Management of Patients With Cardiac Arrest Requiring Interfacility Transport: A Scientific Statement From the American Heart Association.

People who experience out-of-hospital cardiac arrest often require care at a regional center for continued treatment after resuscitation, but many do not initially present to the hospital where they will be admitted. For patients who require interfacility transport after cardiac arrest, the decision to transfer between centers is complex and often based on individual clinical characteristics, resources at the presenting hospital, and available transport resources. Once the decision has been made to transfer a patient after cardiac arrest, there is little direct guidance on how best to provide interfacility transport. Accepting centers depend on transferring emergency departments and emergency medical services professionals to make important and nuanced decisions about postresuscitation care that may determine the efficacy of future treatments. The consequences of early care are greater when transport delays occur, which is common in rural areas or due to inclement weather. Challenges of providing interfacility transfer services for patients who have experienced cardiac arrest include varying expertise of clinicians, differing resources available to them, and nonstandardized communication between transferring and receiving centers. Although many aspects of care are insufficiently studied to determine implications for specific out-of-hospital treatment on outcomes, a general approach of maintaining otherwise recommended postresuscitation care during interfacility transfer is reasonable. This includes close attention to airway, vascular access, ventilator management, sedation, cardiopulmonary monitoring, antiarrhythmic treatments, blood pressure control, temperature control, and metabolic management. Patient stability for transfer, equity and inclusion, and communication also must be considered. Many of these aspects can be delivered by protocol-driven care.

Adjustments of Ventilator Parameters during Operating Room-to-ICU Transition and 28-Day Mortality.

Rationale: Lung-protective mechanical ventilation strategies have been proven beneficial in the operating room (OR) and the ICU. However, differential practices in ventilator management persist, often resulting in adjustments of ventilator parameters when transitioning patients from the OR to the ICU. Objectives: To characterize patterns of ventilator adjustments during the transition of mechanically ventilated surgical patients from the OR to the ICU and assess their impact on 28-day mortality. Methods: Hospital registry study including patients undergoing general anesthesia with continued, controlled mechanical ventilation in the ICU between 2008 and 2022. Ventilator parameters were assessed 1 hour before and 6 hours after the transition. Measurements and Main Results: Of 2,103 patients, 212 (10.1%) died within 28 days. Upon OR-to-ICU transition, VT and driving pressure decreased (-1.1 ml/kg predicted body weight [IQR, -2.0 to -0.2]; P < 0.001; and -4.3 cm H2O [-8.2 to -1.2]; P < 0.001). Concomitantly, respiratory rates increased (+5.0 breaths/min [2.0 to 7.5]; P < 0.001), resulting overall in slightly higher mechanical power (MP) in the ICU (+0.7 J/min [-1.9 to 3.0]; P < 0.001). In adjusted analysis, increases in MP were associated with a higher 28-day mortality rate (adjusted odds ratio, 1.10; 95% confidence interval, 1.06-1.14; P < 0.001; adjusted risk difference, 0.7%; 95% confidence interval, 0.4-1.0, both per 1 J/min). Conclusion: During transition of mechanically ventilated patients from the OR to the ICU, ventilator adjustments resulting in higher MP were associated with a greater risk of 28-day mortality.

Neurological Improvement by One-Thirds Is Associated With Early Recanalization in Stroke With Large Vessel Occlusion.

BACKGROUND: A proportion of large vessel occlusion strokes demonstrate early recanalization, obviating the initial intention to proceed to endovascular thrombectomy. Neurological improvement is a possible surrogate marker for reperfusion. We aimed to determine the optimal threshold of neurological improvement, as defined by the National Institutes of Health Stroke Scale (NIHSS), which best associates with early recanalization. METHODS: We retrospectively analyzed consecutive patients with large vessel occlusion transferred from primary stroke centers to a tertiary comprehensive stroke center in Melbourne, Australia, for possible endovascular thrombectomy from January 2018 to December 2022. Absolute and percentage changes in NIHSS between transfer, as well as other definitions of neurological improvement, were compared using receiver operating characteristic curve analysis for association with recanalization as defined by the absence of occlusion in the internal carotid artery, middle cerebral artery (M1 or M2 segments), or basilar artery on repeat vascular imaging. RESULTS: Six hundred and fifty-four transferred patients with large vessel occlusion were included in the analysis: mean age was 68.8±14.0 years, 301 (46.0%) were women, and 338 (52%) received intravenous thrombolytics. The proportion of extracranial internal carotid artery, intracranial internal carotid artery, M1, proximal M2, and basilar artery occlusion was 18.8%, 13.6%, 48.3%, 15.0%, and 4.3%, respectively, on initial computed tomography angiogram. Median NIHSSprimary stroke center and NIHSScomprehensive stroke center scores were 15 (interquartile range, 9-18) and 13 (interquartile range, 8-19), respectively. Early recanalization occurred in 82 (13%) patients. NIHSS reduction of ≥33% was the best tradeoff between sensitivity (64%) and specificity (83%) for identifying recanalization. NIHSS reduction of ≥33% had the highest discriminative ability to predict recanalization (area under the curve, 0.735) in comparison with other definitions of neurological improvement. CONCLUSIONS: One-third neurological improvement between the primary hospital and tertiary center was the best predictor of early recanalization.

The Role of Integrated Air Transport System in Managing Patients with Abdominal Aortic Aneurysm Rupture.

OBJECTIVE: Ruptured abdominal aortic aneurysms (rAAAs) are highly morbid emergencies. Not all hospitals are equipped to repair them, and an air ambulance network may aid in regionalising specialty care to quaternary referral centres. The association between travel distance by air ambulance and rAAA mortality in patients transferred as an emergency for repair was examined. METHODS: A retrospective review of institutional data. Adults with rAAA (2002 - 2019) transferred from an outside hospital (OSH) to a single quaternary referral centre for repair via air ambulance were identified. Patients who arrived via ground transport or post-repair at an OSH for continued critical care were excluded. Patients were divided into near and far groups based on the 75th percentile of the straight line travel distance (> 72 miles) between hospitals. The primary outcome was 30 day mortality. Multivariable logistic regression was used to assess the association between distance and mortality after adjusting for age, sex, ethnicity, cardiovascular comorbidities, and repair type. RESULTS: A total of 290 patients with rAAA were transported a median distance of 40.4 miles (interquartile range 25.5, 72.7) with 215 (74.1%) near and 75 (25.9%) far patients. Both the near and far groups had similar ages, sex, and ethnicity. There was no difference in pre-operative loss of consciousness, intubation, or cardiac arrest between groups. Endovascular aneurysm repair utilisation and intra-operative aortic occlusion balloon use were also similar. Neither the observed (26.8% vs. 23.9%, p = .61) nor the adjusted odds ratio (0.70, 95% confidence interval 0.36 - 1.39, p = .32) 30 day mortality rate differed significantly between the near and far groups. CONCLUSION: Increasing distance travelled during transfer by air ambulance was not associated with worse outcomes in patients with rAAA. The findings support the regionalisation of rAAA repair to large quaternary centres via an integrated and robust air ambulance network.

Analysis of health inequities in transfers of admitted patients from an academic emergency department to partner community hospital.

BACKGROUND: Many academic medical centers (AMC) transfer patients who require admission but not tertiary care to partner community hospitals from their emergency departments (ED). These transfers alleviate ED boarding but may worsen existing healthcare disparities. We assessed whether disparities exist in the transfer of patients from one AMC ED to a community hospital General Medical Service. METHODS: We performed a retrospective cohort study on all patients screened for transfer between April 1 and December 31, 2021. During the screening process, the treating ED physician determines whether the patient meets standardized clinical criteria and a patient coordinator requests patient consent. We collected patient demographics data from the electronic health record and performed logistic regression at each stage of the transfer process to analyze how individual characteristics impact the odds of proceeding with transfer. RESULTS: 5558 patients were screened and 596 (11%) ultimately transferred. 1999 (36%) patients were Black or Hispanic, 698 (12%) had a preferred language other than English, and 956 (17%) were on Medicaid or uninsured. A greater proportion of Black and Hispanic patients were deemed eligible for interhospital transfer compared to White patients and a greater proportion of Hispanic patients completed transfer to the community hospital (p < 0.017 after Bonferroni correction). After accounting for other demographic variables, patients older than 50 (OR 1.21, 95% CI 1.04-1.40), with a preferred language other than English (OR 1.27, 95% CI 1.00-1.62), and from a priority neighborhood (OR 1.38, 95% CI 1.18-1.61) were more likely to be eligible for transfer, while patients who were male (OR 1.50, 95% CI 1.10-2.05) and younger than 50 (OR 1.85, 95% CI 1.20-2.78) were more likely to consent to transfer (p < 0.05). CONCLUSION: Health disparities exist in the screening process for our interfacility transfer program. Further investigation into why these disparities exist and mitigation strategies should be undertaken.

Areas of consensus on unwarranted and warranted transfers between nursing homes and emergency care facilities in Norway: a Delphi study.

BACKGROUND: Transferring residents from nursing homes (NHs) to emergency care facilities (ECFs) is often questioned as many are terminally ill and have access to onsite care. While some NH to ECF transfers have merit, avoiding other transfers may benefit residents and reduce healthcare system costs and provider burden. Despite many years of research in this area, differentiating warranted (i.e., appropriate) from unwarranted NH to ECF transfers remains challenging. In this article, we report consensus on warranted and unwarranted NH to ECF transfers scenarios. METHODS: A Delphi study was used to identify consensus regarding warranted and unwarranted NH to ECF transfers. Delphi participants included nurses (RNs) and medical doctors (MDs) from NHs, out-of-hours primary care clinics (OOHs), and hospital-based emergency departments. A list of 12 scenarios and 11 medical conditions was generated from the existing literature on causes and medical conditions leading to transfers, and pilot tested and refined prior to conducting the study. Three Delphi rounds were conducted, and data were analyzed using descriptive and comparative statistics. RESULTS: Seventy-nine experts consented to participate, of whom 56 (71%) completed all three Delphi rounds. Participants reached high or very high consensus on when to not transfer residents, except for scenarios regarding delirium, where only moderate consensus was attained. Conversely, except when pain relieving surgery was required, participants reached low agreement on scenarios depicting warranted NH to ECF transfers. Consensus opinions differ significantly between health professionals, participant gender, and rurality, for seven of the 23 transfer scenarios and medical conditions. CONCLUSIONS: Transfers from nursing homes to emergency care facilities can be defined as warranted, discretionary, and unwarranted. These categories are based on the areas of consensus found in this Delphi study and are intended to operationalize the terms warranted and unwarranted transfers between nursing homes and emergency care facilities.

The Association Between Inter-Hospital Transfers and the Prognosis of Pediatric Injury in the Emergency Department.

BACKGROUND: Inter-hospital transfers of severely injured patients are inevitable due to limited resources. We investigated the association between inter-hospital transfer and the prognosis of pediatric injury using the Korean multi-institutional injury registry. METHODS: This retrospective observational study was conducted from January 2013 to December 2017; data for hospitalized subjects aged < 18 years were extracted from the Emergency Department-based Injury in Depth Surveillance database, in which 22 hospitals are participating as of 2022. The survival rates of the direct transfer group and the inter-hospital transfer group were compared, and risk factors affecting 30-day mortality and 72- hour mortality were analyzed. RESULTS: The total number of study subjects was 18,518, and the transfer rate between hospitals was 14.5%. The overall mortality rate was 2.3% (n = 422), the 72-hour mortality was 1.7% (n = 315) and the 30-day mortality rate was 2.2% (n = 407). The Kaplan-Meier survival curve revealed a lower survival rate in the inter-hospital transfer group than in the direct visit group (log-rank, P < 0.001). Cox proportional hazards regression analysis showed that inter-hospital transfer group had a higher 30-day mortality rate and 72-hour mortality (hazard ratio [HR], 1.681; 95% confidence interval [CI], 1.232-2.294 and HR, 1.951; 95% CI, 1.299-2.930) than direct visit group when adjusting for age, sex, injury severity, and head injury. CONCLUSION: Among the pediatric injured patients requiring hospitalization, inter-hospital transfer in the emergency department was associated with the 30-day mortality rate and 72-hour mortality rate in Korea.

Rise of long-distance urology transfer during the COVID-19 pandemic: Identifying factors to enhance transfers of care efficiency and clinical outcomes.

OBJECTIVE: The objective of this study is to identify variables associated with clinical outcomes after urologic transfers before and during the COVID pandemic. METHODS: After IRB approval, a retrospective chart review was performed on adult patients transferred to our institution from 01/01/2018 to 12/31/2019 ("pre-COVID") and from 01/02/2020 to 12/31/2022 ("COVID"). We identified demographics, origin hospitals, ICD-10 pre- and post-transfer diagnoses, distance of transfer, and post-transfer CPT codes. RESULTS: During the study period, our adult urology service accepted 160 transfers with a mean patient age of 71 years. A total of 49/160 (30%) of subjects made up the "pre-COVID" cohort and 111/160 (70%) made up the "COVID" cohort. There were 11/111 (10%) transfers of >100 miles in the COVID period but 0/49 in the pre-COVID period (p = 0.02). Patients from the COVID period waited on average 1.2 days longer for a procedure after transfer compared to pre-COVID period (p = 0.03). The time until a patient's surgical procedure after transfer was a significant predictor of length of stay > 5 days (OR 1.91, CI 1.43 - 2.58, p < 0.01). Different diagnosis upon re-evaluation after transfer was associated with a decreased rate of subsequent readmission (OR 0.30, CI 0.09-0.97, p = 0.05). CONCLUSIONS: Long-distance transfer, even >100 miles (which we termed "mega-transfers"), was a new pandemic-related phenomenon at our institution. Delays in definitive care and changes in diagnoses after transfer were associated with readmission and length of stay. Our findings illustrate the importance of inter-institutional communication, diagnostic accuracy, and post discharge planning when managing transfer patients.

Transition Readiness Assessment Questionnaire: Skill gaps and psychosocial predictors of transition readiness among adolescents and young adults with chronic medical conditions.

BACKGROUND: Transferring from paediatric to adult care can be challenging. Adolescents and young adults (AYAs) with chronic health conditions need to develop a specific set of skills to ensure lifelong medical follow-up due to the chronicity of their condition. The Transition Readiness Assessment Questionnaire-French version (TRAQ-FR) is a 19-item questionnaire measuring such skills. The aims of the study were to (1) describe participant characteristics and (2) identify constructs related to, and predictors of, having learned domain-specific transition readiness skills. METHODS: Participants included 216 AYAs aged 14-20 years (M = 15.93; SD = 1.35; 54.1% male) recruited from five outpatient clinics in a Canadian tertiary hospital. AYAs completed the TRAQ-FR, the Pediatric Quality of Life Inventory 4.0 (PedsQL) and a sociodemographic questionnaire. Descriptive, bivariate and binary logistic regression analyses were conducted. RESULTS: Overall, participants reported significantly higher scores on the Talking with Providers, Managing Daily Activities and Managing Medications subscales than on the Appointment Keeping and Tracking Health Issues subscales (F[41075] = 168.970, p < .001). At the item level, median scores (on a 5-point Likert scale) suggest that AYAs had begun practising five of the 19 skills (median scores ≥4; 'Yes, I have started doing this'), while a median score of 1 ('No, I don't know how') was found for one item ('Do you get financial help with school or work?'). At the subscale level, TRAQ-FR skills and skill gaps were related to AYAs' age, sex and PedsQL scores (ps < .05). CONCLUSION: Older and female AYAs were more likely to have begun practising specific TRAQ-FR subscale skills. Better psychosocial functioning was also related to having learned specific transition readiness skills. AYAs show several gaps in transition readiness. Targeted intervention in transition readiness skill development could take into account AYAs' age, sex and psychosocial functioning for a successful transfer to adult care.

Nurses engaging with referral letters and discharge summaries: A qualitative study.

AIMS: To investigate the ways that nurses engage with referral letters and discharge summaries, and the qualities of these documents they find valuable for safe and effective practice. DESIGN: This study comprised a qualitative, case-study design within a constructivist paradigm using convenience sampling. METHODS: Interviews were conducted with nurses to investigate their practices relating to referral letters and discharge summaries. Data collection also involved nurses' examination and evaluation of a diverse range of 10 referral letters and discharge summaries from medical records at two Australian hospitals through focus-group sessions. The data were transcribed and analysed inductively. RESULTS: In all, 67 nurses participated in interviews or focus groups. Nurses indicated they used referral letters and discharge summaries to inform their work when caring for patients at different times throughout their hospitalisation. These documents assisted them with verbal handovers, to enable them to educate patients about their condition and treatment and to provide a high standard of care. The qualities of referral letters and discharge summaries that they most valued were language and communication, an awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. CONCLUSION: Nurses relied on referral letters and discharge summaries to ensure safe and effective patient care. They used these documents to enhance their verbal handovers, contribute to patient care and to educate the patient about their condition and treatment. They identified several qualities of these documents that assisted them in maintaining patient safety including clarity and conciseness of information. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: It is important that referral letters and discharge summaries are written clearly, concisely and comprehensively because nurses use them as key sources of evidence in planning and delivering care, and in communicating with other health professionals in relaying goals of care and implementing treatment plans. IMPACT: Nurses reported that they regularly used referral letters and discharge summaries as valuable sources of evidence throughout their patients' hospitalisation. The qualities of these documents which they most valued were language and communication styles, awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. This research has important impact on the patient experience in relation to encouraging effective referral letter and discharge summary writing. REPORTING METHOD: We have adhered to the relevant EQUATOR guidelines through the SRQR reporting method. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Clinical outcome and cost effectiveness of acute ischemic stroke transfers for endovascular reperfusion therapy from geographically distant counties: Stroke transfer outcomes.

OBJECTIVES: Endovascular reperfusion therapy (EVT) for acute ischemic stroke (AIS) with large vessel occlusion (LVO) has resulted in increased patient transfers to comprehensive stroke centers (CSCs). Clinical outcomes including the financial impact of these transfers from geographically dispersed population are lacking. Hence, we studied outcomes and cost-effectiveness of stroke transfers from remote areas. MATERIALS AND METHODS: We used a 3-year cohort of AIS patients transferred from geographically dispersed counties (<100 mi., 101-200 mi., and >200 mi.). A 3-month modified Rankin scale (mRS) score of 0-2 defined a favorable clinical outcome. Cost-effectiveness is studied by calculating the incremental cost effectiveness ratio, using hospital costs reimbursed data and utility-weighted (UW)-mRS. RESULTS: Among 172 patients transferred for EVT, patients transferred from nearby counties were more likely to undergo intervention compared to other counties (56.9 % vs. 36.7 % vs. 49.2 % p = .11). Irrespective of proximity (in mi.) to CSC [21.5 (14-56.3)] vs. 185 (137-185) vs. 349 (325-355)], there was a similar delay (in min.) to arrival from all locations [321.5 (244-490), 366 (298-432), and 460 (385-554.5) respectively], but no statistically significant differences in favorable outcomes (18.0 %, 34.1 %, and 22.2 %, respectively, p = .41). Patients undergoing EVT had higher hospital costs reimbursed compared to non-EVT patients [$37,303 (25,745-40,658) vs. $14,008 (8,640-21,273) respectively, p < .001] and no statistically significant difference in UW-mRS [0.32 (0.06-0.56) vs. 0.06 (0-0.56), p = .30]. CONCLUSIONS: Our study identifies a need for targeted interventions to improve community awareness and optimize systems of care to improve outcomes and cost-effectiveness of EVT.

Experience from transport teams on interhospital transfer of patients with extracorporeal membrane oxygenation support: A qualitative study.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) can be a life-saving treatment for patients requiring advanced cardiopulmonary support. Several ECMO centres offer interhospital transport (ECMO IHT) services that involve establishing ECMO teams to initiate ECMO at referring hospitals and then transfer patients to ECMO centres. ECMO IHT is often high risk and complex. Understanding the experience of transport team members is crucial to ensure patient safety and promote quality improvement. AIM: To explore the experiences of transport teams performing ECMO IHT. STUDY DESIGN: A descriptive qualitative methodology was adopted. RESULTS: Thirteen health care professionals who have performed ECMO IHT at a general hospital in China agreed to be interviewed and enrolled in this study. Two investigators conducted face-to-face individual interviews in September-November 2022. All interviews were audio-recorded, transcribed verbatim and analysed using inductive thematic analysis. Three main themes and nine sub-themes were developed: (1) practicing with good organizational management (conducting training programs, cultivating the spirit of good teamwork and developing a standardized transport procedure), (2) dedicated to ensuring patient safety (adequate preparation and regular checking to reduce risk, accurate evaluation to avoid futility and maintaining communication to increase safety) and (3) having confidence despite being uneasy (feeling stressed is common, facing insecurity in transport settings and gaining confidence through practice). CONCLUSIONS: Health care professionals must adequately prepare and assess ECMO IHT to ensure patient safety. Supportive measures should be taken to ensure team members' health and improve patient safety. Good communication and teamwork could improve this challenging task. Further research is required for training programs and establishing standardized transport procedures. RELEVANCE TO CLINICAL PRACTICE: This study presents multi-professional perspectives on the experience of performing ECMO IHT to help management identify what needs to be further developed. With the increasing number of ECMO IHT, promoting its standardization is warranted.

Outcomes of medically retrieved infants with bronchiolitis in high-income countries: A scoping review.

INTRODUCTION: Bronchiolitis is the most common respiratory infection and reason for hospitalisation in infancy; however, outcomes of infants with bronchiolitis who require interhospital transfer by specialist medical retrieval services are poorly understood. OBJECTIVES: The objective of this study was to summarise current evidence of the rate, therapy, and outcomes of infants with bronchiolitis who required medical retrieval for ongoing management. REVIEW METHOD: A scoping literature review informed by the Joanna Briggs Institute methodology was used including published studies in any language covering the period 1996 to December 2022 and grey literature sources comprised of reports from retrieval services in high-income countries with comparable healthcare systems. DATA SOURCES: Medline, CINAHL, and the Cochrane Database of Systematic Reviews electronic databases were the sources for published studies. Grey literature sources were retrieval service web pages/social media sites from Australia, Canada, New Zealand, the United Kingdom, and the United States of America. RESULTS: Searching identified 12 677 records, with 12 069 ineligible records and 286 duplicates excluded at screening. Of the 72 papers included for title and abstract review, 16 were selected for full-text review. Six papers fulfilled inclusion criteria. Infants with bronchiolitis were the primary focus of three studies. Transfer rate was reported in four studies, ranging from 4.3% to 18.5%. Use of respiratory therapy was variably reported and was associated with prematurity. Outcomes following retrieval such as respiratory therapies, days on therapies, length of stay in the intensive care unit, and hospital length of stay were only reported in two studies. Of 103 identified medical retrieval services and data registries, no reports were found that included information on the number of transfers or outcomes for infants with bronchiolitis. CONCLUSIONS: Up to one in five infants with bronchiolitis require medical retrieval. Only two published studies and no reports reported on the number and outcomes of infants. Given the frequency and severity of bronchiolitis, understanding indications for medical retrieval and outcomes of those infants may help to better target care and interventions for this common illness. Benefits could include diminishing the costly burden to families and the healthcare system of avoidable medical retrieval and interhospital transfer.

Nutritional gap after transfer from the intensive care unit to a general ward - A retrospective quality assurance study.

BACKGROUND: Adequate nutrition is important for recovery after critical illness. Even so, our knowledge of patients' nutritional intake after intensive care unit (ICU) discharge is scarce. OBJECTIVES: We aimed to explore nutritional planning and achieved nutritional intake in ICU patients who transfer from the ICU to general wards. METHODS: A retrospective quality assurance study. INCLUSION CRITERIA: adult ICU patients transferring to a general ward at Copenhagen University Hospital-Herlev from May to August 2021. Primary outcomes were as follows: having a nutritional plan on the day of ICU transfer. A nutritional plan was defined as follows: (i) individual assessment of energy and protein requirement; (ii) intake, documented as achieved percentage of energy and protein requirements; (iii) prescribed type of nutrition. If using enteral or parenteral nutrition; (iv) the prescribed doses; and (v) the prescribed product. Secondary outcomes were as follows: achieved percentage of energy and protein requirements from day -1 before ICU transfer until day +1 and day +3 after ICU transfer. RESULTS: We included 57 patients; the mean age was 64 years (±11.1); 43 (75%) patients were male; the median ICU stay was 6 days (interquartile range: 3-11). One (2%) patient had a full nutritional plan according to listed criteria. Patients' median percentage of requirements met declined significantly from the day before to the day after ICU discharge (energy: from 94% to 30.5%; p = 0.0051; protein: from 73% to 27.5%; p = 0.0117). The decline in percentage of requirements met remained unchanged from day 1 to 3 after ICU transfer. CONCLUSIONS: In conclusion, few patients had a nutritional plan when transferring from the ICU to a general ward. After ICU discharge, percentage of energy and protein requirements met declined significantly and remained insufficient during the first 3 days at the general ward.

Race, Ethnic, Sex, and Socioeconomic Inequities in Interhospital Transfer for Acute Ischemic Stroke in the United States.

BACKGROUND: Patients with stroke in the United States can be transferred for higher level of care. Little is known about possible inequities in interhospital transfers (IHTs) for acute ischemic stroke. We hypothesized that historically marginalized populations would have lower odds of IHT. METHODS: A cross-sectional analysis was done for adults with a primary diagnosis of acute ischemic stroke in 2010 to 2017; n=747 982 were identified in the National Inpatient Sample. Yearly rates for IHT were assessed and adjusted odds ratios (aORs) of IHT in 2014 to 2017 were compared with that of 2010 to 2013. Multinomial logistic regression was used to determine the aOR of IHT, adjusting for sociodemographic variables (model 1), sociodemographic and medical variables such as comorbidity and mortality risk (model 2), and sociodemographic, medical, and hospital variables (model 3). RESULTS: After adjusting for sociodemographic, medical, and hospital characteristics, there were no significant temporal differences in IHT from 2010 to 2017. Overall, women were less likely than men to be transferred in all models (model 3: aOR, 0.89 [0.86-0.92]). Compared with those who were White, individuals who were Black (aOR, 0.93 [0.88-0.99]), Hispanic (aOR, 0.90 [0.83-0.97]), other (aOR, 0.90 [0.82-0.99]), or of unknown race, ethnicity (aOR, 0.89 [0.80-1.00]) were less likely to be transferred (model 2), but these differences dissipated when further adjusting for hospital-level characteristics (model 3). Compared with those with private insurance, those with Medicaid (aOR, 0.86 [0.80-0.91]), self-pay (aOR, 0.64 [0.59-0.70]), and no charge (aOR, 0.64 [0.46-0.88]) were less likely to be transferred (model 3). Individuals with lower income were less likely to be transferred compared with those with higher income (model 3: aOR, 0.85 [0.80-0.90], third versus fourth quartile). CONCLUSIONS: Adjusted odds of IHT for acute ischemic stroke remained stable from 2010 to 2017. There are numerous inequities in the rates of IHT by race, ethnicity, sex, insurance, and income. Further studies are needed to understand these inequities and develop policies and interventions to mitigate them.

Distinct Origins and Transmission Pathways of blaKPC Enterobacterales across Three U.S. States.

Carbapenem-resistant Enterobacterales (CRE) are among the most concerning antibiotic resistance threats due to high rates of multidrug resistance, transmissibility in health care settings, and high mortality rates. We evaluated the potential for regional genomic surveillance to track the spread of blaKPC-carrying CRE (KPC-CRE) by using isolate collections from health care facilities in three U.S. states. Clinical isolates were collected from Connecticut (2017 to 2018), Minnesota (2012 to 2018), and Tennessee (2016 to 2017) through the U.S. Centers for Disease Control and Prevention's Multi-site Gram-negative Surveillance Initiative (MuGSI) and additional surveillance. KPC-CRE isolates were whole-genome sequenced, yielding 255 isolates from 214 patients across 96 facilities. Case report data on patient comorbidities, facility exposures, and interfacility patient transfer were extracted. We observed that in Connecticut, most KPC-CRE isolates showed evidence of importation from outside the state, with limited local transmission. In Minnesota, cases were mainly from sporadic importation and transmission of blaKPC-carrying Klebsiella pneumoniae ST258, and clonal expansion of blaKPC-carrying Enterobacter hormaechei ST171, primarily at a single focal facility and its satellite facilities. In Tennessee, we observed transmission of diverse strains of blaKPC-carrying Enterobacter and Klesbiella, with evidence that most derived from the local acquisition of blaKPC plasmids circulating in an interconnected regional health care network. Thus, the underlying processes driving KPC-CRE burden can differ substantially across regions and can be discerned through regional genomic surveillance. This study provides proof of concept that integrating genomic data with information on interfacility patient transfers can provide insights into locations and drivers of regional KPC-CRE burden that can enable targeted interventions.

A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks.

Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism. CONTEXT: Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers. METHODS: To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research. FINDINGS: The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity. CONCLUSIONS: The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.

Inter-Hospital Transfer of Patients With Ruptured Abdominal Aortic Aneurysm in Switzerland.

OBJECTIVE: To analyse the association between inter-hospital transfer and hospital mortality in patients with ruptured abdominal aortic aneurysms (rAAA) in Switzerland. METHODS: Secondary data analysis of case related hospital discharge data from the Swiss Federal Statistical Office for the years 2009 - 2018. All cases with rAAA as primary or secondary diagnosis were included. Cases with rAAA as a secondary diagnosis without surgical treatment and cases that had been transferred to another hospital without surgical treatment at the referring hospital were excluded. Logistic regression models for hospital mortality were constructed with age, sex, type of admission, van Walraven comorbidity score, type of treatment, insurance class, hospital level, and year of treatment as independent variables. RESULTS: A total of 1 798 cases with rAAA were treated either surgically (62.5%) or palliatively (37.5%) in Switzerland from 1 January 2009 to 31 December 2018. Of these cases, 72.9% were treated directly (surgically or palliatively) at the hospital of first presentation, whereas 27.1% of all cases with rAAA were transferred between hospitals. The overall crude hospital mortality was 50.3%; being 23.1% in the surgically treated cohort and 95.7% in the palliatively treated cohort. Inter-hospital transfer was associated with better survival compared with patients who were admitted directly (OR 0.52; 95% CI 0.36 - 0.75; p < .001). Treatment in major hospitals was associated with significantly higher mortality rate compared with university hospitals (OR 1.98; 1.41 - 2.79; p < .001). There was no evidence of an association between open repair and hospital mortality (OR 1.06; 0.77 - 1.48; p = .72) compared with endovascular repair. CONCLUSION: In a healthcare system such as Switzerland's with a highly specialised rescue chain, transfer of haemodynamically stable patients with rAAA is probably safe. In this setting, centralised medical care might outweigh the potential disadvantages of a short delay due to patient transfer. Further studies are needed to address potential confounding factors such as haemodynamic and anatomical features.

Timing of Transport of Patients with COVID-19.

RATIONALE: The objective of this study was to evaluate the risk of mortality or ECMO cannulation for patients with confirmed or suspected COVID-19 transferred from sending hospitals to receiving tertiary care centers as a function of the duration of time at the sending hospital. OBJECTIVE: To determine outcomes of critically ill patients with COVID-19 who were transferred to tertiary or quarternary care medical centers. MATERIALS AND METHODS: Retrospective cohort study of critical care transports of patients to one of seven consortium tertiary care centers from March 1, 2020, through September 4, 2020. Age 14 years and older with confirmed or suspected COVID-19 transported from a sending hospital to a receiving tertiary care center by the critical care transport organization. RESULTS: Patients transported with confirmed or suspected COVID-19 to tertiary care centers had a mortality rate of 38.0%. Neither the number of days admitted, nor the number of days intubated at the sending hospital correlated with mortality (correlation coefficient 0.051 and -0.007, respectively). Similarly, neither the number of days admitted, nor number of days intubated at the sending hospital correlated with ECMO cannulation (correlation coefficient 0.008 and -0.036, respectively). CONCLUSION: It may be reasonable to transfer a critically ill COVID-19 patient to a tertiary care center even if they have been admitted at the sending hospital for several days.

Characterizing the process of urgent referrals and transfers to a large tertiary care apheresis centre in Ontario: A retrospective database review.

BACKGROUND: Therapeutic plasma exchange (TPE) and red blood cell exchange (RBCX) are life-saving apheresis procedures offered in 7 Ontario hospitals. Most referrals are directed by CritiCall Ontario (CritiCall), a 24/7 service funded by the Ontario Ministry of Health and Long-Term Care. We used CritiCall data to examine referral requests, acceptances, and transfers for urgent apheresis to our centre. METHODS: Retrospective CritiCall referral and transfer data for urgent apheresis between October 2013 and December 2018 were included. Continuous variables were analyzed by linear regression. Categorical variables were analyzed using nonparametric tests. RESULTS: Eighty-five cases (52 TPE, 33 RBCX) were identified. Median patient age was 52 years (interquartile range [IQR] 32) for TPE, 29 years (IQR 18) for RBCX. Most patients (58%) were female. Total time from referral to arrival at our centre was 243 (IQR 166) minutes. The greatest proportion of this total was from patient acceptance to arrival (169 [IQR 112] minutes). Median distance between referring and accepting centres was 39 (IQR 30) kilometres, with ground transportation used most often. Multiple linear regression examining factors that contribute to total time demonstrated that the number of physicians contacted prior to patient acceptance and inter-hospital distance were independently associated (p = 0.007 and p = 0.048, respectively). INTERPRETATION: Addressing modifiable factors to reduce time is important given that time to initiate treatment is associated with better outcomes. Quality improvement strategies should be aimed at coordinated provincial resource sharing, pairing referrals with nearest available apheresis centres, and creating efficiency in the interval between patient acceptance and arrival.