Abstract P265: Identifying Factors Associated With Early Transfer Death of Stroke Patients Can Improve Transfer Criteria

Abstract

Introduction: Mortality is an important performance metric monitored by CMS, US News and World Report, and Vizient UHC. Large academic medical centers have high mortality given higher severity of disease and volume. We analyzed mortality of stroke patients transferred to our university hospital from community EDs. Transferring patients who die within 48 hours raises questions about resources, financial burden, and unrealistic expectations from families. We analyzed our transfer early death (TED) population to improve identification of patients who likely do not benefit from transfer out of a community hospital. Methods: Patients with DRG codes for ischemic and hemorrhagic strokes admitted from July 2018-June 2020 were identified. Transfer patients were isolated and grouped as outside hospital (OSH) or intra-system transfers. Data were analyzed for overall hospital mortality and TED mortalities and characteristics. Demographic and clinic variables were compared between intra-system and outside transfers by chi-square test, Fisher’s exact test, t test or Wilcoxon rank sum test. Results: The total stroke mortality rate was 13% with 276 deaths out of 2,145 patients. There were 171 early deaths out of 276 deaths (62%). There were a total of 923 transfer patients in the 2-year period; 76 were TED (8%) and TED accounted for 27% of all in-hospital mortality at our center. Median age of TED was 67, median NIHSS was 27, 39% were >70, and 80% were ICH with a median ICH score 4. The mean volume of ICH was 68mL (SD=55.2). There were no significant associations between age, sex and ethnicity with TED compared with patients who survived beyond 48 hrs. Among TED, 31 (41%) were from within our health system and 45 (59%) were OHS transfers. There were no significant differences among stroke type, severity (GCS, NIHSS, ICH score, MRS), or demographics between intra-system and OSH transfers. Conclusions: TED patients are more likely to have severe ICH where medical care may be futile. Strategies are needed to work with community hospitals to establish goals of care and implement approaches to provide end-of-life services at these facilities. Identification and implementation of such strategies may also reduce intra-system transfers of patients with high mortality.