Interfacility Transfer Research Articles

The prehospital paediatric emergency care burden managed by a public ambulance service in the Western Cape, South Africa

BackgroundPaediatric mortality rates in low- and middle-income countries account for over 80% of the global burden. In South Africa, one in every 33 children will not reach the age of five. Despite the high mortality rate, there is a paucity of data describing the prehospital paediatric under-five emergency care burden in South Africa. Such data are essential to inform the development of local prehospital emergency care guidelines and targeted prevention strategies.AimThis study describes the prehospital paediatric under-five emergency care burden managed by the Western Cape Government Health and Wellness (WCGHW) Emergency Medical Services (EMS) in South Africa.MethodsA retrospective review of the prehospital records was conducted, extracting epidemiological and clinical data from the WCGHW EMS patient record database. The review included all paediatric cases under-five, managed between 1 January 2022 and 31 December 2023, in the Western Cape of South Africa.ResultsIn the 87 457 cases, there was a similar distribution between the primary cases (50.7%) and interfacility transfers (49.3%). Most activations emanated from rural areas (47 980, 54.9%), with respiratory emergencies (30 934, 35.4%), non-cardiac pain (11 381, 13.0%) and trauma (10 831,12.4%) being the most common presenting complaints. Most cases were prioritised as priority 2 (46 034, 52.6%), with most of these being older children between one and five years old (29 008, 63.0). Low acuity cases accounted for 67.2% (58 818) of the sample, with the highest mortality occurring between 29 days and 12 months (190, 52.9.%). Most patients spent less than one hour in the prehospital setting (64 431, 73.7%), with advanced airway management (748, 43.1%) being the most common airway intervention.ConclusionThis first description of the prehospital paediatric under-five emergency care burden managed by the WCGHW EMS reveals a unique burden, particularly regarding the high interfacility transfer rates. As illustrated in graphical abstract, these findings underscore critical considerations for healthcare planners and the prehospital training environment. Future research among this population should focus on characterising the reasons for the high interfacility transfer rates through assessments of healthcare access, EMS care quality and post-EMS follow-up.Graphical

Hypothermia on Admission Predicts Poor Outcomes in Adult Trauma Patients

BackgroundHypothermia is known to contribute to poor outcomes in trauma patients during acute phases. The aim of our study is to evaluate the effect of hypothermia on admission, upon in-hospital complications and mortality in adult trauma patients. MethodsWe performed a 5-year analysis of ACS-TQIP database (2017-2021). Patients with incomplete data, burns, inter-facility transfers, or documented as dead on arrival were excluded. Hypothermia (HT) was defined as a temperature of <35 degrees Celsius(°C), and Normothermia (NT) as ≥35°C to≤40°C measured at the time of patient arrival. Data were collected including demographic variables, mechanism of injury, injury severity, injury patterns, and shock index. Outcome variables were mortality, ICU length of stay (LOS), duration of mechanical ventilation, hospital LOS, and in-hospital complications. Multivariable regression analysis was performed. ResultsA total of 3,043,030 patients were included and 1% were hypothermic. HT patients were severely injured, developed in-hospital complications (17.1%vs.4.5%), had longer ICU LOS (4 (2-9) vs. 3 (2-5) days), hospital LOS (5 (2-12) vs. 4 (2-6) days), and higher mortality (23.4% vs. 2.3%). Hypothermia was independently associated with higher odds of mortality (OR:1.934 [1.858–2.013]). Subgroup analysis of patients with isolated traumatic brain injury revealed pre-hospital hypothermia to still be an independent predictor of mortality (OR: 1.728[1.600–1.867]). HT who underwent rewarming had a lower mortality, shorter hospital and ICU LOS. ConclusionPre-hospital hypothermia is independently associated with higher resource utilization, in-hospital complications, and mortality. Even in patients with isolated TBI, pre-hospital hypothermia increases the odds of mortality. Rewarming interventions can potentially improve outcomes among patients, even with mild hypothermia.

Impact of COVID-19 pandemic on traumatic brain injury emergency department visits, interfacility transfer and mortality in the United States, 2016–2020: a cross-sectional study

ObjectiveThe aim of this study was to determine how the COVID-19 pandemic affected patient demographics, injury mechanisms, interhospital transfers and mortality of patients with traumatic brain injuries (TBIs) treated in...

Community perspectives on barriers to injury care in Northern Malawi: a three delays framed assessment using focus groups and photovoice

IntroductionThe global burden of injury is huge, falling disproportionately on poorer populations. The benefits of qualitative research in injury care are recognised and its application is growing. We used a novel application of focus group discussions with photovoice to rapidly assess barriers at each of three delay stages; seeking (delay-1), reaching (delay-2) or receiving (delay-3) injury care in Northern Malawi.MethodsThree community Focus Group Discussions (FGDs) of individuals with (FGD1) and without (FGD2) recent injury experience and community leaders (FGD3) discussed barriers to seeking, reaching or receiving care following injury. Participants from FGD1 subsequently used a digital camera and, following training in photovoice, took photographs illustrating barriers to injury care. Participants reconvened to discuss images which they believed illustrated important barriers. A framework method analysis compared barriers generated to those identified by an earlier Delphi study.ResultsSeven of eight invited adult community members attended each discussion group. Within the FGDs, all prior Delphi derived delay 1 barriers were described. Within delay 2, all but three were discussed by community participants. Those not covered were: 1) “communication” ;2) “prehospital care”; 3) “coordination”. Within Delay 3, only “capacity”was not highlighted by participants during the study.Additional health system barriers not identified in the Delphi were inductively derived. Within Delay 1, these were labelled; “religious or other beliefs”; “indecision”;“fear or lacking courage”; and “community/bystander engagement”. Within Delay 2, “lack of assistance” was derived. Within Delay 3; “alleged corruption”; “interfacility transfer”; and “police processes” were all identified during analysis. The photovoice group provided 21 photographs evidencing 15 barriers. Delay 1 was the most frequently captured by images (12/21).The individual barriers most frequently described were “transport” and “roads” (6/21 and 5/21, respectively). The photovoice group did not describe any additional barriers not covered in the prior FGDs.ConclusionWe identified several barriers within this health system. Participants illustrated how some barriers impact on multiple phases of delay. The method was quick, low cost and participants grasped the technique and research question effectively. We recommend this approach for future health system assessments.

Validation of the PHASE Measure for Admissions to an ICU and After Interfacility Transfer.

Validation of the PHASE Measure for Admissions to an ICU and After Interfacility Transfer.

Interfacility Transfer for Thrombectomy: A Promising Therapeutic Window.

Currently, most acute ischemic stroke patients presenting with a large vessel occlusion are first evaluated at a nonthrombectomy-capable center before transfer to a comprehensive stroke center that performs thrombectomy. Interfacility transfer is a complex process that requires extensive coordination between the referring, transporting, and receiving facilities. As a result, long delays are common, contributing to poor clinical outcomes. In this review, we summarize the accumulating literature about the clinical as well as radiological-infarct growth, collateral change, arterial recanalization, and hemorrhagic transformation-changes during interfacility transfer for thrombectomy. Recent evidence shows that clinical/radiological changes during transfer are heterogeneous across patients and impact long-term functional outcomes, highlighting the urgent need to optimize care during this time window. We review some of the most promising therapeutic strategies-for example, penumbral protection to reduce infarct growth-that may improve clinical outcome in patients being transferred to thrombectomy-capable centers. Finally, we discuss key methodological considerations for designing clinical trials aimed at reducing infarct growth during transfer.

Travel Distances for Interhospital Transfers of Critically Ill Children: A Geospatial Analysis.

The U.S. pediatric acute care system has become more centralized, placing increasing importance on interhospital transfers. We conducted a geospatial analysis of critically ill children undergoing interfacility transfer with a specific focus on understanding travel distances between the patient's residence and the hospitals in which they receive care. Retrospective geospatial analysis using five U.S. state-level administrative databases; four states observed from 2016 to 2019 and one state from 2018 to 2019. Participants included 10,665 children who experienced 11,713 episodes of critical illness involving transfer between two hospitals. Travel distances and the incidence of "potentially suboptimal triage," in which patients were transferred to a second hospital less than five miles further from their residence than the first hospital. Patients typically present to hospitals near their residence (median distance from residence to first hospital, 4.2 miles; interquartile range [IQR], 1.8-9.6 miles). Transfer distances are relatively large (median distance between hospitals, 28.9 miles; IQR, 11.2-53.2 miles), taking patients relatively far away from their residences (median distance from residence to second hospital, 30.1 miles; IQR, 12.2-54.9 miles). Potentially suboptimal triage was frequent: 24.2 percent of patients were transferred to a hospital less than five miles further away from their residence than the first hospital. Potentially suboptimal triage was most common in children living in urban counties, and became less common with increasing medical complexity. The current pediatric critical care system is organized in a hub-and-spoke model, which requires large travel distances for some patients. Some transfers might be prevented by more efficient prehospital triage. Current transfer patterns suggest the choice of initial hospital is influenced by geography as well as by attempts to match hospital resources with perceived patient needs.

Associations of interfacility transfer with clinical presentation and early mortality in patients with type a acute aortic dissection: a registry study

Abstract Background Acute aortic dissection (AAD), particularly Stanford type A, is a life-threatening condition with high morbidity and mortality that requires prompt diagnosis and urgent intensive treatment including surgical repair. Our reginal aortic network has been established to develop the effective and safe transfer system for patients with AAD. Purpose This study aimed to assess how interfacility transfer impacts clinical presentation and early mortality in type A AAD patients using multicenter registry data. Methods We studied 1024 consecutive patients (age: 70 [58-79] years, 55% male) who were hospitalized for type A AAD within 24 hours after symptom onset during 2017–2018. Patients with cardiopulmonary arrest before hospital arrival were excluded. Multivariable logistic regression analysis was used to evaluate the association between interfacility transfer and operative mortality. Results In this study cohort, 539 patients were transferred from another facility, whereas the remaining 485 were directly admitted to the presenting hospital. Patients with transfer had a longer time from symptom onset to emergency surgery than those without transfer (326 [267–472] min vs. 282 [216–390] min, p&amp;lt;0.001). AAD-related complications (cardiac tamponade, cardiac arrest, shock, aortic rupture, end-organ malperfusion) were more frequent in patients without transfer (32.0% vs 24.5%, p=0.008). Patients with transfer underwent surgical and/or endovascular treatment more frequently (92.9% vs. 74.8%, p&amp;lt;0.001) and had a lower 30-day mortality rate than those without transfer (7.1% vs. 21.9%, p&amp;lt;0.001). The operative mortality was also lower in patients with transfer than in those without transfer (30/501 [6.0%] vs. 43/363 [11.8%], p=0.002). The multivariable analysis conducted in this study revealed that the presence of AAD-related complications at admission was associated with a higher operative mortality (odds ratio [OR]: 5.10; 95% confidence interval [CI]: 3.00–8.67, p&amp;lt;0.001), whereas interfacility transfer was associated with a lower operative mortality (OR: 0.54; 95% CI:0.31–0.95, p=0.031). Conclusion These findings underscore the critical role of efficient transfer systems and early intervention in managing type A AAD. Despite the delay from symptom onset to surgical intervention, interfacility transfer did not lead to adverse outcomes for patients with type A AAD.

Interfacility Transfer of Children With Time-Sensitive Surgical Conditions, 2002-2017

Surgical care for children in the United States has become increasingly regionalized among fewer centers over time. The degree to which regionalization may be associated with access to urgent surgical care for time-sensitive conditions is not clear. To investigate whether transfers and travel distance have increased for 4 surgical conditions, and whether changes in transfers and travel distance have been more pronounced for rural vs urban children. This retrospective cross-sectional study analyzed data from 9 State Inpatient Databases from 2002 to 2017. Participants included children aged younger than 18 years undergoing urgent or emergent procedures for malrotation with volvulus, esophageal foreign body, and ovarian and testicular torsion. Residential and hospital zip codes were categorized as rural or urban. Hospitals were categorized as pediatric hospitals, adult hospitals with pediatric services, and adult hospitals without pediatric services. Primary outcomes were transfer for care and travel distance between patients' home residences and the hospitals where care was provided. Transfer and travel distance were analyzed using multivariable regression models. Among the 5865 children younger than 18 years undergoing procedures for malrotation with volvulus, esophageal foreign body, ovarian torsion, or testicular torsion, 461 (7.9%) resided in a rural area; 1097 (20.5%) were Hispanic, 1334 (24.9%) were non-Hispanic Black, and 2255 (42.0%) were non-Hispanic White; 2763 (47.1%) were covered by private insurance and 2535 (43.2%) were covered by Medicaid; and the median (IQR) age was 9 (2-14) years. Most care was provided at adult hospitals (73.4% with and 16.9% without pediatric services); the number of hospitals providing this care decreased from 493 to 292 hospitals (2002 vs 2017). Transfer was associated with rural residence (adjusted odds ratio [aRR], 2.3 [95% CI, 1.8-3.0]; P < .001) and increased over time (2017 vs 2002: aOR, 2.8 [95% CI, 2.0-3.8]; P < .001). Similarly, travel distance was associated with rural residence (adjusted risk ratio [aRR], 4.4 [95% CI, 3.9-4.8]; P < .001) and increased over time (2017 vs 2002: aRR, 1.3 [95% CI, 1.2-1.4]; P < .001). Rural children were more frequently transferred (2017 vs 2002) for esophageal foreign body (48.0% [12 of 25] vs 7.3% [4 of 55]; P < .001), ovarian torsion (26.7% [4 of 15] vs 0% [0 of 18]; P = .01), and testicular torsion (18.2% [2 of 11] vs 0% [0 of 16]; P = .04). Travel distance for rural children increased the most for torsions, from a median (IQR) of 19.1 (2.3-35.4) to 43.0 (21.6-98.8) miles (P = .03) for ovarian torsion and from 7.3 (0.4-23.7) to 44.5 (33.1-48.8) miles (P < .001) for testicular torsion. In this cross-sectional study of children with time-sensitive surgical conditions, the number of hospitals providing urgent surgical care to children decreased over time. Transfers of care, especially among rural children, and travel distance, especially for those with ovarian and testicular torsion, increased over time.

The polk county screening tool screening for detecting subarachnoid hemorrhage

IntroductionThe subarachnoid space in the brain contains crucial blood vessels and cerebrospinal fluid. Aneurysms in these vessels can lead to subarachnoid hemorrhage (SAH), a serious stroke subtype with high morbidity and mortality rates. SAH treatment includes procedures like coiling and clipping, but these are available only at comprehensive stroke centers (CSCs), necessitating urgent diagnosis and transfer to specialized facilities.MethodsThis IRB-approved study was conducted by Polk County Fire Rescue (PCFR) in Florida. PCFR, serving an 850,000-person population, implemented a three-step SAH protocol. The protocol uses both Ottawa SAH criteria and recurring symptoms, such as new-onset seizures and high systolic blood pressure, that were identified by EMS. Acute management included administering labetalol, levetiracetam, and ondansetron.ResultsOf 2175 stroke patients, 80 screened positive for SAH and were eligible for transfer. Patients had a median age of 66, and 33% had an initial systolic BP over 220 mmHg. The interfacility transfer rate dropped from 12.9 to 3.6% after implementing the protocol.ConclusionThe PCFR protocol’s effectiveness suggests its potential for nationwide implementation. Early SAH recognition and prompt transfer to CSCs reduce complications and improve outcomes. Accurate field diagnosis by EMTs can prevent unnecessary transfers and enhance patient care. Future improvements may include portable diagnostic tools and enhanced EMT training to further improve SAH patients’ pre-hospital care.

Assessing variations in care delivered to rural out of hospital cardiac arrest patients in the interfacility transfer setting.

There is significant variation in out-of-hospital cardiac arrest (OHCA) outcomes between different regions. We sought to evaluate outcomes of OHCA patients in the interfacility transfer (IFT) setting, between critical care transport (LifeFlight) and community Emergency Medical Services (EMS), in the state of Maine. This was a retrospective analysis of our institution's electronic medical record and the Maine EMS database. Data were collected from January 1, 2019, to December 31, 2021. Only adult OHCA encounters requiring an IFT for definitive post-cardiac-arrest care were included. Demographics, EMS agency, IFT vital signs, targeted temperature management (TTM) medications, cerebral performance category (CPC) scores, survival to discharge, and other descriptive variables were collected. Ninety-three patients met inclusion criteria, with LifeFlight transferring 30 of them (32.3%). LifeFlight was more likely to initiate TTM compared to other EMS agencies (p=0.012), have run-sheets reported (p=0.001), and serve rural areas (p=0.036). LifeFlight was associated with more epinephrine (0.034) and norepinephrine (<0.001) use. Only 37% of IFTs had physician orders, with none (0.0%) of them defining vital sign targets. No difference in survival to discharge or CPC scores was observed between LifeFlight and other EMS agencies. No significant variation in comorbidities or vital signs was observed. There was no difference in survival to discharge or CPC scores between LifeFlight and ad hoc EMS agency. LifeFlight was associated with more TTM and vasopressor utilization during IFT. Most IFT encounters did not have dedicated physician orders, and none of the orders included vital sign targets.

Differences in Interfacility Transfer from Emergency Department and Inpatient Services for Inpatient Neurologic Care.

Interhospital transfer is an important mechanism for improving access to specialized neurologic care but there are large gaps in our understanding of interhospital transfer for the management of non-stroke-related neurologic disease. This observational study included consecutive patients admitted to an adult academic general neurology service via interhospital transfer from July 1, 2015 to July 1, 2017. Characteristics of the referring hospital and transferred patients were obtained through the American Hospital Association Directory, a hospital transfer database maintained by the accepting hospital, and the electronic medical record. The analyses used descriptive statistics to examine the cohort overall and compare characteristics of patients transferred from an emergency department and inpatient service. 504 patients were admitted via interhospital transfer during the study period. Of these, 395 patients (78.4%) were transferred because the referring hospital lacked capability, and 139 patients (27.6%) were transferred from an emergency department as opposed to inpatient service. Seizures was the most common diagnosis (23.8%). Patients who were transferred from an emergency department had a higher proportion covered by Medicaid (44.6%) than those transferred from an inpatient service (28.8%) and had a shorter median length of stay (3days; IQR 2-7 vs 7days; IQR 4-12). The majority of observed interhospital non-stroke neurologic transfers occurred to improve access to specialized neurological care for patients, though patients transferred from the ED, as opposed to an inpatient service, had lower health care utilization, and this will be important to consider when developing systems of care and in future research.

Assessing the need for specialty consultation for isolated medial orbital wall fractures

ObjectiveThis objective was to assess if the current practice of interfacility transfer and immediate specialty consult is justified by the rate of surgical repair for isolated medial orbital wall fractures. Study DesignThis is a retrospective descriptive study utilizing the records of all patients with isolated medial orbital wall fractures who presented to the ED at Boston Medical Center from January 2014 to December 2022. A descriptive analysis was completed. Results65 patients with isolated medial orbital wall fractures were identified. No patient underwent surgical intervention for repair of their fracture. 15% of the patients were transferred from an outside facility. The facial trauma team was consulted for 70% of the patients. Concomitant consultation of the ophthalmology and facial trauma teams occurred for 54% of the patients. Patients with no specialty consult had the shortest average length of ED stay. The no-show rate for follow-up appointments was 70%. ConclusionsThe absence of surgical repair for isolated medial orbital wall fractures across multiple surgical specialties, multiple attending providers, a wide age range, and all mechanisms of injury along with a 70% follow-up no-show rate may call into question the conventional approach of interfacility transfer and specialty consult for these fractures.

Assessing the Risk of Interfacility Transport in Pregnant Patients Due to Progression of Labor: Lessons From a Specialized Maternal-Fetal Transport Program.

Background Pregnant laboring patients sometimes require interfacility transfer to a higher level of care. There is a paucity of evidence to inform when it is safe to transfer a laboring patient and when delivery may be too imminent to transfer. Methods This is a retrospective study of pregnant patients undergoing interfacility transfer with a specialized obstetric transport team deployed from a large Midwest regional healthcare system. The primary outcome was delivery prior to or within one hour of arrival at the receiving institution due to progression of labor. Data collected included basic demographics, vital signs, gravidity, parity, gestational age, contraction frequency if contractions were present, and cervical dilation. We sought to define the association between these variables and the primary outcome to inform risk assessment for precipitous delivery among patients being considered for interfacility transfer. Results Of the 370 pregnant patients for whom the specialized transfer team was requested, 11 (3%) met the primary outcome. Those with more advanced cervical dilation and those who did not receive regular prenatal care were more likely to meet the criteria for the primary outcome. For every centimeter of cervical dilation, the odds of meeting the primary outcome increased 2.3-fold (95% CI: 1.5-3.4). Conclusions We identified risk factors for early delivery among pregnant patients for whom an interfacility transfer was requested and described patients who were high-risk for obstetric interfacility transport due to the progression of labor. Our results can help inform risk assessments for transferring potentially high-risk laboring patients.

Rural-Urban Disparities in Hospital Services and Outcomes for Children With Medical Complexity

Limited availability of inpatient pediatric services in rural regions has raised concerns about access, safety, and quality of hospital-based care for children. This may be particularly important for children with medical complexity (CMC). To describe differences in the availability of pediatric services at acute care hospitals where rural- and urban-residing CMC presented for hospitalization; identify rural-urban disparities in health care quality and in-hospital mortality; and determine whether the availability of pediatric services at index hospitals or the experience of interfacility transfer modified rural-urban differences in outcomes. This retrospective cohort study examined all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 to 2017. Analysis was conducted from May 2023 to July 2024. Participants included CMC younger than 18 years residing in these states and hospitalized during the study period. Rural or urban residence was determined using Rural-Urban Commuting Area codes. Hospitals were categorized as children's hospitals or general hospitals with comprehensive, limited, or no dedicated pediatric services using American Hospital Association survey data. Interfacility transfers between index and definitive care hospitals were identified using health care claims. In-hospital mortality, all-cause 30-day readmission, medical-surgical safety events, and surgical safety events were operationalized using Agency for Healthcare Research and Quality measure specifications. Among 36 943 CMC who experienced 79 906 hospitalizations, 16 525 (44.7%) were female, 26 034 (70.5%) were Medicaid-insured, and 34 008 (92.1%) were urban-residing. Rural-residing CMC were 6.55 times more likely to present to hospitals without dedicated pediatric services (rate ratio [RR], 6.55 [95% CI, 5.86-7.33]) and 2.03 times more likely to present to hospitals without pediatric beds (RR, 2.03 [95% CI, 1.88-2.21]) than urban-residing CMC, with no significant differences in interfacility transfer rates. In unadjusted analysis, rural-residing CMC had a 44% increased risk of in-hospital mortality (RR, 1.44 [95% CI, 1.03-2.02]) with no significant differences in other outcomes. Adjusting for clinical characteristics, the difference in in-hospital mortality was no longer significant. Index hospital type was not a significant modifier of observed rural-urban outcomes, but interfacility transfer was a significant modifier of rural-urban differences in surgical safety events. In this cohort study, rural-residing CMC were significantly more likely to present to hospitals without dedicated pediatric services. These findings suggest that efforts are justified to ensure that all hospital types are prepared to care for CMC.

Management of Patients With Cardiac Arrest Requiring Interfacility Transport: A Scientific Statement From the American Heart Association.

People who experience out-of-hospital cardiac arrest often require care at a regional center for continued treatment after resuscitation, but many do not initially present to the hospital where they will be admitted. For patients who require interfacility transport after cardiac arrest, the decision to transfer between centers is complex and often based on individual clinical characteristics, resources at the presenting hospital, and available transport resources. Once the decision has been made to transfer a patient after cardiac arrest, there is little direct guidance on how best to provide interfacility transport. Accepting centers depend on transferring emergency departments and emergency medical services professionals to make important and nuanced decisions about postresuscitation care that may determine the efficacy of future treatments. The consequences of early care are greater when transport delays occur, which is common in rural areas or due to inclement weather. Challenges of providing interfacility transfer services for patients who have experienced cardiac arrest include varying expertise of clinicians, differing resources available to them, and nonstandardized communication between transferring and receiving centers. Although many aspects of care are insufficiently studied to determine implications for specific out-of-hospital treatment on outcomes, a general approach of maintaining otherwise recommended postresuscitation care during interfacility transfer is reasonable. This includes close attention to airway, vascular access, ventilator management, sedation, cardiopulmonary monitoring, antiarrhythmic treatments, blood pressure control, temperature control, and metabolic management. Patient stability for transfer, equity and inclusion, and communication also must be considered. Many of these aspects can be delivered by protocol-driven care.

Acquisition of Prehospital Stroke Severity Scale is associated with shorter door-to-puncture times in patients with prehospital notifications transported directly to a thrombectomy center

BackgroundWe sought to identify systemic factors influencing door-to-puncture times (DTP) among patients with pre-arrival notifications presenting directly to a comprehensive stroke center (CSC) and undergoing emergent mechanical thrombectomy (MT).MethodsIn this...

Using Teletrauma to Improve Access to Trauma Care in the US: A Call for Action.

Nearly 30 million, mostly rurally-located Americans lack timely access to level I or II trauma center care, resulting in inefficient resource use and potentially preventable deaths. Although significant progress has been made in the care of the injured patient over the last few decades, rural trauma patients continue to face significant challenges in accessing high quality trauma care with resultant outcomes disparities and increased expenditures associated with potentially avoidable interfacility transfers. Current mitigation strategies have not sufficiently improved access to trauma care among this population, necessitating a search for alternative strategies such as integration of telehealth for trauma care or teletrauma. Telehealth is well-established in several healthcare areas resulting in improved patient and system-level outcomes. While telehealth has been used in trauma with some success, it remains underused. Members of a 2023 ACS Committee on Trauma Spotlight Session on the role of teletrauma present an introduction to the applications, potential benefits and future directions for telehealth use in trauma care.

A proposed method for identifying Interfacility transfers in Medicare claims data.

To develop a method of consistently identifying interfacility transfers (IFTs) in Medicare Claims using patients with ST-Elevation Myocardial Infarction (STEMI) as an example. 100% Medicare inpatient and outpatient Standard Analytic Files and 5% Carrier Files, 2011-2020. Observational, cross-sectional comparison of patient characteristics between proposed and existing methods. We limited to patients aged 65+ with STEMI diagnosis using both proposed and existing methods. We identified 62,668 more IFTs using the proposed method (86,128 versus 23,460). A separately billable interfacility ambulance trip was found for more IFTs using the proposed than existing method (86% vs. 79%). Compared with the existing method, transferred patients under the proposed method were more likely to live in rural (p < 0.001) and lower income (p < 0.001) counties and were located farther away from emergency departments, trauma centers, and intensive care units (p < 0.001). Identifying transferred patients based on two consecutive inpatient claims results in an undercount of IFTs and under-represents rural and low-income patients.

Initial Defibrillator Pad Position and Outcomes for Shockable Out-of-Hospital Cardiac Arrest

Ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) are the most treatable causes of out-of-hospital cardiac arrest (OHCA). Yet, it remains unknown if defibrillator pad position, placement in the anterior-posterior (AP) or anterior-lateral (AL) locations, impacts patient outcomes in VF or pVT OHCA. To determine the association between initial defibrillator pad placement position and OHCA outcomes for patients presenting with VF or pVT. This prospective cohort study included patients with OHCA and VF or pVT treated by a single North American emergency medical services (EMS) agency from July 1, 2019, through June 30, 2023. The study included patients with OHCA treated by a large suburban fire-based EMS agency that covers a population of 550 000. Consecutive patients with an initial EMS-assessed rhythm of VF or pVT receiving EMS defibrillation were included. Pediatric patients (younger than 18 years), interfacility transfers, arrests of obvious traumatic etiology, and patients with preexisting do-not-resuscitate status were excluded. AP or AL pad placement. Return of spontaneous circulation (ROSC) at any time with secondary outcomes of pulses present at emergency department (ED) arrival, survival to hospital admission, survival to hospital discharge, and functional survival at hospital discharge (cerebral performance category score of 2 or less). Measures included adjusted odds ratios (aOR), multivariable logistic regressions, and Fine-Gray competing risks regression. A total of 255 patients with OHCA were included (median [IQR] age, 66 [55-74] years; 63 females [24.7%]), with initial pad positioning documented as either AP (158 patients [62.0%]; median [IQR] age, 65 [54-74] years; 37 females [23.4%]) or AL (97 patients [38.0%]; median [IQR] age, 66 [57-74] years; 26 females [26.8%]). Patients with AP placement had higher adjusted odds ratio (aOR) of ROSC at any time (aOR, 2.64 [95% CI, 1.50-4.65]), but not significantly different odds of pulses present at ED arrival (1.34 [95% CI, 0.78-2.30]), survival to hospital admission (1.41 [0.82-2.43]), survival to hospital discharge (1.55 [95% CI, 0.83-2.90]), or functional survival at hospital discharge (1.86 [95% CI, 0.98-3.51]). Competing risk analysis found significantly greater cumulative incidence of ROSC among those at risk with initial AP placement compared with AL (subdistribution hazard ratio, 1.81 [95% CI, 1.23-2.67]; P = .003). In this cohort study of patients with OHCA and VF or pVT, AP defibrillator pad placement was associated with higher ROSC compared with AL placement.