Need For Inter-hospital Transfer Research Articles

External validation of the updated Brain Injury Guidelines for complicated mild traumatic brain injuries: a retrospective cohort study.

Approximately 10% of patients with mild traumatic brain injury (mTBI) have intracranial bleeding (complicated mTBI) and 3.5% eventually require neurosurgical intervention, which is mostly available at centers with a higher level of trauma care designation and often requires interhospital transfer. In 2018, the Brain Injury Guidelines (BIG) were updated in the United States to guide emergency department care and patient disposition for complicated mild to moderate TBI. The aim of this study was to validate the sensitivity and specificity of the updated BIG (uBIG) for predicting the need for interhospital transfer in Canadian patients with complicated mTBI. This study took place at three level I trauma centers. Consecutive medical records of patients with complicated mTBI (Glasgow Coma Scale score 13-15) who were aged ≥ 16 years and presented between September 2016 and December 2017 were retrospectively reviewed. Patients with a penetrating trauma and those who had a documented cerebral tumor or aneurysm were excluded. The primary outcome was a combination of neurosurgical intervention and/or mTBI-related death. Sensitivity and specificity analyses were performed. A total of 477 patients were included, of whom 8.4% received neurosurgical intervention and 3% died as a result of their mTBI. Forty patients (8%) were classified as uBIG-1, 168 (35%) as uBIG-2, and 269 (56%) as uBIG-3. No patients in uBIG-1 underwent neurosurgical intervention or died as a result of their injury. This translates into a sensitivity for predicting the need for a transfer of 100% (95% CI 93.2%-100%) and a specificity of 9.4% (95% CI 6.8%-12.6%). Using the uBIG could potentially reduce the number of transfers by 6% to 25%. The patients in uBIG-1 could be safely managed at their initial center without the need for transfer to a center with a higher level of neurotrauma care. Although the uBIG could decrease the number of transfers, further refinement of the criteria could improve its specificity.

Validation of a new risk score for nurse inter-hospital cardiologic transfer

Because of the unequal distribution of invasive cardiology resources in France, need for inter-hospital transfer to tertiary centers is frequent, mainly supported by the Emergency Medical Service (SAMU). Inter-Hospital Nurse Transfers (IHNT) is a growing option to preserve medical resources, promoted by health policy. However, no dedicated IHNT framing protocol has been validated to date. Our objective was to retrospectively validate a new IHNT protocol (NEWS-GAP score) designed to select patients and estimate the risk of short term degradation during transport. We conducted a 2 years single center retrospective study with the SAMU 05, analyzing the outcomes of patients transferred by IHNT to tertiary high-volume cardiac cenrers with cathlab facilities. Adverse events during transportation were systematically collected. We investigated the predictive value of our NEWS-GAP score. Compared to GRACE and RSTP score, the NEWS-GAP is a dedicated IHNT two steps score. It combines a patient selection guideline allowing to consider IHNT, and a second step assessing patient transportability and risk of short term complications based on a well validated early warning score (NEWS2 score). Additional items complete this score, depending on distances and potential medical “rescue” from pre-hopsital healthcare provider. GRACE, RSTP and NEWS-GAP score were retrospectively evaluated for all patients. The study population group was composed of 140 patients. Acute coronary syndrome represented 85 % of the population. Ten adverse events were reported during transportation (5 desaturations, 3 chest pains, 1 non sustained rhythm disorder and 1 acute heart failure). None of those adverse events were life threatening, and all nurse-managed, except one requiring diversion toward the nearest ICU for medical management. The NEWS-GAP provides the best with AUC 0.97 on ROC curve analysis, and negative predictive value of 99.2 %, in addition to simplicity and versatility. GRACE score and RSTP had a negative predictive value of 0.95 and 0.93, respectively; ROC curve AUC for RSTP is 0.65 (Fig. 1). Nurse management for IHT of patients with acute coronary events, to preserve medical resource, is a safe and easy alternative to medical transport, for selected patients. The NEWS-GAP score seems suitable to support and supervise these specific inter-hospital transfer modalities.

Characteristics and outcomes of patients admitted to regional and rural intensive care units in Australia

Objective: To describe the characteristics and outcomes of patients admitted to regional and rural intensive care units (ICUs). Design, setting and participants: Retrospective database review using the Australian and New Zealand Intensive Care Society Adult Patient Database for admissions between January 2009 and June 2019. Characteristics and outcomes of patients admitted to regional and rural ICUs were compared with metropolitan and tertiary ICUs. Main outcome measures: Primary outcome was hospital mortality. Secondary outcomes included patient characteristics, ICU mortality, ICU and hospital length of stay, need for mechanical ventilation and need for interhospital transfer. Results: Over the sampling period, admissions to regional/rural ICUs averaged nearly 19 000 episodes per annum and comprised 20% of critical care admissions in Australia. Unadjusted mortality was lower, a result that persisted after adjustment for a range of confounders (odds ratio, 0.73; 95% CI, 0.67-0.80; P < 0.01). Admissions are more likely to be emergencies, and patients are more likely to live in areas of relative disadvantage and to require interhospital transfer, but are less likely to require mechanical ventilation. Conclusions: Although illness severity is lower for patients admitted to regional/rural ICUs, hospital mortality after adjustment for a range of confounders is lower. Compared with tertiary ICUs, emergency admissions are more likely, which may have implications for surge capacity during pandemic illness, while mechanical ventilation is less frequently required. Regional/rural ICUs provide care to a substantial proportion of critically ill patients and have a crucial role in the support of regional Australians.

Perfil epidemiológico dos traumatismos crânio encefálicos em um hospital pediátrico da Serra Catarinense

Introdução: o traumatismo craniano encefálico (TCE) na infância é causa frequente de atendimento nas emergências do Brasil e do mundo. Reconhecer precocemente a gravidade dele e oferecer o manejo adequado reduz, de forma acentuada, a morbimortalidade. A Organização Mundial da Saúde (OMS) define TCE como qualquer agressão capaz de provocar lesão anatômica ou comprometimento funcional do couro cabeludo, crânio, meninges ou encéfalo. Objetivos: traçar o perfil epidemiológico dos pacientes com diagnóstico de TCE na infância. Métodos: estudo retrospectivo, quantitativo e descritivo a partir da avaliação dos prontuários dos pacientes internados em um hospital de médio porte da serra catarinense com alta complexidade em urgência e emergência no ano de 2017 com diagnóstico de traumatismo crânio encefálico. As variáveis coletadas foram: idade, sexo, mês da ocorrência, procedência (cidade), local do acidente, mecanismo do acidente, transporte pré-hospitalar, escala de coma de Glasgow (ECG), tipo de lesão, exames de imagem, internação em Unidade de terapia intensiva (UTI), necessidade de neurocirurgia, necessidade de transferência inter-hospitalar, tempo de permanência hospitalar. Resultados: dos 50 prontuários analisados houve um predomínio de TCE no sexo masculino (53%), na faixa etária entre 6 e 10 anos (33%), no mês de abril (18%), em ambiente domiciliar (52%), por queda da própria altura (24%) e procedência de Lages (62%). A maioria foi classificado como TCE leve (72%), realizaram tomografia computadorizada de crânio (80%) e receberam apenas tratamento clínico (98%). O tempo médio de internação hospitalar foi de 1 a 3 dias (80%). Destes 2% dos pacientes foram a óbito. Conclusões: o perfil desses pacientes aponta para a necessidade de implantação de medidas de prevenção como a retirada dos fatores de risco e a elaboração de um protocolo mais atualizado de atendimento aos pacientes vítimas desse agravo.

Inter-hospital Transfer of ECMO-assisted Patients with a Portable Miniaturized ECMO device: 4 Years Experiences

Objectives: Extracorporeal membrane oxygenation (ECMO) in patients with severe pulmonary failure can keep patients alive until organ regeneration until shunting out for further diagnostic and therapeutic options or until transportation to specialized centers. Nonetheless, extracorporeal techniques require a high degree of expertise, so that a confinement to specialized centers is meaningful. Following from this requirement, the need for inter-hospital transfer of patients with severely compromised pulmonary function is rising.

Inter-hospital transfer of ECMO-assisted patients with a portable miniaturized ECMO device: 4 years of experience.

Extracorporeal membrane oxygenation (ECMO) in patients with severe pulmonary failure is able to keep patients alive until organ regeneration, until shunting out for further diagnostic and therapeutic options or until transportation to specialized centers. Nonetheless, extracorporeal techniques require a high degree of expertise, so that a confinement to specialized centers is meaningful. Following from this requirement, the need for inter-hospital transfer of patients with severely compromised pulmonary function is rising. We report about our experience with a portable ECMO system during inter-hospital air or ground transfer of patients with cardiopulmonary failure. The portable ECMO system was used for transportation to the center and in-hospital treatment in 36 patients with an average age of 53 years suffering from respiratory failure. Accordingly, the ECMO system was implanted as a veno-venous extracorporeal system. Pre-ECMO ventilation time was 5.2 (2-9) days. Twelve patients were transported to our institution by ground and 24 patients by air ambulance over a median distance of 46 km. With the assistance of the ECMO device, prompt stabilization of cardiopulmonary function could be achieved in all patients without any technical complications. Post-ECMO ventilation was 9.8 days. Weaning from the ECMO system was successful in 61% of all patients after a median device working period of 12.7 days; median ICU stay was 34 days and a survival rate of 64% of patients was achieved. Technical (8%) and device-associated bleeding (11%)/thromboembolic (8%) complication rates showed very acceptable levels. Our experience demonstrates that miniaturized, portable ECMO therapy allows location-independent, out-of-center stabilization of pulmonary compromised patients with consecutive inter-hospital transfer and further in-house treatment, so that sophisticated ECMO therapy can be offered to every patient, even in hospitals with primary healthcare.

First experience with the deltastream® DP3 in venovenous extracorporeal membrane oxygenation and air-supported inter-hospital transport

Based on continuous technical innovations and recent research, extracorporeal membrane oxygenation (ECMO) has become a promising tool in the treatment of patients with acute (cardio)pulmonary failure. Nevertheless, any extracorporeal technique requires a high degree of experience and knowledge, so that a restriction to specialized centres seems to be reasonable. As a consequence of this demand, the need for inter-hospital transfer of patients with severely impaired (cardio)pulmonary function is rising. Unfortunately, most of the ECMO devices used in the clinical setting are not suitable for inter-hospital transport because of their size, weight or complexity. In this article, we describe our first experiences with the airborne transport of 6 patients on a new portable, miniaturized and lightweight extracorporeal circulation system, the Medos deltastream® DP3. Six patients suffering acute respiratory failure were taken on venovenous ECMO (DP3) out-of-centre and transferred to the University Medical Center Regensburg by helicopter. All cardiorespiratory-relevant parameters of the patients and the technical functioning of the device were continuously monitored and documented. Implantation of the device and air-supported transport were performed without any technical complications. The patients were transported from a distance of 66-178 km, requiring a time of 40-120 min. With the help of the new deltastream® DP3 ECMO device, a prompt stabilization of the cardiopulmonary function could be achieved in all patients. One patient was under ongoing cardiopulmonary resuscitation by the time our ECMO team arrived at the peripheral hospital and died shortly after arrival in the central emergency ward. Our experience shows that the deltastream® DP3 is an absolutely reliable and safe ECMO device that could gain growing importance in the field of airborne transportation of patients on ECMO due to its unsophisticated, miniaturized and lightweight characteristics.

Interhospitaltransfer - Planung und Vorbereitung von Intensivtransporten / -verlegungen

The need for interhospital transfer of intensive care and high risk patients is increasing. These transfers are dangerous and challenging. Successful organisation and scheduling includes the appropriate selection of the transport vehicle and the preliminary consultation and cooperation of all participants according to predefined rules. This article describes definitions and fundamentals, specific characteristics of different transport vehicles, recommended consultation and typical pitfalls.

An 8-factor prognostic model predicted early death in patients with traumatic bleeding

Does a prognostic model accurately estimate risk for early death in patients with traumatic bleeding? 2 cohort studies: Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial (derivation) and Trauma Audit and Research Network (TARN) dataset (validation). 274 hospitals in 40 countries (derivation cohort) and 60% of hospitals that received trauma patients in England and Wales and some hospitals in Europe (validation cohort). Derivation cohort: 20 127 trauma patients with, or at risk for, significant bleeding within 8 hours of injury (median age 30 y, median 2 h from injury). Validation cohort: 14 220 patients > 15 years of age (median age 39 y, median 1 h from injury) who arrived at hospital alive and had ≥ 1 of death from injury during admission, hospitalization > 3 days, need for intensive or high-dependency care, or need for interhospital transfer for specialist care. Patients who had isolated closed limb injuries or were > 65 years of age with isolated fractured neck of femur or pubic ramus fracture were excluded. DESCRIPTION OF PREDICTION GUIDE: The prognostic model included country (low, middle, or high income), age, time since injury, Glasgow coma score, systolic blood pressure, respiratory rate, heart rate, and type of injury (blunt or penetrating) (available at www.crash2.lshtm.ac.uk). Early death (in-hospital death within 4 wk of injury). 15% and 12% of patients from the derivation and validation cohorts died. The operating characteristics of the model in the derivation and validation cohorts are in the Table. An 8-factor prognostic model predicted early death in patients with traumatic bleeding.

269 Delays in Transfer for Primary PCI

Primary PCI is the preferred treatment modality for STEMI patients. Patients presenting to non-PCI capable facilities are increasingly being transferred for primary PCI. Transfer delays may be associated with poorer outcomes. We assessed the reasons for these delays within a referral network in Calgary, Alberta. We analyzed data from our STEMI registry regarding all walk-in acute STEMI patients presenting to non-PCI capable Calgary area hospitals between January 2008 and February 2012. The median DTRT (115 min, SD 70) was significantly longer for transfer patients (n=254) than for all patients presenting directly to the PCI centre (61 min, SD 45; n=1,071; p<0.001), as well as for direct walk-in patients (99 min, SD 72; n=117; p=0.046). 169 transfer patients had DTRT greater than 90 minutes. Areas where delays were identified are outlined in Table 1 (some patients had delays in more than one area).Tabled 1 Longer DTRT in transfer pPCI patients is largely related to the obligatory need for inter-hospital transfer. However, rapid ED assessment and activation of transport services may help to reduce reperfusion time.

Interhospitaltransfer - Indikationen, Ablauf und Organisation

An obvious trend of concentrating treatment options on specialized centres may take effect later in an increased need for inter-hospital transfer. Patients initially referred to secondary or tertiary hospitals require a safe and systematically organised transport in order to ensure a continuation of initiated actions in intensive care. This review will focus of appropriate preparations, equipment and transport modalities, possible sources of shortcomings as well as solutions of conflicts during inter-hospital transfers.

The N.E.W.S. Checklist: Enhancing interhospital transfer of trauma patients

Regionalised trauma care aims to transport seriously injured trauma patients to an appropriate facility from the scene of injury. This ensures definitive care is provided as early as possible by an institution which is fully equipped and organised to manage seriously injured trauma patients — a Major Trauma Service. However, not all seriously injured patients go directly to a Major Trauma Service. Errors in prehospital triage, and patients who self present may preclude the need for interhospital transfer. To facilitate the interhospital transfer process and ensure trauma patients are adequately and safely “packaged” for transfer, the Trauma Department of Liverpool Hospital developed the “N.E.W.S. Checklist”©.

Hospital practices influence the pattern of infective endocarditis

To identify factors contributing to infective endocarditis at a major teaching hospital. Retrospective review of clinical records of patients diagnosed with endocarditis by standard case definitions with respect to causative organisms, clinical features and outcome. One hundred and ninety-three episodes of endocarditis seen between 1979 and 1992 at Westmead Hospital, Sydney, were reviewed. In the 174 cases where the causative organism was isolated, 75 (43%) were Staphylococcus aureus and 50 (29%) were viridans streptococci. Nosocomial acquisition and/or inter-hospital transfer accounted for 83 episodes; 48 (58%) S. aureus (P < 0.001) and nine (11%) viridans streptococci (P < 0.001). In cases from the local community, viridans streptococci were more common than S. aureus (37% versus 25%); these included 18 episodes (14 S. aureus) in intravenous drug users. We conclude that, compared with community-acquired infections, the aetiology of endocarditis in a large teaching hospital is influenced strongly by the prevalence of nosocomial endocarditis and the need for interhospital transfer of complicated cases.

Presence of three or more rib fractures as an indicator of need for interhospital transfer.

During a 42-month period, 3,282 patients with blunt trauma were admitted to our hospital. Group I (n = 3,143) was defined as patients sustaining zero to two rib fractures, Group II (n = 139) as patients sustaining three or more rib fractures. Groups I and II differed in age and mechanism of injury. Two other descriptive variables (sex and year of admission) showed statistically significant associations with outcome. To adjust for the joint effect of these four variables, a log-linear model (binary outcomes) or a linear regression model (continuous outcomes) was used. We defined need for interhospital transfer (NIT) based on the following: death, an Injury Severity Score of greater than or equal to 16, or direct admission to the operating room or intensive care unit. We conclude that the presence of three or more rib fractures identified a group of patients requiring transfer to a trauma center (positive predictive value = 92.8%). A population-based study is needed to verify this finding.

Prediction of Neonatal Death or Need for Interhospital Transfer by Prenatal Risk Characteristics of Mother

A closed-circuit television system is implemented between neonatal specialists at a large neonatal care hospital and nurses caring for infants in the newborn nursery in a small community hospital located in an inner city, predominantly black, economically deprived area. Data are systematically collected relating prenatal risk characteristics of mothers to outcome measures, including selected intrapartum maternal complications, neonatal morbidity and mortality, neonatal therapeutic interventions, and transfer of neonates from the small hospital to the larger hospital. To our knowledge, study of factors predicting transfer has received little attention in the literature. A log linear model is used to identify specific groups of prenatal risk characteristics capable of predicting maternal and neonatal outcomes.