Ambulance Transfer Research Articles

Abstract TP120: Hospital Finance Optimization Through AI-based Stroke Care Coordination Platform

Introduction: AI-based Stroke Care Coordination Platforms (AI-SCCP) have been shown to improve patient transfer decisions and provide access to the highest quality standards of care for all patients. Since strokes happen everywhere and anytime, we examine the economic benefits of implementing AI-SCCPs for two different hospital types: CSC - a comprehensive 24/7 stroke program inclusive of endovascular surgical care and PSC - “Acute Stroke Ready” facilities with radiological imaging and thrombolytic medication treatment capacities but no endovascular surgical care and patients/families. Methods: Using 2021 Medicare MS-DRG payment averages, we calculate the AI-SCCP's PSC break-even point, its effects on CSC finances, and the reduced transfers' economic benefits for the patient and family. Results: Avoided transfers enable the PSC to continue caring for the patient locally, increasing patient volume and resulting in increases in total contribution margin and net revenues beyond the costs of the AI-SCCP. While these retained patients decrease the CSC patient transfer volume, the CSCs will still provide care to all PSC patients needing surgical interventions and patients with MS-DRGs 61-66 who arrive at their locations via initial presentation in their emergency departments. Only 1.7% of all non-surgical stroke discharges were from PCS rural/small-town community hospitals (15% of all US hospitals), illustrating that there is room to avoid more futile transfers. Futile transfers have financial costs for family members, such as hotels, transportation, meals, and lost wages during the patient’s care and increased negative impacts on the patient’s health. Futile transfers increase the episode of care costs to the healthcare system through added ambulance transfers and physician and facility bills, adding out-of-pocket patient costs without adding health outcomes or value. Conclusions: AI-SCCPs offer financial benefits to the PSC and CSC by ensuring patients are at the facility, which provides the best possible benefits for them, a triple “win” for the PCS, CSC, and patients/families. For financially strained PCSs, the retained revenue is critical. Using AI-SCCPs ensures that local hospital/emergency departments can provide timely, expert stroke care for patients and their families in situ. In cases of necessary transfer, the receiving CSC team is prepared and ready to treat these patients, saving valuable time and brain immediately.

Abstract WP156: 911 Stat Ambulance Transfer in Comparison with Contracted Ambulance Reduces Door In Door Out Time for Transfer Patients with Emergent Large Vessel Occlusion

Abstract WP156: 911 Stat Ambulance Transfer in Comparison with Contracted Ambulance Reduces Door In Door Out Time for Transfer Patients with Emergent Large Vessel Occlusion

Ambulance offload performance, patient characteristics and disposition for patients offloaded to different areas of the emergency department.

Ambulance transfer of care (TOC) is a key performance indicator for New South Wales EDs, with 90% of ambulances to be offloaded within 30 min of arrival. Nepean Hospital ED has a number of strategies to improve TOC, including ambulatory areas where patients can be offloaded immediately. Offload data are supplied by ambulance and there is no study into its accuracy. The aim is to audit the accuracy of ambulance data of TOC compared to times recorded in the Nepean ED information system, and to examine TOC and patient demographics for different offload destinations. A retrospective observational study was performed for patients presenting by ambulance between 1 July and 31 December 2022. TOC was calculated from FirstNet and compared to ambulance data using a paired-sample t test. Patients were categorised by offload destination within the ED and examined for age, TOC, disposition and specialty team if admitted. TOC for ambulance and ED data was 60.8% versus 64.1%, respectively (difference 3.33%, P < 0.001). Patients offloaded to acute care were older, with 61.9% being >65 years; had a TOC of 37.3% compared to the resuscitation and ambulatory areas with TOC close to 90%; and were likely to be admitted with a 63.8% admission rate and 24.1% of admissions being under the geriatric service. Patients arriving by ambulance requiring an acute care bed were likely to be elderly and frail, and suffered substantial ambulance offload delays. Delays to ambulance offload for these patients is likely driven by acute care bed availability and access block.

A cost-consequence analysis of the Queensland specialist palliative rural telehealth (SPaRTa) service

Background Telehealth can extend the reach of specialist palliative care providers to ensure that patients can access specialist services closer to home. Aim To examine the cost and consequences of the Specialist Palliative Rural Telehealth (SPaRTa) service compared to the traditional non-specialist general practice-based services for people requiring palliative care. Design The costs and outcomes for SPaRTa were compared using cost-consequence analysis principles, with a focus on net benefit and return on investment. Costs were estimated from the perspective of the health service provider for the 2020/2021 financial year, and cost-offsets associated with change in location of death and change in hospital transfers. Setting/participants Patients of the SPaRTa in Queensland Australia. Results During study period 5472 consultations were conducted from four major metropolitan hub sites to regional, rural, and remote areas at a total cost of $4 426 644. When remuneration for consultations, change to location of death and reduction in ambulance transfers were taken into account, the net-benefit to the state health system was $1 244 060, giving a return on investment of $1.28 for every dollar spent. SPaRTa complimented existing local care services, and enabled access to specialist care into the home. Conclusions SPaRTa resulted in potential cost savings for the health service by enabling more convenient access to palliative care services outside of hospital settings. Decisions regarding funding for telepalliative care should consider not only the costs, but also the potential benefits to both the service providers, and the patients and families receiving this care.

The Safety of Methoxyflurane for Emergency Pain Relief in Children and Adolescents: A Retrospective Cohort Study

Objectives The use of methoxyflurane is becoming increasingly popular in the treatment of pain in an emergency setting, in part due to its ease of administration. However, little is known about the risk of serious adverse events in children and adolescents. The aim of this study was to examine the safety of methoxyflurane in a pediatric population. Methods The study was a retrospective cohort study of pediatric prehospital events using probabilistic linked health data. All ambulance transfers in Western Australia between 1990 and 2016 involving children and adolescent patients were identified. Patients were categorized based on administered analgesia: methoxyflurane, an opioid analgesic, both methoxyflurane and an opioid analgesic, or no analgesic. Hospital and mortality data were linked to transferred patients to identify deaths, adverse drug reactions, liver and kidney toxicity, and re-admissions to hospital following ambulance transfer. Generalized linear models, adjusting for sociodemographic and ambulance transfer characteristics, were used to compare outcomes between children exposed to methoxyflurane and the other three groups. Results The study cohort consisted of 37,211 children, including 9,472 patients (25.5%) treated with methoxyflurane alone, 2,764 (7.4%) treated with an opioid analgesic, 1,235 (3.3%) treated with both methoxyflurane and an opioid analgesic, and 23,740 (63.8%) treated with no analgesic. Death in children and adolescents was uncommon, with less than five deaths (<0.1%) observed in the 12 months following treatment with methoxyflurane and no deaths in those treated with both methoxyflurane and an opioid analgesic. Adverse drug reaction was rare (<0.1%) in patients treated with methoxyflurane, as was liver and kidney toxicity with no case observed. At 90-days follow-up, there was no significant difference in hospitalization in patients treated with methoxyflurane and those treated with methoxyflurane and an opioid analgesic (adjusted OR:1.01, 95%CI:0.85-1.21). Compared with methoxyflurane treated patients, patients treated with an opioid analgesic were more likely to be hospitalized (aOR:1.23, 95%CI:1.09-1.39), while patients treated with no analgesic were less likely to be hospitalized (aOR:0.85, 95%CI:0.79-0.92). Conclusions In children and adolescents transported by ambulance, the use of methoxyflurane was not associated with an increased risk of hospitalization, death, serious adverse drug reactions or liver and kidney toxicity.

670 Investigating Delay During Presentation of Trauma in Young Adults: A UK Major Trauma Centre Retrospective Audit and a Systematic Review of the Literature

Abstract Introduction The current evidence in major trauma highlights that delays at multiple points along the patient care pathway, from incident to surgery, are associated with decreased survival. The aim of this audit was to assess performance across select delay parameters in juveniles aged 16-18 presenting to an adult MTC service following a systematic review of the literature. Method Patient records were interrogated between 1/10/2022-1/3/2023 and audited against 3 national standards: (1) Ambulance Response and Transfer (7 and 45mins respectively) (2) Tranexamic Acid infusion (&amp;lt;3hrs) and (3) CT scan (&amp;lt;60mins). A systematic search was also performed using EMBASE and OVID databases (01/01/2005-/01/11/2023). All studies assessing impact of time to theatre in patients with acute trauma were considered. Results 32 consecutive patients (3F:29M) (median 18 years[16-18]) were identified within the audit period. 40%(n=13) presented following penetrating injury and 35%(n=11) following a road traffic accident. Mean time from incident to admission was 83mins[±36], from incident to tranexamic acid infusion 50mins[±35], and from admission to CT Trauma Series 61mins[+/-100]. Median length of stay was 4 days [IQR=5]. The systematic search yielded 25 studies which were included in the analysis. An Incident2Surgery framework is presented which highlights key time-critical points for diagnosis and intervention. Conclusions Local compliance to national standards for tranexamic acid infusion in appropriate patients and performance of trauma CT was excellent with poor compliance to ambulance arrival and transfer time. The proposed Incident2Surgery framework could be incorporated into mortality prediction and audit tools and assist in the assessment of interventions.

Ambulance transfer for organ donors after a medically assisted death: a report of 3 cases

Ambulance transfer for organ donors after a medically assisted death: a report of 3 cases

Association between hospital case volume and maternal adverse events in patients with placental abruption: An analysis using a Japanese national inpatient database.

To clarify the relationship between the prognosis of patients with placental abruption (PA) and the healthcare delivery system using data from a large national inpatient database in Japan. Using the Diagnosis Procedure Combination database, we conducted a retrospective cohort study with the data of patients in almost 1000 hospitals with the primary diagnosis of PA who were hospitalized from April 2014 to March 2021. We divided the hospitals into four groups based on the number of deliveries per month. We performed multilevel logistic regression analysis to analyze the relationship between hospital case volume and maternal end-organ injury (MEOI). Altogether, 8222 patients were included for analysis; among whom, 3575 (44%) were transferred by ambulance. MEOI was noted in 977 patients (12%) with no obvious difference by hospital case volume. Ambulance transfer, age, gestational weeks at admission, delivery on the first day of hospitalization, and history of eclampsia were significantly associated with a higher incidence of MEOI, but the hospital case volume was not. Using a Japanese administrative database, our study shows that hospital case volume was not significantly associated with the severity of maternal illness among patients with PA.

Secondary Ambulance Transfers During the Mass-Casualty Terrorist Attack in Israel on October 7, 2023.

On October 7, 2023, Israel experienced the worst terror attack in its history - 1,200 people were killed, 239 people were taken hostage, and 1,455 people were wounded. This mass-casualty event (MCE) was more specifically a mega terrorist attack. Due to the overwhelming number of victims who arrived at the two closest hospitals, it became necessary to implement secondary transfers to centers in other areas of the country. Historically, secondary transfer has been implemented in MCEs but usually for the transfer of critical patients from a Level 2 or Level 3 Trauma Center to a Level 1 Center. Magen David Adom (MDA), Israel's National Emergency Pre-Hospital Medical Organization, is designated by the Health Ministry as the incident command at any MCE. On October 7, in addition to the primary transport of victims by ambulance to hospitals throughout Israel, they secondarily transported patients from the two closest hospitals - the Soroka Medical Center (SMC; Level 1 Trauma Center) in Beersheba and the Barzilai Medical Center (BMC; Level 2 Trauma Center) in Ashkelon. Secondary transport began five hours after the event started and continued for approximately 12 hours. During this time, the terrorist infiltration was still on-going. Soroka received 650 victims and secondarily transferred 26, including five in Advanced Life Support (ALS) ambulances. Barzilai received 372 and secondarily transferred 38. These coordinated secondary transfers helped relieve the overwhelmed primary hospitals and are an essential component of any MCE strategy.

Neonatal transport practices and effectiveness of the use of low-cost interventions on outcomes of transported neonates in Sub-Saharan Africa: A systematic review and narrative synthesis.

Neonatal deaths contribute significantly to under-5 mortality worldwide with Sub-Saharan Africa (SSA) alone accounting for 43% of global newborn deaths. Significant challenges in the region's health systems evidenced by huge disparities in health facility deliveries and poor planning for preterm births are major contributors to the high neonatal mortality. Many neonates in the region are delivered in suboptimal conditions and require transportation to facilities equipped for specialized care. This review describes neonatal transport across the subregion, focusing on low-cost interventions employed. We conducted a systematic review of studies on neonatal transport in SSA followed by a narrative synthesis. A search in the databases CINAHL, EMBASE, MEDLINE, Web of Science, African Index Medicus, and Google Scholar was performed from inception to March 2023. Two authors reviewed the full texts of relevant studies to determine eligibility for inclusion which was subsequently cross-checked by a third reviewer using a random 30% overlay. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. A total of 20 studies were included in this review involving 11,895 neonates from 10 countries. All studies evaluated the transfer of neonates into referral centers from the peripheries. Most neonates were transferred by public transport (n = 12), mostly in the arms of caregivers with little communication between referring facilities. Studies reporting on ambulance transfers reported pervasive inadequacies in both human resources and transport equipment. No study reported on the use of Kangaroo mother care (KMC) in the transfer process. The neonatal transport system across the SSA region is poorly planned, poorly resourced, and executed with little communication between facilities. Using cost-effective measures like KMC and improved training of community health workers may be key to improving the outcomes of transported neonates.

Development and inter-rater reliability of a simple prehospital mobility score for use in emergency patients

BackgroundMobility assessment enhances the ability of vital sign-based early warning scores to predict risk. Currently mobility is not routinely assessed in a standardized manner in Denmark during the ambulance transfer of unselected emergency patients. The aim of this study was to develop and test the inter-rater reliability of a simple prehospital mobility score for pre-hospital use in ambulances and to test its inter-rater reliability.MethodFollowing a pilot study, we developed a 4-level prehospital mobility score based of the question”How much help did the patient need to be mobilized to the ambulance trolley”. Possible scores were no-, a little-, moderate-, and a lot of help. A cross-sectional study of inter-rater agreement among ambulance personnel was then carried out. Paramedics on ambulance runs in the North- and Central Denmark Region, as well as The Fareoe Islands, were included as a convenience sample between July 2020—May 2021. The simple prehospital mobility score was tested, both by the paramedics in the ambulance and by an additional observer. The study outcomes were inter-rater agreements by weighted kappa between the paramedics and between observers and paramedics.ResultsWe included 251 mobility assessments where the patient mobility was scored. Paramedics agreed on the mobility score for 202 patients (80,5%). For 47 (18.7%), there was a deviation of one between scores, in two (< 1%) there was a deviation of two and none had a deviation of three (Table 1).Inter-rater agreement between paramedics in all three regions showed a kappa-coefficient of 0.84 (CI 95%: 0.79;0.88). Between observers and paramedics in North Denmark Region and Faroe Islands the kappa-coefficient was 0.82 (CI 95%: 0.77;0.86).ConclusionWe developed a simple prehospital mobility score, which was feasible in a prehospital setting and with a high inter-rater agreement between paramedics and observers.

Abstract 77: A Regional Transfer Center Pilot Improves Door-in-Door-out Time in a Large Integrated Healthcare System

Background: Successful treatment of patients with large vessel occlusions (LVO) is time dependent, yet timely transfers between hospitals for endovascular therapy (EVT) can be challenging. At Kaiser Permanente Northern California (KPNC) a wide variety of ambulance and EMS agencies may be involved in Urgent interfacility transfers. We evaluated a region-wide pilot utilizing a central transfer center to facilitate these transfers within a large integrated healthcare system. Methods: KPNC implemented a regional transfer center (TC) in March 2023, which arranged transfers for 17 of 19 primary stroke centers (PSC) from 8am to 9pm. Two centers were excluded as they were utilizing 911 transport rather than interfacility ambulance hub transfers. The study cohort included all stroke patients arriving to a PSC with LVO who were transferred to one of our Comprehensive Stroke Centers for EVT from 3/6/23 through 8/4/23. Data were compared to a similar cohort 10/6/23 through 3/5/23 (pre-TC). All patients were evaluated by teleneurologists on arrival, who requested initiation of ambulance transfer. Before TC, the ambulance request was made by the local ED facility; after the implementation of the TC, ambulance was arranged by the TC and communicated with teleneurology and the local ED. Door in door out (DIDO) times were measured for all transfers. Results: The pre-TC group had 81 transfers. The post-TC group had 68 patients. After TC, median DIDO dropped from 105 minutes to 83.5 minutes (p=0.02). The percent of patients transferred within 90 minutes rose from 41% to 57% (p=0.04) and the percent transferred with 75 minutes rose from 25% to 35% (p=0.14). Similar improvements were seen regardless of sex or ethnicity [Table]. Conclusions: Preliminary results show a significant improvement in DIDO times with initiation of a centralized TC to facilitate LVO transfers in a large integrated delivery system. Systems wishing to improve DIDO performance should consider implementing a similar TC.

Ambulance nurses' experiences as the sole caregiver with critical patients during long ambulance transports: an interview study.

Working in rural areas involves tackling long distances and occasional lack of supportive resources. Ambulance nurses are faced with the responsibility of making immediate autonomous decisions and providing extended care to critically ill patients during prolonged ambulance transport to reach emergency medical facilities. This study aims to expose the experiences of ambulance nurses acting as primary caregivers for critically ill patients during lengthy ambulance transfers in rural regions. Fifteen nurses employed in an ambulance service within sparsely populated rural areas were subjected to semi-structured interviews. The collected data underwent qualitative content analysis. The analysis resulted in one overarching theme with two categories. The theme is 'Safety in the Professional Role,' and the two categories are 'Working in sparsely populated areas presents challenges' and 'Rare events: when routine cannot be established.' The findings suggest that working as an ambulance nurse in a rural setting poses various challenges that can be highly stressful. Delivering care to critically ill patients during extended ambulance transports requires the knowledge, experience, and careful planning of the healthcare provider in charge. The findings underscore the necessity for thorough planning and adaptable thinking when attending to critically ill patients during extended transport scenarios. The absence of supporting resources can render the task demanding. Nevertheless, participants reported an inherent tranquility that aids them in maintaining focus amid their responsibilities.

Pattern of hospital admissions and costs associated with acute rheumatic fever and rheumatic heart disease in Australia, 2012-2017.

ObjectiveThis study aims to describe the pattern and trends in acute rheumatic fever (ARF)/rheumatic heart disease (RHD)-related hospitalisations and costs for Australians aged <65 years.MethodsThis retrospective linked data study measured trends in hospitalisations and costs for ARF, RHD and complications of ARF/RHD in Northern Territory, South Australia, Western Australia, Queensland and New South Wales between 1 July 2012 and 30 June 2017. Persons with ARF/RHD were identified from RHD registers and/or hospital records.ResultsOver the 5-year study period, 791 children, aged <16years (86.3% Indigenous), and 2761 adults, aged 16-64years (44.8% Indigenous), were hospitalised for ARF, RHD or associated complications. On average there were 296 paediatric admissions per year, increasing 6.1% annually (95% CI: 2.4-9.6%, P=0.001) and 1442 adult admissions per year, increasing 1.7% annually (95% CI: 0.1-3.4%, P=0.03). Total 5-year costs were AU$130.6m (AU$17.6m paediatric, AU$113.0m adult). Paediatric costs were mostly for ARF-related admissions whereas adult costs mostly involved valvular surgery. Emergency admissions and air ambulance transfers were common, particularly for non-metropolitan residents.ConclusionsSuccessful ARF/RHD prevention would deliver significant hospital cost savings. Investment in primary and specialist health care in regional areas may reduce emergency admissions and regional transfers, further reducing hospital burden.

Community Intervention Team Management of Urology patients in the Community

Introduction: Urinary catheters are a necessary and frequent intervention in the acute clinical setting but can be successfully implemented in a patient’s home with the appropriate protocols. Caredoc Community Intervention Teams (CIT) work closely with local hospitals to establish structured, streamlined referral pathways for patients requiring catheterisation to be managed in the community, thus reducing hospital admissions and visits. Caredoc CIT nurses have been equipped with the requisite skills to successfully manage urology patients, many who are post-operative, outside of the hospital setting, ensuring that this cohort can be managed safely at home with the support of family and/or carers.&#x0D; Aims, Objectives, Theory Or Methods: The purpose of the CIT urology pathway is to provide rapid acute nursing care interventions to patients in their own homes. Patients are identified by urology consultants at local hospitals or by their GPs and referred to CIT for a period of continuous care, with home visits carried out by specialist nurses during a defined timeframe. This facilitates both early hospital discharge and admission avoidance as well as reducing waiting lists for outpatient ambulatory and scheduled care. This shared care initiative aims to transition vital urinary catheter care to the community resulting in a person-centred approach that keeps discharged patients comfortable and well in their own environment.&#x0D; Highlights Or Results Or Key Findings: Patients are managed safely in their own homes by the CIT Team for the duration of their ongoing treatment. By providing a spectrum of catheter care and education, such as teaching patients on the colour of their urinary output, how and when to empty their drainage bag and how to use a fluid balance sheet to record volume emptied, patients are given the knowledge to monitor their urinary output and are enabled to recognise potential red flags for infection and any catheter-related issues that may debilitate or affect their quality of life, with a particular emphasis on the prevention of sepsis in older patients. 24-hour catheter care support is offered by way of a telephone line for patients and their carers should they need advice - prior to the instantiation of the CIT service, patients with subrapubic catheters in residential care or who sought care in the out-of-hours were referred to emergency department via ambulance transfer, as the specialism required for management of these patients was not otherwise available.&#x0D; Conclusions: The CIT Team have successfully demonstrated integrated care pathways for managing patients requiring catheterisation in the community, leading to positive patient outcomes and experiences as well as having a significant impact on urology waiting lists and emergency department attendances. &#x0D; Implications For Applicability/Transferability, Sustainability And Limitations: Sustainability of this process is guided by an integrated, systematic approach to proactive care of people who require catheter care at home, with the aim to improve delivery methods, reduce the burden on acute hospitals and achieve better patient outcomes.

Nurse escorts' perceptions of nurse-led inter-hospital ambulance transfer in the Wheatbelt region of Western Australia: A descriptive survey study.

The Western Australia (WA) Country Health Service (WACHS) requires the ward or emergency department (ED) registered nurse (RN) to assume the responsibility of conducting nurse-led interhospital patient road ambulance transfers, in the absence of an available registered paramedic (RP). The generalist nurse escort with no specialised training is allocated to the patient transport from their rostered shifts when the need arises, and, in some instances, this nurse may not have been in an ambulance before. Patients requiring transfer are usually prioritised over hospital patient care because of the life-threatening nature of these situations and the urgency to get them to tertiary care facilities. This study explored nurses' perceptions about caring for a patient during road ambulance transfer, with an aim of supporting future policy formulation and decision-making to guide nurses' training, induction and ongoing education on interhospital transfers. To examine the perceptions of hospital-employed registered nurses caring for a patient during road ambulance transfer from rural Western Australia. A descriptive survey design included 23 questions to clarify the level of experience and training, the prevalence of clinical deterioration and the confidence to manage patient care. Findings from the surveys indicated that nurses often felt overwhelmed by the responsibility of the patient transfer, unclear guidelines, limited preparation and handover, lack of orientation to the ambulance environment, difficulty escalating care during transfer and no insight into the return to base process. To explore how the RN who normally works within a well-organised and accessible multidisciplinary team manages caring for a patient in an unfamiliar mobile environment, the study was conducted within WACHS in the Wheatbelt Region of WA involving 27 health care sites. Participating nurses were asked several broad questions to explore their perceptions on how well-equipped they are in managing clinical care and deterioration during transfer; what are the challenges that they face while doing so and how confident they are about their knowledge, skill level and scope of clinical practice in supporting patients during interhospital transfer? Wheatbelt nurse escorts were capable, generalist nurses with a demonstrated skill set in managing patient care during transfer when needed. The 'back of the ambulance' was a challenging environment for nurses to engage in the type of care usually provided in the hospital setting, which come with a high level of uncertainty and anxiety for both patient outcome and own well-being.

Afterhours telehealth in Australian residential aged care facilities: a mixed methods evaluation

BackgroundThe aged care system in Australia is under pressure. Residential aged care facilities (RACFs) and general practitioners (GPs) have difficulty providing the care needed by their residents, particularly after hours. Many residents are given ambulance support and transferred to hospital emergency departments (EDs) for care that could be provided at RACFs. The MyEmergencyDoctor (MED) service was commissioned in a 12-month program (February 2020-February 2021) using ED physicians to provide afterhours telehealth care in six RACFs.MethodsUsing the NASSS framework, we synthesised descriptive analyses of statistical data from the MED service, RACFs and the ambulance service and a thematic analysis of interview data collected from GPs, RACF and MED service staff, and family members of residents.ResultsMost calls to MED (179/209) were resolved with in-house treatment thereby reducing ambulance usage and hospital admissions. Interviews further revealed that MED enabled timely care for residents who were unwell but did not need hospital transfer. Technology, training, and rapid access to MED assisted RACF staff and complemented usual GP care. MED potentially reduced GP burnout. Refresher training was considered important especially in RACFs with high staff turnover, as was greater afterhours access to medications.ConclusionsThe afterhours telehealth model provided in-house care and reduced ambulance transfers, and GPs and RACF staff generally felt supported. The service was easy to use and fostered good communications with GPs and RACF staff. Some GPs preferred to provide their own care, commenting on the need for a good understanding of patient and family needs and of the local context. Other stakeholders suggested this model could be extended to palliative care settings and to normal business hours when GPs were unavailable. The reduced ambulance and hospital use suggested benefits to wider health systems, however policies and funding that remunerate GPs, support community-based care and provide additional staffing in RACFs are needed to sustain afterhours telehealth in RACFs. Use of the NASSS (non-adoption, abandonment, scale-up, spread, and sustainability) Framework provided a valuable explanatory lens for our analyses.

Impact of a ground intermediate transport from the helicopter landing site at a hospital on transport duration and patient safety

BackgroundHelicopter emergency medical service provides timely care and rapid transport of severely injured or critically ill patients. Due to constructional or regulatory provisions at some hospitals, a remote helicopter landing site necessitates an intermediate ground transport to the emergency department by ambulance which might lengthen patient transport time and comprises the risk of disconnection or loss of vascular access lines, breathing tubes or impairment of other relevant equipment during the loading processes. The aim of this study was to evaluate if a ground intermediate transport at the hospital site prolonged patient transport times and operating times or increases complication rates.MethodsA retrospective analysis of all missions of a German air rescue service between 2012 and 2020 was conducted. Need of a ground transport at the accepting hospital, transfer time from the helipad to the hospital, overall patient transport time from the emergency location or the referring hospital to the accepting hospital and duration of the mission were analyzed. Several possible confounders such as type of mission, mechanical ventilation of the patient, use of syringe infusion pumps (SIPs), day- or nighttime were considered.ResultsOf a total of 179,003 missions (92,773 (51,8%) primary rescue missions, 10,001 (5,6%) polytrauma patients) 86,230 (48,2%) secondary transfers) an intermediate transport by ambulance occurred in 40,459 (22,6%) cases. While transfer times were prolonged from 6.3 to 8.8 min for primary rescue cases (p < 0.001) and from 9.2 to 13.5 min for interhospital retrieval missions (p < 0.001), the overall patient transport time was 14.8 versus 15.8 min (p < 0.001) in primary rescue and 23.5 versus 26.8 min (p < 0.001) in interhospital transfer. Linear regression analysis revealed a mean time difference of 3.91 min for mechanical ventilation of a patient (p < 0.001), 7.06 min for the use of SIPs (p < 0.001) and 2.73 min for an intermediate ambulance transfer (p < 0.001). There was no relevant difference of complication rates seen.ConclusionsAn intermediate ground transport from a remote helicopter landing site to the emergency department by ambulance at the receiving hospital had a minor impact on transportation times and complication rates.

Associations between basic physiological observations recorded pre-thrombectomy and functional outcome: a systematic review and meta-analysis

IntroductionMechanical thrombectomy results in more favourable functional outcomes for patients with acute large vessel occlusion (LVO) stroke. Key clinical determinants of thrombectomy outcome include symptom severity, age and time from onset to treatment, but associations have also been reported with baseline physiological observations including systolic/diastolic blood pressure (SBP/DBP), blood/serum glucose, atrial fibrillation and conscious level. As these items are routinely available during initial emergency assessment, they might help to inform early prehospital and hospital triage decisions if evidence consistently shows associations with post-thrombectomy outcome. We undertook a meta-analysis of studies reporting pre-thrombectomy physiological observations and functional outcome.MethodPRISMA guidelines were followed to search electronic bibliographies, select articles and extract data. Medline, PubMed, Cochrane HTA, Cochrane Central and Embase were searched. Included articles were observational or interventional thrombectomy studies published between 01/08/2004-19/04/2023 reporting 3-month modified Rankin Scale, split as favourable (0–2) and unfavourable (3–6). A modified version of the Quality in Prognostic Studies (QUIPS) tool was used to assess risk of bias. RevMan 5 was used to calculate Inverse Variance with Weighted Mean Differences (WMD) and Mantel-Haenszel Odds Ratios (OR) for continuous and categorical factors respectively.ResultsThirty seven studies were eligible from 8,687 records. Significant associations were found between unfavourable outcome and higher blood/serum glucose as a continuous (WMD = 1.34 mmol/l (95%CI 0.97 to 1.72); 19 studies; n = 3122) and categorical (OR = 2.44 (95%CI 1.9 to 3.14) variable; 6 studies; n = 5481), higher SBP (WMD = 2.98 mmHg (95%CI 0.86 to 5.11); 16 studies; n = 4,400), atrial fibrillation (OR = 1.48 (95%CI 1.08 to 2.03); 3 studies; n = 736), and lower Glasgow Coma Scale (WMD = −2.72 (95%CI −4.01 to −1.44); 2 studies; n = 99). No association was found with DBP (WMD = 0.36 mmHg (95%CI −0.76 to 1.49); 13 studies; n = 3,614).ConclusionBasic physiological observations might assist early triage decisions for thrombectomy and could be used in combination with other information to avoid futile treatment and ambulance transfers. It is important to acknowledge that data were only from thrombectomy treated patients in hospital settings and it cannot be assumed that the predictors identified are independent or that modification can change outcome. Further work is needed to establish the optimal combination of prognostic factors for clinical care decisions.

A Telemedicine Solution to Minimize Unnecessary Emergency Department Transfers for Low-acuity Pediatric Orthopaedic Patients: A Model for Cost Minimization.

Unnecessary emergency department (ED) transfers represent a notable source of excess costs and misutilization of healthcare resources, particularly with management of acute pediatric musculoskeletal injuries. This study used institutional data to create a model investigating the expected costs of a formal peer-to-peer telemedicine intervention designed to triage pediatric orthopaedic transfers, which we hypothesized would decrease healthcare costs by minimizing unwarranted ED-to-ED transfers. In this retrospective modeling analysis, 350 pediatric orthopaedic trauma patients transferred to two in-network referral hospitals from outside facilities were identified and stratified into three groups representing how patients theoretically optimally could have been treated. Group 1 patients required ambulance transfer, group 2 patients required ED-level care but no ambulance transfer, and group 3 patients did not require ED-level care. Base case estimates for the proportions of patients in each group, probability of ambulance transport, and direct costs of care for each patient were derived from the database. A decision tree was developed to evaluate the expected costs of two triaging strategies: (1) transfer everyone or (2) triage first using e-consultation. Probabilistic sensitivity analyses were used to determine how the results of the decision analysis varied across ranges of cost and probability estimates. In the base case analysis, the telemedicine triage strategy was cheaper than the transfer-all strategy ($4,858 versus $6,610). In a 2-way sensitivity analysis comparing cost of a telemedicine visit and proportion of telemedicine triaged patients requiring ambulance transport, the telemedicine triage strategy remained cheaper than the transfer-all strategy across almost all possibilities for both variables. Additional potential benefits of triage before transfer, such as decreased length of time to completion of ED visit, cost to the family, and patient comfort and satisfaction, were not incorporated into this analysis. The potential for misdiagnosis related to telehealth and its potential costs were not included. We revealed substantial cost savings for the healthcare system from implementing a telehealth platform for peer-to-peer consultation when considering patient transfer for musculoskeletal trauma. Initial peer-to-peer e-consultations cost less than reflexive ambulance transfer in most situations. Economic Level II.