Interhospital Transfer Of Patients Research Articles

Effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome

Restrictions on the nonurgent use of hospital services were imposed in March 2003 to control an outbreak of severe acute respiratory syndrome (SARS) in Toronto, Ont. We describe the impact of these restrictions on health care utilization and suggest lessons for future epidemics. We performed a retrospective population-based study of the Greater Toronto Area (hereafter referred to as Toronto) and unaffected comparison regions (Ottawa and London, Ont.) before, during and after the SARS outbreak (April 2001-March 2004). We determined the adjusted rates of hospital admissions, emergency department and outpatient visits, diagnostic testing and drug prescribing. During the early and late SARS restriction periods, the rate of overall and medical admissions decreased by 10%-12% in Toronto; there was no change in the comparison regions. The rate of elective surgery in Toronto fell by 22% and 15% during the early and late restriction periods respectively and by 8% in the comparison regions. The admission rates for urgent surgery remained unchanged in all regions; those for some acute serious medical conditions decreased by 15%-21%. The rates of elective cardiac procedures declined by up to 66% in Toronto and by 71% in the comparison regions; the rates of urgent and semi-urgent procedures declined little or increased. High-acuity visits to emergency departments fell by 37% in Toronto, and inter-hospital patient transfers fell by 44% in the circum-Toronto area. Drug prescribing and primary care visits were unchanged in all regions. The restrictions achieved modest reductions in overall hospital admissions and substantial reductions in the use of elective services. Brief reductions occurred in admissions for some acute serious conditions, high-acuity visits to emergency departments and inter-hospital patient transfers suggesting that access to care for some potentially seriously ill patients was affected.

REDUCING TIME TO URGENT SURGERY BY TRANSPORTING RESOURCES TO THE TRAUMA PATIENT

Time to definitive trauma care directly influences patient survival. Patient transport (retrieval) services are essential for the transportation of remotely located trauma patients to a major trauma centre. Trauma surgical expertise can potentially be combined with the usual retrieval response (surgically supported response) and delivered to the patient before patient transportation. We identified the frequency and circumstances of such surgically supported retrievals. Retrospective review of trauma patients transported by the NRMA CareFlight, New South Wales Medical Retrieval Service, Australia, from 1999 to 2003, identifying patients who had a surgically supported retrieval response and an urgent surgical procedure carried out before patient transportation to an major trauma centre. Seven hundred and forty-nine trauma interhospital patient transfers were identified of which 511 (68%) were categorized as urgent and 64% of which were rural based. Three (0.4%) patients had a surgically supported retrieval response and had an urgent surgical procedure carried out before patient transportation. All patients benefited from that early surgical intervention. A surgically supported retrieval response allows for the more timely delivery of urgent surgical care. Patients can potentially benefit from such a response. There are, however, important operational considerations in providing a surgically supported retrieval response.

Uterine artery embolisation to treat uterine fibroids

be transported directly to a facility with the necessary resources to resuscitate, investigate, and initially manage multiple injuries. It is expected that all acute hospitals and all neuroscience units accepting patients directly from the incident will have these resources, and that these resources will be appropriate for the patient's age.* Local guidelines on the interhospital transfer of patients with head injuries should be drawn up between the refer ring hospital trusts, the neuroscience unit, and the local ambulance service. These should recognise the merit of transferring all patients with serious head injuries (GCS <8), irrespective of their need for neurosurgery. However, if transfer of those who do not require neurosur gery is not possible, ongoing liaison with the neuroscience unit regarding clinical management is essential.*

Analysis of critical incidents during the interhospital transport of critically ill patients

In this study we created a database to analyse the incidence and types of critical incidents that occurred during the interhospital transfer of critically ill patients. The transfer of critically ill patients presents important risks and the safety of patients has been shown to be facilitated by the development of standard equipment and specialist teams [1]. The West of Scotland Shock team is a designated regional transfer service based in Glasgow. We are involved in the interhospital transfer of patients and not primary retrieval. A recent study looking at critical incidents during the intrahospital transport of the critically ill highlighted the risks posed, and recommended the monitoring of incidents in order to aid the continuous improvement in patient safety [2]. No similar study has been carried out looking at the interhospital transport of the critically ill patient.

Are Patients Being Transferred to Level-I Trauma Centers for Reasons Other Than Medical Necessity?

In the United States, the Emergency Medical Treatment and Active Labor Act defines broad guidelines regarding interhospital transfer of patients who have sought care in the emergency department. However, patient transfers for nonmedical reasons are still considered a common practice. The purpose of this study was to evaluate the possible risk factors for hospital transfer in a population of patients unlikely to require transfer to a level-I center for medical reasons. A retrospective case-control national database study was performed with use of data from the National Trauma Data Bank (version 4.3). The study group consisted of patients with low Injury Severity Scores (< or =9) who were transferred to a level-I trauma center from another hospital. The controls were patients with low Injury Severity Scores who were treated at any hospital that was lower than a level-I trauma center and were not transferred. Hypothesized risk factors for hospital transfer were the age, gender, race, and insurance status of the patient; the time of day the transfer was received; and the number and type of comorbidities. The total sample included 97,393 patients, 21% of whom were transferred to a level-I trauma center. The odds ratios adjusted for all risk factors indicated that transfer rates were higher for male patients compared with female patients (adjusted odds ratio = 1.46), children compared with seniors (3.54), blacks compared with whites (1.28), evening or night transfers compared with morning or afternoon transfers (2.25), patients with Medicaid compared with those with other types of insurance (2.02), and for those with one or more comorbidities compared with those with no comorbidity (2.79). These results suggest the need for prospective studies to further investigate the relationships between hospital transfer and medical and nonmedical factors.

Ranking Hospitals According to Acute Myocardial Infarction Mortality

The objective of this population-based observational cohort study was to estimate the extent to which the inclusion/exclusion of transferred patients with acute myocardial infarction (AMI) impacts on hospital performance rankings. The authors studied 91,633 adult patients admitted to 116 acute care hospitals in Quebec, Canada, with a primary diagnosis of AMI between 1992 and 1999. Hospital performance ranks, based on 30-day AMI mortality rates, were estimated with hierarchical models and compared using 3 different methods for handling transferred patients (exclude all transfers; include transfers and assign outcome to the referring hospital; include transfers and assign outcome to the receiving hospital). The explanatory variable of interest was the hospital to which the patient's outcome was attributed. Using the 3 methods, 4 hospitals were ranked "best performers" once, and 1 hospital ranked among the best in 2 of the 3 analyses performed. Nine hospitals were ranked "worst performers" at least once (4 of which ranked among the "worst" once only, 2 ranked among the "worst" twice, and 3 were consistently ranked "worst performers" in all analyses). There was significant variation in mortality rates among hospitals, and the difference in the rates between the highest and lowest ranking hospitals exceeded the clinically relevant benchmark of 1%. Performance evaluation studies that compare hospital mortality rates typically exclude transferred patients. However, methods used to deal with AMI patient transfers influenced hospital ranks when comparing 30-day mortality rates. Excluding transfers may lead to an inaccurate depiction of the quality of healthcare services in regionalized healthcare systems that call for the timely interhospital transfer of patients with AMI.

Designated Consultants for the Inter-Hospital Transfer of Patients with Brain Injury: A Survey of Practice among Neurosurgical Units in the UK and Ireland

Designated Consultants for the Inter-Hospital Transfer of Patients with Brain Injury: A Survey of Practice among Neurosurgical Units in the UK and Ireland

Hyperbare Sauerstofftherapie

Hyperbaric oxygenation (HBO) is a decisive component of a comprehensive interdisciplinary intensive care therapy for numerous disorders, such as gas embolism, severe decompression illness or carbon monoxide (CO) intoxication. However, barochambers with 24 h accessibility are often not readily available, thus, requiring an interhospital transport of critically ill patients. In order to minimise additional risks, a skilled transportation team should be involved. Furthermore, the specific physical and physiological features of HBO require that the transportation personnel must be trained adequately. Specific characteristics of the interhospital transfer of HBO patients are described as well as adverse effects and their specific therapy.

Transfer of brain injured patients – time for a change?

Transfer of brain injured patients – time for a change?

Emergency Medical Treatment andActive Labor Act andTrauma Triage

The Emergency Medical Treatment andActive Labor Act (EMTALA) was conceived as a means to ensure that patients with emergent conditions would receive stabilizing care andto avert the potentially dangerous, economically driven, interhospital transfer of patients. This legislation andits subsequent application arrived near the time that regional andstatewide trauma systems were established. Trauma systems were developed to guide optimal resource use for the injured patient regardless of the patient's ability to pay. Unfortunately, when coupled with current economic andlitigation threats to community emergency andsurgical practitioners, EMTALA represents a threat to the continuation of the trauma system concept. Trauma systems are dependent on a tiered hospital network where severely injured patients are taken to a hospital with resources aligned to manage the worst of injuries. When primary triage from the field cannot accomplish this task, secondary triage from a nondesignated or lower-level hospital to the higher-level trauma center is needed. EMTALA has served as a driver to change the priority for secondary triage from addressing the needs of the severely injured patient to filling community hospital surgical specialist emergency department on-call coverage gaps for less severely injured patients. Further, legal action associated with claims of EMTALA violations has needlessly extended medical examination and“stabilization” efforts at community emergency departments prior to needed secondary triage. Higher-level trauma centers will benefit from codifying system-wide emergency medical services practices related to primary andsecondary triage, establishing trauma center capacity anddivert practices, andinitiating “transfer center” operations that control transfer of patients to these centers.

Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury

Objective: To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care. Methods: We collected data from 1999...

Transfer of intubated patients with traumatic brain injury to Auckland City Hospital

Delays in patient transfer to definitive neurosurgical care after traumatic brain injury are important in determining neurological outcome. The efficiency of interhospital transfer of patients to Auckland City Hospital (ACH) was analysed and compared with international standards. The ACH Department of Critical Care Medicine database for the year 2002 was reviewed, with supplementary information obtained from transfer organizations, hospital notes, radiology archives, and operative logbooks. Thirty-four adult patients with traumatic brain injury and no special reasons for delayed transfer were transported intubated from other hospitals in the North Island of New Zealand. The median time from injury to arrival at ACH was 6.5 h. It took a median 4.4 h for patients to get from initial computed tomographic imaging to ACH. For those requiring evacuation of haematomas, the mean time from arrival at ACH to the start of the operation was 1.4 h. Only 33% of patients from other metropolitan Auckland hospitals, and none from hospitals outside the city, arrived within 4 h from the time of injury. Transfer times for brain trauma patients are currently longer than recommended for optimal neurological outcome. Referring hospitals and transfer organizations should review their systems to identify areas for improvement. Direct admission to theatre needs to be expedited within ACH when required. Triage of all trauma patients in metropolitan Auckland with a Glasgow Coma Scale score of less than 14 to ACH would be likely to improve time to treatment. A mobile acute neurosurgical service based in Auckland that would support general surgeons initiating acute decompressive cranial operations would be likely to reduce time to surgery and improve outcomes for patients admitted to hospitals outside Auckland. The development of a mobile acute neurosurgery service which would complete decompressive procedures started by general surgeons would likely improve trauma outcomes for patients injured outside Auckland.

Interhospital transfers of patients with surgical emergencies: Areas for improvement

To review mortality associated with interhospital transfers of patients with surgical emergencies from rural and peripheral metropolitan areas. A retrospective case note review. All hospitals within an area health service including metropolitan and rural hospitals. All patients with a surgical emergency who died in hospital after interhospital transfer within an area health service. Factors associated with death and interhospital transfer. In total, 22 patients were identified. The mean age was 77 years. Thirty-six per cent of patients were assessed by a surgeon prior to transfer. The mean time taken for transfer was five hours. Ten patients were physiologically unstable prior to transfer. No medical escort accompanied these patients. Four patients deteriorated during the transport process. Seventy-three per cent of patients arrived out of normal working hours. Fifty per cent of patients required an operation within 24 hours of arrival. All of these patients had significant medical co-morbidities. Seventy-two per cent of these operations were performed out of hours as an emergency case. Twenty-three per cent did not receive any operative intervention or intensive care admission at the tertiary referral centre. Forty-one per cent of deaths were related to peritonitis and intra-abdominal soiling. Hospital systemic issues associated with mortality included extensive time delays in transfers, an inadequate transport process and frequent out-of-hours emergency operations. Patient features related to mortality included advanced age, significant medical co-morbidity and surgical pathology with a poor prognosis. Improvements concerning interhospital transfers of patients should address both systemic and patient issues.

Towards safer neonatal transfer: the importance of critical incident review

Background: Critical incidents are common during the inter-hospital transfer of sick patients, and infants are an especially vulnerable group. Aims: To examine the effect of critical incident review on the...

A multicasualty event: out-of-hospital and in-hospital organizational aspects.

In a wedding celebration of 700 participants, the third floor of the hall in which the celebration was taking place suddenly collapsed. While the walls remained intact, all three floors of the building collapsed, causing Israel's largest disaster. To study the management of a multicasualty event (MCE), in the out-of-hospital and in-hospital phases, including rescue, emergency medical services (EMS) deployment and evacuation of casualties, emergency department (ED) deployment, recalling staff, medical care, imaging procedures, hospitalization, secondary referral, and interhospital transfer of patients. Data on all the victims who arrived at the four EDs in Jerusalem were collected through medical files, telephone interviews, and hospital computerized information. The disaster resulted in 23 fatalities and 315 injured people; 43% were hospitalized. During the first hour, 42% were evacuated and after seven hours the scene was empty. Ninety-seven basic life support ambulances, 18 mobile intensive care units, 600 emergency medical technicians, 40 paramedics, and 15 physicians took part in the out-of-hospital stage. At the hospitals, about 1,300 staff members arrived immediately, either on demand or voluntarily, a number that seems too large for this disaster. Computed tomography (CT) demand was over its capability. During this MCE, the authors observed "rotating" bottleneck phenomena within out-of-hospital and in-hospital systems. For maximal efficiency, hospitals need to fully coordinate the influx and transfer of patients with out-of-hospital rescue services as well as with other hospitals. Each hospital has to immediately deploy its operational center, which will manage and monitor the hospital's resources and facilitate coordination with the relevant institutions.

Derivation of a preliminary clinical decision rule to guide the interhospital transfer of patients with traumatic brain injury using a resource utilization outcome

Study objectives: We derive a preliminary clinical decision rule for persons with traumatic brain injury (TBI) to identify the group of patients requiring specialized tertiary care resources within 72 hours of presentation, using variables readily available to the clinician. Trained medical record abstractors collected data on a retrospective cohort of consecutive persons with blunt head injury using a structured data collection instrument from 1999 through 2003. Patients aged 18 to 65 years, transported directly from the scene of injury, evaluated in the emergency department (ED) of a Level I trauma center, and retrospectively identified as having a serious head injury (Abbreviated Injury Scale [AIS] score ≥3) were included in the analysis. Resource-based high therapeutic intensity (HTI) measures warranting specialized trauma care were identified a priori (all within 72 hours after ED arrival), including neurosurgical intervention, exploratory laparotomy, intensive care (ventilator support >48 hours, transfusion ≥6 units of packed RBC, vasopressor support), or death. We used classification and regression tree analysis to derive a preliminary decision rule using 19 covariates (patient demographics, comorbid disease, vital signs, laboratory values, and radiographic findings) and cross-validation techniques to estimate rule sensitivity and specificity. Binomial 95% confidence intervals (CIs) are provided for the derivation sample. Results: Five hundred four consecutive trauma patients were identified as having a head injury, of whom 258 patients (51%) required at least 1 of the HTI measures. Five variables (emergency medical services [EMS] Glasgow Coma Scale [GCS] score, ED GCS, serum bicarbonate level, EMS respiratory rate, and ED respiratory rate) had a sensitivity of 93% and specificity of 42% for identifying patients requiring 1 of the HTI measures (derivation sample: sensitivity 95% [95% CI 92% to 98%] and specificity 52% [95% CI 46% to 58%]). Conclusion: This preliminary decision rule identified most patients with TBI in the derivation sample requiring urgent tertiary trauma care resources and was much more specific than using a standard injury-based criterion for transfer (eg, head AIS score ≥3). The generalizability of this rule for head-injured patients presenting to nontrauma hospitals will need to be evaluated.

Prehospital mortality in an EMS system using medical priority dispatching: a community based cohort study.

This study was planned to record prehospital death rates in four medical priority categories (A, B, C and D) and to evaluate if deaths in lower urgency categories C and D (target response times 20 and 90 min) could have been avoided by a faster ambulance response. The design was a community based cohort study including an expert panel evaluation of the deaths. The study was conducted in the Emergency Medical Services in Helsinki, Finland. All consecutive ambulance calls excluding interhospital patient transfers between 1 January 1999 and 31 December 2002 were included. Prehospital mortality and avoidability of prehospital deaths by a faster ambulance response (maximum 8 min) were used as main outcome measures. A total of 151928 calls were prioritized in the dispatching centre (category A 8677 calls, B 41005, C 71991 and D 30255). Prehospital death occurred 451 times in category A, 468 times in category B, 73 times in category C and 8 times in category D calls. Respectively, the prehospital death rates per 1000 calls were 52.0 (A), 11.4 (B), 1.0 (C) and 0.3 (D) (P < 0.0001). The expert panel judged that 1 (1.3%) of category C deaths would have been avoidable, 24 (32.9%) potentially avoidable and 48 (65.8%) not avoidable by a more rapid ambulance response. The corresponding figures for category D deaths were 0 (0%), 5 (62.5%) and 3 (37.5%), respectively. The use of medical priority dispatching was associated with very low prehospital mortality in lower urgency categories C and D. Approximately, one-third of those deaths could probably be prevented by a faster ambulance response but the price would be a three-fold increase in calls with blue lights and siren. Further studies are needed to find out if our results are applicable to other types of EMS systems.

Prehospital mortality in an EMS system using medical priority dispatching: a community based cohort study*1

Objectives: This study was planned to record prehospital death rates in four medical priority categories (A, B, C and D) and to evaluate if deaths in lower urgency categories C and D (target response times 20 and 90 min) could have been avoided by a faster ambulance response. Methods: The design was a community based cohort study including an expert panel evaluation of the deaths. The study was conducted in the Emergency Medical Services in Helsinki, Finland. All consecutive ambulance calls excluding interhospital patient transfers between 1 January 1999 and 31 December 2002 were included. Prehospital mortality and avoidability of prehospital deaths by a faster ambulance response (maximum 8 min) were used as main outcome measures. Results: A total of 151 928 calls were prioritised in the dispatching centre (category A 8677 calls, B 41 005, C 71 991 and D 30 255). Prehospital death occurred 451 times in category A, 468 times in category B, 73 times in category C and 8 times in category D calls. Respectively, the prehospital death rates per 1000 calls were 52.0 (A), 11.4 (B), 1.0 (C) and 0.3 (D) (P<0.0001). The expert panel judged that 1 (1.3%) of category C deaths would have been avoidable, 24 (32.9%) potentially avoidable and 48 (65.8%) not avoidable by a more rapid ambulance response. The corresponding figures for category D deaths were 0 (0%), 5 (62.5%) and 3 (37.5%), respectively. Conclusions: The use of medical priority dispatching was associated with very low prehospital mortality in lower urgency categories C and D. Approximately, one-third of those deaths could probably be prevented by a faster ambulance response but the price would be a three-fold increase in calls with blue lights and siren. Further studies are needed to find out if our results are applicable to other types of EMS systems.

Reduction of time to definitive care in trauma patients: effectiveness of a new checklist system

This study evaluated the feasibility of establishing a new trauma transfer checklist and assessed its impact on trauma-related interhospital transfers. A standard envelope with a printed checklist (N.E.W.S.) incorporating four key concepts in the care and transfer of trauma patients was used. A prospective comparison of consecutive interhospital trauma transfers to the major trauma service between July 1999–May 2000 (pre-N.E.W.S.) and August 2000–November 2000 (post-N.E.W.S.) was made. Changes in management satisfaction were assessed by a Likert scale (1=poor to 5=excellent). Pre-N.E.W.S., 88 trauma patients were transferred and 20 trauma transfers were recorded post-N.E.W.S. The time to definitive care pre-N.E.W.S. was 443±322 min, and 339±108 min ( P=0.014) post-N.E.W.S. The time in the referring hospital was also reduced from 343±310 min pre-N.E.W.S. to 197±90 min post-N.E.W.S ( P=0.0002). The checklist system prompted changes in the management of the trauma patient in 20% of the cases and there was a high level of satisfaction expressed by users of the checklist (4.6±0.7). The N.E.W.S. checklist is effective in facilitating the interhospital transfer of trauma patients by shortening the time to definitive care.

Safe Retrieval and Transfer: the Practical Approach

There is a considerable number of published papers that demonstrate the risks associated with the interhospital transfer of sick patients. Unfortunately, with a national shortage of intensive care beds, the number of interhospital transfers shows no sign of reducing. This book provides a framework for safe transfer of sick patients and is written by a multi-professional group representing the Advanced Life Support Group. It is also the course manual for the Safe Transfer and Retrieval (StaR) course run by the same organization. The subject of effective patient transfer is not littered with entertaining anecdotes, and most readers are likely to want to be taken through the subject quickly and painlessly. The book is well laid-out with short chapters, many of which can be read in only a few minutes. Many readers might find the style too didactic but, if seen as one safe method of achieving the desired objectives, this ceases to be a problem. The subject is covered comprehensively. Areas that are vital (and often neglected), such as effective patient packaging and stabilization, are given good coverage. Other areas are of relevance, but are unlikely to be utilized regularly by most transfer doctors e.g. radio voice procedure. Three-and-a-half sides are devoted to diagrams and text on the fixation of tracheal tubes'obviously one of the authors has bad memories of a tube displacement on a rainy motorway somewhere. Most of the content is predictable and well thought out'unlike some multi-author texts, the editors have ensured consistency. Well-established ‘ABC’ type treatments form the mainstay of the guidelines. However, some areas touched upon are controversial, and it would be useful if they were highlighted as such for the less experienced reader. For example, it is suggested that not all critically ill patients necessarily need a doctor to transfer them from one hospital to another. It may be that the specific circumstances where this is appropriate are explained in the StaR course, but reading the book alone could cause problems. Also, the suggestion that the administration of steroids in spinal injury is mandatory will be questioned by some UK neurosurgical units. Overall, this book achieves its aims well, and adhering to the clear and well-presented guidelines will undoubtedly reduce the number of preventable adverse events during patient transfers by anyone that follows them.