; 63:E422-E430. [PMID: 33009903 PMCID: PMC7608708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2019] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Failure to rapidly identify bleeding in trauma patients leads to substantial morbidity and mortality. We aimed to develop and validate a simple bedside score for identifying bleeding patients requiring escalation of care beyond initial resuscitation. METHODS We included patients with major blunt or penetrating trauma, defined as those with an Injury Severity Score greater than 12 or requiring trauma team activation, at The Ottawa Hospital from September 2014 to September 2017. We used logistic regression for derivation. The primary outcome was a composite of the need for massive transfusion, embolization or surgery for hemostasis. We prespecified clinical, laboratory and imaging predictors using findings from our prior systematic review and survey of Canadian traumatologists. We used an AIC-based stepdown procedure based on the Akaike information criterion and regression coefficients to create a 5-variable score for bedside application. We used bootstrap internal validation to assess optimism-corrected performance. RESULTS We included 890 patients, of whom 133 required a major intervention. The main model comprised systolic blood pressure, clinical examination findings suggestive of hemorrhage, lactate level, focused assessment with sonography in trauma (FAST) and computed tomographic imaging. The C statistic was 0.95, optimism-corrected to 0.94. A simplified Canadian Bleeding (CAN-BLEED) score was devised. A score cut-off of 2 points yielded sensitivity of 97.7% (95% confidence interval [CI] 93.6 to 99.5) and specificity 73.2% (95% CI 69.9 to 76.3). An alternative version that included mechanism of injury rather than CT had lower discriminative ability (C statistic = 0.89). CONCLUSION A simple yet promising bleeding score is proposed to identify highrisk patients in need of major intervention for traumatic bleeding and determine the appropriateness of early transfer to specialized trauma centres. Further research is needed to evaluate the performance of the score in other settings, define interrater reliability and evaluate the potential for reduction of time to intervention.
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Affiliation(s)
- Alexandre Tran
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Monica Taljaard
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Kasim E Abdulaziz
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Maher Matar
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Jacinthe Lampron
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Ewout W Steyerberg
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Christian Vaillancourt
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
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Arleth T, Rudolph SS, Svane C, Rasmussen LS. Time from injury to arrival at the trauma centre in patients undergoing interhospital transfer. Dan Med J 2020; 67:A03200138. [PMID: 32862836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Trauma patients may require interhospital transfer to definitive care following initial assessment at a primary facility. A prolonged time to transfer may be associated with a poor outcome. The aim of this study was to determine the time from injury to arrival in patients undergoing interhospital transfer to the Trauma Centre at Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. METHODS Data were obtained from our local trauma registry for the period from 1 November 2016 to 31 October 2019. We included patients who underwent interhospital transfer to our trauma centre. Patients were compared according to a 360-minute time interval between injury and arrival. RESULTS In the study period, 250 patients underwent interhospital transfer to our trauma centre. The median age was 47 years (interquartile range (IQR) 26-65), the majority were male (68.4%) and a total of 113 patients (46.9%) had an Injury Severity Score (ISS) > 15. The 30-day mortality was 6% (95% confidence interval (CI) 3.6-9.7). The median time from injury to arrival at our trauma centre was 255 minutes (IQR 192-371). We found that 67 patients (27%; 95% CI 21.7-32.6) arrived at our trauma centre more than 360 minutes after time of injury. The patients arriving later than 360 minutes were significantly older (p = 0.004) than the remaining patients. There was no significant difference in the unadjusted 30-day mortality (odds ratio (OR) 1.01, 95% CI 0.3-3.3). CONCLUSIONS Time from injury to arrival at our trauma centre exceeded 360 minutes for 67 patients (27%) who were significantly older than the remaining patients transferred. FUNDING departmental funding. TRIAL REGISTRATION not relevant.
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Wang J, Zong L, Zhang J, Sun H, Harold Walline J, Sun P, Xu S, Li Y, Wang C, Liu J, Li F, Xu J, Li Y, Yu X, Zhu H. Identifying the effects of an upgraded 'fever clinic' on COVID-19 control and the workload of emergency department: retrospective study in a tertiary hospital in China. BMJ Open 2020; 10:e039177. [PMID: 32819955 PMCID: PMC7440187 DOI: 10.1136/bmjopen-2020-039177] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE COVID-19 started spreading widely in China in January 2020. Outpatient fever clinics (FCs), instituted during the SARS epidemic in 2003, were upgraded to serve for COVID-19 screening and prevention of disease transmission in large tertiary hospitals in China. FCs were hoped to relieve some of the healthcare burden from emergency departments (EDs). We aimed to evaluate the effect of upgrading the FC system on rates of nosocomial COVID-19 infection and ED patient attendance at Peking Union Medical College Hospital (PUMCH). DESIGN A retrospective cohort study. PARTICIPANTS A total of 6365 patients were screened in the FC. METHODS The FC of PUMCH was upgraded on 20 January 2020. We performed a retrospective study of patients presenting to the FC between 12 December 2019 and 29 February 2020. The date when COVID-19 was declared an outbreak in Beijing was 20 January 2020. Two groups of data were collected and subsequently compared with each other: the first group of data was collected within 40 days before 20 January 2020; the second group of data was collected within 40 days after 20 January 2020. All necessary data, including patient baseline information, diagnosis, follow-up conditions and the transfer records between the FC and ED, were collected and analysed. RESULTS 6365 patients were screened in the FC, among whom 2912 patients were screened before 21 January 2020, while 3453 were screened afterward. Screening results showed that upper respiratory infection was the major disease associated with fever. After the outbreak of COVID-19, the number of patients who were transferred from the FC to the ED decreased significantly (39.21% vs 15.75%, p<0.001), and patients generally spent more time in the FC (55 vs 203 min, p<0.001), compared with before the outbreak. For critically ill patients waiting for their screening results, the total length of stay in the FC was 22 min before the outbreak, compared with 442 min after the outbreak (p<0.001). The number of in-hospital deaths of critically ill patients in the FC was 9 out of 29 patients before the outbreak and 21 out of 38 after the outbreak (p<0.05). Nineteen cases of COVID-19 were confirmed in the FC during the period of this study. However, no other patients nor any healthcare providers were cross-infected. CONCLUSION The workload of the FC increased significantly after the COVID-19 outbreak. New protocols regarding the use of FC likely helped prevent the spread of COVID-19 within the hospital. The upgraded FC also reduced the burden on the ED.
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Affiliation(s)
- Jiangshan Wang
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Liang Zong
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinghong Zhang
- School of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Han Sun
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Joseph Harold Walline
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Pengxia Sun
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shengyong Xu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Li
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunting Wang
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jihai Liu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Fan Li
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun Xu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Li
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuezhong Yu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Huadong Zhu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Bengtson AM, Colvin C, Kirwa K, Cornell M, Lurie MN. Estimating retention in HIV care accounting for clinic transfers using electronic medical records: evidence from a large antiretroviral treatment programme in the Western Cape, South Africa. Trop Med Int Health 2020; 25:936-943. [PMID: 32406961 PMCID: PMC8841816 DOI: 10.1111/tmi.13412] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Estimates of retention in antiretroviral treatment (ART) programmes may be biased if patients who transfer to healthcare clinics are misclassified as lost to follow-up (LTFU) at their original clinic. In a large cohort, we estimated retention in care accounting for patient transfers using medical records. METHODS Using linked electronic medical records, we followed adults living with HIV (PLWH) in Cape Town, South Africa from ART initiation (2012-2016) through database closure at 36 months or 30 June 2016, whichever came first. Retention was defined as alive and with a healthcare visit in the 180 days between database closure and administrative censoring on 31 December 2016. Participants who died or did not have a healthcare visit in > 180 days were censored at their last healthcare visit. We estimated the cumulative incidence of retention using Kaplan-Meier methods considering (i) only records from a participant's ART initiation clinic (not accounting for transfers) and (ii) all records (accounting for transfers), over time and by gender. We estimated risk differences and bootstrapped 95% confidence intervals to quantify misclassification in retention estimates due to patient transfers. RESULTS We included 3406 PLWH initiating ART. Retention through 36 months on ART rose from 45.4% (95% CI 43.6%, 47.2%) to 54.3% (95% CI 52.4%, 56.1%) after accounting for patient transfers. Overall, 8.9% (95% CI 8.1%, 9.7%) of participants were misclassified as LTFU due to patient transfers. CONCLUSIONS Patient transfers can appreciably bias estimates of retention in HIV care. Electronic medical records can help quantify patient transfers and improve retention estimates.
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Affiliation(s)
| | - Christopher Colvin
- Department of Epidemiology, Brown University, Providence, RI, USA
- Division of Social and Behavioural Sciences, University of Cape Town, Cape Town, South Africa
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Kipruto Kirwa
- Department of Environmental Health Engineering, Tufts University, Medford, MA, USA
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Mark N Lurie
- Department of Epidemiology, Brown University, Providence, RI, USA
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Horwood CR, Ricci K, Sobol CG, Evans D, Eiferman D. Stop Flying the Patients! Evaluation of the Overutilization of Helicopter Transport of Trauma Patients. J Surg Res 2020; 256:290-294. [PMID: 32712443 DOI: 10.1016/j.jss.2020.06.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 04/08/2020] [Accepted: 06/16/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Helicopter transport is a resource intensive and expensive method for transportation of patients by helicopter. The primary objective of this study was to evaluate the appropriateness of helicopter transport determined by procedural care within 1-h of transfer at an urban level I trauma center. METHODS All trauma patients transported by helicopter from January 2015-December 2017 to an urban level I trauma center from referring hospitals or the scene were retrospectively analyzed. A subgroup analysis was performed evaluating patients that required a procedure or operation within 1-h of transport compared with the remainder of the patient cohort who were transported via helicopter. RESULTS A total of 1590 patients were transported by helicopter. Thirty-nine percent of patients (n = 612) were admitted directly to the floor from the trauma bay and 16% (n = 249) of patients required only observation or were discharged home after helicopter transfer. Approximately one-third of the entire study cohort (36%, n = 572) required any procedure, with a median time to procedure of 31.5 h (interquartile range 54.4). Only 13% (n = 74) required a procedure within 1-h of helicopter transport. The average distance (in miles) if the patient had been driven by ground transport rather than helicopter was 67.0 miles (SD ± 27.9) and would take an estimated 71.5 min (±28.4) for patients who required a procedure within 1-h compared with 61.6 miles (SD ± 30.9) with an estimated 66.1 min (SD ± 30.8) for the remainder of the cohort (P value 0.899 and 0.680, respectively). CONCLUSIONS This analysis demonstrates that helicopter transport was not necessary for the vast majority of trauma patients transported via helicopter.
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Affiliation(s)
- Chelsea R Horwood
- Department of Trauma and Critical Care, The Ohio State University, Columbus, Ohio
| | - Kevin Ricci
- Department of Trauma and Critical Care, The Ohio State University, Columbus, Ohio
| | - Carly G Sobol
- Department of Trauma and Critical Care, The Ohio State University, Columbus, Ohio
| | - David Evans
- Department of Trauma and Critical Care, The Ohio State University, Columbus, Ohio
| | - Daniel Eiferman
- Department of Trauma and Critical Care, The Ohio State University, Columbus, Ohio.
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Kosaka M, Miyatake H, Arita S, Masunaga H, Ozaki A, Nishikawa Y, Beniya H. Emergency transfers of home care patients in Fukui Prefecture, Japan: A retrospective observational study. Medicine (Baltimore) 2020; 99:e21245. [PMID: 32702904 PMCID: PMC7373611 DOI: 10.1097/md.0000000000021245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Little is known about how emergency transfers take place and what outcomes they lead to in the patients who receive home care in Japan. We aimed to assess outcomes of emergency transfers and factors associated with such outcomes in the Japanese home care setting.A retrospective analysis of patient data from a home care clinic in Fukui, Japan, included all patients who experienced emergency transfers which were reported to the clinic during 2018 and 2019. We collected data on patients' sociodemographic and clinical characteristics, as well as the transfer process and its outcome, using patient charts and other administrative records. We first analyzed the overall outcome and then evaluated whether transfer outcomes would differ according to by whom and from where the emergency medical service (EMS) was called, by univariate and multivariate analyses.We considered 63 patients who experienced emergency transfers during the study period. Of the total, 10 (15.9%) returned to their residences without being admitted or being dead on arrival. Although only 2.6% (1/39) of patients whose transfers were determined by health care professionals (HCPs) returned home without being admitted, a direct return was observed for 37.5% (9/24) of patients whose transfer was determined by those other than HCPs (odds ratio of direct return to residences 22.80, 95% confidence interval 2.65-195.87). There was no other variable which was significantly associated with the outcomes after the emergency transfers, although all the patients who have no available caregivers resulted in hospitalization.In this preliminary analysis in the Japanese home care setting, only a small proportion of patients returned to their residences without being admitted following emergency transfers. Patients whose EMS transfer was requested by an HCP usually resulted in an admission to the clinic, whereas transfers requested by non-HCPs frequently did not.
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Razak F, Shin S, Pogacar F, Jung HY, Pus L, Moser A, Lapointe-Shaw L, Tang T, Kwan JL, Weinerman A, Rawal S, Kushnir V, Mak D, Martin D, Shojania KG, Bhatia S, Agarwal P, Mukerji G, Fralick M, Kapral MK, Morgan M, Wong B, Chan TCY, Verma AA. Modelling resource requirements and physician staffing to provide virtual urgent medical care for residents of long-term care homes: a cross-sectional study. CMAJ Open 2020; 8:E514-E521. [PMID: 32819964 PMCID: PMC7850232 DOI: 10.9778/cmajo.20200098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities. METHODS We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments. RESULTS There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each. INTERPRETATION The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.
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Affiliation(s)
- Fahad Razak
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont.
| | - Saeha Shin
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Frances Pogacar
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Hae Young Jung
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Laura Pus
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Andrea Moser
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Lauren Lapointe-Shaw
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Terence Tang
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Janice L Kwan
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Adina Weinerman
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Shail Rawal
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Vladyslav Kushnir
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Denise Mak
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Danielle Martin
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Kaveh G Shojania
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Sacha Bhatia
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Payal Agarwal
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Geetha Mukerji
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Michael Fralick
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Moira K Kapral
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Matthew Morgan
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Brian Wong
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Timothy C Y Chan
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Amol A Verma
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
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Lee YH, Hong CM, Kim DH, Lee TH, Lee J. Clinical Course of Asymptomatic and Mildly Symptomatic Patients with Coronavirus Disease Admitted to Community Treatment Centers, South Korea. Emerg Infect Dis 2020; 26:2346-2352. [PMID: 32568662 PMCID: PMC7510714 DOI: 10.3201/eid2610.201620] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
We evaluated the clinical course of asymptomatic and mildly symptomatic patients with laboratory-confirmed coronavirus disease (COVID-19) admitted to community treatment centers (CTCs) for isolation in South Korea. Of 632 patients, 75 (11.9%) had symptoms at admission, 186 (29.4%) were asymptomatic at admission but developed symptoms during their stay, and 371 (58.7%) remained asymptomatic during their entire clinical course. Nineteen (3.0%) patients were transferred to hospitals, but 94.3% (573/613) of the remaining patients were discharged from CTCs upon virologic remission. The mean virologic remission period was 20.1 days (SD + 7.7 days). Nearly 20% of patients remained in the CTCs for 4 weeks after diagnosis. The virologic remission period was longer in symptomatic patients than in asymptomatic patients. In mildly symptomatic patients, the mean duration from symptom onset to virologic remission was 11.7 days (SD + 8.2 days). These data could help in planning for isolation centers and formulating self-isolation guidelines.
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Liu VX, Lu Y, Carey KA, Gilbert ER, Afshar M, Akel M, Shah NS, Dolan J, Winslow C, Kipnis P, Edelson DP, Escobar GJ, Churpek MM. Comparison of Early Warning Scoring Systems for Hospitalized Patients With and Without Infection at Risk for In-Hospital Mortality and Transfer to the Intensive Care Unit. JAMA Netw Open 2020; 3:e205191. [PMID: 32427324 PMCID: PMC7237982 DOI: 10.1001/jamanetworkopen.2020.5191] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Risk scores used in early warning systems exist for general inpatients and patients with suspected infection outside the intensive care unit (ICU), but their relative performance is incompletely characterized. OBJECTIVE To compare the performance of tools used to determine points-based risk scores among all hospitalized patients, including those with and without suspected infection, for identifying those at risk for death and/or ICU transfer. DESIGN, SETTING, AND PARTICIPANTS In a cohort design, a retrospective analysis of prospectively collected data was conducted in 21 California and 7 Illinois hospitals between 2006 and 2018 among adult inpatients outside the ICU using points-based scores from 5 commonly used tools: National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), Between the Flags (BTF), Quick Sequential Sepsis-Related Organ Failure Assessment (qSOFA), and Systemic Inflammatory Response Syndrome (SIRS). Data analysis was conducted from February 2019 to January 2020. MAIN OUTCOMES AND MEASURES Risk model discrimination was assessed in each state for predicting in-hospital mortality and the combined outcome of ICU transfer or mortality with area under the receiver operating characteristic curves (AUCs). Stratified analyses were also conducted based on suspected infection. RESULTS The study included 773 477 hospitalized patients in California (mean [SD] age, 65.1 [17.6] years; 416 605 women [53.9%]) and 713 786 hospitalized patients in Illinois (mean [SD] age, 61.3 [19.9] years; 384 830 women [53.9%]). The NEWS exhibited the highest discrimination for mortality (AUC, 0.87; 95% CI, 0.87-0.87 in California vs AUC, 0.86; 95% CI, 0.85-0.86 in Illinois), followed by the MEWS (AUC, 0.83; 95% CI, 0.83-0.84 in California vs AUC, 0.84; 95% CI, 0.84-0.85 in Illinois), qSOFA (AUC, 0.78; 95% CI, 0.78-0.79 in California vs AUC, 0.78; 95% CI, 0.77-0.78 in Illinois), SIRS (AUC, 0.76; 95% CI, 0.76-0.76 in California vs AUC, 0.76; 95% CI, 0.75-0.76 in Illinois), and BTF (AUC, 0.73; 95% CI, 0.73-0.73 in California vs AUC, 0.74; 95% CI, 0.73-0.74 in Illinois). At specific decision thresholds, the NEWS outperformed the SIRS and qSOFA at all 28 hospitals either by reducing the percentage of at-risk patients who need to be screened by 5% to 20% or increasing the percentage of adverse outcomes identified by 3% to 25%. CONCLUSIONS AND RELEVANCE In all hospitalized patients evaluated in this study, including those meeting criteria for suspected infection, the NEWS appeared to display the highest discrimination. Our results suggest that, among commonly used points-based scoring systems, determining the NEWS for inpatient risk stratification could identify patients with and without infection at high risk of mortality.
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Affiliation(s)
- Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Yun Lu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kyle A. Carey
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Emily R. Gilbert
- Department of Medicine, Loyola University Medical Center, Chicago, Illinois
| | - Majid Afshar
- Department of Medicine, Loyola University Medical Center, Chicago, Illinois
| | - Mary Akel
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Nirav S. Shah
- Department of Medicine, University of Chicago, Chicago, Illinois
- NorthShore University HealthSystem, Evanston, Illinois
| | - John Dolan
- NorthShore University HealthSystem, Evanston, Illinois
| | | | - Patricia Kipnis
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Dana P. Edelson
- Department of Medicine, University of Chicago, Chicago, Illinois
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Kim HS, Kang DR, Kim I, Lee K, Jo H, Koh SB. Comparison between urban and rural mortality in patients with acute myocardial infarction: a nationwide longitudinal cohort study in South Korea. BMJ Open 2020; 10:e035501. [PMID: 32273319 PMCID: PMC7245421 DOI: 10.1136/bmjopen-2019-035501] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES This study investigated the risk associated with interhospital transfer of patients with acute myocardial infarction (AMI) and clinical outcomes according to the location of the patient' residence. DESIGN A nationwide longitudinal cohort. SETTING National Health Insurance Service database of South Korea. PARTICIPANTS This study included 69 899 patients with AMI who visited an emergency centre from 2013 to 2015, as per the Korea National Health Insurance Service database. PRIMARY OUTCOME MEASURE The clinical outcome of a patient with AMI was defined as mortality within 7 days, 30 days and 1 year. RESULTS Clinical outcomes were analysed and compared with respect to the location of the patient's residence and occurrence of interhospital transfer. We concluded that the HR of mortality within 7 days was 1.49 times higher (95% CI 1.18 to 1.87) in rural patients than in urban patients not subjected to interhospital transfer and 1.90 times higher (95% CI 1.13 to 3.19) in transferred rural patients than in non-transferred urban patients. CONCLUSIONS To reduce health inequality in rural areas, a healthcare policy considering regional characteristics, rather than a central government-led, catch-all approach to healthcare policy, must be formulated. Additionally, a local medical emergency delivery system, based on allocation of roles between different medical facilities in the region, must be established.
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Affiliation(s)
- Hye Sim Kim
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Dae Ryong Kang
- Department of Precision Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Inah Kim
- Department of Occupational and Environmental Medicine, Hanyang University College of Medicine, Seongdong-gu, South Korea
| | - Kyungsuk Lee
- National Institute of Agricultural Science, Rural Development Administration, Jeonju, South Korea
| | - Hoon Jo
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Sang Baek Koh
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
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Abstract
IMPORTANCE The availability of pediatric hospital care for common conditions is decreasing across the US. The consequences of this decrease on access to care for specific conditions need to be evaluated. OBJECTIVE To evaluate the degree of regionalization of pediatric seizure care in the US by characterizing the activity of hospital systems in 6 diverse states. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study used inpatient and emergency department administrative data sets from all acute care hospitals in Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York from 2014. All patients younger than 18 years who visited a hospital and had a primary diagnosis of seizures were included. Data were analyzed between January and June 2019. MAIN OUTCOMES AND MEASURES Characteristics of hospital encounters and pediatric Hospital Capability Index scores of transferring and admitting hospitals. RESULTS Among 57 930 encounters with pediatric patients with seizures (median [range] age, 4 [1-11] years; 31 968 [55.2%] boys) identified in 621 acute care hospitals, 15 467 patients (26.7%) were admitted as inpatients and 3748 patients (6.5%) were transferred between acute care hospitals. Among encounters that resulted in transfers between hospitals, seizure was the only diagnosis in 1554 patients (41.5%). A total of 42 463 encounters began as emergency department visits, of which 38 173 encounters (90.0%) resulted in routine discharge. While 536 hospitals (86.3%) transferred children with seizures, only 232 hospitals (37.4%) ever admitted them and only 63 hospitals (10.1%) ever received a pediatric seizure transfer. The median (interquartile range) pediatric Hospital Capability Index score of all hospitals was 0.10 (0.02-0.28), while that of hospitals occasionally admitting pediatric seizure patients was 0.34 (0.22-0.55). However, although most patients who were admitted had brief stays (ie, ≤2 days) and no comorbidities, three-quarters of all admissions (12 002 admissions [77.6%]) were to very highly capable centers (ie, hospitals with pediatric Hospital Capability Index scores >0.75). Across all states, the number of referral hospitals for pediatric seizures was less than the number of Dartmouth Atlas Hospital Referral Regions (47 referral hospitals vs 63 hospital referral regions). CONCLUSIONS AND RELEVANCE These findings suggest that although children with seizures are seen in almost all acute care hospital emergency departments, most hospitals transfer children who require admission. Condition-specific interhospital dependency challenges standard definitions of network adequacy and should be accounted for in emergency medical service planning, access to care policies, and health services research.
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Affiliation(s)
- Urbano L. França
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Michael L. McManus
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Mhyre J, Ward N, Whited TM, Anders M. Randomized Controlled Simulation Trial to Compare Transfer Procedures for Emergency Cesarean. J Obstet Gynecol Neonatal Nurs 2020; 49:272-282. [PMID: 32101767 DOI: 10.1016/j.jogn.2020.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To test the hypothesis that capping intravenous and epidural lines would reduce time to transfer women in labor to the operating room and time to readiness for general anesthesia for emergency cesarean. The secondary purpose was to identify latent threats to patient safety. DESIGN Mixed methods analysis of a randomized, controlled, in situ simulation trial. SETTING Labor and delivery unit at high-risk referral center. PARTICIPANTS Fifteen interprofessional teams that included labor and delivery nurses and anesthesiology residents. METHODS Immediately before simulation, we randomized bedside nurses and anesthesiology residents to one of two groups: usual transfer or the cap and run procedure. Simulation scenarios started with fetal heart rate decelerations that necessitated position changes followed by emergency cesarean. An embedded simulated obstetrician announced the decision for cesarean; completion of an OR checklist confirmed team readiness to induce general anesthesia. Postsimulation debriefing was focused on teamwork and opportunities to improve safety, and we used qualitative analysis to synthesize results. RESULTS We found no statistically significant difference in the overall time from decision for cesarean to readiness for general anesthesia between the two groups (usual transfer median = 445 seconds [interquartile range, 425-465] vs. cap and run 390 seconds [interquartile range, 383-443], p = .12). The time in the operating room was less in the cap and run group than in the usual transfer group (median = 300 seconds vs. 250 seconds, p = .038). Qualitative analysis of the debriefing data indicated advantages of the capping procedure, including better bed maneuverability and fewer tangled lines. CONCLUSION We found no evidence of decreased overall time from decision for cesarean to readiness for general anesthesia based on whether the nurse capped the intravenous and epidural lines or pushed the intravenous pole alongside the bed. However, nurses perceived improved patient safety with the cap and run procedure.
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Mohr NM, Wu C, Ward MJ, McNaughton CD, Richardson K, Kaboli PJ. Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study. BMC Health Serv Res 2020; 20:110. [PMID: 32050947 PMCID: PMC7014752 DOI: 10.1186/s12913-020-4956-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 02/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers. METHODS This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility- and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence. RESULTS Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%). CONCLUSIONS VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.
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Affiliation(s)
- Nicholas M. Mohr
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242 USA
| | - Chaorong Wu
- Institute for Clinical and Translational Sciences, University of Iowa, Iowa City, Iowa USA
| | - Michael J. Ward
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Candace D. McNaughton
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Kelly Richardson
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
| | - Peter J. Kaboli
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa USA
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Beller JP, Hawkins RB, Mehaffey JH, Chancellor WZ, Fonner CE, Speir AM, Quader MA, Rich JB, Yarboro LT, Teman NR, Ailawadi G. Impact of transfer status on real-world outcomes in nonelective cardiac surgery. J Thorac Cardiovasc Surg 2020; 159:540-550. [PMID: 30878161 PMCID: PMC6689463 DOI: 10.1016/j.jtcvs.2018.12.107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 12/07/2018] [Accepted: 12/21/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Transfer from hospital to hospital for cardiac surgery represents a large portion of some clinical practices. Previous literature in other surgical fields has shown worse outcomes for transferred patients. We hypothesized that transferred patients would be higher risk and demonstrate worse outcomes than those admitted through the emergency department. METHODS All patients undergoing cardiac operations with a Society of Thoracic Surgeons Predicted Risk of Mortality were evaluated from a multicenter, statewide Society of Thoracic Surgeons database. Only patients requiring admission before surgery were included. Patients were stratified by admission through the emergency department or in transfer. Transfers were further stratified by the cardiothoracic surgery capabilities at the referring center. RESULTS A total of 13,094 patients met the inclusion criteria of admission before surgery. This included 7582 (57.9%) transfers, of which 502 (6.6%) were referred from cardiac centers. Compared with emergency department admissions, transfers had increased hospital costs despite lower operative risk (Predicted Risk of Mortality 1.5% vs 1.6%, P < .01) and equivalent postoperative morbidity (15.6% vs 15.3% P = .63). In risk-adjusted analysis, transfer status was not independently associated with worse outcomes. Patients transferred from centers that perform cardiac surgery are higher risk than general transfers (Predicted Risk of Mortality 2.5% vs 1.5, P < .01), but specialized care results in excellent risk-adjusted outcomes (observed/expected: mortality 0.81; morbidity or mortality 0.90). CONCLUSIONS Transfer patients have similar rates of postoperative complications but increased resource use compared with patients admitted through the emergency department. Patients transferred from centers that perform cardiac surgery represent a particularly high-risk subgroup.
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Affiliation(s)
- Jared P Beller
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - William Z Chancellor
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | | | - Alan M Speir
- INOVA Heart and Vascular Institute, Falls Church, Va
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Va
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
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Venkatasubba Rao CP, Suarez JI, Martin RH, Bauza C, Georgiadis A, Calvillo E, Hemphill JC, Sung G, Oddo M, Taccone FS, LeRoux PD. Global Survey of Outcomes of Neurocritical Care Patients: Analysis of the PRINCE Study Part 2. Neurocrit Care 2020; 32:88-103. [PMID: 31486027 DOI: 10.1007/s12028-019-00835-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study. METHODS We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality. RESULTS We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47). CONCLUSION PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality.
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MESH Headings
- Academic Medical Centers/statistics & numerical data
- Adult
- Aged
- Asia/epidemiology
- Brain Injuries, Traumatic/epidemiology
- Brain Injuries, Traumatic/physiopathology
- Brain Injuries, Traumatic/therapy
- Brain Neoplasms/epidemiology
- Brain Neoplasms/physiopathology
- Brain Neoplasms/therapy
- Cerebral Hemorrhage/epidemiology
- Cerebral Hemorrhage/physiopathology
- Cerebral Hemorrhage/therapy
- Critical Care
- Disease Management
- Emergency Service, Hospital
- Europe/epidemiology
- Female
- Glasgow Coma Scale
- Health Resources
- Heart Arrest/epidemiology
- Heart Arrest/physiopathology
- Heart Arrest/therapy
- Hematoma, Subdural/epidemiology
- Hematoma, Subdural/physiopathology
- Hematoma, Subdural/therapy
- Hemodynamic Monitoring/statistics & numerical data
- Hospital Mortality
- Hospitals, Private/statistics & numerical data
- Hospitals, Public/statistics & numerical data
- Humans
- Intensive Care Units
- Internationality
- Ischemic Stroke/epidemiology
- Ischemic Stroke/physiopathology
- Ischemic Stroke/therapy
- Latin America/epidemiology
- Length of Stay/statistics & numerical data
- Logistic Models
- Male
- Middle Aged
- Middle East/epidemiology
- Multivariate Analysis
- Neurophysiological Monitoring/statistics & numerical data
- North America/epidemiology
- Oceania/epidemiology
- Odds Ratio
- Palliative Care/statistics & numerical data
- Patient Admission/statistics & numerical data
- Patient Comfort
- Patient Transfer/statistics & numerical data
- Referral and Consultation/statistics & numerical data
- Reflex, Pupillary
- Resuscitation Orders
- Risk Factors
- Severity of Illness Index
- Subarachnoid Hemorrhage/epidemiology
- Subarachnoid Hemorrhage/physiopathology
- Subarachnoid Hemorrhage/therapy
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Affiliation(s)
- Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014C, Baltimore, MD, 21287, USA.
| | - Renee H Martin
- Medical University of South Carolina, Charleston, SC, USA
| | - Colleen Bauza
- Department of Health Informatics, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Alexandros Georgiadis
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Eusebia Calvillo
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014C, Baltimore, MD, 21287, USA
| | | | - Gene Sung
- University of Southern California, Los Angeles, CA, USA
| | - Mauro Oddo
- CHUV Lausanne University Hospital, Lausanne, Switzerland
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