Nontransferred Patients Research Articles

Abstract 4148085: Transfer to ‘Hub’ Hospitals and Outcomes in Cardiogenic Shock

Introduction: Patients with cardiogenic shock (CS) have high mortality. Many CS patients present to non-tertiary care centers. Limited data exist on outcomes for patients transferred to “hub” CS centers for both acute myocardial infarction (AMI) and non-AMI etiologies. This study sought to compare the characteristics and outcomes of transferred CS patients compared to patients presenting to a hub center. Methodology: Adults (≥18 years) with a primary or secondary diagnosis of CS were identified from the National Readmissions Database (2016-2020) and stratified by transfer status. Overlap propensity score (PS) weighting was performed to assess the association between in-hospital mortality, length of stay (LOS) and transfer status. Results: Of 314,098 CS patients (AMICS 27%, non-AMICS 73%), 30,630 (9.8%) were transferred. Compared to non-transferred patients, transferred patients were on average younger (65 [interquartile range {IQR} 55-73] vs. 68 [IQR 58-77] years), more likely to be female (34% vs. 37%), less frequently with Medicare as primary payor (55% vs. 62%), and with higher comorbidity (Elixhauser index 8 [IQR 6-9] vs. 6 [IQR 5-8]) (all p <0.001). Transferred patients had higher rates of respiratory failure (70% vs. 64%), renal failure (71% vs. 60%), hepatic failure (25% vs. 17%), bleeding complications (28% vs. 17%), and arrhythmias (59% vs. 52%) (all p <0.001). Transferred patients were also more likely to undergo percutaneous coronary intervention (22% vs. 19%), coronary artery bypass grafting (13% vs. 8%), pulmonary artery catheter insertion (36% vs.16%), placement of intra-aortic balloon pump (25% vs.13%), percutaneous left ventricular assist device (13% vs. 7%), and extracorporeal membrane oxygenation (7% vs. 2%), receive invasive mechanical ventilation (3% vs. 2%), and undergo hemodialysis (17% vs. 11%) (all p <0.001). In-hospital mortality was significantly lower in transferred patients – 39% vs. 47.1%; unadjusted odds ratio 0.71 (95% confidence interval 0.70-0.73); adjusted PS weighting odds ratio 0.73 (95% confidence interval 0.71-0.76), p <0.001. Transferred patients had a longer median LOS (13 [IQR 7-22] vs. 6 [IQR 3-11] days, p <0.001). Conclusion: Transferred CS patients had higher use of cardiovascular procedures and organ support therapies and lower in-hospital mortality suggesting patients were appropriately selected for transfer.

Mortality association with extremity trauma and transferring patients for higher level of care.

Rising healthcare costs and reduced Medicaid reimbursements pose lasting challenges for trauma centers. Various studies have highlighted the adverse effect of these cost-related circumstances on trauma center survival and the need for local hospitals to transfer patients to tertiary and quaternary care centers. Our study seeks to assess the relationship between patient transfer status to a higher-level health center and its association with mortality. A total of 19417 patients were identified, of which 15317 patients presented directly to the higher level health center, and 3830 patients who transferred from 49 different outside hospitals within a 500-mile radius. Data collection was collected from the receiving higher level of care hospital trauma registry. IBM SPSS version 23 was used to analyze the data. A 1:1 propensity-matched analysis based on age, sex, and injury severity score yielded 3566 patients that presented directly to ARMC and 3566 patients who were transferred to ARMC for a higher level of care. Amongst various factors we considered mechanism of injury, response levels, arrival methods, and transfusion of blood products. The univariate analysis of the propensity-matched analysis demonstrated 88% blunt injury in the nontransferred group and 82% in the transferred group (P<0.001). Overall, hospital mortality was 3% in nontransferred patients versus 4% in the transferred group (P<0.001). A multivariate logistic regression demonstrated mortality is more likely in patients with higher injury severity scores [odd ratio (OD) 2.351 (1.029-1.082), P<0.001] and lack of packed red blood cell (pRBC) transfusions received within first 4h [OD 6.852 (3.525-13.318), P=0.001]. The transfer of trauma patients with extremity injuries to level 1 trauma centers has significant implications on patient outcomes. In our retrospective observational cohort study, the authors noted increased mortality among patients with higher injury severity scores, penetrating injuries, pRBC administration within the first 4h of hospitalization, and among patient transfers.

Impact of Hospital Transfers on Cardiac Surgery Outcomes: A Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis

BackgroundTransfers for cardiac surgery are not well studied. We sought to understand the risk profile of transferred patients and determine whether transfer rates vary by cardiac surgery and whether outcomes of transferred patients vary with type of referral hospital/surgery. MethodsPatients undergoing cardiac surgery with operative risk models were identified from The Society of Thoracic Surgeons database between July 1, 2014, and December 31, 2022. Patients were stratified as no transfer, transferred from hospital with cardiac surgery, and transferred from hospital without cardiac surgery. Risk associated with transfer compared with no transfer was derived by using multivariable logistic regression for operative mortality and select perioperative outcomes. ResultsIncluded were 1,828,787 patients at 1145 hospitals, with 1,452,491 no-transfer patients (79.4%), 28,862 transfers (1.6%) from hospitals with cardiac surgery, and 347,434 transfers (19.0%) from hospitals without cardiac surgery. Most transferred patients underwent coronary artery bypass grafting (83.6%); however, transfers from hospitals with cardiac surgery were most common for mitral valve replacement (17.9%). Transferred patients had increased comorbid diseases and urgent/emergent procedures. In multivariable analysis, transfers from hospitals with/without cardiac surgery were not associated with differential risk of adverse outcomes by procedure type. Patients transferred from hospitals with cardiac surgery undergoing mitral and aortic valve replacement and coronary artery bypass grafting had significantly lower adjusted mortality risk compared with nontransferred patients, whereas composite morbidity/mortality was higher in mitral valve repair. ConclusionsPatients transferred for cardiac surgery are generally higher risk; yet, outcomes at transfer to hospitals are as expected or better. However, further research is necessary to examine patients who are transferred but do not undergo surgery.

Association of Time Since Diagnosis of Pediatric Ileocolic Intussusception With Success of Attempted Reduction: Analysis in 1065 Patients.

BACKGROUND: Radiologists generally treat pediatric ileocolic intussusceptions emergently given potential worse outcomes from delayed reduction attempts. However, relevant literature is conflicting. OBJECTIVE: To identify factors associated with successful image-guided ileocolic intussusception reduction in children, with attention to the time interval since diagnosis. METHODS: This retrospective study included patients <6 years old who underwent attempted image-guided enema reduction of ileocolic intussusception between May 2009 and July 2023. Patients were separated into two groups: those presenting directly to the institution (nontransferred patients, who all underwent attempted reduction <8 hours after ultrasound diagnosis), and those transferred from outside facilities. EHR data were extracted. Each patient's first image-guided reduction attempt was classified as successful or unsuccessful. Univariable and multivariable analyses were performed. RESULTS: The study included 1065 patients (649 male, 416 female; mean age, 18.1 months; age range, 2.2-71.0 months; 793 nontransferred and 272 transferred patients). In nontransferred patients, the mean interval between ultrasound diagnosis and reduction attempt was 150.8 minutes; in transferred patients, the mean interval between outside facility advanced imaging and reduction attempt was 460.1 minutes (p<.001). Successful reduction occurred in 84.6% and 81.6% of nontransferred and transferred patients, respectively (p=.25). In nontransferred patients, success occurred in 85.6% of attempts <2 hours after diagnosis versus 84.0% of attempts 2-<8 hours after diagnosis (p=.54); the mean interval from diagnosis to attempted reduction was 149.7 minutes and 156.8 minutes for successful and unsuccessful attempts, respectively (p=.53). In multivariable analysis, factors showing independent associations with success were proximal intussusception location (OR=3.63, p<.001) and absence of high-risk ultrasound findings (OR=2.57, p<.001); success was not independently associated with age, sex, bloody stools, reduction method, or time since diagnosis <2 hours (p>.05). In transferred patients, the mean interval from outside advanced imaging to attempted reduction was 463.1 minutes and 440.2 minutes for successful and unsuccessful attempts, respectively (p=.74). CONCLUSION: Intussusception reduction may not require completion emergently (within 2 hours after diagnosis), but potentially may be safely performed on an urgent basis (within 8 hours). CLINICAL IMPACT: The findings have implications for determining the standard of care, including criteria for oncall activation of radiologic resources, in pediatric intussusception management.

Operational outcomes of community-to-academic emergency department patient transfers

BackgroundMany patients require inter-hospital transfer (IHT) to tertiary Emergency Departments (EDs) to access specialty services. The purpose of this study is to determine operational outcomes for patients undergoing IHT to a tertiary academic ED, with an emphasis on timing and specialty consult utilization. MethodsThis study was a retrospective observational cohort study at a tertiary academic hospital from 10/1/22–9/30/23. Key operational metrics, including specialty consultations, were queried from the ED Information System (EDIS). Data were analyzed for temporal variation in operational metrics and consulting patterns between transferred and non-transferred patients, stratified by time of day and week. ResultsDuring the study period there were 50,589 ED patient encounters, of which 3196 (6.3 %) were identified as IHTs. Transferred patients made up a larger proportion of patient arrivals in off-hours compared to daytime hours (p < 0.001). Transferred patients were more likely to be admitted to the hospital (76 % vs 35 %, p < 0.001), go directly to a procedure (6 % vs 2 %, p < 0.001), or receive a specialty consult (90 % vs 42 %, p < 0.001), regardless of the day of week or time of day. Relative risk of consults amongst transferred patients varied by service, though was particularly increased amongst surgical sub-specialties. ConclusionsTransferred patients represented a larger proportion of ED volume during evening and overnight hours, received more consults, and had higher likelihood of admission. Consults for transfers were disproportionately surgical subspecialties, though few patients went directly to a procedure. These findings may have operational implications in optimizing availability of specialty services across regionalized health systems.

Influence of Hospital Type on Outcomes of Patients With Acute Spontaneous Intracerebral Hemorrhage: A Population-Based Study.

Whether the outcome of patients with spontaneous intracerebral hemorrhage (ICH) differs depending on the type of hospital where they are admitted is uncertain. The objective of this study was to determine influence of hospital type at admission (telestroke center [TSC], primary stroke center [PSC], or comprehensive stroke center [CSC]) on outcome for patients with ICH. We hypothesized that outcomes may be better for patients admitted to a CSC. This is a multicenter prospective observational and population-based study of a cohort of consecutively recruited patients with ICH (March 2020-March 2022). We included all patients with spontaneous ICH in Catalonia (Spain) who had a pre-ICH modified Rankin scale (mRS) score of 0-3 and who were admitted to the hospital within 24 hours of onset. We compared patients admitted to a TSC/PSC (n = 641) or a CSC (n = 1,320) and also analyzed the subgroup of patients transferred (n = 331) or not transferred (n = 310) from a TSC/PSC to a CSC. The main outcome was the 3-month mRS score obtained by blinded investigators. Outcomes were compared using adjusted ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI for a shift in mRS scores. A propensity score matching (PSM) analysis was performed for the subgroup of transferred patients. Relevant data were obtained from 1961 of a total of 2,230 patients, with the mean (SD) age of 70 (14.1) years, and 713 (38%) patients were women. After adjusting for confounders (age, NIH Stroke Scale score, intraventricular hemorrhage, hematoma volume, and pre-ICH mRS score), type of hospital of initial admission (CSC vs TSC/PSC) was not associated with outcome (adjusted common OR 1.13, 95% CI 0.93-1.38). A PSM analysis indicated that transfer to a CSC was not associated with more favorable outcomes (OR 0.77, 95% CI 0.55-1.10; p = 0.16). In this population-based study, we found that, after adjusting for confounders, hospital types were not associated with functional outcomes. In addition, for patients who were transferred from a TSC/PSC to a CSC, PSM indicated that outcomes were similar to nontransferred patients. Our findings suggest that patient characteristics are more important than hospital characteristics in determining outcome after ICH. ClinicalTrials.gov Identifier: NCT03956485.

The Impact of Hospital Transfers on Surgical Delay and Associated Postoperative Outcomes for Hip Fracture Patients in Scotland: A Cohort Study.

Background/Objectives: Hip fractures exert a substantial burden on hospital systems. Within Scotland 20% of the population resides rurally, warranting investigation of how this impacts prompt access to surgical care. This study aims to determine whether indirect hospital admission via hospital transfer affects the likelihood of surgical management within 36 h for hip fracture patients. Methods: A retrospective cohort study was performed. This used Scottish Hip Fracture Audit data including patients aged ≥50 split into two propensity matched groups based on their transfer status. Descriptive analysis compared patient characteristics. Regression assessed achieving surgery within 36 h of admission in the unmatched and matched cohorts. Secondary outcomes included time to surgery, mortality, mobilization, returning to residence and length of stay. A sensitivity analysis was undertaken to assess for residual confounding effects. Results: The unmatched analysis included 20,132 patients. Transfer patients were younger (p = 0.007) and less-comorbid (p < 0.001). In the matched population, 711 (63.6%) transfer patients had surgery with 36 h of presentation to hospital, compared to 852 (75.3%) non-transfer patients. Transfer patients had 43% reduced odds of timely surgery (OR (95% CI) 0.57 (0.48 to 0.69); p < 0.001). No disparities emerged in mortality, mobilisation or returning to residence., Transfer patients experienced a significant increase in length of stay in hospital (median (IQR) 16 (8 to 33) vs. 13 (8 to 30); p = 0.024). Conclusions: Hospital transfer is associated with significantly reduced odds of timely surgery, a longer time to surgery and longer length of stay. Development of structured network pathways that minimize delay to transfer are required to potentially optimize outcomes and reduce associated cost.

A POCUS-first pathway to streamline care for children with suspected ileocolic intussusception.

As point-of-care ultrasound (POCUS) has emerged as a valuable tool for intussusception screening, this quality improvement study aimed to implement a "POCUS-first" pathway in a Pediatric Emergency Department (ED) to streamline workflow and expedite care for children with suspected intussusception. This was a prospective analysis of children diagnosed with ileocolic intussusception in a Pediatric ED between June 2022 and June 2023. The study compared the "POCUS-first" cohort with the group receiving only radiology-performed ultrasound. Key outcomes included physician initial assessment to radiology-performed US time and physician initial assessment to reduction time. Continuous improvement efforts incorporated pediatric emergency medicine physician training, education, and pathway dissemination through plan-do-study-act cycles. The study included 29 patients in the "POCUS-first" pathway group and 70 patients in the non-POCUS group. The "POCUS-first" pathway demonstrated a significantly shorter physician initial assessment to reduction time compared to the non-POCUS group (170.7min vs. 240.6min, p = 0.02). Among non-transferred patients, the "POCUS-first" group also had a significantly shorter emergency department length of stay (386min vs. 544min, p = 0.047). Implementation of a "POCUS-first" pathway for managing ileocolic intussusception led to notable improvements in process efficiency. The shorter physician initial assessment to reduction time highlights the potential for expedited decision-making and intervention. These study findings support the potential of this pathway to optimize the management and outcomes of children with ileocolic intussusception.

Period of hospitalization and mortality in transferred versus non-transferred COVID-19 patients: results from Germany

COVID-19 was a challenge for health-care systems worldwide, causing large numbers of hospitalizations and inter-hospital transfers. We studied whether transfer, as well as its reason, was associated with the duration of hospitalization in non-ICU and ICU patients. For this purpose, all patients hospitalized due to COVID-19 between August 1st and December 31st, 2021, in a network of hospitals in Southern Germany were comprehensively characterized regarding their clinical course, therapy, complications, transfers, reasons for transfer, involved levels of care, total period of hospitalization and in-hospital mortality, using univariate and multiple regression analyses. While mortality was not significantly associated with transfer, the period of hospitalization was. In non-ICU patients (n = 545), median (quartiles) time was 7.0 (4.0–11.0) in non-transferred (n = 458) and 18.0 (11.0–29.0) days in transferred (n = 87) patients (p < 0.001). In ICU patients (n = 100 transferred, n = 115 non-transferred) it was 12.0 (8.3–18.0) and 22.0 (15.0–34.0) days (p < 0.001). Beyond ECMO therapy (4.5%), reasons for transfer were medical (33.2%) or capacity (61.9%) reasons, with medical/capacity reasons in 32/49 of non-ICU and 21/74 of ICU patients. Thus, the transfer of COVID-19 patients between hospitals was associated with longer periods of hospitalization, corresponding to greater health care utilization, for which specific patient characteristics and clinical decisions played a role.

Unit-to-unit transfer due to shortage of intensive care beds in Sweden 2015–2019 was associated with a lower risk of death but a longer intensive care stay compared to no transfer: a registry study

BackgroundIntensive care unit-to-unit transfer due to temporary shortage of beds is increasing in Sweden. Transportation induces practical hazards, and the change of health care provider may prolong the length of stay in intensive care. We previously showed that the risk of death at 90 days did not differ between patients transferred due to a shortage of beds and non-transferred patients with a similar burden of illness in a tertiary intensive care unit. The aim of this study was to widen the analysis to a nation-wide cohort of critically ill patients transferred to another intensive care unit in Sweden due to shortage of intensive care beds.MethodsRetrospective comparison between capacity transferred and non-transferred patients, based on data from the Swedish Intensive Care Registry during a 5-year period before the COVID-19 pandemic. Patients with insufficient data entries or a recurring capacity transfer within 90 days were excluded. To assess the association between capacity transfer and death as well as intensive care stay within 90 days after ICU admission, logistic regression models with step-wise adjustment for SAPS3 score, primary ICD-10 ICU diagnosis and the number of days in the intensive care unit before transfer were applied.ResultsFrom 161,140 eligible intensive care admissions, 2912 capacity transfers were compared to 135,641 discharges or deaths in the intensive care unit. Ninety days after ICU admission, 28% of transferred and 21% of non-transferred patients were deceased. In the fully adjusted model, capacity transfer was associated with a lower risk of death within 90 days than no transfer; OR (95% CI) 0.71 (0.65–0.69) and the number of days spent in intensive care was longer: 12.4 [95% CI 12.2–12.5] vs 3.3 [3.3–3.3].ConclusionsIntensive care unit-to-unit transfer due to shortage of bed capacity as compared to no transfer during a 5-year period preceding the COVID-19 pandemic in Sweden was associated with lower risk of death within 90 days but with longer stay in intensive care.

Abstract WP126: Improved Stroke Outcomes Following Implementation of RapidAI Platform at Ascension-Illinois

Introduction: The rapid advancement of artificial intelligence (AI) technologies holds promise for improving healthcare outcomes. RapidAI is a software solution that utilizes AI to rapidly analyze imaging data to identify vascular occlusions and salvageable tissue. Physicians receive notifications and can review source images on the Rapid mobile app (RMA). Methods: Data for this study were obtained from the Get with the Guidelines Stroke database. The study focused on adult patients (18 years or older) admitted to Alexian Brothers Medical Center in Illinois between 2019-2022 who were diagnosed with acute ischemic stroke. Primary outcomes were the number of AIS patients treated with thrombolysis (IV tPA or IV TNK) and/or mechanical thrombectomy (MT) and time to treatment. Door to MT puncture times for transfer patients were analyzed separately from direct presentation patients. Discharge Modified Rankin score (mRS) was assessed as a secondary clinical outcome. Results: This analysis included 1,732 patients, 1,193 prior to installation of the RapidAI platform and 539 after installation of Rapid CTP, CTA, ASPECTS, LVO and RMA. Median door to femoral puncture time for MT cases decreased from 2 hr 28 min to 1 hr 58 min (p=0.012) post-Rapid for non-transfer patients. Door to femoral puncture times for transfer patients were unchanged. MT procedure volume increased from 9.6% to 14.5% (p=0.007). IV tPA/TNK volume and door-to-needle (DTN) times were unchanged; 15% treated with tPA/TNK pre-Rapid and 14% post-Rapid, DTN 48 vs 47 min. There was an improvement in the distribution of discharge mRS scores in post-Rapid patients (p&lt;0.0001). Discussion: Following implementation of the AI software platform there was a significant increase in patients treated with MT, faster door to MT times for non-transfer patients, and improved discharge mRS scores. These data support future studies expanding the use of AI technology to improve stroke outcomes.

Perforated peptic ulcer disease in transferred patients is associated with significant increase in length of stay.

Perforated peptic ulcer disease (PPUD) has a prevalence of 0.004-0.014% with mortality of 23.5% (Tarasconi et al. in World J Emerg Surg 15(PG-3):3, 2020). In this single center study, we examined the impact associated with patient transfer from outside facilities to our center for definitive surgical intervention (exploratory laparotomy). Using EPIC report workbench, we identified 27 patients between 2018 and 2021 undergoing exploratory laparotomy with a concurrent diagnosis of peptic ulcer disease, nine of which were transferred to our institution for care. We queried this population for markers of disease severity including mortality, length of stay, intensive care unit (ICU) length of stay, and readmission rates. Manual chart reviews were performed to examine these outcomes in more detail and identify patients who had been transferred to our facility for surgery from an outside hospital. A total of 27 patients were identified undergoing exploratory laparotomy for definitive treatment of PPUD. The majority of patients queried underwent level A operations, the most urgent level of activation. In our institution, a Level A operation needs to go to the operating room within one hour of arrival to the hospital. Average mortality for this patient population was 14.8%. The readmission rate was 40.1%, and average length of ICU stay post-operatively was 16days, with 83% of non-transfer patients requiring ICU admission and 100% of transfer patients requiring ICU admission, although this was not found to be statistically significant. Average length of hospital stay was 27days overall. For non-transfer patients and transfer patients, LOS was 20days and 41days, respectively, which was statistically significant by one-sided t-test (p = 0.05). Patients transferred for definitive care of PPUD in a population otherwise notable for high mortality and high readmission rates: their average length of stay compared to non-transfer patients was over twice the length, which was statistically significant. Transferred patients also had higher rates of ICU care requirement although this was not statistically significant. Further inquiry to identify modifiable variables to facilitate the care of transferred patients is warranted, especially in the context of improving quality metrics known to enhance patient outcomes, satisfaction, and value.

Inter-Hospital Transfer Is an Independent Risk Factor for Hospital-Associated Infection.

Background: Regionalization of surgical care shifts higher acuity patients to larger centers. Hospital-associated infections (HAIs) are important quality measures with financial implications. In our ongoing efforts to eliminate HAIs, we examined the potential role for inter-hospital transfer in our cases of HAI across a multihospital system. Hypothesis: Surgical patients transferred to a regional multihospital system have a higher risk of National Healthcare Safety Network (NHSN)-labeled HAIs. Patients and Methods: The analysis cohort of adult surgical inpatients was filtered from a five-hospital health system administration registry containing encounters from 2014 to 2021. The dataset contained demographics, health characteristics, and acuity variables, along with the NHSN defined HAIs of central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI). Univariable and multivariable statistics were performed. Results: The surgical cohort identified 92,832 patients of whom 3,232 (3.5%) were transfers. The overall HAI rate was 0.6% (528): 86 (0.09%) CLABSI, 133 (0.14%) CAUTI, and 325 (0.35%) CDI. Across the three HAIs, the rate was higher in transfer patients compared with non-transfer patients (CLABSI: n = 18 (1.3%); odds ratio [OR], 4.79; CAUTI: n = 25 (1.8%); OR, 4.20; CDI: n = 37 (1.1%); OR, 3.59); p < 0.001 for all. Multivariable analysis found transfer patients had an increased rate of HAIs (OR, 1.56; p < 0.001). Conclusions: There is an increased risk-adjusted rate of HAIs in transferred surgical patients as reflected in the NHSN metrics. This phenomenon places a burden on regional centers that accept high-risk surgical transfers, in part because of the downstream effects of healthcare reimbursement programs.

Abstract 14181: Interhospital Transfer for Heart Failure in the United States: A Patient and Hospital-Level Analysis From GWTG-HF

Background: Cardiovascular diseases, particularly heart failure (HF), are common reasons for interhospital transfer (IHT) in the United States. IHT targets patients requiring a higher level of care, and has been associated with increased cost, length of stay (LOS), and mortality. We aim to describe the characteristics and outcomes of patients undergoing IHT, as well as variation in the use of IHT across hospitals. Methods: Patients hospitalized for HF who were admitted from another hospital were compared to those who were not within the Get With The Guidelines-Heart Failure registry between January 2015 and June 2022. Hospital characteristics were obtained from the 2018 American Hospital Association Survey. Clinical data from the receiving hospital were analyzed. Results: Overall, 662,575 patients across 622 hospitals (156,263 patients at 127 transplant centers; 19,852 patients at 55 rural sites) were included, of which 36,375 (5.5%) arrived as IHT. IHT patients were younger (70.0 vs 73.0 years), more male (58 vs 52%), white (72 vs 66%), and more often had private insurance (31% vs 27%). IHT patients had a lower median left ventricular ejection fraction (37 vs 45%), median blood pressure (130/74 vs 139/77 mmHg), and a longer mean LOS (6.3 vs 5.0 days). In a multivariable model, IHT patients had higher in-hospital mortality (OR 1.85, 95% CI 1.76-1.95), were less likely to discharge home (OR 0.79, 95% CI 0.77-0.81), and were more likely to be prescribed most guideline-directed therapies (Figure). Conclusions: More than 1 in 20 patients hospitalized for HF was transferred from another hospital. Sex, racial, economic, and geographic differences exist in which HF patients get transferred, and rates of IHT varied across hospitals. IHT was associated with higher mortality and longer LOS compared with non-transferred patients.

Abstract 13320: Age-Based Trends in Improvement in Door-to-Balloon Time Over 15 Years

Background: In April 2004, an in-house 24x7 interventional cardiology program was implemented at our center to improve door-to-balloon time (D2BT) in ST-segment elevation myocardial infarction (STEMI). Data on our program published in 2010 showed improved D2BT along with improvement in major adverse cardiovascular events and mortality. Hypothesis: We hypothesized that the median D2BT has further improved over time in both elderly and young patients. Aims: The primary objective was to evaluate aged-based yearly trends in median D2BT in patients with STEMI since the implementation of the 24x7 program. Methods: We collected data on all non-transfer adult patients with STEMI at our center from April 1, 2004, to March 31, 2019. Median two-sample test was used to compare medians. Results: A total of 1,889 patients with STEMI (median age [IQR] of 61 [54-71] years, 31% female) were evaluated. Of these, 221 (11.7%) were aged ≥80 years and 1,668 (88.3%) were aged &lt;80 years. Females made up 60% of the elderly group and 27% in the younger group. In the overall cohort, the median D2BT in patients aged &gt;80 years was significantly higher than in the younger group (54 min vs. 49 min, P = 0.004). Temporal trends in the median D2BT are shown in the figure. There was a decreasing trend in median D2BT in both age groups, but D2BT remained longer for the older patients compared with the young for most of the study period. In patients aged &lt;80 years, the median D2BT decreased from 68 minutes in 2004 to 45 minutes in 2019 (P trend &lt; .001), and in patients aged ≥80 years, the median D2BT decreased from 81 minutes in 2004 to 68 minutes in 2019 (P trend = .016). Conclusion: Even though the national averages are beaten by our 24x7 program, D2BT remains higher in the elderly cohort. This is likely due to atypical presentation in elderly females, complexity of the decision-making process in the elderly, and frailty of elderly patients on presentation.

Abstract 13867: Sustained Improvement in Door-to-Balloon Time Over 15 Years: The Aurora St. Luke’s 24x7 STEMI Program With Redefinition of Contemporary Door-to-Balloon Time Less Than 60 Minutes: 60 is the New 90

Background: In April 2004, Aurora St. Luke’s Medical Center implemented an in-house 24x7 interventional cardiology program to improve door-to-balloon time (D2BT) in ST-segment elevation myocardial infarction (STEMI). Previously published data showed a significant reduction in median D2BT, from 98 minutes (January 1, 2002-March 31, 2004) to 55 minutes (April 1, 2004-June 30, 2008), along with a reduction in major adverse cardiovascular events (MACE) and mortality after implementation of the program. Hypothesis: We hypothesized that the continued experience with the 24x7 program would demonstrate further gain in STEMI outcomes in regard to D2BT. Aims: The primary objective was to evaluate the overall median D2BT over a 15-year period. The secondary objectives were to evaluate median D2BT stratified by weekdays and weekends, on- and off-hours, the proportion of D2BT &lt;90 minutes, and the proportion of D2BT &lt;60 minutes over time. Methods: We collected data on all non-transfer adult patients with STEMI from April 1, 2004, to March 31, 2019, at our center. On-hours were from 7:30 a.m. to 5 p.m. and off-hours from 5 p.m. to 7:30 a.m. Results: A total of 1889 patients with STEMI (median age [IQR] 61 [54-71] years, 31% female) were evaluated. Over 15 years, median D2BT decreased from 69 minutes to 46 minutes (P &lt; .001; Fig 1A). The decreasing trend was seen on weekdays and weekends (Fig 1B) and on-hours and off-hours. The percentage of cases with a median D2BT &lt;90 minutes increased from 77% to 97% over 15 years, and those with a median D2BT &lt;60 minutes increased from 36% to 76% (Fig 1B). Conclusion: We show sustained improvement in our median D2BT and remarkable improvement in the proportion of D2BT &lt;60 minutes. This paves the way for redefining the contemporary D2BT from &lt;90 to &lt;60 minutes.

Outcomes of Patients Transferred to Tertiary Care Centers for Treatment of Cardiogenic Shock: A Cardiogenic Shock Working Group Analysis

BackgroundConsensus recommendations for cardiogenic shock (CS) advise transfer of patients in need of advanced options beyond the capability of ‘spoke’ centers to tertiary/ ‘hub’ centers with higher capabilities. However, outcomes associated with such transfers are largely unknown, beyond those reported in individual health networks. ObjectivesTo analyze a contemporary, multicenter CS cohort with an aim to compare characteristics and outcomes of patients between transfer (between spoke and hub center) and non-transfer cohorts (those primarily admitted to a hub center), for both acute myocardial infarction (AMI-CS) and heart failure related (HF-CS) shock. We also aim to identify clinical characteristics of the transfer cohort that are associated with in-hospital mortality. MethodsThe Cardiogenic Shock Working Group (CSWG) registry is a national, multicenter, prospective registry including high volume (mostly hub) CS centers. Fifteen U.S. sites contributed data for this analysis from 2016–2020. ResultsOf 1890 consecutive CS patients enrolled into the CSWG registry, 1028 (54.4%) patients were transferred. Of these, 528 (58.1%) had heart failure related CS (HF-CS) and 381 (41.9%) had CS related to acute myocardial infarction (AMI-CS). Upon arrival to the CSWG site, transfer patients were more likely to be in SCAI stage C and D, when compared to non-transfer patients. Transfer patients had higher mortality (37% vs. 29%, <0.001) than non-transfer patients with the differences primarily driven by the HF-CS cohort. Logistic regression identified increasing age, mechanical ventilation, renal replacement therapy, and higher number of vasoactive drugs prior to, or within 24 hours after CSWG site transfer as independent predictors of mortality among HF-CS patients. Conversely, pulmonary artery catheter use prior to transfer, or within 24 hours of arrival was associated with decreased mortality. Among transfer AMI-CS patients BMI>28 kg/m2, worsening renal failure, lactate>3 mg/dl and increasing number of vasoactive drugs were associated with increased mortality. ConclusionMore than half of CS patients managed at high volume CS centers were transferred from another hospital. Although transfer patients had higher mortality than those who were primarily admitted to hub centers, outcomes and their predictors varied significantly when classified by HF-CS versus AMI-CS.

THU238 Experience In Transition From Pediatric To Adult Care In Chronic Endocrinological Pathology

Abstract Disclosure: S. Tormo: None. M.S. Kastelic: None. M.V. Forclaz: None. S.A. Varela: None. E. Giacoia: None. Introduction: Advances in medicine in recent decades have increased the survival of pediatric patients with complex chronic pathologies who reach adulthood. Transition refers to the process followed by young persons with chronic conditions to transfer health care, in our case from the pediatric endocrinologist to the adult endocrinologist. It is a dynamic, complex process and must be planned considering medical, psychosocial and educational needs of the adolescent in the change of care that implies an increase in autonomy. ObjectivesPrimary: describe the demographic characteristics of the population that attended the transitional endocrinology clinic. Secondary: evaluate the result of the TRAQ.5.0 survey (Transition readiness assessment questionnaire) in this population. Material and methods Design: observational, cross-sectional and analytical study. The medical records of 155 patients over 15 years old in follow-up for chronic endocrinological diseases in the transition clinic from November 2018 to August 2022, were analyzed. The patients underwent the TRAQ questionnaire validated in Argentina. Statistical Analysis: Quantitative variables are presented with medians and range and qualitative variables with absolute and relative frequencies. The comparisons between the subgroups were made through the Mann Whitney test, considering a p value &amp;lt;0.05 as statistically significant. Results: 155 patients with a median age of 20 years (r:15-30 years) were included. Most were women (61%). 75 % were derived from pediatrics at our hospital. 81% of them attended accompanied. 98% of the patients completed the Questionnaire (TRAQ). No statistically significant changes were found in the TRAQ score according to sex, age and whether the patients were accompanied or not. 79.8 % of the patients stated that they were studying at the time of follow-up, 11% of patients work. 15% (24 patients) were transferred to adult clinics, of which 87% continue follow-up. 80% of non-transferred patients continue follow up. When comparing the TRAQ questionnaire between the transferred patients and those who continue in follow-up, we found significant differences in medication management with a median of 3.6 in the referred group and 3.1 in the follow-up group p: &amp;lt;0.03, and appointment attendance: with a median of 3 in the referred group, 2.3 in the follow-up group (p &amp;lt; 0.01) Conclusions: The goal of the transition is to reduce loss of follow-up and improve the quality of life of patients through an orderly process. We highlight the usefulness of certain tools, such as the TRAQ questionnaire to assess the preparation of patients for the transition. Presentation: Thursday, June 15, 2023

Adherence to the transfer recommendations of the German Trauma Society in severely injured children: a retrospective study from the TraumaRegister DGU

Particularly for pediatric trauma patients, it is of utmost importance that the right patient be treated in the right place at the right time. While unnecessary interhospital transfers must be avoided, the decision against transfer should not lead to higher complication rates in trauma centers without added pediatric qualifications. We therefore identified independent predictive factors for an early transfer of severely injured patients and compared these factors with the current transfer recommendations of the German Trauma Society. Additionally, the quality of the self-assessment based on the mortality of children who were not transferred was evaluated. A national dataset from the TraumaRegister DGU® was used to retrospectively identify factors for an early interhospital transfer (< 48 h) to a superordinate trauma center. Severely injured pediatric patients (age < 16 years) admitted between 2010 and 2019 were included in this analysis. Adjusted odds ratios (OR) with 95% confidence intervals (CI) for early transfer were calculated from a multivariable model. Prognostic factors for hospital mortality in non-transferred patients were also analyzed. In total, 6069 severely injured children were included. Of these, 65.2% were admitted to a Level I trauma center, whereas 27.7% and 7.1% were admitted to Level II and III centers, respectively. After the initial evaluation in the emergency department, 25.5% and 50.1% of children primarily admitted to a Level II or III trauma center, respectively, were transferred early. Statistically significant predictors of an early transfer were: Serious traumatic brain injury (OR 1.76, 95% CI 1.28–2.43), Injury severity score (ISS) ≥ 16 points (ISS 16–24: OR 2.06, 95% CI 1.59–2.66; ISS 25–33: OR 3.0, 95% CI 2.08–4.31; ISS 34–75: OR 5.42, 95% CI 3.0–9.81, reference category: ISS 9–15), age < 10 years (age 0–1: OR 1.91, 95% CI 1.34–2.71; age 2–5: 2.04, 95% CI 1.50–2.78; age 6–9: 1.62, 95% CI 1.23–2.14; reference category: age 10–15). The most important independent factor for mortality in non-transferred patients was age < 10 years (age 0–1: 5.35, 95% CI 3.25–8.81; age 2–5: 2.46, 95% CI 1.50–4.04; age 6–9: OR 1.7, 95% CI 1.05–2.75; reference category: age 10–15). Knowing the independent predictors for an early transfer, such as a young patient's age, a high injury severity, serious traumatic brain injury (TBI), may improve the choice of the appropriate trauma center. This may guide the rapid decision for an early interhospital transfer. There is still a lack of outcome data on children with early interhospital transfers in Germany, who are the most vulnerable group.

Increased Mortality in Patients Transferred to a Level 1 Trauma Center With Blunt and Penetrating Extremity Vascular Injuries: A 10-year Analysis

Trauma centers serve a uniquely vulnerable population. These patients depend on a complex transfer system to ensure timely and adequate care at major trauma centers. Patient outcomes depend on the reliability of their management between a local or community hospital and a tertiary or quaternary trauma institution. Patients with polytrauma, extremity trauma, and vascular injuries require multidisciplinary management at a trauma hospital. Our study investigates outcomes in this population at a level one trauma center covering the largest geographic county in the contiguous United States. A retrospective review of all extremity trauma patients that presented to a high-capacity level 1 trauma center over 10 years was collected. This cohort was divided into two groups: (1) transferred from another medical center for higher level of care; or (2) those who presented directly. Overall, 19,417 patients were identified, with 15,317 that presented directly and 3830 patients transferred from an outside hospital. Vascular injuries were seen in 268 patients. Demographic data was ascertained which included injury severity score (ISS), mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality. A total of 268 vascular injury patients were analyzed, with 207 non-transferred and 61 transferred patients. In the univariate analysis, ISS was an average 11.4 in non-transferred patients vs 8.4 in transferred (P < .001), 50% of blunt injury in the non-transferred group and 28% in the transferred group (P < .001), in-hospital mortality was 4% in non-transferred patients vs 28% in the transferred group (P < .001). A multivariate logistic regression demonstrated mortality is eight times more likely if a patient with vascular extremity injuries was transferred (Table). A 10% mortality rate was seen in patients without blood transfusion within 4 hours of arrival to the trauma center (compared with 3% mortality in transferred patients transfused blood). Extremity trauma with vascular injuries can be lethal if not triaged appropriately. Transferred patients to our level 1 trauma center had a substantial increase in mortality compared with non-transferred patients. Blood transfusion within the first 4 hours of arrival to the trauma center was associated with better survival. More research efforts are needed to treat this vulnerable patient population.TableBinary logistic regression with mortality and transfer status as dependent variablesCharacteristicClinical variables of mortality in vascular patients (binary logistic regression analysis)aClinical variables of transfer status in vascular patients (binary logistic regression analysis)aOdds ratio (n = 266)95% Confidence intervalPaOdds ratio (n = 266)95% Confidence intervalPaAge1.0150.985-1.046.3270.9890.969-1.009.284Injury Severity Score0.9850.906-1.070.7190.9650.912-1.021.220Location of injury (upper and lower extremity)0.3940.095-1.640.2012.6921.058-6.484.038Injury type5.0211.338-18.845.0171.9830.984-3.997.056Response level0.7860.476-1.295.3441.3540.962-1.907.082Transfer status7.9012.933-21.286.001–––Mortality–––8.2543.115-21.868.001Packed red blood cells (1st 4 hours) (%)0.5340.061-4.654.5700.0750.009-0.623.016aTotal cases analyzed = 268. Open table in a new tab