Predicting Outcomes for Interhospital Transferred Patients of Emergency General Surgery.

Background: Interhospital transferred (IHT) emergency general surgery (EGS) patients are associated with high care intensity and mortality. However, prior studies do not focus on patient-level data. Our study, using each IHT patient's data, aimed to understand the underlying cause for IHT EGS patients' outcomes. We hypothesized that transfer origin of EGS patients impacts outcomes due to critical illness as indicated by higher Sequential Organ Failure Assessment (SOFA) score and disease severity. Materials and Methods: We conducted a retrospective analysis of all adult patients transferred to our quaternary academic center's EGS service from 01/2014 to 12/2016. Only patients transferred to our hospital with EGS service as the primary service were eligible. We used multivariable logistic regression and probit analysis to measure the association of patients' clinical factors and their outcomes (mortality and survivors' hospital length of stay [HLOS]). Results: We analyzed 708 patients, 280 (39%) from an ICU, 175 (25%) from an ED, and 253 (36%) from a surgical ward. Compared to ED patients, patients transferred from the ICU had higher mean (SD) SOFA score (5.7 (4.5) vs. 2.39 (2), P < 0.001), longer HLOS, and higher mortality. Transferring from ICU (OR 2.95, 95% CI 1.36-6.41, P=0.006), requiring laparotomy (OR 1.96, 95% CI 1.04-3.70, P=0.039), and SOFA score (OR 1.22, 95% CI 1.13-1.32, P < 0.001) were associated with higher mortality. Conclusions: At our academic center, patients transferred from an ICU were more critically ill and had longer HLOS and higher mortality. We identified SOFA score and a few conditions and diagnoses as associated with patients' outcomes. Further studies are needed to confirm our observation.

Effect of Blood Pressure Variability on Outcomes in Emergency Patients with Intracranial Hemorrhage.

INTRODUCTION: Patients with spontaneous intracranial hemorrhage (sICH) have high mortality and morbidity, which are associated with blood pressure variability. Additionally, blood pressure variability is associated with acute kidney injury (AKI) in critically ill patients, but its association with sICH patients in emergency departments (ED) is unclear. Our study investigated the association between blood pressure variability in the ED and the risk of developing AKI during sICH patients' hospital stay. METHODS: We retrospectively analyzed patients with sICH, including those with subarachnoid and intraparenchymal hemorrhage, who were admitted from any ED and who received an external ventricular drain at our academic center. Patients were identified by the International Classification of Diseases, Ninth Revision (ICD-9). Outcomes were the development of AKI, mortality, and being discharged home. We performed multivariable logistic regressions to measure the association of clinical factors and interventions with outcomes. RESULTS: We analyzed the records of 259 patients: 71 (27%) patients developed AKI, and 59 (23%) patients died. Mean age (± standard deviation [SD]) was 58 (14) years, and 150 (58%) were female. Patients with AKI had significantly higher blood pressure variability than patients without AKI. Each millimeter of mercury increment in one component of blood pressure variability, SD in systolic blood pressure (SBPSD), was significantly associated with 2% increased likelihood of developing AKI (odds ratio [OR] 1.02, 95% confidence interval [CI], 1.005-1.03, p = 0.007). Initiating nicardipine infusion in the ED (OR 0.35, 95% CI, 0.15-0.77, p = 0.01) was associated with lower odds of in-hospital mortality. No ED interventions or blood pressure variability components were associated with patients' likelihood to be discharged home. CONCLUSION: Our study suggests that greater SBPSD during patients' ED stay is associated with higher likelihood of AKI, while starting nicardipine infusion is associated with lower odds of in-hospital mortality. Further studies about interventions and outcomes of patients with sICH in the ED are needed to confirm our observations.

Factors associated with refractory pain in emergency patients admitted to emergency general surgery.

BACKGROUND: Oligoanalgesia in emergency departments (EDs) is multifactorial. A previous study reported that emergency providers did not adequately manage patients with severe pain despite objective findings for surgical pathologies. Our study aims to investigate clinical and laboratory factors, in addition to providers' interventions, that might have been associated with oligoanalgesia in a group of ED patients with moderate and severe pains due to surgical pathologies. METHODS: We conducted a retrospective study of adult patients who were transferred directly from referring EDs to the emergency general surgery (EGS) service at a quaternary academic center between January 2014 and December 2016. Patients who were intubated, did not have adequate records, or had mild pain were excluded. The primary outcome was refractory pain, which was defined as pain reduction <2 units on the 0-10 pain scale between triage and ED departure. RESULTS: We analyzed 200 patients, and 58 (29%) had refractory pain. Patients with refractory pain had significantly higher disease severity, serum lactate (3.4±2.0 mg/dL vs. 1.4±0.9 mg/dL, P=0.001), and less frequent pain medication administration (median [interquartile range], 3 [3-5] vs. 4 [3-7], P=0.001), when compared to patients with no refractory pain. Multivariable logistic regression showed that the number of pain medication administration (odds ratio [OR] 0.80, 95% confidence interval [95% CI] 0.68-0.98) and ED serum lactate levels (OR 3.80, 95% CI 2.10-6.80) were significantly associated with the likelihood of refractory pain. CONCLUSIONS: In ED patients transferring to EGS service, elevated serum lactate levels were associated with a higher likelihood of refractory pain. Future studies investigating pain management in patients with elevated serum lactate are needed.

Ground Same Intratransport Efficacy as Air for Acute Aortic Diseases.

INTRODUCTION: Patients with acute aortic diseases (AAoD) usually require transfer to tertiary centers for possible surgical care, for which intratransport management represents important continuing spectrum of care. There is little information comparing intratransport efficacy of air (ART) vs ground transport (GRT), nor how effectively they manage these patients' pain. Our study aims to compare how effective ART and GRT manage patients' intratransport HR, pressure. METHODS: Charts were reviewed of adult patients interhospital transferred to a quaternary academic center (UMMC) between 01/01/2011 and 09/30/2015. Outcomes were percentages of patients achieving target hemodynamic parameters, mortality. RESULTS: We analyzed 226 patients, 58 (26%) transported by Air and 102 (45%) type A dissection. Ground transport was associated with higher percentage of patients with target HR 60-80 bpm comparing to ART (58% vs 43%, 95% CI 0.3-0.99). Both ART and GRT were associated with similar frequencies of patients achieving target SBP and adequate pain control. Time intervals from transfer request to surgery, and mortality were similar for both types of transport. CONCLUSION: Ground transport teams were more successful at achieving predefined target heart rate than Air transport. Intra-transport management of other vital signs and pain were equally effectively between both Air and Ground transport.

Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection.

BACKGROUND: Acute aortic dissection (AoD) is a hypertensive emergency often requiring the transfer of patients to higher care hospitals; thus, clinical care documentation and compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) is crucial. The study assessed emergency providers (EP) documentation of clinical care and EMTALA compliance among interhospital transferred AoD patients. METHODS: This retrospective study examined adult patients transferred directly from a referring emergency department (ED) to a quaternary academic center between January 1, 2011 and September 30, 2015. The primary outcome was the percentage of records with adequate documentation of clinical care (ADoCC). The secondary outcome was the percentage of records with adequate documentation of EMTALA compliance (ADoEMTALA). RESULTS: There were 563 electronically identified patients with 287 included in the final analysis. One hundred and five (36.6%) patients had ADoCC while 166 (57.8%) patients had ADoEMTALA. Patients with inadequate documentation of EMTALA (IDoEMTALA) were associated with a higher likelihood of not meeting the American Heart Association (AHA) ED Departure SBP guideline (OR 1.8, 95% CI 1.03-3.2, P=0.04). Male gender, handwritten type of documentation, and transport by air were associated with an increased risk of inadequate documentation of clinical care (IDoCC), while receiving continuous infusion was associated with higher risk of IDoEMTALA. CONCLUSION: Documentation of clinical care and EMTALA compliance by Emergency Providers is poor. Inadequate EMTALA documentation was associated with a higher likelihood of patients not meeting the AHA ED Departure SBP guideline. Therefore, Emergency Providers should thoroughly document clinical care and EMTALA compliance among this critically ill group before transfer.