Interhospital Transfer Of Patients Research Articles

Impact of COVID-19 pandemic on interhospital transfer of patients with major trauma in Korea: a retrospective cohort study

BackgroundInterhospital transfer (IHT) is necessary for providing ultimate care in the current emergency care system, particularly for patients with severe trauma. However, studies on IHT during the pandemic were limited. Furthermore, evidence on the effects of the coronavirus disease 2019 (COVID-19) pandemic on IHT among patients with major trauma was lacking.MethodThis retrospective cohort study was conducted in an urban trauma center (TC) of a tertiary academic affiliated hospital in Daegu, Korea. The COVID-19 period was defined as from February 1, 2020 to January 31, 2021, whereas the pre-COVID-19 period was defined as the same duration of preceding span. Clinical data collected in each period were compared. We hypothesized that the COVID-19 pandemic negatively impacted IHT.ResultsA total of 2,100 individual patients were included for analysis. During the pandemic, the total number of IHTs decreased from 1,317 to 783 (− 40.5%). Patients were younger (median age, 63 [45–77] vs. 61[44–74] years, p = 0.038), and occupational injury was significantly higher during the pandemic (11.6% vs. 15.7%, p = 0.025). The trauma team activation (TTA) ratio was higher during the pandemic both on major trauma (57.3% vs. 69.6%, p = 0.006) and the total patient cohort (22.2% vs. 30.5%, p < 0.001). In the COVID-19 period, duration from incidence to the TC was longer (218 [158–480] vs. 263[180–674] minutes, p = 0.021), and secondary transfer was lower (2.5% vs. 0.0%, p = 0.025).ConclusionWe observed that the total number of IHTs to the TC was reduced during the COVID-19 pandemic. Overall, TTA was more frequent, particularly among patients with major trauma. Patients with severe injury experienced longer duration from incident to the TC and lesser secondary transfer from the TC during the COVID-19 pandemic.

Abstract TMP16: Impact of Door-to-Imaging and Imaging-to-Door Times on Door-in-Door-out Times in Interhospital Transfers of Patients With Stroke

Introduction: Urgent inter-hospital transfer ensures timely access to therapies for acute ischemic stroke. Door-in-door-out (DIDO) represents the total amount of time a patient spends in the transferring emergency department (ED) before transfer. DIDO time is an important quality metric for the care of acute stroke; however, little is known about the influence of process steps on DIDO times and which steps most often cause delays. Methods: This was a retrospective cohort study of patients in the American Heart Association Get With The Guidelines®-Stroke registry with ischemic stroke presenting January 2019 to December 2021 transferred from the ED at the presenting hospital to another acute care hospital for evaluation of thrombolytics, endovascular therapy or post-thrombolytic care. The primary independent variables were door-to-imaging and imaging-to-door times, and the primary outcome was DIDO time. Multivariate GEE regression models were performed to assess the comparative contributions of interval process times to variation in DIDO time, controlling for patient and hospital-level characteristics. Results: Among 24,662 patients (50.5% male, mean age 68.3 years, 73.2% White), mean DIDO time was 171.4 min (SD: 149.5), mean door-to-imaging time was 18.3 min (SD: 34.1) and mean imaging-to-door time was 153.1 min (SD: 141.5). A 1 min increase in door-to-imaging time was associated with a 1.33 min increase in the mean DIDO time, while a 1 min increase in imaging-to-door time was associated with a 1.02 min increase in mean DIDO time. The baseline model (without door-to-imaging or imaging-to-door included) had an R2 of 0.03. With door-to-imaging included in the GEE model, R2 was 0.13; whereas the model with imaging-to-door included had an R2 of 0.95. Conclusion: Imaging-to-door time accounts for a greater proportion of the variance in DIDO times than door-to-imaging time. Though the opportunity for improvement in DIDO is greater through reduction of imaging-to-door time, door-to-imaging time has greater per-minute effect on DIDO. While existing guidelines and care resources heavily focus on reducing door-to-imaging times, further attention is warranted to reduce imaging-to-door times in the management of acute ischemic stroke.

The COVID-19 pandemic and the incidence of acute coronary syndromes at General Hospital of Veroia

Background: Although deaths from Acute Coronary Syndromes (ACS) are the most prevalent globally, during the outbreak of the new SARS-CoV-2 coronavirus pandemic, there was a declining trend in hospital admissions for ACS patients. Inevitably a reduction of invasive procedures in cardiac catheterization laboratories was observed. Moreover, an increase in sudden out-of-hospital cardiac deaths was recorded. On the other hand, patients that eventually treated in the hospital had a much worse outcome in terms of cardiac function. Inadequate treatment of acute myocardial infarction resulted in a further increase in mortality due to coronary artery disease. The aim of our study was the comparison of admissions of the patients with ACS before and during the COVID-19 pandemic. Methods: A retrospective single center study was conducted. We recorded all admissions with ACS underwent invasive interventions during the period of lockdown due to COVID-19 pandemic, in Greece, from 16 March 2020 to 1 May 2020 (study period A), as well as in the period of gradual withdraw of restrictions from 2 May 2020 to 1 June 2020 (study period B),. The data were compared with those of the periods of 2019 (control period A and B). Results: One hundred thirty eight patients were the group of study period and 158 were the group of the control period. The reduction rate was 12.7% in study period. The largest decrease in admissions concerned with elderly patients over 75 years old, as well as females (by 52% - 53% respectively). The severity of the restrictions but also the fear of the spread of the coronavirus may be relevant to the insufficient seek of help for these groups of patients. Conclusion: Our study showed that during the pandemic period, the invasive interventions were fewer than those of 2019. However, the expected reduction of catheterizations during this two and a half months period was mitigated by the increase of inter-hospital transfers of patients with ACS from neighboring hospitals, without a catheterization laboratory.

Consensus statement on the interhospital transfer of patients with acute aortic syndrome: TRAVERSING Delphi study

BackgroundStandardisation of referral pathways and the transfer of patients with acute aortic syndromes (AAS) to regional centres are recommended by NHS England in the Acute Aortic Dissection Toolkit. The aim...

Patient and Hospital Characteristics Associated With the Interhospital Transfer of Adult Patients With Sepsis.

The interhospital transfer (IHT) of patients with sepsis to higher-capability hospitals may improve outcomes. Little is known about patient and hospital factors associated with sepsis IHT. We evaluated patterns of hospitalization and IHT and determined patient and hospital factors associated with the IHT of adult patients with sepsis. Retrospective cohort study. A total of 349,938 adult patients with sepsis at 329 nonfederal hospitals in California, 2018-2019. We evaluated patterns of admission and outward IHT between low sepsis-, intermediate sepsis-, and high sepsis-capability hospitals. We estimated odds of IHT using generalized estimating equations logistic regression with bootstrap stepwise variable selection. Among the cohort, 223,202 (66.4%) were initially hospitalized at high-capability hospitals and 10,870 (3.1%) underwent IHT. Nearly all transfers (98.2%) from low-capability hospitals were received at higher-capability hospitals. Younger age (< 65 yr) (adjusted odds ratio [aOR] 1.54; 95% CI, 1.40-1.69) and increasing organ dysfunction (aOR 1.22; 95% CI, 1.19-1.25) were associated with higher IHT odds, as were admission to low-capability (aOR 2.79; 95% CI, 2.33-3.35) or public hospitals (aOR 1.35; 95% CI, 1.09-1.66). Female sex (aOR 0.88; 95% CI, 0.84-0.91), Medicaid insurance (aOR 0.59; 95% CI, 0.53-0.66), home to admitting hospital distance less than or equal to 10 miles (aOR 0.92; 95% CI, 0.87-0.97) and do-not-resuscitate orders (aOR 0.48; 95% CI, 0.45-0.52) were associated with lower IHT odds, as was admission to a teaching hospital (aOR 0.83; 95% CI, 0.72-0.96). Most patients with sepsis are initially hospitalized at high-capability hospitals. The IHT rate for sepsis is low and more likely to originate from low-capability and public hospitals than from high-capability and for-profit hospitals. Transferred patients with sepsis are more likely to be younger, male, sicker, with private medical insurance, and less likely to have care limitation orders. Future studies should evaluate the comparative benefits of IHT from low-capability hospitals.

Evaluation of the interhospital patient transfer after implementation of a regionalized trauma care system (TraumaNetzwerk DGU®) in Germany.

The aim of the study was to evaluate how many patients are being transferred between trauma centers and and their characteristics in the 2006 initiated TraumaNetzwerk DGU® (TNW). We further investigated the time point of transfer and differences in outcome, compared to patients not being transferred. We wanted to know how trauma centers judged the performance of the TNW in transfer. (1) We analyzed the data of the TraumaRegister DGU® (TR-DGU) from 2014-2018. Included were patients that were treated in German trauma centers, maximum AIS (MAIS) >2 and MAIS 2 only in case of admission on ICU or death of the patient. Patients being transferred were compared to patients who were not. Characteristics were compared, and a logistic regression analysis performed to identify predictive factors. (2) We performed a survey in the TNW focussing on frequency, timing and communication between hospitals and improvement through TNW. Study I analyzed 143,195 patients from the TR-DGU. Their mean ISS was 17.8 points (SD 11.5). 56.4% were admitted primarily to a Level-I, 32.2% to a Level-II and 11.4% to a Level-III Trauma Center. 10,450 patients (7.9%) were transferred. 3,667 patients (22.7%) of the admitted patients of Level-III Center and 5,610 (12.6%) of Level-II Center were transferred, these patients showed a higher ISS (Level-III: 18.1 vs. 12.9; Level-II: 20.1 vs. 15.8) with more often a severe brain injury (AIS 3+) (Level-III: 43.6% vs. 13.1%; Level-II: 53.2% vs. 23.8%). Regression analysis showed ISS 25+ and severe brain injury AIS 3+ are predictive factors for patients needing a rapid transfer. Study II: 215 complete questionnaires (34%) of the 632 trauma centers. Transfers were executed within 2 h after the accident (Level-III: 55.3%; Level-II: 25.0%) and between 2-6 h (Level-III: 39.5%; Level-II: 51.3%). Most trauma centers judged that implementation of TNW improved trauma care significantly (Level III: 65.0%; Level-II: 61.4%, Level-I: 56.7%). The implementation of TNW has improved the communication and quality of comprehensive trauma care of severely injured patients within Germany. Transfer is mostly organized efficient. Predictors such as higher level of head injury reveal that preclinical algorithm present a potential of further improvement.

Consensus Statement on the Interhospital Transfer of Patients with Acute Aortic Syndrome – TRAVERSING Delphi Study

Consensus Statement on the Interhospital Transfer of Patients with Acute Aortic Syndrome – TRAVERSING Delphi Study

Exploring inter-hospital emergency patient referral network

Transferring patients between hospitals is a common and necessary element of emergency departments and patient care. Inter-hospital referrals establish a network, which is also an indicator of how well health institutions are performing. The interaction between hospitals and patient transfers can be similar to the person's relation in a social network. In the study, it is aimed to determine how the measurable differences in the service delivery of the hospitals in the Eastern Black Sea region of Türkiye affect the direction of patient referral flows between hospitals. The study encompasses inter-hospital patient transfers conducted by 112 ambulances and includes data from the years 2015, 2016, and 2017, involving 110,688 patient referrals among 42 provinces and 272 hospitals.The study was analyzed using the network analysis program NODEXL. As a result of the research, the roles and positions of the hospitals and the hospitals that were most efficient were identified. The hospitals in the region exhibit strong and heterogeneous connections with each other, indicating a high degree of coordination. Although geographic distances have an impact on patient referrals, it has also been revealed that there is a relationship between the characteristics and capacities of hospitals and their centrality. It was determined for which reasons the patients in the region were referred the most and from which disease group they were referred. It is thought that the study will contribute to the health sector on a country basis, since focusing on the analysis of all hospitals in a region is a representative of sub-component of the health system. This is the first thorough regional study in the national literature to indicate that social network analysis may be used to evaluate inter-hospital patient referrals.

Safe handoff practices and improvement of communication in different paediatric settings

Inadequate information management, especially during patient handoff, contributes to a large part of health care-related adverse events. The Committee for Quality of Care and Patient Safety of the Asociación Española de Pediatría has developed this document to provide an overview of handover practices in different paediatric care settings (emergency, inpatient, intensive care, neonatal and primary care). It describes resources to achieve safe and effective communication in all these settings, such as standardised handoff tools. It also proposes recommendations for the prevention of medication errors during the handover process, to improve safety in interhospital and intrahospital patient transfer, and to optimise communication and continuity of care in chronically ill and medically complex children.

It is (not) always on Friday: inter-hospital patient transfers in orthopedic and trauma surgery

BackgroundWhile inter-hospital transfers for patients who have suffered major trauma have been well investigated, patient flows for other injured patients, or cases with orthopedic complications, are rarely described. This study aims to analyze the affected collective and to show possible reasons, patterns, and pitfalls to optimize the process in future.Materials and methodsIn a prospective cohort study, all consecutive transfers to a Level I trauma center in Germany were documented and assessed. Patients suffering a major trauma were excluded. Data on the primary treating hospital, patient characteristics, and differences between emergency and elective surgery were analyzed.ResultsA total of 227 patients were included; 162 were injured, while 65 had suffered a complication after elective orthopedic surgery or had a complex orthopedic pathology.The most common diagnoses leading to transfer were pathologies of the extremities (n = 62), pathologies of the spine (n = 50), and infections (n = 18). The main reasons stated by the transferring hospitals were a lack of expertise (137 cases) and a lack of capacity (43 cases). There was a significantly higher rate of transfers due to trauma (n = 162) than for orthopedic patients (n = 65), p < 0.0001.ConclusionThere is currently no structured procedure or algorithm for transferring patients in orthopedics and trauma surgery.

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED). To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times. US registry-based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals. Patient- and hospital-level characteristics. The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy. Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (-20.1 minutes; 95% CI, -22.1 to -18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (-66.7 minutes; 95% CI, -68.7 to -64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (-16.8 minutes; 95% CI, -21.0 to -12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times. In this US registry-based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.

Transferencia segura de pacientes y mejora de la comunicación en distintos entornos asistenciales

Inadequate information management, especially during patient handoff, contributes to a large part of health care-related adverse events. The Committee for Quality of Care and Patient Safety of the Asociación Española de Pediatría has developed this document to provide an overview of handover practices in different paediatric care settings (emergency, inpatient, intensive care, neonatal and primary care). It describes resources to achieve safe and effective communication in all these settings, such as standardized handoff tools. It also proposes recommendations for the prevention of medication errors during the handover process, to improve safety in interhospital and intrahospital patient transfer, and to optimize communication and continuity of care in chronically ill and medically complex children.

The Relationship Between Hospital Capability and Mortality in Sepsis: Development of a Sepsis-Related Hospital Capability Index.

Regionalized sepsis care could improve sepsis outcomes by facilitating the interhospital transfer of patients to higher-capability hospitals. There are no measures of sepsis capability to guide the identification of such hospitals, although hospital case volume of sepsis has been used as a proxy. We evaluated the performance of a novel hospital sepsis-related capability (SRC) index as compared with sepsis case volume. Principal component analysis (PCA) and retrospective cohort study. A total of 182 New York (derivation) and 274 Florida and Massachusetts (validation) nonfederal hospitals, 2018. A total of 89,069 and 139,977 adult patients (≥ 18 yr) with sepsis were directly admitted into the derivation and validation cohort hospitals, respectively. None. We derived SRC scores by PCA of six hospital resource use characteristics (bed capacity, annual volumes of sepsis, major diagnostic procedures, renal replacement therapy, mechanical ventilation, and major therapeutic procedures) and classified hospitals into capability score tertiles: high, intermediate, and low. High-capability hospitals were mostly urban teaching hospitals. Compared with sepsis volume, the SRC score explained more variation in hospital-level sepsis mortality in the derivation (unadjusted coefficient of determination [ R2 ]: 0.25 vs 0.12, p < 0.001 for both) and validation (0.18 vs 0.05, p < 0.001 for both) cohorts; and demonstrated stronger correlation with outward transfer rates for sepsis in the derivation (Spearman coefficient [ r ]: 0.60 vs 0.50) and validation (0.51 vs 0.45) cohorts. Compared with low-capability hospitals, patients with sepsis directly admitted into high-capability hospitals had a greater number of acute organ dysfunctions, a higher proportion of surgical hospitalizations, and higher adjusted mortality (odds ratio [OR], 1.55; 95% CI, 1.25-1.92). In stratified analysis, worse mortality associated with higher hospital capability was only evident among patients with three or more organ dysfunctions (OR, 1.88 [1.50-2.34]). The SRC score has face validity for capability-based groupings of hospitals. Sepsis care may already be de facto regionalized at high-capability hospitals. Low-capability hospitals may have become more adept at treating less complicated sepsis.

Facilitators and inhibitors of traumatic brain injury transfers: A fieldwork investigation.

Intensified healthcare specialization has increased the need for patient transfers. We aimed to describe in-hospital and interhospital patient transfer decisions during the traumatic brain injury (TBI) trajectory from a nursing perspective. Ethnographic fieldwork. We used participant observation and interviews at three sites representing the acute, subacute and stable stages of the TBI trajectory. Deductive analysis was applied supported by transition theory. During the acute stage (neurointensive care), transfer decisions were facilitated by physicians assisted by critical care nurses, in the subacute stage (highly specialized rehabilitation), transfer decisions were collaborative among in-house healthcare professionals, community staff and family, and during the stable stage (municipal rehabilitation), transfer decisions were made by non-clinical staff. Most of the resources allocated during the trajectory went towards highly specialized rehabilitation, whereas more resources are needed during the end of the trajectory. Patients and the public were not involved in this study .

Inter-hospital Transfer Decision-making During the COVID-19 Pandemic: a Qualitative Study.

Inter-hospital patient transfers to hospitals with greater resource availability and expertise may improve clinical outcomes. However, there is little guidance regarding how patient transfer requests should be prioritized when hospital resources become scarce. To understand the experiences of healthcare workers involved in the process of accepting inter-hospital patient transfers during a pandemic surge and determine factors impacting inter-hospital patient transfer decision-making. We conducted a qualitative study consisting of semi-structured interviews between October 2021 and February 2022. Eligible participants were physicians, nurses, and non-clinician administrators involved in the process of accepting inter-hospital patient transfers. Participants were recruited using maximum variation sampling. Semi-structured interviews were conducted with healthcare workers across Michigan. Twenty-one participants from 15 hospitals were interviewed (45.5% of eligible hospitals). About half (52.4%) of participants were physicians, 38.1% were nurses, and 9.5% were non-clinician administrators. Three domains of themes impacting patient transfer decision-making emerged: decision-maker, patient, and environmental factors. Decision-makers described a lack of guidance for transfer decision-making. Patient factors included severity of illness, predicted chance of survival, need for specialized care, and patient preferences for medical care. Decision-making occurred within the context of environmental factors including scarce resources at accepting and requesting hospitals, organizational changes to transfer processes, and alternatives to patient transfer including use of virtual care. Participants described substantial moral distress related to transfer triaging. A lack of guidance in transfer processes may result in considerable variation in the patients who are accepted for inter-hospital transfer and in substantial moral distress among decision-makers involved in the transfer process. Our findings identify potential organizational changes to improve the inter-hospital transfer process and alleviate the moral distress experienced by decision-makers.

Inter-Hospital Transfer of Patients With Ruptured Abdominal Aortic Aneurysm in Switzerland

Inter-Hospital Transfer of Patients With Ruptured Abdominal Aortic Aneurysm in Switzerland

Impact of lifting the mandatory evacuation order after the Fukushima Daiichi Nuclear Power Plant accident on the emergency medical system: a retrospective observational study at Minamisoma City with machine learning analysis

ObjectivesThis study aimed to identify factors that delayed emergency medical services (EMS) in evacuation order zones after the 2011 Great East Japan Earthquake and Fukushima Daiichi Nuclear Power Plant accident...

Surgical interhospital transfer mortality: national analysis.

Interhospital transfers of surgical patients are an independent risk factor for mortality. The Australian and New Zealand Audit of Surgical Mortality (ANZASM) aims to improve surgical care through assessment of all cases of surgical mortality. This study aimed to describe common clinical management issues that contributed to interhospital transfer patient mortality. Data for all surgical patient mortality in Australia (except New South Wales) that underwent interhospital transfer between 1 January 2010 and 31 December 2019 were extracted from ANZASM. The surgeons' reports and assessors' evaluations were examined to identify clinical management issues. Thematic analysis was performed to develop pertinent themes and subthemes. Some 8679 patients were identified over the 10-year period. Of these, 2171 (25.0 per cent) had 3259 clinical management issues identified. Prominent themes were operative design (n = 466, 14.3 per cent), decision to operate (n = 425, 13.0 per cent), medical conditions (n = 344, 10.6 per cent), diagnosis (n = 326, 10 per cent), transfer (n = 293, 10.0 per cent), intraoperative issues (n = 278, 8.5 per cent), inadequate assessment (n = 238, 7.3 per cent), communication (n = 224, 6.9 per cent), delay in recognizing complications (n = 180, 5.5 per cent), coagulopathy (n = 151, 4.6 per cent), insufficient monitoring (n = 127, 3.9 per cent), infection (n = 107, 3.3 per cent), and hospital resources (n = 100, 3.1 per cent). Assessors considered 58.4 per cent of clinical management issues (n = 1903) probably or definitely preventable. This study identified 13 themes of potentially avoidable management issues present in surgical mortality following interhospital transfers. Quality-improvement initiatives targeting these areas may improve surgical patient outcomes.

Interhospital transfer of pediatric patients with malignant brain tumor not associated with increased mortality, but safe routine discharge.

Interhospital transfer (IHT) to obtain a higher level of care for pediatric patients requiring neurosurgical interventions is common. Pediatric patients with malignant brain tumors often require subspecialty care commonly provided at specialized centers. The authors aimed to assess the impact of IHT in pediatric neurosurgical patients with malignant brain tumors to identify areas of improvement in treatment of this patient population. Pediatric patients (age < 19 years) with malignant primary brain tumors undergoing craniotomy for resection between 2010 and 2018 were retrospectively identified in the Nationwide Readmissions Database. Patient and hospital data for each index admission provided by the Nationwide Readmissions Database was analyzed by univariate and multivariate analyses. Further analysis evaluated association of IHT on specific patient- or hospital-related characteristics. In a total of 2279 nonelective admissions for malignant brain tumors in pediatric patients, the authors found only 132 patients (5.8%) who underwent IHT for a higher level of care. There is an increased likelihood of transfer when a patient is younger (< 7 years old, p = 0.006) or the disease process is more severe, as characterized by higher pediatric complex chronic conditions (p = 0.0004) and increased all patient refined diagnosis-related group mortality index (p = 0.02). Patients who are transferred (OR 1.87, 95% CI 1.04-3.35; p = 0.04) and patients who are treated at pediatric centers (OR 6.89, 95% CI 4.23-11.22; p < 0.0001) are more likely to have a routine discharge home. On multivariate analysis, transfer status was not associated with a longer length of stay (incident rate ratio 1.04, 95% CI 0.94-1.16; p = 0.5) or greater overall costs per patient ($20,947.58, 95% CI -$35,078.80 to $76,974.00; p = 0.50). Additionally, IHT is not associated with increased likelihood of death or major complication. IHT has a significant role in the outcome of pediatric patients with malignant brain tumors. Transfer of this patient population to hospitals providing subspecialized care results in a higher level of care without a significant burden on overall costs, risks, or mortality.

Critical Care Flight Nurses' role within secondary aeromedical services and the inter-hospital transfer of patients with acute spinal cord impairment

Aim: To highlight the role of secondary aeromedical services and required knowledge of Critical Care Flight Nurses (CCFN), in facilitating the safe inter-hospital transfer of patients with acute Spinal Cord Impairment (SCI) from a Major Trauma Centre (MTC) to a specialist SCI centre. Method: Literature search. Results: There is significant demand for secondary aeromedical services in order for patients with acute SCI to be transferred to a SCI centre within 24 h of injury. CCFN play an important role in triaging patients, coordinating patient care, arranging logistics of transport as well as providing direct clinical care inflight. CCFN must have knowledge regarding the pathophysiology of acute SCI, altitude physiology and interventions to manage stressors of flight in the aeromedical environment. Specific clinical challenges encountered by CCFN include the prevention of hypobaric hypoxic hypoxia and achieving appropriate immobilisation of the spine. Conclusion: Mitigating the increased risk associated with transporting critically unwell patients with SCI in the aeromedical environment, relies on aeromedical clinicians with education and training within the clinical specialty of aeromedical retrieval. The availability of secondary aeromedical services to undertake urgent inter-hospital retrieval of patients with acute SCI will be promoted by the continued development of Retrieval Nurse Practitioner (RNP) roles.