387 Outcome Predictors of Interhospital Transferred Patients to Emergency General Surgery Service: Does Transfer Location Matter?

Abstract

The regionalization of medicine further stresses emergency departments (ED) around the country. This paradigm shift that concentrates subspecialties to large academic institutions has increased the need to transfer patients from their initial, primary hospital. The interhospital-transferred (IHT) patients are associated with higher resource utilization and mortality. It is crucial to understand the differences that transferring IHT patients have on their outcome and identify specific clinical indicators that put them at increased risk of morbidity and mortality. We sought to understand the differences in predictors for outcomes between patients who were transferred from other hospitals’ EDs or inpatient units to a tertiary care center for surgical evaluation. We conducted a three-year retrospective analysis from 01/2014 to 12/2016. Adult patients who were transferred to our quaternary academic center’s emergency general surgery (EGS) service as the primary admitting service, were eligible. Our primary outcome was mortality and secondary outcomes were patients’ hospital dispositions and survivors’ hospital length of stay (HLOS). We used multivariable logistic and ordinal regressions to assess the associations of patients’ clinical factors at arrival to our medical center and their outcomes. We analyzed a total of 708 patients, 175 (25%) from the ED, 280 (39%) from the intensive care unit (ICU), and 253 (36%) from the ward. Compared to the ED patients, patients transferred from the ICU had a higher mean (SD) Sequential Organ Failure Assessment (SOFA) score [5.7 (4.5) vs. 2.39 (2), P<0.001], higher mortality, and longer HLOS. Transferring patients from the 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 while gastrointestinal bleed was associated with lower mortality. Transfer from the ED was significantly associated with short HLOS (corr. coeff. 0.46, 95% CI 1.07-2.33, P=0.021) and favorable discharge disposition, discharge home (corr. coeff. 0.63, 95% CI 1.13-3.09, P=0.015). We found that ED patients are nested between ICU and intermediate care unit/floor originating transfers when comparing markers of decompensation (lactate, WBC count, SOFA score). At our academic center, patients who were transferred from other hospitals’ ED were less critically ill, had shorter HLOS, and lower mortality compared to patients from the ICU. We identified that SOFA score at admission was strongly associated with patients’ outcomes. It is important to not overlook the origin of a transfer when determining the needs of a patient. While awaiting future studies’ results, emergency physicians should use readily available scoring mechanisms like the SOFA score to further assess a patient’s risk of decompensation to facilitate earlier transfer to a higher-level care facility. Future research should analyze the contributing factors to patients’ decompensation and increased mortality following transfer to a higher care facility.