Emergency department interventions that could be conducted in subacute care settings for patients with nonemergent conditions transported by paramedics: a modified Delphi study.

BACKGROUND: As the number of patients with nonemergent conditions who are transported by paramedics continues to increase in Ontario, redirecting specific patients to subacute settings may be more beneficial and suitable for both patients and emergency departments. We aimed to evaluate whether emergency department interventions conducted on patients with nonemergent conditions who are transported by paramedics could be conducted in subacute health centres. METHODS: We conducted a RAND/UCLA modified Delphi study in Ontario between Oct. 13 and Dec. 19, 2020. We used purposive sampling to recruit practising emergency and primary care physicians for an expert panel. We abstracted interventions given to adult patients with nonemergent conditions (18 yr of age or older) who were transported by paramedics to an emergency department from the National Ambulatory Care Reporting System (NACRS) database (Jan. 1, 2014, to Mar. 31, 2018). Participants in the expert panel rated the suitability of the 150 most frequently recorded emergency department interventions from the NACRS database, for completion in subacute health care centres. We set consensus at 70% agreement. RESULTS: We invited 25 physician experts, 21 of whom consented to participate; 20 physicians completed round 1, and 18 physicians completed both rounds. After 2 rounds, consensus was reached on 146 (97.3%) interventions; 103 interventions (68.7%) were suitable for subacute centres, 43 (28.7%) for only the emergency department and 4 (2.6%) did not receive consensus. For subacute centres, all 103 interventions were rated for urgent care centres; walk-in medical centres were applicable for 46 (30.6%) interventions and clinics led by nurse practitioners for 47 (31.3%) interventions. INTERPRETATION: Most interventions provided to patients with nonemergent conditions transported by paramedics to emergency departments were identified as suitable for urgent care clinics, with one-third being suitable for either walk-in medical centres or clinics led by nurse practitioners. This study has potential to inform a patient classification model for paramedic-initiated redirection of patients from emergency departments, although further contextualization is required for this to be implemented in clinical practice. STUDY REGISTRATION: ID ISRCTN22901977.

Interhospital Transfer of Patients With Acute Pulmonary Embolism: Challenges and Opportunities.

Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.

Hospital outcomes of children admitted to intensive care in British Columbia via interfacility transfer versus direct admission from 2015 to 2017: a descriptive analysis.

BACKGROUND: Pediatric intensive care relies on having experienced and effective transport systems to transfer critically ill children to the appropriate centre for care. Our aim was to compare hospital outcomes among children admitted directly to a pediatric intensive care unit (PICU) with those of children transferred from another facility. METHODS: We conducted a descriptive study using electronic medical records and the PICU database from the BC Children's Hospital. Patients admitted to the PICU from January 2015 to December 2017 were included. We excluded patients who were admitted electively, were admitted for recovery postoperatively, or had inconsistent or out-of-range addresses. We compared hospital mortality rates, use of mechanical ventilation within 24 hours of admission and length of PICU stay between children admitted directly from the BC Children's Hospital emergency department and those transferred from a referring institution. RESULTS: During the study period, there were 870 unique admissions comprising 386 direct admissions and 484 transferred patients. Transported patients were younger, were more critically ill on presentation and required longer stays. The proportions of children who died and of children who required mechanical ventilation within 24 hours of admission were higher in the transported group than in the group admitted directly from the emergency department (8.3% v. 3.9%, p = 0.008, and 75.8% v. 58.0%, p < 0.001, respectively). INTERPRETATION: Mortality rate and use of intensive care resources were higher among children who were transported. Further research is needed to examine the key factors driving the differences in outcomes, including the severity of illness on first presentation, transport team composition, and transport distance and duration.

Warning system improve the clinical outcomes in transfer patients with ST-segment elevation myocardial infarction.

ABSTRACT: A warning system included directly faxing electrocardiography information to the mobile phone immediately after an ST-segment elevation myocardial infarction (STEMI) diagnosis was made at a non-percutaneous coronary intervention (PCI) capable hospital. This study aimed to explore the outcomes after using a warning system in transfer STEMI patients.From October 2013 to December 2016, 667 patients experienced a STEMI event and received primary PCI at our institution. 274 patients who were divided into transfer group were transferred from non-PCI capable hospitals and connected to a first-line cardiovascular doctor by the warning system. Other 393 patients were divided into the non-transfer group.The transfer group still had a longer pain-to-reperfusion time and presented higher troponin-I level when compared with non-transfer group. There was no significant difference in the use of drug-eluting stent and procedural devices between non-transfer and transfer groups. The prevalence of different anti-platelet agents loading did not differ between non-transfer and transfer groups. Non-significant trend about higher prevalence of statin use was noted in transfer group (78.9% vs 86.1%, P = .058). The transfer group presented similar clinical short-term results regarding both cardiovascular and all-cause mortality when comparing with non-transfer group. The transfer group provided non-significant trend about lower one-year cardiovascular mortality (10.7% vs 6.2%, P = .052) and lower all-cause mortality (12.2% vs 6.9%, P = .026) when compared with non-transfer group. There was a significant difference in the Kaplan-Meier curve of 1-year cardiovascular mortality between the transfer group and the non-transfer group (P = .049).After using the warning system, the inter-facility transfer group had comparable outcomes even though a longer pain-to-reperfusion time and a higher peak troponin-I level when comparing with non-transfer group.

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.

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.

Analysis of European Air Medical Evacuation Flights of Coronavirus Disease 2019 Patients.

OBJECTIVE: As part of the humanitarian response to the coronavirus disease 2019 (COVID-19) pandemic, the German and French Armed Forces provided air transport for patients from overwhelmed regional hospitals in Italy and France. The objective of this study was to analyze the characteristics of the missions and the medical conditions of COVID-19 patients transported during an air medical evacuation on fixed wing aircraft in March and April 2020. METHOD: This was a retrospective analysis of transport records as well as other documents for 58 COVID-19 patients requiring artificial ventilation. RESULTS: The median age of the transported patients was 61.5 years, and 61% of them had preexisting medical conditions. They had been ventilated for a median of 5 days and experienced the first symptoms 18 days before transport. The patients flown out of France had less days of ventilation before flight, a lower end-tidal carbon dioxide level at the beginning of the flight, and a lower Charlson Comorbidity Index. There were also some differences between the ventilation and the flight level flown by the 2 air forces. CONCLUSION: The intensive care transport of ventilated COVID-19 patients requires highly qualified personnel and appropriate equipment and should be planned appropriately.

Improving community care for patients discharged from hospital through zone-wide implementation of a seamless care transition policy.

BACKGROUND: Several studies within the psychiatry literature have illustrated the importance of discharge planning and execution, as well as accessibility of outpatient follow-up post-discharge. We report the results of implementing a new seamless care transition policy to expedite post-discharge follow-up in the community Addiction and Mental Health (AMH) program in the Edmonton Zone, Alberta, Canada. The policy involved a distribution mechanism for assessment by a mental health therapist (MHT) within 7 days of discharge as well as a dedicated roster of community psychiatrists to accept newly discharged patients. OBJECTIVE: Our aim was to assess the feasibility of this novel policy and to assess its effect on our outcome measures of wait time to first outpatient MHT assessment and re-admission rate to hospital. METHODS: Our study involved a retrospective clinical audit with total sampling design and a comparison of data 1 year before (2015/2016 fiscal year) and 1 year after (2017/2018 fiscal year) the implementation of the seamless care policy within the Edmonton Zone. Extracted data were analyzed with simple descriptive statistics and presented as percentages, mean and median. RESULTS: Overall, with the enactment of this policy, follow-up volumes ultimately increased, while wait times for initial assessment decreased on average for patients discharged from the hospital. In the 2015/2016 fiscal year, MHT completed 128 assessments of post-discharge patients who were new to the community AMH program compared to 298 completed new assessments for the 2017/2018 fiscal year. The corresponding wait times for the new MHT assessments were 12.7 days (median of 12 days) and 7.8 days (median of 6 days), respectively. Similarly, psychiatrists completed only 59 assessments of post-discharge patients who were new to AMH compared to 133 new psychiatric assessments for the 2017/2018 fiscal year. The corresponding wait times for the new psychiatric assessments were 15.3 days (median of 14 days) and 8.8 days (median of 7 days), respectively. We correspondingly found a slight decline in readmission rates after the implementation of our model in the subsequent fiscal year. CONCLUSION: We envision that this policy will set a precedent with regard to streamlining post-discharge follow-up care for admitted inpatients, ultimately improving mental health outcomes for patients.

Applying Geriatric Principles to Transitions of Care in the Emergency Department.

Each emergency department (ED) visit represents a crucial transition of care for older adults. Systems, provider, and patient factors are barriers to safe transitions and can contribute to morbidity and mortality in older adults. Safe transitions from ED to inpatient, ED to skilled nursing facility, or ED back to the community require a holistic approach, such as the 4-Ms model-what matters (patient goals of care), medication, mentation, and mobility-along with safety and social support. Clear written and verbal communication with patients, caregivers, and other members of the interdisciplinary team is paramount in ensuring successful care transitions.

Initiation of an inter-hospital extracorporeal membrane oxygenation transfer programme for critically ill patients with coronavirus disease 2019: bringing extracorporeal membrane oxygenation support to peripheral hospitals.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) is a resource-intensive, highly specialized and expensive therapy that is often reserved for high-volume centres. In recent years, we established an inter-hospital ECMO transfer programme that enables ECMO implants in peripheral hospitals. During the pandemic, the programme was expanded to include ECMO support in selected critically ill patients with coronavirus disease 2019 (COVID-19). METHODS: This retrospective single-centre study reports the technical details and challenges encountered during our initial experience with ECMO implants in peripheral hospitals for patients with COVID-19. RESULTS: During March and April 2020, our team at the University Hospital of Zurich performed 3 out-of-centre ECMO implants at different peripheral hospitals. The implants were performed without any complications. The patients were transported by ambulance or helicopter. Good preparation and selection of the required supplies are the keys to success. The implant should be performed by a well-trained, seasoned ECMO team, because options are limited in most peripheral hospitals. CONCLUSIONS: Out-of-centre ECMO implants in well-selected patients with COVID-19 is feasible and safe if a well-established organization is available and if the implantation is done by an experienced and regularly trained team.

Caring for critically ill patients during interhospital transfers: A qualitative study.

BACKGROUND: The coronavirus pandemic has resulted in an increased number of interhospital transfers of patients with artificial airways. The transfer of these patients is associated with risks and has been experienced as highly challenging, which needs to be further explored. AIMS AND OBJECTIVES: To describe critical care nurses' experiences of caring for critically ill patients with artificial airways during interhospital transfers. DESIGN: A cross-sectional study using a qualitative approach was conducted during spring 2020. Participants were critical care nurses (n = 7) from different hospitals (n = 2). METHODS: The data were collected through semi-structured interviews based on an interview guide. A qualitative content analysis using an inductive approach was performed. RESULTS: The analysis resulted in one main theme, "Preserving the safety in an unknown environment," and three sub-themes, "Being adequately prepared is essential to feel secure," "Feeling abandoned and overwhelmingly responsible," and "Being challenged in an unfamiliar and risky environment." CONCLUSIONS: Critical care nurses experienced interhospital transfers of critically ill patients with artificial airways as complex and risky. It is essential to have an overall plan in order to prevent any unpredictable and acute events. Adequate communication and good teamwork are key to the safe transfer of a critically ill patient in that potential complications and dangers to the patient can be prevented. RELEVANCE TO CLINICAL PRACTICE: Standardized checklists need to be created to guide the transfers of critically ill patients with different conditions. This would prevent failures based on human or system factors, such as lack of experience and lack of good teamwork.

Eastern association for the surgery of trauma - quality, patient safety, and outcomes committee - transitions of care: healthcare handoffs in trauma.

BACKGROUND: Handoffs are defined as the transfer of patient information, professional responsibility, and accountability between caregivers. This work aims to clarify the current state of transitions of care related to the management of trauma patients. METHODS: A PubMed database and web search were performed for articles published between 2000 and 2020 related to handoffs and transitions of care. The key search terms used were: handoff(s), handoff(s) AND healthcare, and handoff(s) AND trauma. A total of 55 studies were included in qualitative synthesis. RESULTS: This systematic review explores the current state of healthcare handoffs for trauma patients. Factors found to impact successful handoffs included process standardization, team member accountability, effective communication, and the incorporation of culture. This review was limited by the small number of prospective randomized studies available on the topic. CONCLUSION: Handoffs in trauma care have been studied and should be utilized in the context of published experience and practice. Standardization when applied with accountability has proven benefit to reduce communication errors during these transfers of care.

Evaluation and optimization of a clinical pharmacist driven transitions of care model for malignant hematology.

PURPOSE: To implement and optimize a pilot transitions of care model for scheduled chemotherapy admissions in patients with hematologic malignancies at our institution.Methodology: We utilized the plan-do-study-act (PDSA) quality improvement technique to prospectively measure success of interventions related to improving transitions of care processes that occurred in multiple stages including development of standardized operating procedures, electronic medical record documentation, and education to the malignant hematology multidisciplinary group. Chart review was performed retrospectively for at least nine patients per PDSA cycle. Areas of intervention addressed and measured regarding communication between the ambulatory care and acute care settings included: admission purpose, processes related to insurance benefits investigations for specialty medications required in the post-discharge setting, and plan for growth factors, prophylactic antimicrobials, and follow-up.Results and conclusions: We included 28 patients and performed a total of three PDSA cycles demonstrating specific improvements in: communication regarding status of benefits investigations performed for specialty medications prior to admission, resolution of these benefits investigations at various time points, improvement in efficient use of the electronic medical record for chemotherapy orders, and patient instructions for appropriate use of prophylactic antimicrobials. Although improvement was noted initially with prescribing of discharge antiemetics and antimicrobials, regression to baseline was noted with the third PDSA cycle.

Optimizing Safety for Surgical Patients Undergoing Interhospital Transfer.

Interhospital transfers play a key role in ensuring that patients receive necessary care. However, patients who are transferred between hospitals are a vulnerable population, and outcomes of transferred patients are suboptimal. Despite the critical nature of interhospital transfers, only limited effort has been dedicated to standardization and improvement of the transfer process. Studying and adapting quality improvement efforts directed at other transitions of care, particularly those that cross between different facilities and care teams "such as the transition from hospital to home or extended care facilities" may improve the care of surgical patients transferred between acute care institutions.

Underutilization of Operative Capacity at the District Hospital Level in a Resource-Limited Setting.

INTRODUCTION: Improving surgical care in a resource-limited setting requires the optimization of operative capacity, especially at the district hospital level. METHODS: We conducted an analysis of the acute care surgery registry at Salima District Hospital in Malawi from June 2018 to November 2019. We examined patient characteristics, interventions, and outcomes. Modified Poisson regression modeling was used to identify risk factors for transfer to a tertiary center and mortality of patients transferred to the tertiary center. RESULTS: Eight hundred eighty-eight patients were analyzed. The most common diagnosis was skin and soft tissue infection (SSTI) at 35.9%. 27.5% of patients were transferred to Salima District Hospital, primarily from health centers, with a third for a diagnosis of SSTI. Debridement of SSTI comprised 59% of performed procedures (n = 241). Of the patients that required exploratory laparotomy, only 11 laparotomies were performed, with 59 patients transferred to a tertiary hospital. The need for laparotomy conferred an adjusted risk ratio (RR) of 10.1 (95% confidence interval [CI] 7.1, 14.3) for transfer to the central hospital. At the central hospital, for patients who needed urgent abdominal exploration, surgery had a 0.16 RR of mortality (95% CI 0.05, 0.50) while time to evaluation greater than 48 h at the central hospital had a 2.81 RR of death (95% CI 1.19, 6.66). CONCLUSIONS: Despite available capacity, laparotomy was rarely performed at this district hospital, and delays in care led to a higher mortality. Optimization of the district and health center surgical ecosystems is imperative to improve surgical access in Malawi and improve patient outcomes.

The impact of COVID-19 on pharmacy transitions of care services.

COVID-19 has necessitated alterations to the delivery of healthcare services. Modifications include those made to improve patient and healthcare worker safety such as the use of personal protective equipment. Pharmacy services, specifically pharmacy transitions of care services have not been immune to change which have brought along their own set of unique challenges to consider. This paper discusses how COVID-19 has impacted the delivery of pharmacy transitions of care services with real world examples from Sharp Grossmont Hospital and Hoag Memorial Hospital Presbyterian. Procedures implemented to minimize the spread and contraction of COVID-19 such as minimized patient contact and altered visitor policies have made it more challenging to obtain a best possible medication list the patient was taking prior to arrival to the hospital which has lead to an increased reliance on secondary sources to complete medication histories. Regarding discharge prescriptions, preference has shifted to the use of electronic vs. hard copy prescriptions, mail order, and utilization of med to bed programs and other hospital medication delivery services to limit patient contact in outpatient pharmacies. An improved effort to resolve medication acquisition issues prior to discharge utilizing patient assistance programs and other hospital programs to cover the cost of medications for COVID positive patients under certain circumstances has been seen. This paper highlights the important role pharmacists can play in providing effective communication, supporting continuity of care, and advocating for patient engagement and empowerment during transitions of care in the COVID-19 pandemic.

A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine?

OBJECTIVE: To characterize children who experienced interfacility emergency department (ED) transfers with discharge home, and identify care potentially amenable to telemedicine in lieu of transfer. STUDY DESIGN: Retrospective cohort study (July 2016 to June 2017) of patients transferred from general EDs to an academic pediatric ED and discharged home. The primary outcome was care potentially amenable to telemedicine defined as pediatric emergency medicine (PEM) provider assessment without other in-person subspecialty evaluation, diagnostic evaluation available in a general ED (electrocardiogram, point-of-care, or urine tests), and/or referrals and medications available in a general ED. Analysis included descriptive and χ2 statistics. RESULTS: Of the 1733 patients transferred, 529 (31%) were discharged home and 22% of those discharged home had care potentially amenable to telemedicine. Patients amenable to telemedicine were more likely to be <2 years old (32% vs 17%; P = .002) and to have neurologic (29% vs 17%; P = .005), respiratory (16% vs 4%; P < .001), or urinary (5% vs 1%; P = .004) diagnoses than those whose care was not. Eight in 10 patients received their entire diagnostic evaluation before transfer and one-half received only a PEM provider assessment. An additional 281 cases were evaluated by a subspecialist in person, received routine imaging, or routine interventions. CONCLUSIONS: Children receiving care potentially amenable to telemedicine in lieu of transfer often received their entire diagnostic evaluation before transfer; PEM provider assessment was the mainstay of care after transfer. These findings have implications for informing telemedicine to improve access to PEM expertise and potentially decrease some interfacility transfers.