Non-tertiary Care Hospitals Research Articles

Comparison of Length of Stay and Discharge Disposition after Short-Segment Lumbar Fusion Surgery at Tertiary Care and Non-Tertiary Care Hospitals: A Propensity Score Matched Analysis.

A retrospective study. To compare the perioperative and postoperative outcomes among lumbar fusion patients treated at an orthopaedic specialty hospital (OSH), a hybrid community hospital (HCH), and a conventional community hospital in comparison to a tertiary care hospital (TCH). In spine surgery, strategies to reduce length of stay (LOS) include a myriad of pre-, intra-, and postoperative strategies that require a multidisciplinary infrastructure. The sum of these efforts has led to the creation of orthopedic specialty hospitals and protocols that have been adopted by community hospitals as well. There is a notable lack of information regarding the results of these efforts across different healthcare institution models. This was a retrospective study of patients undergoing elective one or two-level lumbar fusion between 2017 and 2022 at a large urban TCH, an OSH, a HCH, and a conventional CH. Data was collected on patient characteristics, demographics, comorbidities, BMI, smoking status, surgical type, surgical levels, surgery duration, hospital length of stay, readmissions, reoperations, and discharge status within a year. Patients across the four surgical settings were matched based on age, BMI, CCI, type of procedure, and number of levels fused. A total of 1435 patients met the inclusion criteria. Length of hospital stay was significantly longer at TCH compared to OSH, HCH, and CH by an average of 1-2 days (P<0.001). 90-day readmissions were higher at TCH compared to OSH (P=0.001). TCH patients also were less likely to be discharged home than OSH and HCH patients (P=0.001 and P=0.016, respectively). No significant differences were noted in 1-year reoperation rates across all hospital models. Shorter lengths of stays and more home discharges at the orthopaedic specialty hospital and community hospital settings did not compromise surgical quality or postoperative outcomes.

Bringing The Swan Back: Improving Cardiogenic Shock Mortality

<h3>Background</h3> Mortality in cardiogenic shock is historically high, with advances in devices and mechanical cardio-circulatory support treatment is improving. Institutional recognition and implementation is of utmost importance. <h3>Objective</h3> To create early multidisciplinary activation of hemodynamic-guided management which includes early shock identification and implementation of mechanical circulatory support to improve the outcomes of cardiogenic shock patients at a non-tertiary care hospital. <h3>Methods</h3> A single-center, retrospective study was performed on patients who presented with cardiogenic shock secondary to acute decompensated heart failure or acute myocardial infarction between 2016-2020. Use of mechanical support including Impella and intra-aortic balloon pump as well as the use of Swan-Ganz catheters were examined. Endpoints of survival to discharge were also examined. <h3>Results</h3> A total of 209 patients presented with cardiogenic shock over a 5 year period. Data analysis showed that compared to baseline 2016 survival data of 37% (10/27), survival rates increased every year to 43%(12/28) in 2017, 54%(14/26) in 2018, 70 %(40/57) in 2019, and 71% (51/72) in 2020 (p= 0.001; OR 25.22; CI 3.55 to 179.23), facilitated by the implementation of a multidisciplinary cardiogenic shock team in 2018. In addition, the use of Swan-Ganz catheters substantially increased from 0% in 2016 to 100% in 2019. Specifically between 2018 and 2019, Swan-Ganz catheter usage increased from 43% in 2018 to 100% in 2019 as did survival percentage (54% to 71%) (p=0.06). The use of mechanical support increased from 9 patients in 2016 to 35 patients in 2020. The survival to discharge of patients requiring Impella support increased from 17% in 2018 to 67% in 2020. <h3>Conclusions</h3> The results of this study demonstrate that a multidisciplinary team approach to the treatment of cardiogenic shock resulted in better clinical outcomes. Survival to discharge improved substantially from 2016 to 2020. These improved outcomes were driven by a combination of a multidisciplinary team approach, utilization of Swan-Ganz catheters, and effective use of mechanical support devices.

User-Centered Design: Developing the RELI Delivery System - a Low-Cost, Non-Electric, Pneumatic Infusion Pump.

PurposeInfusion pumps are the preferred method for intravenous delivery of drugs and fluids, and an essential tool in health facilities. Their high cost, complexity and reliance on electricity pose serious challenges to wide-spread use, availability and access in low- and middle-income countries. PATH developed the RELI Delivery System (RELI), a low cost, non-electric infusion pump to address these challenges. Input collected from fifty-nine newborn and maternal care providers and from seven national level decision makers in Uganda was used to guide product development, further informing product design requirements, and optimal design features to best serve their needs.MethodsA formative evaluation following a mixed methods approach including focus group discussions (FGDs), stakeholder interviews, and observations was used to collect data from end users.ResultsStakeholders provided critical input on the RELI prototype design features, safety criteria, and contexts of use of infusion pumps, as well as recommendations for design refinements. Infusion systems are greatly needed but not readily available and their use is limited to well-resourced higher level facilities, even though the need is high in non-tertiary care hospital where patient volume is high, resources are scarce, power is inconsistent, and facilities are understaffed and overcrowded. Users expressed a need for an affordable and simple device with an intuitive user interface, clear instructions for use, and basic safety features.ConclusionThe study provided important guidance for further design refinements based on input from respondents and confirmed the need for robust, affordable, infusion pumps that meet the requirements for use in low-resource settings.

Pregnant-Postpartum Women with Severe Epigastric Pain and HELLP Syndrome: A Highly Dangerous Combination

OBJECTIVE: HELLP syndrome is a severe preeclampsia spectrum disorder diagnosed when laboratory evidence of hemolysis, liver dysfunction and thrombocytopenia are present. The presence of epigastric pain with laboratory criteria for HELLP syndrome may indicate higher maternal-fetal risk. Thus we explored maternal outcomes in 42 pregnant/postpartum women that had HELLP syndrome by laboratory criteria in addition to sudden severe epigastric pain. METHODS: A database was constructed from the medical files of all patients with medical/hypertensive disorders evaluated by the first author from 1986-2015 for medicolegal purposes. All patient files of women who presented to their physicians with a diagnosis of presumptive HELLP syndrome were examined. RESULTS: Fifty-eight pregnant/postpartum women fulfilled study inclusion criteria; they presented to physicians for evaluation usually in non-tertiary care hospital settings. Clinical presentation and care including lab data and details of pregnancy outcome were evaluated. A correct diagnosis of HELLP syndrome was verified for 42 women (72.4%); others were determined to have AFLP-Acute Fatty Liver of Pregnancy (n = 8) or TTP-aHUS-Thrombotic thrombocytopenic purpura-adult/atypical hemolytic uremic syndrome (n = 8). All 42 HELLP women (100%) in our cohort had severe epigastric pain. Treatment modalities for maternal HELLP syndrome included magnesium sulfate (n = 35, 83%), antihypertensives (n = 17, 40%); corticosteroids (CORT) for HELLP were not utilized. Major maternal morbidity (21 strokes, 9 liver ruptures/hematomas) affected 41 HELLP women (98%); 22 died, 7 were permanently disabled. CONCLUSION: HELLP syndrome patients presenting with sudden, severe epigastric pain in this highly selected cohort experienced very high maternal morbidity and mortality. Laboratory evidence of HELLP syndrome in association with epigastric pain is a dangerous combination that portends great danger to safe motherhood. We speculate that the absence of CORT use in this cohort contributed to poor maternal outcome (word count = 280 as modified for reviewers).

S0075 Characterization of Treatment Practices of Chronic Pancreatitis Within a Large Health Management Organization

INTRODUCTION: Treatment of Chronic pancreatitis (CP) predominantly includes pain control, pancreatic enzyme supplementation and smoking/alcohol cessation. Opiates are recommended only when other therapeutic treatment options have been exhausted as per latest ACG guidelines. Strong recommendation has been advocated for smoking and alcohol cessation to prevent progression and readmission rates of CP. There is limited data to prove that tertiary care centers (with access to a gastroenterologist) are managed effectively when compared to non-tertiary care hospitals. To better understand the gaps in treatment practices of this chronic, often disabling illness, we performed a retrospective analysis of 215 patients with CP treated at 9 hospitals of MedStar Health. METHODS: Using ICD 10 codes, we retrieved charts of patients presenting to acute care sites- Tertiary care Hospitals (TH) and Non-tertiary care Hospital (NTH) within the MedStar Health system between March 2015 and June 2019. These included emergency room visits and inpatient admissions. The following 3 variables pertaining to the treatment of CP were manually extracted: 1. Differences in narcotics/pancreatic exocrine replacement therapy (PERT) 2. Differences in smoking/alcohol cessation counselling 3. Differences in follow up with a gastroenterologist. Statistical analysis was performed using Chi- Square from Microsoft Excel. RESULTS: 215 encounters were eligible for retrospective chart review. 56% of CP patients were put on narcotics for pain relief. The chances of being prescribed a narcotic was more in the NTH setting (55% vs. 45%). 8% of TH patients received PERT. 80% of these had documented pancreatic insufficiency (fecal elastase/ stool fat). In contrast, 10% of NTH patients received PERT, among which 10% had documented pancreatic insufficiency. Both hospitals performed well in discussing alcohol cessation (>75% of patients) but only >50% patients received smoking cessation instructions. 60% of TH patients were referred and followed by a gastroenterologist in contrast to 41.5% in NTH setting (P = 0.15). CONCLUSION: Treatment guidelines were more likely to be followed in TH given direct access to specialists. PERT was part of the treatment plan in TH only after documenting exocrine insufficiency. There was no significant difference in smoking and alcohol counselling cessation practices between the two settings. Patients were most likely to have an outpatient follow-up with gastroenterologist after a TH visit.Figure 1.: Retrospective Study Characteristics.Table 1.: PERT, Treatment Modalities, Specialist follow up ComparisonTable 2.: Smoking and Alcohol Cessation Counselling Comparison

S0060 Characterization of Diagnostic Patterns of Chronic Pancreatitis Within a Large Health Management Organization

INTRODUCTION: Chronic pancreatitis (CP) is an irreversible and progressive fibro-inflammatory disease of the pancreas causing pain and/or loss of exocrine/endocrine function. It is typically diagnosed with a combination of clinical and imaging criteria including atrophy, ductal dilatation, multiple parenchymal and intraductal calcifications. One of the main challenges in making a diagnosis of CP is the lack of universally agreed gold standard diagnostic criteria. To better understand the diagnostic patterns of this chronic, often disabling illness, we performed a retrospective analysis of 215 patients with CP treated at 9 hospitals of MedStar Health. METHODS: Using ICD 10 codes, we retrieved charts of patients presenting to acute care sites within the MedStar Health system between March 2015 and June 2019. These included emergency room visits and inpatient admissions. The following 7 variables pertaining to diagnosis of CP were manually extracted: 1. How was CP diagnosed? 2. Who made the diagnosis? 3. Demographics including sex, age 4. Length of stay 5. Was a GI consult obtained? 6. Location of care (Tertiary care vs. Non-tertiary care hospital) 7. Presumed etiology. Statistical analysis was performed by ANOVA analysis using GraphPad PRISM for Mac OS (Version 8). RESULTS: We found 215 encounters eligible for retrospective chart review. Average length of stay (in days) was longest when a gastroenterologist made the diagnosis (7.48), followed by the internist (2.02), or when a prior diagnosis was known (1.35). When a gastroenterologist was consulted, the chance of making an accurate diagnosis of CP was highest (53%) vs. when they weren’t consulted (20%). Most patients received a diagnosis of CP at a non-tertiary care center. The specialist making the diagnosis significantly changed the probability of accurate diagnosis (P < 0.0001) by clinical and imaging criteria. CONCLUSION: Most patients with CP are diagnosed at non-tertiary centers within the MedStar Health System. Most of these patients are given a diagnosis based on a prior diagnosis of CP. Accuracy of diagnosis significantly improved when a gastroenterologist was consulted. Non-tertiary centers most commonly made a diagnosis of CP based on inappropriate clinical and imaging criteria. These represent avenues for targeted interventions to standardize the diagnosis of CP across a large health management organization.Table 1.: TablesFigure 1.: Retrospective study design.Figure 2.: Graphs.

Population-Based Analysis of Patient Age and Other Disparities in the Treatment of Ovarian Cancer in Central Appalachia and Kentucky.

Adherence to National Comprehensive Cancer Network (NCCN) guidelines for ovarian cancer treatment improves patient outcomes. The aim of this study was to assess disparities associated with ovarian cancer treatment in the state of Kentucky and central Appalachia. Data on patients diagnosed as having ovarian cancer from 2007 through 2011 were extracted from administrative claims-linked Kentucky Cancer Registry data. NCCN compliance was defined by stage, grade, surgical procedure, and chemotherapy. Selection criteria were reviewed carefully to ensure data quality and accuracy. Descriptive analysis, logistic regression, and Cox regression analyses were performed to examine factors associated with guidelines compliance and survival. Most women were aged 65 years or older (62.5%) and had high-grade (65.9%) and advanced-stage (61.0%) ovarian cancer. Two-thirds of cases (65.9%) received NCCN-recommended treatment for ovarian cancer. The hazard ratio of death for women who did not receive NCCN-compliant care was 62% higher compared with the women who did receive NCCN-compliant treatment. Results from the logistic regression showed that NCCN-compliant treatment was more likely for women aged 65 to 74 years compared with women aged 20 to 49 years, late-stage compared with early-stage cancers, receipt of care at tertiary care hospitals, and privately insured compared with Medicaid or Medicare. When the treatment of ovarian cancer did not follow NCCN recommendations, patients had a significantly higher risk of death. Women were less likely to receive NCCN-compliant care if they were younger (20-49 years), had early-stage disease, did not have private insurance, or had care provided at a nontertiary care hospital.

Extramural Pilot Project: Designated On-Call Intensivist in Tertiary Care Centre Improves Access to Critical Care Consultation/Referral and Resources.

Timely consultation with an intensivist will promote early and appropriate management of critically ill patients. We determined whether implementing a call roster of intensivists who did not have on-call responsibilities in an intensive care unit (ICU) and who received referrals from community physicians would improve access to critical care services. This program created efficiencies to critical care services by: timely access to consultation with an intensivist (<10 minutes) and/or subspecialist, timely referral to an appropriate institution (<30 minutes) and optimal resource utilization by determining the availability of ICU beds at non-tertiary care hospitals capable of providing the care needs of the patient, thus relieving pressure on the neighbouring tertiary/quaternary care centre.

Successful treatment of massive pulmonary embolism using a pulmonary artery catheter during prolonged normothermic cardiopulmonary resuscitation

Massive pulmonary embolism has a high mortality rate. Standard treatment includes systemic thrombolysis. If this fails, surgical embolectomy or a percutaneous catheter-guided approach is advised in current guidelines. However, these treatment options might not be available in many non-tertiary care hospitals. We describe a case of a 25-year old woman with cardiac arrest from massive pulmonary embolism. She was treated with thrombus fragmentation using a pulmonary artery catheter and intra-pulmonary thrombolysis after failure of systemic thrombolysis along with 90 minutes of cardiopulmonary resuscitation (CPR). Neurological recovery was excellent and pulmonary pressure was normalized after one month. Besides catheter guided thrombus fragmentation and thrombolysis, we contribute the successful outcome to a combination of ultrasound-guided therapy, capnography-guided CPR, and “crew resource management” principles. Our case illustrates that a pulmonary artery catheter can be used successfully in a non-tertiary setting, to perform a percutaneous procedure during CPR and that full neurological recovery is possible after 90 minutes of CPR.

Gender inequality in the clinical outcomes of equally treated acute coronary syndrome patients in Saudi Arabia

BACKGROUND AND OBJECTIVESGender associations with acute coronary syndrome (ACS), remain inconsistent. Gender-specific data in the Saudi Project for Assessment of Coronary Events registry, launched in December 2005 and currently with 17 participating hospitals, were explored.DESIGN AND SETTINGSA prospective multicenter study of patient with ACS in secondary and tertiary care centers in Saudi Arabia were included in this analysis.PATIENTS AND METHODSPatients enrolled from December 2005 until December 2007 included those presented to participating hospitals or transferred from non-registry hospitals. Summarized data were analyzed.RESULTSOf 5061 patients, 1142 (23%) were women. Women were more frequently diagnosed with non ST-segment elevation myocardial infarction (NSTEMI [43%]) than unstable angina (UA [29%]) or ST-segment elevation myocardial infarction (STEMI [29%]). More men had STEMI (42%) than NSTEMI (37%) or UA (22%). Men were younger than women (57 vs 63 years) who had more diabetes, hypertension, and hyperlipidemia. More men had a history of coronary artery disease. More women received angiotensin receptor blockers (ARB) and fewer had percutaneous coronary intervention (PCI). Gender differences in the subset of STEMI patients were similar to those in the entire cohort. However, gender differences in the subset of STEMI showed fewer women given β-blockers, and an insignificant PCI difference between genders. Thrombolysis rates between genders were similar. Overall, in-hospital mortality was significantly worse for women and, by ACS type, was significantly greater in women for STEMI and NSTEMI. However, after age adjustment there was no difference in mortality between men and women in patients with NSTEMI. The multivariate-adjusted (age, risk factors, treatments, door-to-needle time) STEMI gender mortality difference was not significant (OR=2.0, CI: 0.7–5.5; P=.14).CONCLUSIONThese data are similar to other reported data. However, differences exist, and their explanation should be pursued to provide a valuable insight into understanding ACS and improving its management.

Dissemination of genetically related IMP-6-producing multidrug-resistant Pseudomonas aeruginosa ST235 in South Korea

The present study aimed to describe the prevalence and molecular epidemiology of metallo-β-lactamase (MBL)-producing Pseudomonas aeruginosa isolates obtained from non-tertiary care hospitals and geriatric hospitals in South Korea. Of the 644 isolates, 224 were carbapenem-resistant, amongst which 41 (18.3%) were MBL-producers and the major MBL type was IMP-6 (35 isolates). IMP-6-producing isolates were multidrug-resistant and showed higher minimum inhibitory concentrations for meropenem than imipenem. All of the IMP-6-producing isolates had class 1 integrons with amplification sizes of 4.5kb/5.5kb (34 isolates) or 3.0kb (1 isolate); 4.5kb/5.5kb integrons had blaIMP-6–qac–aacA4–blaOXA-1–aadA1 (5.5kb) and aadB–cmlA–blaOXA-10–aadA1 (4.5kb). Pulsed-field gel electrophoresis (PFGE) analysis indicated that all IMP-6-producing P. aeruginosa from various geographic areas had nearly identical patterns with >85% similarity. All IMP-6-producing isolates showed high genetic similarity to those obtained from tertiary care hospitals and had the same integron type, indicating the spread of these strains to the three types of hospitals nationwide. These data show the wide spreading of clonally related IMP-6-producing P. aeruginosa (sequence type235) through tertiary, non-tertiary and geriatric hospitals in South Korea. Continuous monitoring and thorough infection control should be performed in all types of hospitals to prevent further spreading of MBL-producing P. aeruginosa.

Correlates of Delayed Recognition and Treatment of Acute Type A Aortic Dissection

Background— In acute aortic dissection, delays exist between presentation and diagnosis and, once diagnosed, definitive treatment. This study aimed to define the variables associated with these delays. Methods and Results— Acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and January 2007 were evaluated for factors contributing to delays in presentation to diagnosis and in diagnosis to surgery. Multiple linear regression was performed to determine relative delay time ratios (DTRs) for individual correlates. The median time from arrival at the emergency department to diagnosis was 4.3 hours (quartile 1–3, 1.5–24 hours; n=894 patients) and from diagnosis to surgery was 4.3 hours (quartile 1–3, 2.4–24 hours; n=751). Delays in acute aortic dissection diagnosis occurred in female patients; those with atypical symptoms that were not abrupt or did not include chest, back, or any pain; patients with an absence of pulse deficit or hypotension; or those who initially presented to a nontertiary care hospital (all P &lt;0.05). The largest relative DTRs were for fever (DTR=5.11; P &lt;0.001) and transfer from nontertiary hospital (DTR=3.34; P &lt;0.001). Delay in time from diagnosis to surgery was associated with a history of previous cardiac surgery, presentation without abrupt or any pain, and initial presentation to a nontertiary care hospital (all P &lt;0.001). The strongest factors associated with operative delay were prolonged time from presentation to diagnosis (DTR=1.35; P &lt;0.001), race other than white (DTR=2.25; P &lt;0.001), and history of coronary artery bypass surgery (DTR=2.81; P &lt;0.001). Conclusions— Improved physician awareness of atypical presentations and prompt transport of acute aortic dissection patients could reduce crucial time variables.

Hospital Mergers and Referrals in the United States: Patient Steering or Integrated Delivery of Care?

Many tertiary care hospitals (acquirers) acquire non-tertiary care hospitals (targets), and some of these mergers lead to a significant increase in referrals from the target to the acquirer. This study examines the hospitals' motives for integration and for increasing referrals using hospital discharge data from the Pittsburgh area. I develop and estimate a model of referral choice based on a reputation mechanism. The results suggest that low- or average-quality acquirers exploit their targets' monopoly power to steer patients to the acquirers. Distinguished acquirers, on the other hand, seem to have motives other than patient steering, including the integrated delivery of care.

Thrombolysis for Acute Lower Extremity Deep Venous Thrombosis in a Tertiary Care Setting

In 2008, the Surgeon General made a Call to Action for the prevention of deep venous thrombosis (DVT), and for the first time, the 2008 American College of Chest Physicians guidelines for treatment of acute lower extremity DVT (ALE DVT) were revised to include thrombolysis as a grade 2B recommendation. Catheter-directed thrombolysis (CDT) therapy for patients with ALE DVT without contraindications can result in more complete clot dissolution than anticoagulation alone and may prevent the long-term sequelae of DVT. We sought to determine the percentage of inpatients with ALE DVT at a tertiary medical center who were candidates for CDT therapy and whether these patients were appropriately offered such treatment. A hospital administrative database search from a tertiary medical center between January 2007 and December 2007 revealed 667 patient admissions associated with a diagnosis of DVT by International Classification of Diseases, Ninth Revision diagnosis codes (451-451.99, 453-453.99). Computerized hospital records were then searched for information regarding medical history, comorbidities, contraindications to thrombolysis, symptoms, imaging findings, and treatment. Of the 667 patient admissions, 157 (24%) had ALE DVT, 31% had upper extremity DVT, 17% carried an old diagnosis DVT, and 28% had venous thromboses in other vessels. Of those 157 patients with ALE DVT, 60 (38%) had proximal iliofemoral or extensive femoral DVT that would be candidates for thrombolysis. Of the 60 patients, only 10 (17%) had no major contraindication thrombolysis. Of these, one was offered CDT but refused treatment, four did not receive consults for thrombolysis; five (9%) were offered CDT and were treated. However, of these 60 patients, 50 (83%) patients had severe illness and major and often multiple contraindications to thrombolysis. Although the majority of patients identified in the 2007 inpatient database with ALE DVT and an absence of contraindications to thrombolysis were appropriately offered CDT therapy, patients in such a tertiary inpatient setting typically have severe medical comorbidities that precluded the use of thrombolysis. Future studies assessing the expanding role of CDT in patients with ALE DVT should focus on outpatient settings or nontertiary care hospitals, where patients are likely to have fewer contraindications to thrombolytic therapy.

Five-year report of national surveillance of antimicrobial resistance in Pseudomonas aeruginosa isolated from non-tertiary care hospitals in Korea (2002–2006)

A nationwide surveillance of the antimicrobial resistance of Pseudomonas aeruginosa isolates from non-tertiary care hospitals was conducted in Korea from 2002 to 2006. Resistance to almost all antimicrobial agents decreased significantly from 2003 ( P < 0.01). Resistance rates to the major antipseudomonal agents, ceftazidime, imipenem, meropenem, and aztreonam, were 18.8%, 20.5%, 18.7%, and 19.7%, respectively, in 2003. However, they had all decreased to below 10% in 2006. The proportion of multidrug-resistant isolates that were resistant to at least 3 of 5 major antipseudomonal agent decreased from 33.5% in 2003 to 23.1% in 2006 ( P < 0.05). In this study, we found a decreasing trend in resistance rates and low resistance rates in P. aeruginosa from non-tertiary care hospitals compared with those from general hospitals, including tertiary care hospitals, in Korea. Our data provide valuable information for the selection of reliable empiric therapies for P. aeruginosa infections in non-tertiary care hospital patients, including outpatients.

Variability of Trauma Transfer Practices among Non–tertiary Care Hospital Emergency Departments

To assess both the variability of interhospital trauma transfer practices and nonclinical factors associated with the transfer of injured patients from emergency departments (EDs) of non-tertiary care hospitals. The authors analyzed a retrospective cohort of trauma patients initially presenting to one of 42 non-tertiary care hospitals (Level 3 or 4 hospitals) and requiring admission or transfer from January 1998 to December 2003. Twenty-one clinical, demographic, and hospital-level variables were included in multivariable logistic regression models (outcome = ED transfer to a tertiary care hospital), with hospital and year included as fixed effects to adjust for clustering. Classification and regression tree analysis was used to determine the importance of different covariates in predicting whether or not a patient was transferred from the ED. Included in the analysis were 10,176 persons, of whom 3,785 (37%) were transferred to a tertiary care hospital from the ED. The hospital of initial presentation was the factor of greatest importance in predicting transfer, and there was substantial variability in transfer practices between hospitals. Several additional nonclinical variables were independently associated with transfer, including type and level of hospital, patient age, increasing distance from the nearest higher-level hospital (a measure of geographic isolation), and the patient's insurance status (particularly among Level 3 hospitals). The non-tertiary care hospital of initial presentation is the strongest predictor for whether an injured patient is transferred to a tertiary center from the ED. There is substantial variability in transfer practices between hospitals after accounting for important clinical factors, and several nonclinical variables are independently associated with transfer.

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...

Preterm Contractions in Community Settings: II. Predicting Preterm Birth in Women With Preterm Contractions

Objective: To examine risk factors for preterm delivery in women who present to nontertiary care hospitals with preterm contractions. Methods: Women who presented to a network of community hospitals in Wisconsin with preterm contractions were followed until delivery. The main outcomes were preterm delivery before completion of 36 weeks of gestation and delivery within 1 week of initial presentation. Results: Of the 266 women presenting with contractions over the 2-year study period, 90% ( n = 239) consented to participate. Multiple factors were associated with premature delivery, but when examined with a multivariate model, only four (ruptured membranes, multiple gestation, cervical effacement at least 80%, and nonwhite race) were associated with prematurity, whereas five (ruptured membranes, multiple gestation, cervical effacement at least 80%, dilation exceeding 1 cm, and being a nonsmoker) predicted delivery within 1 week. A decision model that combined the presence of ruptured membranes and effacement at least 80% could predict delivery at 34 weeks or less within 7 days of presentation with a sensitivity of 71% and a specificity of 98%. Conclusion: Only two clinical cues (ruptured membranes and effacement of the cervix of 80% or more) can predict premature delivery within 7 days. If these results are confirmed prospectively, women with either of these signs could be targeted for administration of steroids, antibiotics, or transfer to tertiary care facilities.