Hemodynamic Deterioration of Trauma Patients Undergoing Interhospital Transfer.

INTRODUCTION: Organized trauma systems reduce morbidity and mortality after serious injury. Rapid transport to high-level trauma centers is ideal, but not always feasible. Thus, interhospital transfers are an important component of trauma systems. However, transferring a seriously injured patient carries the risk of worsening condition before reaching definitive care. In this study, we evaluated characteristics and outcomes of patients whose hemodynamic status worsened during the transfer process. METHODS: We conducted a retrospective cohort study using data from the Pennsylvania Trauma Outcomes Study database from 2011 to 2018. Patients were included if they had a heart rate ≤ 100 and systolic blood pressure ≥ 100 at presentation to the referring hospital and were transferred within 24 h. We defined hemodynamic deterioration (HDD) as admitting heart rate > 100 or systolic blood pressure < 100 at the receiving center. We compared demographics, mechanism of injury, injury severity, management, and outcomes between patients with and without HDD using descriptive statistics and multivariable regression analysis. RESULTS: Of 52,919 included patients, 5331 (10.1%) had HDD. HDD patients were more often moderately-severely injured (injury severity score 9-15; 40.4% versus 39.4%, P < 0.001) and injured via motor vehicle collision (23.2% versus 16.6%, P < 0.001) or gunshot wound (2.1% versus 1.3%, P < 0.001). HDD patients more often had extremity or torso injuries and after transfer were more likely to be transferred to the intensive care unit (35% versus 28.5%, P < 0.001), go directly to surgery (8.4% versus 5.9%, P < 0.001), or interventional radiology (0.8% versus 0.3%, P < 0.001). Overall mortality in the HDD group was 4.9% versus 2.1% in the group who remained stable. These results were confirmed using multivariable analysis. CONCLUSIONS: Interhospital transfers are essential in trauma, but one in 10 transferred patients deteriorated hemodynamically in that process. This high-risk component of the trauma system requires close attention to the important aspects of transfer such as patient selection, pretransfer management/stabilization, and communication between facilities.

A National Analysis of Racial and Sex Disparities Among Interhospital Transfers for Emergency General Surgery Patients and Associated Outcomes.

INTRODUCTION: Studies focusing on Emergency General Surgery (EGS) and Interhospital Transfer (IHT) and the association of race and sex and morbidity and mortality are yet to be conducted. We aim to investigate the association of race and sex and outcomes among IHT patients who underwent emergency general surgery. METHODS: A retrospective review of adult patients who were transferred prior to EGS procedures using the National Surgery Quality Improvement Project from 2014 to 2020. Multivariable logistic regression models were used to compare outcomes (readmission, major and minor postoperative complications, and reoperation) between interhospital transfer and direct admit patients and to investigate the association of race and sex for adverse outcomes for all EGS procedures. A secondary analysis was performed for each individual EGS procedure. RESULTS: Compared to patients transferred directly from home, IHT patients (n = 28,517) had higher odds of readmission [odds ratio (OR): 1.004, 95% confidence interval (CI) (1.002-1.006), P < 0.001], major complication [adjusted OR: 1.119, 95% CI (1.117-1.121), P < 0.001), minor complication [OR: 1.078, 95% CI (1.075-1.080), P < 0.001], and reoperation [OR: 1.014, 95% CI (1.013-1.015), P < 0.001]. In all EGS procedures, Black patients had greater odds of minor complication [OR 1.041, 95% CI (1.023-1.060), P < 0.001], Native Hawaiian and Pacific Islander patients had greater odds of readmission [OR 1.081, 95% CI (1.008-1.160), P = 0.030], while Asian and Hispanic patients had lower odds of adverse outcome, and female patients had greater odds of minor complication [OR 1.017, 95% CI (1.008-1.027), P < 0.001]. CONCLUSIONS: Procedure-specific racial and sex-related disparities exist in emergency general surgery patients who underwent interhospital transfer. Specific interventions should be implemented to address these disparities to improve the safety of emergency procedures.

Factors influencing secondary overtriage in trauma patients undergoing interhospital transfer: A 10-year multi-center study in Hong Kong.

BACKGROUND: With the development of regionalised trauma networks, interhospital transfer of trauma patients is an inevitable component of the trauma system. However, unnecessary transfer is a common phenomenon, and it is not without risk and cost. A better understanding of secondary overtriage would enable emergency physicians to make better decisions about trauma transfers and allow guidelines to be developed to support this decision making. This study aimed to describe the pattern of secondary overtriage in Hong Kong and identify its associated factors. METHODS: This was a retrospective review of 10-years of prospectively collected multi-center data from two trauma registries in the New Territories of Hong Kong (2013-2022). The primary outcome is secondary overtriage, which was defined as early discharge alive within 48 h, Injury Severity Score (ISS) <15, and no surgical operation done. Patient characteristics, physiology, anatomy and investigation variables were compared against secondary overtriage using univariate and multivariable analyses. RESULTS: During the study period, 3852 patients underwent interhospital transfer from a non-trauma center to a trauma center, and 809 (21 %) of the transfers were considered secondary overtriage. The secondary overtriage rate was higher in pediatric age groups at 34.8 % (97/279). Logistic regression analysis showed secondary overtriage to be associated with blunt trauma and an Abbreviated Injury Scale (AIS) score of <3 for head or neck, thorax, abdomen and extremities. CONCLUSION: Interhospital transfer is an essential component of the trauma system. However, over one-fifth of the transfers were considered unnecessary in Hong Kong, and this could be considered to be an inefficient use of resources as well as cause inconvenience to patients and their families. We have identified related factors including blunt trauma, AIS <3 scores for head or neck, thorax, abdomen and extremities, and opportunities to establish and improve on transfer protocols. Further research should be aimed to safely reduce interhospital transfers in the future to improve the efficiency of the Hong Kong trauma system.

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.

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.

Complexity of Transferred Geriatric Adults Requiring Emergency General Surgery: A Rural Tertiary Center Experience.

INTRODUCTION: As the American population ages, the number of geriatric adults requiring emergency general surgery (EGS) care is increasing. EGS regionalization could significantly affect the pattern of care for rural older adults. The aim of this study was to determine the current pattern of care for geriatric EGS patients at our rural academic center, with a focus on transfer status. MATERIALS AND METHODS: We performed a retrospective chart review of patients aged ≥65 undergoing EGS procedures within 48 h of admission from 2014 to 2019 at our rural academic medical center. We collected demographic, admission, operative, and outcomes data. The primary outcomes of interest were mortality and nonhome discharge. Univariate and multivariate analyses were performed. RESULTS: Over the 5-y study period, 674 patients underwent EGS procedures, with 407 (60%) transferred to our facility. Transfer patients (TPs) had higher American Society of Anesthesiology (ASA) scores (P < 0.001), higher rates of open abdomen (13% versus 5.6%, P = 0.001), and multiple operations (24 versus 11%, P < 0.001) than direct admit patients. However, after adjustment there was no difference in mortality (OR 1.64; 95% CI, 0.82-3.38) or nonhome discharge (OR 1.49; 95% CI, 0.95-2.36). CONCLUSIONS: At our institution, the majority of rural geriatric EGS patients were transferred from another hospital for care. These patients had higher medical and operative complexity than patients presenting directly to our facility for care. After adjustment, transfer status was not independently associated with in-hospital mortality or nonhome discharge. These patients were appropriately transferred given their level of complexity.

Operation of national coordinating service for interhospital transfer from emergency departments: experience and implications from Korea.

BACKGROUND: Since 2014, Korea has been operating the National Emergency Medical Situation Room (NEMSR) to provide regional emergency departments (EDs) with coordination services for the interhospital transfer of critically ill patients. The present study aimed to describe the NEMSR's experience and interhospital transfer pattern from EDs nationwide, and investigate the factors related to delayed transfers or transfers that could not be arranged by the NEMSR. METHODS: This study was a retrospective cross-sectional analysis of the NEMSR's coordination registry from 2017 to 2019. The demographic and hospital characteristics related to emergency transfers were analyzed with hierarchical logistic models. RESULTS: The NEMSR received a total of 14,003 requests for the arrangement of the interhospital transfers of critically ill patients from 2017 to 2019. Of 10,222 requests included in the analysis, 8297 (81.17%) successful transfers were coordinated by the NEMSR. Transfers were requested mainly due to a shortage of medical staff (59.79%) and ICU beds (30.80%). Delayed transfers were significantly associated with insufficient hospital resources. The larger the bed capacity of the sending hospital, the more difficult it was to coordinate the transfer (odds ratio [OR] for transfer not arranged = 2.04; 95% confidence interval [CI]: 1.48-2.82, ≥ 1000 beds vs. < 300 beds) and the longer the transfer was delayed (OR for delays of more than 44 minutes = 2.08; 95% CI: 1.57-2.76, ≥ 1000 beds vs. < 300 beds). CONCLUSIONS: The operation of the NEMSR has clinical importance in that it could efficiently coordinate interhospital transfers through a protocolized process and resource information system. The coordination role is significant as information technology in emergency care develops while regional gaps in the distribution of medical resources widen.

Nonurgent Pediatric Interhospital Transfers: A Narrative Enquiry of Nurses' Experiences in Australia.

INTRODUCTION: This study aimed to explore nonurgent pediatric interhospital transfers through the lens of nurses' experiences and perceptions when undertaking these transfers. METHODS: Using a narrative inquiry approach, data were collected via semistructured interviews with registered nurses (N = 7) who had experience undertaking patient transfers between nonurgent low-acuity and urgent high-acuity hospital settings. RESULTS: Findings established the following 8 themes: ensuring transfer preparation for risk mitigation, practicing confident advocacy, being accountable for risk mitigation of the deteriorating patient during transfer, maintaining standardized procedure, using training and mentorship to support confidence, maintaining interhospital and intrahospital relationships, recognizing the significance of transfer on families, and acknowledging the burden of transfer and delay. DISCUSSION: By exploring the stories and experiences of emergency nurses who undertake pediatric interhospital transfers, a deep investigation of the risks and challenges has been described, an area often underrepresented in the literature. Findings from this study highlight important learnings for pediatric interhospital transfer that add value to the wider body of evidence.

A narrative review of the training structure, role, and safety profile of advanced critical care practitioners in adult intensive services in the United Kingdom.

OBJECTIVE: Advanced clinical practitioners are a growing part of the National Health Service workforce in the United Kingdom (UK). The concept stems from the progression of skills, knowledge, and experience of healthcare professionals (including nursing, physiotherapists, paramedics, and pharmacists) to a higher level of practice. The addition of advanced critical care practitioners (ACCPs) to the multidisciplinary team of the UK adult critical care is recent; they form part of the fabric of the advanced clinical practitioner workforce. This is a narrative review of the role of ACCPs, considering the evolution of the role, training, accreditation, and evidence supporting the safety profile in adult intensive care in the UK. METHOD: This is a narrative review. CONCLUSION: ACCPs have evolved from an ad hoc and local training structure, to a UK-wide competency standard and training developed within the Faculty of Intensive Care Medicine. This formed in concert with the advanced clinical practitioner concept. As advanced practice is very much multiprofessional in the UK, a single regulator for multiple base professions is likely neither feasible nor realistic. Over the last 5 years, the UK picture of advanced practice has slowly standardised; an ACCP securely fits under the advanced clinical practitioner umbrella. The ACCP workforce has moved from a handful of early adopters, regional hubs, to a position across most critical care units now have or are developing a team of practitioners. The evidence base for the safety profile of ACCPs is evolving and shows parity in outcomes in the areas currently investigated. The ACCP role provides a vision of a multiprofessional workforce for the future of staffing of critical care services that is diverse and inclusive, not with the intention of competing with our medical colleagues.

"Our Hands Are Tied Until Your Doctor Gets Here": Nursing Perspectives on Inter-hospital Transfers.

BACKGROUND: The transfer of patients between hospitals (inter-hospital transfer, or IHT) is a common occurrence for patients, but guidelines to ensure safe and effective IHTs are lacking. Poor IHTs result in higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Nurses are often the first point of contact for IHT patients and can provide valuable insights on key challenges to IHT processes. OBJECTIVE: To characterize the experiences of inpatient floor-level bedside nurses caring for IHT patients and identify care coordination challenges and solutions. DESIGN/PARTICIPANTS/APPROACH: Qualitative study using semi-structured focus groups and interviews conducted from October 2019 to July 2020 with 21 inpatient floor-level nurses caring for adult medicine patients at an academic hospital. Nurses were recruited using a purposive convenience sampling approach. A combined inductive and deductive coding approach guided by thematic analysis was used for data analysis. KEY RESULTS: Results from this study are mapped to the Agency for Healthcare Research and Quality Care Coordination Measurement Framework domains of communication, assessing needs and goals, and negotiating accountability. The following key themes characterize nurses' experiences with IHT related to these domains: (1) challenges with information exchange and team communication during IHT, (2) environmental and information preparation needed to anticipate transfers, and (3) determining responsibility and care plans after the IHT patient has arrived at the accepting facility. CONCLUSIONS: Nurses described the absence of standardized processes to coordinate care before or at the time of patient arrival. Challenges to communication and coordination during IHTs negatively impacted patient care and nursing professional satisfaction. To streamline care for IHT patients and reduce nursing stress, future IHT interventions should include standardized handoff reports, timely identification and easy access to admitting clinicians, and timely clinician evaluation and orders.

Relationship between insurance status and interhospital transfers among cancer patients in the United States.

BACKGROUND: The relationship between insurance status and interhospital transfers has not been adequately researched among cancer patients. Hence this study aimed for understanding this relationship using a nationally representative database. METHODS: A retrospective analysis was conducted using National Inpatient Sample (NIS) data collected during 2010-2016 and included all cancer hospitalization between 18 and 64 years of age. Interhospital transfers were compared based on insurance status (Medicare, Medicaid, private, and uninsured). Weighted multivariable logistic regressions were used to calculate the odds of interhospital transfers based on insurance status, after adjusting for many covariates. RESULTS: There were 3,580,908 weighted cancer hospitalizations, of which 72,353 (2.02%) had interhospital transfers. Uninsured patients had significantly higher rates of interhospital transfers, compared to those with Medicare (P = 0.005) and private insurance (P < 0.001). Privately insured patients had significantly lower rates of interhospital transfers, compared to those with Medicare (P < 0.001) and Medicaid (P < 0.001). Logistic regression analyses showed that the odds of having interhospital transfers were significantly higher among uninsured (adjusted odds ratio [aOR], 1.57, 95% CI: 1.45-1.69), Medicare (aOR, 1.38, 95% CI: 1.32-1.45) and Medicaid (aOR, 1.23, 95% CI: 1.16-1.30) patients when compared to those with private insurance coverages. CONCLUSION: Among cancer patients, uninsured and Medicare and Medicaid beneficiaries were more likely to experience interhospital transfers. In addition to medical reasons, factors such as affordability and socioeconomic status are influencing interhospital transfer decisions, indicating existing healthcare disparities. Further studies should focus on identifying the causal associations between factors explored in this study as well as additional unexplored factors.

Emergency department and transport predictors of neurological deterioration in patients with spontaneous intracranial hemorrhage.

BACKGROUND: Patients with spontaneous intracranial hemorrhage (sICH) and intracranial hypertension are associated with poor outcomes. Blood pressure variability (BPV) and neurological deterioration (ND) are known factors associated with sICH outcomes, but the relationship between BPV and ND in the hyperacute phase remains poorly described. We hypothesized that BPV is associated with ND during patients' initial emergency department (ED) stay and during interhospital transport (IHT) to a tertiary care center. METHODS: A retrospective study of adult patients with sICH was performed. Patients who were transferred from an ED to a tertiary care center between 01/01/2011 and 09/30/2015 and underwent external ventricular drainage were eligible. The outcome was ND at any time before arrival at a tertiary care center. Classification and Regression Tree (CART) analysis, a machine learning algorithm, was used to assign "relative variable importance" (RVI) for important predictive clinical factors. RESULTS: 153 eligible patients were analyzed. Sixty-five (42%) patients developed ND. Maximum ED systolic blood pressure (ED SBPMax) was most predictive of sICH patients developing ND (RVI = 100%). Other important factors for ND included standard deviation in SBP (SBPSD) during ED stay and IHT, with RVI of 43% and 20%, respectively. CONCLUSION: ED SBPMax was the strongest predictive factor of ND, while other BPV components were also significant. Our study found evidence that BPV should be prioritized as it may also increase the risk of ND among patients with sICH who required external ventricular drain placement. Future studies should examine whether fluctuations in BP in an ED or IHT setting are associated with increased risk of worsening outcomes.

Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments.

BACKGROUND: Emergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States. METHOD: We analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010-2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital. RESULTS: Of 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16-1.21) and older patients (OR 1.02 (95% CI 1.02-1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03-1.15) or other insurance (OR 1.34 (95% CI 1.07-1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48-44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44-9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00-5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53-3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43-2.00)) relative to urban non-teaching hospitals. CONCLUSION: Medically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.

Timing of Transfer and Mortality in Neonates with Hypoplastic Left Heart Syndrome in California.

Maternal race/ethnicity is associated with mortality in neonates with hypoplastic left heart syndrome (HLHS). We investigated whether maternal race/ethnicity and other sociodemographic factors affect timing of transfer after birth and whether timing of transfer impacts mortality in infants with HLHS. We linked two statewide databases, the California Perinatal Quality Care Collaborative and records from the Office of Statewide Health Planning and Development, to identify cases of HLHS born between 1/1/06 and 12/31/11. Cases were divided into three groups: birth at destination hospital, transfer on day of life 0-1 ("early transfer"), or transfer on day of life ≥ 2 ("late transfer"). We used log-binomial regression models to estimate relative risks (RR) for timing of transfer and Cox proportional hazard models to estimate hazard ratios (HR) for mortality. We excluded infants who died within 60 days of life without intervention from the main analyses of timing of transfer, since intervention may not have been planned in these infants. Of 556 cases, 107 died without intervention (19%) and another 52 (9%) died within 28 days. Of the 449 included in analyses of timing of transfer, 28% were born at the destination hospital, 49% were transferred early, and 23% were transferred late. Late transfer was more likely for infants of low birthweight (RR 1.74) and infants born to US-born Hispanic (RR 1.69) and black (RR 2.45) mothers. Low birthweight (HR 1.50), low 5-min Apgar score (HR 4.69), and the presence of other major congenital anomalies (HR 3.41), but not timing of transfer, predicted neonatal mortality. Late transfer was more likely in neonates born to US-born Hispanic and black mothers but was not associated with higher mortality.

National Trends in Transfer of Patients with Primary Intracerebral Hemorrhage: An Analysis of 12-Year Nationwide Data.

OBJECTIVES: The guidelines of the American Hospital Association encourage transferring intracerebral hemorrhage patients from community hospitals to centers with stroke expertise. However, research on the differences in outcomes between transferred intracerebral hemorrhage hospitalizations and directly admitted hospitalizations have been largely limited to small single-center studies. In this study, we explored the national trends in transferred intracerebral hemorrhage hospitalizations, as well as evaluated the differences, in terms of demographic characteristics, co-morbidity, resource utilization, and outcomes, between transferred intracerebral hemorrhage hospitalizations and directly admitted hospitalizations. MATERIALS AND METHODS: From the National Inpatient Sample (2004 - 2016), we assessed the linear trends in the proportion of interhospital transfers for intracerebral hemorrhage hospitalizations. We constructed a series of multivariate logistic regression models to explore the association of transfer status with inpatient mortality and discharge disposition, controlling for demographic, clinical, and hospital characteristics. We used survey design variables to report nationally weighted estimates. RESULTS: Among 786,999 hospitalizations, 137,340 (17.5%, 95% CI: 16.4-18.6) were transferred. Overall, interhospital transfers for intracerebral hemorrhage has been increasing over the 12-year period of this study. Patients in transferred hospitalizations were younger, more likely to be white, and more likely to have private insurance. Transferred hospitalizations were associated with significantly lower adjusted odds of inpatient mortality, compared to directly admitted hospitalizations. CONCLUSIONS: As the US healthcare system continues shifting towards value-based care, evidence on the short- and long-term outcomes of transfer of intracerebral hemorrhage patients will inform optimal management of intracerebral hemorrhage patients.

Negative impact of Interhospital Transfer on Clinical Outcomes of Mechanical Thrombectomy for Fast Progressive Stroke.

OBJECTIVES: The time-dependence of the clinical outcome of mechanical thrombectomy is higher in the "fast progressor" in whom cerebral ischemia progresses rapidly. The impact of time-consuming interhospital transfer (IT) on the clinical outcome of such patients is unknown. The effect on clinical outcomes of IT of fast progressors was investigated. METHODS: Among the patients enrolled in the Tokyo/Tama REgistry of Acute endovascular Thrombectomy, fast progressor cerebral ischemia cases were retrospectively investigated. In this study, a fast progressor was defined as a case with an Alberta Stroke Program Early CT Score less than 6 and last known well (LKW) to arterial puncture within 6 h. Patients' background characteristics, treatment progress, and the modified Rankin Scale (mRS) score at 3 months were examined. RESULTS: Of a total of 1182 patients, 92 (7.8%) were included, with 76 patients in the direct transfer (DT) group, and 16 patients in the IT group. Median LKW to reperfusion was 190 min and 272 min, respectively (P<.001). The number of patients with mRS scores 0-2 at three months was 22 (28.9%) in the DT group and 1 (6.2%) in the IT group. Interhospital transfer was an independent factor associated with worse outcomes (odds ratio 0.08, 95% confidence interval 0.01-0.87, P=.038). CONCLUSION: This study showed that, among fast progressor patients, the IT group had a worse prognosis than the DT group. To provide good clinical outcomes for fast progressor patients, those who are likely to undergo mechanical thrombectomy should be sent directly to a thrombectomy-capable center.

Total Transfer Time for Ground vs. Air Transport for Interhospital and Scene Transfers of Acute Stroke Patients.

OBJECTIVES: Stroke patients are frequently transported to a comprehensive stroke center for treatment, either from a regional hospital via interhospital transfer or from the field via direct-from-scene transfer, by air or ground transportation. We sought to determine whether air or ground transport was faster in both transfer circumstances. MATERIALS AND METHODS: A retrospective study of patients transferred to a single comprehensive stroke center for stroke treatment was conducted. EMS and medical records were used to evaluate the time and distance of transfer and functional outcome. RESULTS: Of the 205 transfers, 47 were interhospital transfers by air (22.9%), 68 were interhospital transfers by ground (33.2%), 40 were scene transfers by air (19.5%), and 50 were scene transfers by ground (24.4%). Ground transfers had shorter alarm to EMS departure times (30 min. vs 40 min.; p<0.0001). Air transfers had shorter EMS departure to arrival times when normalized by transfer distance indicating a faster travel velocity. Interhospital transfers by air were predicted to be faster than ground over 40 miles, and scene transfers by air were predicted to be faster than ground over 28 miles. Transfer mode had no significant effect on functional outcome when controlling for tPA, thrombectomy, and NIH Stroke Scale in this small study. CONCLUSIONS: Transfer efficiency for stroke patients depends on logistics prior to EMS arrival as well as the speed of travel. While air transport clearly results in faster travel velocity, total interhospital transfer times are faster for air transportation only when traveling more than 40 miles.

Identifying Racial/Ethnic Disparities in Interhospital Transfer: an Observational Study.

BACKGROUND: Interhospital transfer (IHT) is often performed to provide patients with specialized care. Racial/ethnic disparities in IHT have been suggested but are not well-characterized. OBJECTIVE: To evaluate the association between race/ethnicity and IHT. DESIGN: Cross-sectional analysis of 2016 National Inpatient Sample data. PATIENTS: Patients aged ≥ 18 years old with common medical diagnoses at transfer, including acute myocardial infarction, congestive heart failure, arrhythmia, stroke, sepsis, pneumonia, and gastrointestinal bleed. MAIN MEASURES: We performed a series of logistic regression models to estimate adjusted odds of transfer by race/ethnicity controlling for patient demographics, clinical variables, and hospital characteristics and to identify potential mediators. In secondary analyses, we estimated adjusted odds of transfer among patients at community hospitals (those more likely to transfer patients) and performed subgroup analyses by region and primary medical diagnosis. KEY RESULTS: Of 5,774,175 weighted hospital admissions, 199,015 (4.5%) underwent IHT, including 4.7% of White patients, compared with 3.9% of Black patients and 3.8% of Hispanic patients. Black (OR 0.83, 95% CI 0.78-0.89) and Hispanic (OR 0.81, 95% CI 0.75-0.87) patients had lower crude odds of transfer compared with White patients, but this became non-significant after adjusting for hospital-level characteristics. In secondary analyses among patients hospitalized at community hospitals, Hispanic patients had lower adjusted odds of transfer (aOR 0.89, 95% CI 0.79-0.98). Disparities in IHT by race/ethnicity varied by region and medical diagnosis. CONCLUSIONS: Black and Hispanic patients had lower odds of IHT, largely explained by a higher likelihood of being hospitalized at urban teaching hospitals. Racial/ethnic disparities in transfer were demonstrated at community hospitals, in certain geographic regions and among patients with specific diseases.

Effects of Medical Transport on Outcomes in Children Requiring Intensive Care.

BACKGROUND AND OBJECTIVES: The need to centralize patients for specialty care in the setting of regionalization may delay access to specialist services and compromise outcomes, particularly in a large geographic area. The aim of this study was to explore the effects of interhospital transferring of children requiring intensive care in a Canadian regionalization model. METHODS: A retrospective cohort design with a matched pair analysis was adopted to compare the outcomes in children younger than 17 years admitted to a pediatric intensive care unit (PICU) of a Canadian children's hospital by a specialized transport team (pediatric critical care transported [PCCT] group) and those children admitted directly to PICU from its pediatric emergency department (PED group). The outcomes of interest included mortality 72 hours from initial contact with the critical care team (ie, either PICU transport team or intrahospital PICU team). RESULTS: In total, 680 (27%) transports met our inclusion criteria, whereas 866 (7%) cases of 11 570 total PICU admissions were admitted directly from the emergency department. A total of 493 pairs were formed for the matched analyses. Odds of mortality within 72 hours in the PCCT group were significantly higher than in the PED group (odds ratio [OR]: 2.18, 95% confidence interval [CI]: 1.07-4.45; P = .032). When excluding cases who had at least one episode of cardiac arrest before involvement of the pediatric critical care (PCC) transport team, the OR dropped to 1.66 (95% CI: 0.77-3.46). CONCLUSIONS: Children transported from nonpediatric hospitals had a higher 72-hour mortality when compared to those children admitted directly to a children's hospital PICU from its own PED in a Canadian regionalized health-care model.

Effect of Specialized Critical Care Transport Unit on Short-Term Mortality of Critically ILL Patients Undergoing Interhospital Transport.

Objective: To minimize risk and prevent harmful incidents during interhospital transport, the critical care transport unit service called Seoul Mobile Intensive Care Unit (SMICU) was organized and initiated its service within the city of Seoul. We sought to evaluate the effectiveness of critical care transport units on outcomes of critically ill patients undergoing interhospital transport in Seoul. Methods: A retrospective observational case-control study was designed to evaluate the effectiveness of critical care transport units on outcomes of critically ill patients undergoing interhospital transport. ED patients transported from other hospitals in Seoul during 2016 were identified in the National Emergency Department Information System (NEDIS) and according to use of the SMICU. One-to-one propensity matching was performed to balance covariates between groups. The association of SMICU transport on survival outcome was calculated in a multivariable logistic regression model. Results: Among 42,188 ED patients transported from other hospitals in 2016, 482 (1.1%) of patients were transported by SMICU. Patients transported by SMICU had a higher proportion of severe emergency disease and use of a mechanical ventilator. The adjusted odds ratio for 24-hour mortality after interhospital transport was 0.45 (95% CI: 0.26-0.81) in total cohort and was 0.34 (95% CI: 0.16-0.71) in a one-to-one propensity-matched cohort. Conclusions: Transport by specialized critical care transport unit for patients undergoing interhospital transport was associated with lower 24-hour mortality, demonstrating the benefits of the SMICU.