Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions.

Justin Brooten,Carl Grey,Zvi Harris,Alyssa Buckenheimer,Candace Breznau,Jeff Williamson,David Cline,David Welsh,Joy Hallmark,Jennifer Gabbard,Tyler Mcqueen

doi:10.5811/westjem.2020.5.46067

Abstract

IntroductionInter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Goals of care (GoC) discussions prior to transfer are necessary in patients at high risk for decline to ensure that the intended outcome of transfer is goal concordant. However, the frequency of these discussions is not well understood. This study was intended to assess the prevalence of GoC discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality.MethodsThis was a retrospective study of IHT patients aged 18 and older who died within 72 hours of transfer to Wake Forest Baptist Medical Center between October 1, 2016-October 2018. Documentation of GoC discussions within the electronic health record (EHR) prior to transfer was the primary outcome. We also assessed charts for primary diagnosis associated with in-hospital mortality, code status changes prior to death, in-hospital healthcare interventions, and frequency of palliative care consults.ResultsWe included in this study a total of 298 patients, of whom only 10.1% had documented GoC discussion prior to transfer. Sepsis (29.9%), respiratory failure (28.2%), and cardiac arrest (27.5%) were the top three diagnoses associated with in-hospital mortality, and 73.2% of the patients transitioned to comfort measures prior to death. After transfer, 18.1% of patients had invasive procedures performed with 9.7% undergoing major surgery. Palliative care consultation occurred in only 4.4%.ConclusionThe majority (89.9%) of IHT patients with early mortality did not have GoC discussion documented within EHR prior to transfer, although most transitioned to comfort measures prior to their deaths, highlighting that additional work is needed in this area.

Highlights

Inter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients
Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions
This study was intended to assess the prevalence of Goals of care (GoC) discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality

Summary

Introduction

Inter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Studies have shown that 75% of adults aged 65 and older with significant pre-existing conditions visit an ED within the last six months of life and 51% in the last month.[1,2,3] Many of these patients receive aggressive and invasive intensive care interventions at the end of life, sometimes without clear benefit.[4,5,6,7] This is especially true for patients subject to inter-hospital transfer (IHT) to a tertiary medical center, which occurs regularly and in up to 1.5% of all Medicare patients.[8,9] Studies have shown that IHT patients have up to 2.7-fold increased risk of in-hospital mortality compared to non-transferred patients.[10,11,12] In addition, up to 50% of these patients undergo inappropriate repeated procedures and tests.[13] One study showed that IHTs was the most expensive non-therapeutic intervention performed in the acute setting.[14]

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Conclusion