Abstract TP89: A Pilot Project To Reduce Futile Ich Transfers Across A Large Hospital System

Abstract

Introduction: Academic medical centers (AMCs) that are part of a large hospital system often act as the central facility for transfers and high acuity stroke cases which enhances the quality of care for critically ill patients. Mortality is an important metric monitored by CMS and other quality programs. Volume and acuity are higher at AMCs compared with sister facilities making it necessary to appropriately triage patients and accept transfers that would benefit from a higher level of care (HLOC) and reduce the transfer of futile cases. Stroke patients that are transferred and die within 48 hours (early death) of admission may be a valuable population to examine to determine if transfer is futile. Methods: Patients with DRG codes for ischemic and hemorrhagic strokes admitted to an AMC from July 2018-June 2020 were identified. Data were used to calculate mortality rates based on overall, transfer, and early death status. Transfer early death (TED) patients are defined as those who die within 48 hours of transfer into the AMC. Stroke characteristics (type, ICH volume, NIHSS, etc.) were also analyzed. Results: In our AMC, the total stroke mortality rate was 13% from July 2018-June 2020 (276 deaths out of 2,145 patients). There were 923 transfers of which 76 were TED (8%). Of the 76 TEDs, 31 (41%) were from within our health system, 45 (59%) were outside hospital transfers, and none received intervention. Median age of TED was 67, 39% were > age 70, median NIHSS was 27, 80% were ICH patients, and 63% had an ICH score 4-6 prior to transfer. The mean volume of ICH was 68mL (SD=55.2). Prior to transfer, one patient was DNR. Conclusions: Transfers of stroke patients with large ICHs represent a subpopulation to target for quality improvement. An IRB approved QI project has been designed to initiate goals-of-care discussions with families of catastrophic ICH patients by our AMC stroke team via phone/video-chat prior to transfer. The primary outcome is to reduce the transfer of ICH patients who would not benefit from a HLOC. This would potentially increase bed availability for patients that could benefit and improve resource utilization across hospitals. This project is aiding a multidisciplinary process review and implementation of futility guidelines within the system.