Impact of COVID-19 pandemic on interhospital transfer of patients with major trauma in Korea: a retrospective cohort study.

BACKGROUND: Interhospital transfer (IHT) is necessary for providing ultimate care in the current emergency care system, particularly for patients with severe trauma. However, studies on IHT during the pandemic were limited. Furthermore, evidence on the effects of the coronavirus disease 2019 (COVID-19) pandemic on IHT among patients with major trauma was lacking. METHOD: This retrospective cohort study was conducted in an urban trauma center (TC) of a tertiary academic affiliated hospital in Daegu, Korea. The COVID-19 period was defined as from February 1, 2020 to January 31, 2021, whereas the pre-COVID-19 period was defined as the same duration of preceding span. Clinical data collected in each period were compared. We hypothesized that the COVID-19 pandemic negatively impacted IHT. RESULTS: A total of 2,100 individual patients were included for analysis. During the pandemic, the total number of IHTs decreased from 1,317 to 783 (- 40.5%). Patients were younger (median age, 63 [45-77] vs. 61[44-74] years, p = 0.038), and occupational injury was significantly higher during the pandemic (11.6% vs. 15.7%, p = 0.025). The trauma team activation (TTA) ratio was higher during the pandemic both on major trauma (57.3% vs. 69.6%, p = 0.006) and the total patient cohort (22.2% vs. 30.5%, p < 0.001). In the COVID-19 period, duration from incidence to the TC was longer (218 [158-480] vs. 263[180-674] minutes, p = 0.021), and secondary transfer was lower (2.5% vs. 0.0%, p = 0.025). CONCLUSION: We observed that the total number of IHTs to the TC was reduced during the COVID-19 pandemic. Overall, TTA was more frequent, particularly among patients with major trauma. Patients with severe injury experienced longer duration from incident to the TC and lesser secondary transfer from the TC during the COVID-19 pandemic.

Transition of care from post-acute services for the older adults in Quebec: a pilot impact evaluation.

BACKGROUND: Early discharge of frail older adults from post-acute care service may result in individuals' reduced functional ability to carry out activities of daily living, and social, emotional, and psychological distress. To address these shortcomings, the Montreal West Island Integrated University Health and Social Services Centre in Quebec, Canada piloted a post-acute home physiotherapy program (PAHP) to facilitate the transition of older adults from the hospital to their home. This study aimed to evaluate: (1) the implementation fidelity of the PAHP program; (2) its impact on the functional independence, physical and mental health outcomes and quality of life of older adults who underwent this program (3) its potential adverse events, and (4) to identify the physical, psychological, and mental health care needs of older adults following their discharge at home. METHODS: A quasi-experimental uncontrolled design with repeated measures was conducted between April 1st, 2021 and December 31st, 2021. Implementation fidelity was assessed using three process indicators: delay between referral to and receipt of the PAHP program, frequency of PAHP interventions per week and program duration in weeks. A battery of functional outcome measures, including the Functional Independence Measure (FIM) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 scale, as well as fall incidence, emergency visits, and hospitalizations were used to assess program impact and adverse events. The Patient's Global Impression of Change (PGICS) was used to determine changes in participants' perceptions of their level of improvement/deterioration. In addition, the Camberwell Assessment of Need for the Elderly (CANE) questionnaire was administered to determine the met and unmet needs of older adults. RESULTS: Twenty-four individuals (aged 60.8 to 94 years) participated in the PAHP program. Implementation fidelity was low in regards with delay between referral and receipt of the program, intensity of interventions, and total program duration. Repeated measures ANOVA revealed significant improvement in FIM scores between admission and discharge from the PAHP program and between admission and the 3-month follow-up. Participants also reported meaningful improvements in PGICS scores. However, no significant differences were observed on the physical or mental health T-scores of the PROMIS Global-10 scale, in adverse events related to the PAHP program, or in the overall unmet needs. CONCLUSION: Findings from an initial sample undergoing a PAHP program suggest that despite a low implementation fidelity of the program, functional independence outcomes and patients' global impression of change have improved. Results will help develop a stakeholder-driven action plan to improve this program. A future study with a larger sample size is currently being planned to evaluate the overall impact of this program. CLINICAL TRIAL REGISTRATION: Retrospectively registered NCT05915156 (22/06/2023).

Estudio sobre las características de la información sanitaria en las conducciones entre centros penitenciario / Study of the characteristics of medical information in transfers between prisons

Introducción: La movilidad de la población penitenciaria precisa que la información transmitida en los traslados entre centros garantice una óptima continuidad asistencial. Objetivo: Valorar la calidad de la transmisión de información sanitaria cuando los internos son trasladados en conducción entre centros penitenciarios de todo el territorio español. Material y método: Estudio observacional, descriptivo y transversal, consistente en la revisión de historias clínicas de los internos que transitaron por el Centro Penitenciario (CP) Madrid III en un periodo de tres meses. Todas las variables medidas fueron cualitativas, expresadas en frecuencias absolutas y relativas. Resultados: Durante ese tiempo, 1.168 internos transitaron por el CP Madrid III. Solo 21 procedían de centros penitenciarios de Cataluña, País Vasco o Navarra, cuya historia clínica es diferente a la del resto del Estado, y solo el 57,14% aportaban algún tipo de información sanitaria. Del resto de internos, el 70,79% aportaba algún tipo de información: el 63,90% del total tenía medicación prescrita y el 5% metadona. De aquellos que tenían medicación, el 89,10% la tenían prescrita en la prescripción electrónica, siendo correcta en el 98% de los casos. Respecto a la metadona, solo el 75,44% lo tenía prescrito electrónicamente, siendo correcta en todos los casos. La fecha de la última dosis administrada solo se indicó en el 72,40% de los tratamientos. Discusión: Solo el 34,70% de las historias presentaban una calidad óptima en cuanto a la información transmitida, siendo en el 2,50% de los casos la información recibida deficiente. El uso de herramientas informáticas facilita la transmisión de la información, reduce la carga de trabajo y mejora la seguridad del paciente.(AU)

Introduction: The mobility of the prison population creates a need for information transmitted in transfers between centers that can guarantee optimal care continuity. Objective: To assess the quality of transmission of health information when inmates are transferred between prisons in Spain. Material and method: Observational, descriptive and cross-sectional study, consisting of a review of medical records of inmates who passed through Madrid III Prison in a three-month period. All measured variables were qualitative, and were expressed in absolute and relative frequencies. Results: 1,168 inmates passed through Madrid III Prison in this period. Only 21 came from prisons in Catalonia, the Basque Country or Navarre, where their medical records are different from those in the rest of Spain, and only 57.14% provided some type of health information. Of the remaining inmates, 70.79% provided some type of information: 63.90% of the total had prescriptions for medication and 5% were prescribed with methadone. Of those taking medication, 89.10% were prescribed it in electronic prescriptions, which were correct in 98% of the cases. For methadone, only 75.44% had electronic prescriptions,which were correct in all cases. The date of the last dose administered was only indicated in 72.40% of the treatments. Discussion: Only 34.70% of the records presented optimal quality in terms of the information transmitted, and in 2.50% of the cases the information received was deficient. The use of computerized tools facilitates the transmission of information, reduces the workload and improves patient safety.(AU)

Original Research: Breaking Through the Bottleneck: Acuity Adaptability in Noncritical Trauma Care.

BACKGROUND: Achieving efficient throughput of patients is a challenge faced by many hospital systems. Factors that can impede efficient throughput include increased ED use, high surgical volumes, lack of available beds, and the complexities of coordinating multiple patient transfers in response to changing care needs. Traditionally, many hospital inpatient units operate via a fixed acuity model, relying on multiple intrahospital transfers to move patients along the care continuum. In contrast, the acuity-adaptable model allows care to occur in the same room despite fluctuations in clinical condition, removing the need for transfer. This model has been shown to be a safe and cost-effective approach to improving throughput in populations with predictable courses of hospitalization, but has been minimally evaluated in other populations, such as patients hospitalized for traumatic injury. PURPOSE: This quality improvement project aimed to evaluate implementation of an acuity-adaptable model on a 20-bed noncritical trauma unit. Specifically, we sought to examine and compare the pre- and postimplementation metrics for throughput efficiency, resource utilization, and nursing quality indicators; and to determine the model's impact on patient transfers for changes in level of care. METHODS: This was a retrospective, comparative analysis of 1,371 noncritical trauma patients admitted to a level 1 trauma center before and after the implementation of an acuity-adaptable model. Outcomes of interest included throughput efficiency, resource utilization, and quality of nursing care. Inferential statistics were used to compare patients pre- and postimplementation, and logistic regression analyses were performed to determine the impact of the acuity-adaptable model on patient transfers. RESULTS: Postimplementation, the median ED boarding time was reduced by 6.2 hours, patients more often remained in their assigned room following a change in level of care, more progressive care patient days occurred, fall and hospital-acquired pressure injury index rates decreased respectively by 0.9 and 0.3 occurrences per 1,000 patient days, and patients were more often discharged to home. Logistic regression analyses revealed that under the new model, patients were more than nine times more likely to remain in the same room for care after a change in acuity and 81.6% less likely to change rooms after a change in acuity. An increase of over $11,000 in average daily bed charges occurred postimplementation as a result of increased progressive care-level bed capacity. CONCLUSIONS: The implementation of an acuity-adaptable model on a dedicated noncritical trauma unit improved throughput efficiency and resource utilization without sacrificing quality of care. As hospitals continue to face increasing demand for services as well as numerous barriers to meeting such demand, leaders remain challenged to find innovative ways to optimize operational efficiency and resource utilization while ensuring delivery of high-quality care. The findings of this study demonstrate the value of the acuity-adaptable model in achieving these goals in a noncritical trauma care population.

Characterizing changes to older adults' care transition patterns from hospital to home care in the initial year of COVID-19.

BACKGROUND: Skilled home healthcare (HH) provided in-person care to older adults during the COVID-19 pandemic, yet little is known about the pandemic's impact on HH care transition patterns. We investigated pandemic impact on (1) HH service volume; (2) population characteristics; and (3) care transition patterns for older adults receiving HH services after hospital or skilled nursing facility (SNF) discharge. METHODS: Retrospective, cohort, comparative study of recently hospitalized older adults (≥ 65 years) receiving HH services after hospital or SNF discharge at two large HH agencies in Baltimore and New York City (NYC) 1-year pre- and 1-year post-pandemic onset. We used the Outcome and Assessment Information Set (OASIS) and service use records to examine HH utilization, patient characteristics, visit timeliness, medication issues, and 30-day emergency department (ED) visit and rehospitalization. RESULTS: Across sites, admissions to HH declined by 23% in the pandemic's first year. Compared to the year prior, older adults receiving HH services during the first year of the pandemic were more likely to be younger, have worse mental, respiratory, and functional status in some areas, and be assessed by HH providers as having higher risk of rehospitalization. Thirty-day rehospitalization rates were lower during the first year of the pandemic. COVID-positive HH patients had lower odds of 30-day ED visit or rehospitalization. At the NYC site, extended duration between discharge and first HH visit was associated with reduced 30-day ED visit or rehospitalization. CONCLUSIONS: HH patient characteristics and utilization were distinct in Baltimore versus NYC in the initial year of the COVID-19 pandemic. Study findings suggest some older adults who needed HH may not have received it, since the decrease in HH services occurred as SNF use decreased nationally. Findings demonstrate the importance of understanding HH agency responsiveness during public health emergencies to ensure older adults' access to care.

Care Transitions for Incarcerated Pregnant People: A Needs Assessment.

Incarcerated pregnant people face significant barriers when seeking health care services in prisons and jails, but little is known about their transitions from state prison health care systems to outside hospitals. This project analyzed current policies and procedures for care transitions for incarcerated people and presents policy recommendations to address issues of concern. We conducted in-depth interviews with stakeholders at a state prison, academic hospital, and private hospital to identify the barriers and facilitators to care transitions. Themes emerging from these interviews were operational, including medical records, communication, and education; and structural, including implicit biases and care of marginalized groups. These findings are likely applicable to similar facilities throughout the United States. A multipronged, interdisciplinary approach is needed to address challenges of care transitions.

The Acceptance and Use of Digital Technologies for Self-Reporting Medication Safety Events After Care Transitions to Home in Patients With Cancer: Survey Study.

BACKGROUND: Actively engaging patients with cancer and their families in monitoring and reporting medication safety events during care transitions is indispensable for achieving optimal patient safety outcomes. However, existing patient self-reporting systems often cannot address patients' various experiences and concerns regarding medication safety over time. In addition, these systems are usually not designed for patients' just-in-time reporting. There is a significant knowledge gap in understanding the nature, scope, and causes of medication safety events after patients' transition back home because of a lack of patient engagement in self-monitoring and reporting of safety events. The challenges for patients with cancer in adopting digital technologies and engaging in self-reporting medication safety events during transitions of care have not been fully understood. OBJECTIVE: We aim to assess oncology patients' perceptions of medication and communication safety during care transitions and their willingness to use digital technologies for self-reporting medication safety events and to identify factors associated with their technology acceptance. METHODS: A cross-sectional survey study was conducted with adult patients with breast, prostate, lung, or colorectal cancer (N=204) who had experienced care transitions from hospitals or clinics to home in the past 1 year. Surveys were conducted via phone, the internet, or email between December 2021 and August 2022. Participants' perceptions of medication and communication safety and perceived usefulness, ease of use, attitude toward use, and intention to use a technology system to report their medication safety events from home were assessed as outcomes. Potential personal, clinical, and psychosocial factors were analyzed for their associations with participants' technology acceptance through bivariate correlation analyses and multiple logistic regressions. RESULTS: Participants reported strong perceptions of medication and communication safety, positively correlated with medication self-management ability and patient activation. Although most participants perceived a medication safety self-reporting system as useful (158/204, 77.5%) and easy to use (157/204, 77%), had a positive attitude toward use (162/204, 79.4%), and were willing to use such a system (129/204, 63.2%), their technology acceptance was associated with their activation levels (odds ratio [OR] 1.83, 95% CI 1.12-2.98), their perceptions of communication safety (OR 1.64, 95% CI 1.08-2.47), and whether they could receive feedback after self-reporting (OR 3.27, 95% CI 1.37-7.78). CONCLUSIONS: In general, oncology patients were willing to use digital technologies to report their medication events after care transitions back home because of their high concerns regarding medication safety. As informed and activated patients are more likely to have the knowledge and capability to initiate and engage in self-reporting, developing a patient-centered reporting system to empower patients and their families and facilitate safety health communications will help oncology patients in addressing their medication safety concerns, meeting their care needs, and holding promise to improve the quality of cancer care.

Period of hospitalization and mortality in transferred versus non-transferred COVID-19 patients: results from Germany.

COVID-19 was a challenge for health-care systems worldwide, causing large numbers of hospitalizations and inter-hospital transfers. We studied whether transfer, as well as its reason, was associated with the duration of hospitalization in non-ICU and ICU patients. For this purpose, all patients hospitalized due to COVID-19 between August 1st and December 31st, 2021, in a network of hospitals in Southern Germany were comprehensively characterized regarding their clinical course, therapy, complications, transfers, reasons for transfer, involved levels of care, total period of hospitalization and in-hospital mortality, using univariate and multiple regression analyses. While mortality was not significantly associated with transfer, the period of hospitalization was. In non-ICU patients (n = 545), median (quartiles) time was 7.0 (4.0-11.0) in non-transferred (n = 458) and 18.0 (11.0-29.0) days in transferred (n = 87) patients (p < 0.001). In ICU patients (n = 100 transferred, n = 115 non-transferred) it was 12.0 (8.3-18.0) and 22.0 (15.0-34.0) days (p < 0.001). Beyond ECMO therapy (4.5%), reasons for transfer were medical (33.2%) or capacity (61.9%) reasons, with medical/capacity reasons in 32/49 of non-ICU and 21/74 of ICU patients. Thus, the transfer of COVID-19 patients between hospitals was associated with longer periods of hospitalization, corresponding to greater health care utilization, for which specific patient characteristics and clinical decisions played a role.

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.

Perfil clínico, abordaje y pronóstico del paciente con shock cardiogénico sometido a traslado interhospitalario en España / Clinical profile, management and outcomes of patients with cardiogenic shock undergoing transfer between centers in Spain

Introducción y objetivos El objetivo es analizar el perfil clínico, el abordaje y el pronóstico del shock cardiogénico (SC) por infarto agudo de miocardio con elevación del segmento ST (IAMCEST) que requiere traslado interhospitalario, así como el impacto pronóstico de las variables estructurales de los centros en este contexto. Métodos Se incluyó a los pacientes con SC-IAMCEST atendidos en centros con capacidad de revascularización (2016-2020). Se consideró a: a) pacientes atendidos durante todo el ingreso en hospitales con cardiología intervencionista sin cirugía cardiaca; b) pacientes atendidos en hospitales con cardiología intervencionista y cirugía cardiaca, y c) pacientes trasladados a centros con cardiología intervencionista y cirugía cardiaca. Se analizó la asociación del volumen de SC-IAMCEST atendidos y la disponibilidad de cuidados intensivos cardiológicos (UCIC) y trasplante cardiaco con la mortalidad hospitalaria. Resultados Se incluyeron 4.189 episodios, 1.389 (33,2%) del grupo A, 2.627 del grupo B (62,7%) y 173 del grupo C (4,1%). Los pacientes trasladados eran más jóvenes, tenían más riesgo cardiovascular y recibieron más frecuentemente revascularización, asistencia circulatoria y trasplante cardiaco durante el ingreso (p<0,001). Los pacientes trasladados presentaron menor tasa bruta de mortalidad (el 46,2 frente al 60,3% del grupo A y el 54,4% del grupo B; p<0,001). Mayor volumen asistencial (OR=0,75; p =0,009) y disponibilidad de UCIC (OR=0,80; p =0,047) se asociaron con menor mortalidad. Conclusiones El porcentaje de SC-IAMCEST trasladados en nuestro medio es bajo. Los pacientes trasladados son más jóvenes y reciben más procedimientos invasivos. Los traslados a centros con mayor volumen y UCIC presentan menor mortalidad. (AU)

Introduction and objectives The aim of this study was to analyze the clinical profile, management, and prognosis of ST segment elevation myocardial infarction-related cardiogenic shock (STEMI-CS) requiring interhospital transfer, as well as the prognostic impact of structural variables of the treating centers in this setting. Methods This study included patients with STEMI-CS treated at revascularization-capable centers from 2016 to 2020. The patients were divided into the following groups: group A: patients attended throughout their admission at hospitals with interventional cardiology without cardiac surgery; group B: patients treated at hospitals with interventional cardiology and cardiac surgery; and group C: patients transferred to centers with interventional cardiology and cardiac surgery. We analyzed the association between the volume of STEMI-CS cases treated, the availability of cardiac intensive care units (CICU), and heart transplant with hospital mortality. Results A total of 4189 episodes were included: 1389 (33.2%) from group A, 2627 from group B (62.7%), and 173 from group C (4.1%). Transferred patients were younger, had a higher cardiovascular risk, and more commonly underwent revascularization, mechanical circulatory support, and heart transplant during hospitalization (P<.001). The crude mortality rate was lower in transferred patients (46.2% vs 60.3% in group A and 54.4% in group B, (P<.001)). Lower mortality was associated with a higher volume of care and CICU availability (OR, 0.75, P=.009; and 0.80, P=.047). Conclusions The proportion of transfers in patients with STEMI-CS in our setting is low. Transferred patients were younger and underwent more invasive procedures. Mortality was lower among patients transferred to centers with a higher volume of STEMI-CS cases and CICU. (AU)

Community health navigator-assisted transition of care from hospital to community: protocol for a randomised controlled trial.

INTRODUCTION: The objective of this parallel group, randomised controlled trial is to evaluate a community health navigator (CHN) intervention provided to patients aged over 40 years and living with chronic health conditions to transition from hospital inpatient care to their homes. Unplanned hospital readmissions are costly for the health system and negatively impact patients. METHODS AND ANALYSIS: Patients are randomised post hospital discharge to the CHN intervention or usual care. A comparison of outcomes between intervention and control groups will use multivariate regression techniques that adjust for age, sex and any independent variables that are significantly different between the two groups, using multiple imputation for missing values. Time-to-event analysis will examine the relationship between seeing a CHN following discharge from the index hospitalisation and reduced rehospitalisations in the subsequent 60 days and 6 months. Secondary outcomes include medication adherence, health literacy, quality of life, experience of healthcare and health service use (including the cost of care). We will also conduct a qualitative assessment of the implementation of the navigator role from the viewpoint of stakeholders including patients, health professionals and the navigators themselves. ETHICS APPROVAL: Ethics approval was obtained from the Research Ethics and Governance Office, Sydney Local Health District, on 21 January 2022 (Protocol no. X21-0438 and 2021/ETH12171). The findings of the trial will be disseminated through peer-reviewed journals and national and international conference presentations. Data will be deposited in an institutional data repository at the end of the trial. This is subject to Ethics Committee approval, and the metadata will be made available on request. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN 12622000659707). ARTICLE SUMMARY: The objective of this trial is to evaluate a CHN intervention provided to patients aged over 40 years and living with chronic health conditions to transition from hospital inpatient care to their homes.

Trends in Patient Transfers From Overall and Caseload-Strained US Hospitals During the COVID-19 Pandemic.

Importance: Transferring patients to other hospitals because of inpatient saturation or need for higher levels of care was often challenging during the early waves of the COVID-19 pandemic. Understanding how transfer patterns evolved over time and amid hospital overcrowding could inform future care delivery and load balancing efforts. Objective: To evaluate trends in outgoing transfers at overall and caseload-strained hospitals during the COVID-19 pandemic vs prepandemic times. Design, Setting, and Participants: This retrospective cohort study used data for adult patients at continuously reporting US hospitals in the PINC-AI Healthcare Database. Data analysis was performed from February to July 2023. Exposures: Pandemic wave, defined as wave 1 (March 1, 2020, to May 31, 2020), wave 2 (June 1, 2020, to September 30, 2020), wave 3 (October 1, 2020, to June 19, 2021), Delta (June 20, 2021, to December 18, 2021), and Omicron (December 19, 2021, to February 28, 2022). Main Outcomes and Measures: Weekly trends in cumulative mean daily acute care transfers from all hospitals were assessed by COVID-19 status, hospital urbanicity, and census index (calculated as daily inpatient census divided by nominal bed capacity). At each hospital, the mean difference in transfer counts was calculated using pairwise comparisons of pandemic (vs prepandemic) weeks in the same census index decile and averaged across decile hospitals in each wave. For top decile (ie, high-surge) hospitals, fold changes (and 95% CI) in transfers were adjusted for hospital-level factors and seasonality. Results: At 681 hospitals (205 rural [30.1%] and 476 urban [69.9%]; 360 [52.9%] small with <200 beds and 321 [47.1%] large with ≥200 beds), the mean (SD) weekly outgoing transfers per hospital remained lower than the prepandemic mean of 12.1 (10.4) transfers per week for most of the pandemic, ranging from 8.5 (8.3) transfers per week during wave 1 to 11.9 (10.7) transfers per week during the Delta wave. Despite more COVID-19 transfers, overall transfers at study hospitals cumulatively decreased during each high national surge period. At 99 high-surge hospitals, compared with a prepandemic baseline, outgoing acute care transfers decreased in wave 1 (fold change -15.0%; 95% CI, -22.3% to -7.0%; P < .001), returned to baseline during wave 2 (2.2%; 95% CI, -4.3% to 9.2%; P = .52), and displayed a sustained increase in subsequent waves: 19.8% (95% CI, 14.3% to 25.4%; P < .001) in wave 3, 19.2% (95% CI, 13.4% to 25.4%; P < .001) in the Delta wave, and 15.4% (95% CI, 7.8% to 23.5%; P < .001) in the Omicron wave. Observed increases were predominantly limited to small urban hospitals, where transfers peaked (48.0%; 95% CI, 36.3% to 60.8%; P < .001) in wave 3, whereas large urban and small rural hospitals displayed little to no increases in transfers from baseline throughout the pandemic. Conclusions and Relevance: Throughout the COVID-19 pandemic, study hospitals reported paradoxical decreases in overall patient transfers during each high-surge period. Caseload-strained rural (vs urban) hospitals with fewer than 200 beds were unable to proportionally increase transfers. Prevailing vulnerabilities in flexing transfer capabilities for care or capacity reasons warrant urgent attention.

Effect of Delirium on Interhospital Transfer Outcomes.

OBJECTIVES: Interhospital transfer (IHT) and in-hospital delirium are both independently associated with increased length of stay (LOS), mortality, and discharge to facility. Our objective was to investigate the joint effects between IHT and the presence of in-hospital delirium on the outcomes of LOS, discharge to a facility, and in-hospital mortality. METHODS: This was a single-center retrospective cohort study of 25,886 adult hospital admissions at a tertiary-care academic medical center. Staged multivariable logistic and linear regression models were used to evaluate the association between IHT status and the outcomes of discharge to a facility, LOS, and mortality while considering the joint impact of delirium. The joint effects of IHT status and delirium were evaluated by categorizing patients into one of four categories: emergency department (ED) admissions without delirium, ED admissions with delirium, IHT admissions without delirium, and IHT admissions with delirium. The primary outcomes were LOS, in-hospital mortality, and discharge disposition. RESULTS: The odds of discharge to a facility were 4.48 times higher in admissions through IHT with delirium when compared with ED admissions without delirium. IHT admissions with delirium had a 1.97-fold (95% confidence interval 1.88-2.06) longer LOS when compared with admission through the ED without delirium. Finally, admissions through IHT with delirium had 3.60 (95% confidence interval 2.36-5.49) times the odds of mortality when compared with admissions through the ED without delirium. CONCLUSIONS: The relationship between IHT and delirium is complex, and patients with IHT combined with in-hospital delirium are at high risk of longer LOS, discharge to a facility, and mortality.

Insights from an advisory board: Facilitating transition of care into adulthood in brain cancer survivors with acquired pediatric growth hormone deficiency.

OBJECTIVE: Children with growth hormone deficiency (GHD) face multiple challenges that can negatively impact the transition from pediatric to adult endocrinology care. For children with GHD resulting from brain cancer or its treatment, the involvement of oncology care providers and possible disease-related comorbidities add further complexity to this transition. DESIGN: An advisory board of pediatric and adult endocrinologists was convened to help better understand the unique challenges faced by childhood cancer survivors with GHD, and discuss recommendations to optimize continuity of care as these patients proceed to adulthood. Topics included the benefits and risks of growth hormone (GH) therapy in cancer survivors, the importance of initiating GH replacement therapy early in the patient's journey and continuing into adulthood, and the obstacles that can limit an effective transition to adult care for these patients. RESULTS/CONCLUSIONS: Some identified obstacles included the need to prioritize cancer treatment over treatment for GHD, a lack of patient and oncologist knowledge about the full range of benefits provided by long-term GH administration, concerns about tumor recurrence risk in cancer survivors receiving GH treatment, and suboptimal communication and coordination (e.g., referrals) between care providers, all of which could potentially result in treatment gaps or even complete loss of follow-up during the care transition. Advisors provided recommendations for increasing education for patients and care providers and improving coordination between treatment team members, both of which are intended to help improve continuity of care to maximize the health benefits of GH administration during the critical period when childhood cancer survivors transition into adulthood.

Mapping the Discharge Process After Surgery.

Importance: Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process. Objective: To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery. Design, Setting, and Participants: This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide. Exposure: Postoperative hospital discharge. Main Outcomes and Measures: Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings. Results: At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination. Conclusions and Relevance: These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.

Clinical Issues - March 2024.

Exoskeleton use in the OR Key words: exoskeleton, exosuit, ergonomics, musculoskeletal injury, fatigue and pain. The Revised National Institute for Occupational Safety and Health Lifting Equation Key words: ergonomic risk, Revised NIOSH Lifting Equation (RNLE), lifting index (LI), load, lifting task. Surgical smoke safety during transurethral resection of the prostate procedures Key words: surgical smoke, smoke evacuation, transurethral resection of the prostate (TURP), vaporization, resectoscope. Preventing accidental dislodgement of tubes, drains, and catheters Key words: patient transfer, dislodgement, catheters, tubes, drains.

Incorporating the Six Core Elements of Health Care Transition in Type 1 Diabetes Care for Emerging Adults.

A growing body of literature finds persistent problems in the provision of recommended health care transition services, as well as adverse outcomes associated with the lack of these services in emerging adults with type 1 diabetes. The Six Core Elements of Health Care Transition offers a structured approach to the phases of health care transition support for both pediatric and adult diabetes practices. This article reviews strategies to incorporate the Six Core Elements into ambulatory diabetes care to support successful health care transition for emerging adults with type 1 diabetes.