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McDougall G, Loubani O. Interfacility transfer of the critically ill: Transfer status does not influence survival. J Crit Care 2024; 82:154813. [PMID: 38636357 DOI: 10.1016/j.jcrc.2024.154813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE To estimate differences in case-mix adjusted hospital mortality between adult ICU patients who are transferred during their ICU-stay and those who are not. METHODS 19,260 visits to 12 ICUs in Nova Scotia (NS), Canada April 2018-September 2023 were analyzed. Data were obtained from the NS Provincial ICU database. Generalized additive models (GAMs) were used to estimate differences in case-mix adjusted hospital mortality between patients who underwent transfer and those who did not. RESULTS 1040/19,260 (5%) ICU visits involved interfacility-transfer. No difference in hospital mortality was identified between transferred and non-transferred patients by GAM (OR, 0.99, 95% CI, 0.82 to 1.19; p = 0.91). No mortality difference was observed between patients undergoing a single transfer versus multiple (OR, 0.87; 95% CI, 0.45 to -1.69; p = 0.68). A GAM including the categories no transfer, one transfer, and multiple transfers identified a difference in hospital mortality for patients that underwent multiple transfers compared to non-transferred patients (OR, 0.68; 95% CI, 0.46 to 1.00, p = 0.05), but no difference was identified in a post-hoc matched cohort sensitivity analysis (OR, 0.68; 95% CI, 0.46 to 1.01, p = 0.05). CONCLUSION The transfer of critically ill patients between ICUs in Nova Scotia did not impact case-mix adjusted hospital mortality.
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Affiliation(s)
- Garrett McDougall
- Department of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Osama Loubani
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada.
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Naar L, Hechi MWE, Gallastegi AD, Renne BC, Fawley J, Parks JJ, Mendoza AE, Saillant NN, Velmahos GC, Kaafarani HMA, Lee J. Intensive Care Unit Volume of Sepsis Patients Does Not Affect Mortality: Results of a Nationwide Retrospective Analysis. J Intensive Care Med 2022; 37:728-735. [PMID: 34231406 DOI: 10.1177/08850666211024184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is little research evaluating outcomes from sepsis in intensive care units (ICUs) with lower sepsis patient volumes as compared to ICUs with higher sepsis patient volumes. Our objective was to compare the outcomes of septic patients admitted to ICUs with different sepsis patient volumes. MATERIALS AND METHODS We included all patients from the eICU-CRD database admitted for the management of sepsis with blood lactate ≥ 2mmol/L within 24 hours of admission. Our primary outcome was ICU mortality. Secondary outcomes included hospital mortality, 30-day ventilator free days, and initiation of renal replacement therapy (RRT). ICUs were grouped in quartiles based on the number of septic patients treated at each unit. RESULTS 10,716 patients were included in our analysis; 272 (2.5%) in low sepsis volume ICUs, 1,078 (10.1%) in medium-low sepsis volume ICUs, 2,608 (24.3%) in medium-high sepsis volume ICUs, and 6,758 (63.1%) in high sepsis volume ICUs. On multivariable analyses, no significant differences were documented regarding ICU and hospital mortality, and ventilator days in patients treated in lower versus higher sepsis volume ICUs. Patients treated at lower sepsis volume ICUs had lower rates of RRT initiation as compared to high volume units (medium-high vs. high: OR = 0.78, 95%CI = 0.66-0.91, P-value = 0.002 and medium-low vs. high: OR = 0.57, 95%CI = 0.44-0.73, P-value < 0.001). CONCLUSION The previously described volume-outcome association in septic patients was not identified in an intensive care setting.
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Affiliation(s)
- Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Majed W El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - B Christian Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jarone Lee
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Patel P, Rotundo L, Orosz E, Afridi F, Pyrsopoulos N. Hospital teaching status on the outcomes of patients with esophageal variceal bleeding in the United States. World J Hepatol 2020; 12:288-297. [PMID: 32742571 PMCID: PMC7364324 DOI: 10.4254/wjh.v12.i6.288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/10/2020] [Accepted: 05/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute variceal bleeding is a major complication of portal hypertension and is a leading cause of death in patients with cirrhosis. There is limited data on the outcomes of patients with esophageal variceal bleeding in teaching versus nonteaching hospitals. Because esophageal variceal bleeding requires complex management, it may be hypothesized that teaching hospitals have lower mortality. AIM To assess the differences in mortality, hospital length of stay (LOS) and cost of admission for patients admitted for variceal bleed in teaching versus nonteaching hospitals across the US. METHODS The National Inpatient Sample is the largest all-payer inpatient database consisting of approximately 20% of all inpatient admissions to nonfederal hospitals in the United States. We collected data from the years 2008 to 2014. Cases of variceal bleeding were identified using the International Classification of Diseases, Ninth Edition, Clinical Modification codes. Differences in mortality, LOS and cost were evaluated for patients with esophageal variceal bleed between teaching and nonteaching hospitals and adjusted for patient characteristics and comorbidities. RESULTS Between 2008 and 2014, there were 58362 cases of esophageal variceal bleeding identified. Compared with teaching hospitals, mortality was lower in non-teaching hospitals (8.0% vs 5.3%, P < 0.001). Median LOS was shorter in nonteaching hospitals as compared to teaching hospitals (4 d vs 5 d, P < 0.001). A higher proportion of non-white patients were managed in teaching hospitals. As far as procedures in nonteaching vs teaching hospitals, portosystemic shunt insertion (3.1% vs 6.9%, P < 0.001) and balloon tamponade (0.6% vs 1.2%) were done more often in teaching hospitals while blood transfusions (64.2% vs 59.9%, P = 0.001) were given more in nonteaching hospitals. Using binary logistic regression models and adjusting for baseline patient demographics and comorbid conditions the mortality, LOS and cost in teaching hospitals remained higher. CONCLUSION In patients admitted for esophageal variceal bleeding, mortality, length of stay and cost were higher in teaching hospitals versus nonteaching hospitals when controlling for other confounding factors.
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Affiliation(s)
- Pavan Patel
- Division of Gastroenterology and Hepatology, Rutgers - New Jersey Medical School, Newark, NJ 07101-1709, United States
| | - Laura Rotundo
- Department of Medicine, Rutgers - New Jersey Medical School, Newark, NJ 07101-1709, United States
| | - Evan Orosz
- Department of Medicine, Rutgers - New Jersey Medical School, Newark, NJ 07101-1709, United States
| | - Faiz Afridi
- Division of Gastroenterology and Hepatology, Rutgers - New Jersey Medical School, Newark, NJ 07101-1709, United States
| | - Nikolaos Pyrsopoulos
- Division of Gastroenterology and Hepatology, Rutgers - New Jersey Medical School, Newark, NJ 07101-1709, United States.
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Dunn H, Quinn L, Corbridge S, Kapella M, Eldeirawi K, Steffen A, Collins E. A latent class analysis of prolonged mechanical ventilation patients at a long-term acute care hospital: Subtype differences in clinical outcomes. Heart Lung 2019; 48:215-221. [PMID: 30655004 PMCID: PMC6874913 DOI: 10.1016/j.hrtlng.2019.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 12/29/2018] [Accepted: 01/02/2019] [Indexed: 01/15/2023]
Abstract
RATIONALE Patients on prolonged mechanical ventilation (PMV) at Long-Term Acute Care Hospital's (LTACHs) are clinically heterogeneous making it difficult to manage care and predict clinical outcomes. OBJECTIVES Identify and describe subgroups of patients on PMV at LTACHs and examine for group differences. METHODS Latent class analysis was completed on data obtained during medical record review at Midwestern LTACH. MAIN RESULTS A three-class solution was identified. Class 1 contained young, obese patients with low clinical and co-morbid burden; Class 2 contained the oldest patients with low clinical burden but multiple co-morbid conditions; Class 3 contained patients with multiple clinical and co-morbid burdens. There were no differences in LTACH length of stay [F(2,246) = 2.243, p = 0.108] or number of ventilator days [F(2,246) = 0.641, p = 0.528]. Class 3 patients were less likely to wean from mechanical ventilation [χ2(2, N = 249) = 25.48, p < 0.001] and more likely to die [χ2(2, N = 249) = 23.68, p < 0.001]. CONCLUSION Patient subgroups can be described that predict clinical outcomes. Class 3 patients are at higher risk for poor clinical outcomes when compared to patients in Class 1 or Class 2.
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Affiliation(s)
- Heather Dunn
- The University of Iowa College of Nursing, United States.
| | - Laurie Quinn
- University of Illinois at Chicago College of Nursing, United States
| | - Susan Corbridge
- University of Illinois at Chicago College of Nursing, United States
| | - Mary Kapella
- University of Illinois at Chicago College of Nursing, United States
| | - Kamal Eldeirawi
- University of Illinois at Chicago College of Nursing, United States
| | - Alana Steffen
- University of Illinois at Chicago College of Nursing, United States
| | - Eileen Collins
- University of Illinois at Chicago College of Nursing, United States
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Simon EL, Shakya S, Liu L, Griffin G, Smalley CM, Podolsky S, Engineer R. Comparison of critically ill patients from three freestanding ED's compared to a tertiary care hospital based ED. Am J Emerg Med 2018; 37:1307-1312. [PMID: 30348469 DOI: 10.1016/j.ajem.2018.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 10/05/2018] [Accepted: 10/10/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Freestanding emergency departments (FEDs) care for all patients, including critically ill, 24/7/365. We characterized patients from three FEDs transferred to intensive care units (ICU) at a tertiary care hospital, and compared hospital length of stay(LOS) between patients admitted to ICUs from FEDs versus a hospital-based ED (HBED). METHODS We performed a retrospective, observational cohort study from January 2014 to December 2016. Demographic and clinical information was compared between FED and HBED patients with chi-square and fisher's exact tests for categorical variables and Student's t-test for continuous variables. The main outcome of interest was hospital LOS. Multi-variable linear regression was performed to estimate association between LOS and emergency facility type, while adjusting for potential confounders. RESULTS We included 500 critically ill patients (FED = 250 and HBED = 250). Patients did not differ by age, gender, or BMI. FED patients were more likely to be white (89.6% vs. 70.8%, p < 0.001) and have higher Charlson Co-morbidity Index scores (3.5 vs. 2.4, p < 0.001). Average LOS for FED patients was 5 days, compared to 7 days for HBED patients (p < 0.001). After adjusting for demographic and clinical confounders, there was significant correlation between ED facility type and LOS in hospital (p < 0.001). CONCLUSION Patients transferred from FEDs to an ICU were similar in age and gender, but more likely to be white with a higher Charlson Comorbidity Index score. FED patients experienced shorter hospital length of stay compared to patients admitted from a HBED.
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Affiliation(s)
- Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, United States.
| | - Sunita Shakya
- Cleveland Clinic Akron General, Department of Emergency Medicine, United States
| | - Louisa Liu
- Cleveland Clinic Akron General, Department of Emergency Medicine, United States
| | - Greg Griffin
- Cleveland Clinic Akron General, Department of Emergency Medicine, United States
| | - Courtney M Smalley
- Cleveland Clinic Emergency Services Institute, Department of Emergency Medicine, United States
| | - Seth Podolsky
- Cleveland Clinic Emergency Services Institute, Department of Emergency Medicine, United States
| | - Rakesh Engineer
- Cleveland Clinic Emergency Services Institute, Department of Emergency Medicine, United States
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Gutierrez C, Cárdenas YR, Bratcher K, Melancon J, Myers J, Campbell JY, Feng L, Price KJ, Nates JL. Out-of-Hospital ICU Transfers to an Oncological Referral Center: Characteristics, Resource Utilization, and Patient Outcomes. J Intensive Care Med 2016; 34:55-61. [PMID: 28030995 DOI: 10.1177/0885066616686536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE: To determine resource utilization and outcomes of out-of-hospital transfer patients admitted to the intensive care unit (ICU) of a cancer referral center. DESIGN: Single-center cohort. SETTING: A tertiary oncological center. PATIENTS: Patients older than 18 years transferred to our ICU from an outside hospital between January 2013 and December 2015. MEASUREMENTS AND MAIN RESULTS: A total of 2127 (90.3%) were emergency department (ED) ICU admissions and 228 (9.7%) out-of-hospital transfers. The ICU length of stay (LOS) was longer in the out-of-hospital transfers when compared to all other ED ICU admissions ( P = .001); however, ICU and hospital mortality were similar between both groups. The majority of patients were transferred for a higher level of care (77.2%); there was no difference in the amount of interventions performed, ICU LOS, and ICU mortality between nonhigher level-of-care and higher level-of-care patients. Factors associated with an ICU LOS ≥10days were a higher Sequential Organ Failure Assessment (SOFA) score, weekend admissions, presence of shock, need for mechanical ventilation, and acute kidney injury on admission or during ICU stay ( P < .008). The ICU mortality of transferred patients was 17.5% and associated risk factors were older age, higher SOFA score on admission, use of mechanical ventilation and vasopressors during ICU stay, and renal failure on admission ( P < .0001). Data related to the transfer such as LOS at the outside facility, time of transfer, delay in transfer, and longer distance traveled were not associated with increased LOS or mortality in our study. CONCLUSION: Organ failure severity on admission, and not transfer-related factors, continues to be the best predictor of outcomes of critically ill patients with cancer when transferred from other facilities to the ICU. Our data suggest that transferring critically ill patients with cancer to a specialized center does not lead to worse outcomes or increased resource utilization when compared to patients admitted from the ED.
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Affiliation(s)
- Cristina Gutierrez
- 1 Division of Anesthesia and Critical Care, Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yenny R Cárdenas
- 2 Critical Care Department, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Kristie Bratcher
- 1 Division of Anesthesia and Critical Care, Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Judd Melancon
- 1 Division of Anesthesia and Critical Care, Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason Myers
- 1 Division of Anesthesia and Critical Care, Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannee Y Campbell
- 1 Division of Anesthesia and Critical Care, Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lei Feng
- 3 Division of Quantitative Sciences, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston TX, USA
| | - Kristen J Price
- 1 Division of Anesthesia and Critical Care, Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph L Nates
- 1 Division of Anesthesia and Critical Care, Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Rishu AH, Aldawood AS, Haddad SH, Tamim HM, Al-Dorzi HM, Al-Jabbary A, Al-Shimemeri A, Sohail MR, Arabi YM. Demographics and outcomes of critically ill patients transferred from other hospitals to a tertiary care academic referral center in Saudi Arabia. Ann Intensive Care 2013; 3:26. [PMID: 23937989 PMCID: PMC3751539 DOI: 10.1186/2110-5820-3-26] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 07/18/2013] [Indexed: 12/12/2022] Open
Abstract
Background The objective of this study was to examine the outcomes of critically ill patients who were transferred from other hospitals to a tertiary care center in Saudi Arabia as a quality improvement project. Methods This was a retrospective study of adult patients admitted to the medical-surgical intensive care unit (ICU) of a tertiary care hospital. Patients were divided according to the source of referral into three groups: transfers from other hospitals, and direct admissions from emergency department (ED) and from hospital wards. Standardized mortality ratio (SMR) was calculated. Multivariate analysis was performed to determine the independent predictors of mortality. Results Of the 7,654 patients admitted to the ICU, 611 patients (8%) were transferred from other hospitals, 2,703 (35.3%) were direct admissions from ED and 4,340 (56.7%) from hospital wards. Hospital mortality for patients transferred from other hospitals was not significantly different from those who were directly admitted from ED (35% vs. 33.1%, p = 0.37) but was lower than those who were directly admitted from hospital wards (35% vs. 51.2%, p < 0.0001). SMRs did not differ significantly across the three groups. Conclusions Critically ill patients who were transferred from other hospitals constituted 8% of all ICU admissions. Mortality of these patients was similar to patients with direct admission from the ED and lower than that of patients with direct admission from hospital wards. However, risk-adjusted mortality was not different from the other two groups.
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Affiliation(s)
- Asgar H Rishu
- Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, PO Box 22490, Mail code 1425, Riyadh, 11426, Saudi Arabia.
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Association between out-of-hospital emergency department transfer and poor hospital outcome in critically ill stroke patients. J Crit Care 2011; 26:620-5. [DOI: 10.1016/j.jcrc.2011.02.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 02/16/2011] [Accepted: 02/20/2011] [Indexed: 11/22/2022]
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Gerber DR, Schorr C, Ahmed I, Dellinger RP, Parrillo J. Location of patients before transfer to a tertiary care intensive care unit: impact on outcome. J Crit Care 2008; 24:108-13. [PMID: 19272546 DOI: 10.1016/j.jcrc.2008.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 01/18/2008] [Accepted: 03/06/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the impact of the source of patients transferred to a tertiary care intensive care unit (ICU) (referring hospital ICU vs referring hospital emergency department [ED]) on outcomes of transferred patients. DESIGN AND SETTING We performed a retrospective review of data contained in the Project Impact database of a medical-surgical ICU at a university hospital. PATIENTS AND PARTICIPANTS A total of 503 patients transferred from local community hospitals, 283 from EDs and 220 from ICUs, were identified and included. In addition to comparing all ED transfers with all ICU transfers, comparisons between the 2 populations were made for the subgroups of patients with intracranial hemorrhage (group 1), nonhemorrhagic stroke (group 2), and all other patients (group 3). MEASUREMENTS AND RESULTS Patients were evaluated for a variety of outcome parameters, including mortality and ICU and hospital length of stay (LOS) according to their location at the referring hospital at the time of transfer: ICU (ICUtx) or ED (EDtx). Mortality was significantly lower among EDtx in all transferred patients as well as in groups 2 and 3 with no difference in mortality identified in group 1. Intensive care unit LOS was shorter for EDtx and the 3 groups, and hospital LOS was shorter among all EDtx and those in group 3. Group 3 EDtx also had lower than predicted mortality. CONCLUSIONS Transfer of patients to a tertiary care ICU from the ED of a referring hospital is associated with significantly better outcomes than transfers from referring hospital ICUs.
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Affiliation(s)
- David R Gerber
- Critical Care Medicine, Cooper University Hospital, Camden, NJ 08103, USA.
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Hill AD, Vingilis E, Martin CM, Hartford K, Speechley KN. Interhospital transfer of critically ill patients: demographic and outcomes comparison with nontransferred intensive care unit patients. J Crit Care 2008; 22:290-5. [PMID: 18086399 DOI: 10.1016/j.jcrc.2007.06.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Revised: 04/19/2007] [Accepted: 06/01/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE We examined the association between access to intensive care services and mortality in a cohort of critically ill patients. MATERIALS AND METHODS We conducted an observational study involving 6298 consecutive admissions to the intensive care units (ICUs) of a tertiary care hospital. Data including demographics, admission source, and outcomes were collected on all patients. Admission source was classified as "transfer" for patients admitted to the ICU from other hospitals, "ER" for patients admitted from the emergency room, and "ward" for patients admitted from non-ICU inpatient wards. RESULTS Transfer patients had higher crude ICU and hospital mortality rates compared with emergency room admissions (crude odds ratio [OR], 1.51; 95% confidence interval [CI], 1.32-1.75). After adjusting for age, sex, diagnosis, comorbidities, and acute physiology scores, the difference in ICU mortality remained significant (OR, 1.30; 95% CI, 1.09-1.56); however, hospital mortality did not (OR, 1.19; 95% CI, 1.00-1.41). Compared with ward patients, transfer from other hospitals was associated with lower hospital mortality after adjusting for severity of illness and other case-mix variables (OR, 0.81; 95% CI, 0.68-0.95). CONCLUSIONS We found some evidence to suggest that differential access to intensive care services impacts mortality within this case mix of patients. These findings may have implications for current efforts to centralize and regionalize critical care services.
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Affiliation(s)
- Andrea D Hill
- Department of Medicine, London Health Sciences Centre, Ontario, Canada.
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Abstract
PURPOSE OF REVIEW The ageing population, changing societal expectations and medical workforce shortages have created an unprecedented demand for intensive care services. This review describes the challenges to supporting rural-based critical care and discusses potential solutions for ensuring not only that rural patients receive a comparable level of care to their metropolitan counterparts, but also that patient outcomes are equivalent. RECENT FINDINGS The ability of rural hospitals to deliver a high-quality, intensivist-led service depends on implementing a variety of strategies including: promoting recruitment and retention of specialist medical and nursing staff; ensuring appropriate, timely access to medical specialist-led retrieval services; exploring alternate modes of providing access to critical care physicians; expanding telemedicine opportunities; establishing clinical links between rural and metropolitan hospitals with opportunities for staff rotations, protocol sharing, and combined safety and quality, educational and research activities. SUMMARY A number of solutions for supporting critical care in rural communities exist. None of these strategies are stand-alone solutions, nor are they universally applicable. Individual healthcare regions need to implement different strategies depending on local requirements and resources. Ultimately, lobbying for productive changes to healthcare policy will ensure the long-term viability of rural critical care.
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Abstract
CONTEXT Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. PURPOSE To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community. METHODS A semistructured interview of directors of nursing at CAHs that provide intensive care services. RESULTS Two thirds of CAHs that provide intensive care do so in a distinct unit. Most have continuous or computerized electrocardiography and ventilators. Other ICU equipment common in larger hospitals was reported less frequently. Nurse:patient ratio ranged from 1:1 to 1:3, and some or all nursing staff have advanced cardiac life support certification. Most CAHs admit patients to the ICU daily or weekly, primarily treating cardiac, respiratory, gastrointestinal, endocrine, and drug- or alcohol-related conditions. ICUs are also used for postsurgical recovery. Respondents felt that closure of the ICU would be burdensome to patients and families, result in lost revenue, negatively impact staff, and affect the community's perception of the hospital. CONCLUSIONS Intensive care services provided by CAHs fall along a continuum, ranging from care in a unit that resembles a scaled-down version of ICUs in larger hospitals to care in closely monitored medical-surgical beds. Nurse to patient ratio, not technology, is arguably the defining characteristic of intensive care in CAHs. Respondents believe these services to be important to the well-being of the hospital and of the community.
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Affiliation(s)
- Victoria A Freeman
- North Carolina Rural Health Research and Policy Analysis Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7590, USA.
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Bekes C. Transfer surcharge*. Crit Care Med 2007; 35:1612-3. [PMID: 17522534 DOI: 10.1097/01.ccm.0000266828.74601.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Belway D, Henderson W, Keenan SP, Levy AR, Dodek PM. Do specialist transport personnel improve hospital outcome in critically ill patients transferred to higher centers? A systematic review. J Crit Care 2006; 21:8-17; discussion 17-8. [PMID: 16616617 DOI: 10.1016/j.jcrc.2005.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of the study was to determine whether the use of specialist transport personnel improves patient outcome at the receiving hospital for critically ill patients transferred to higher centers. MATERIALS AND METHODS A search of 6 electronic databases, 15 relevant journals, and the reference lists of all retrieved articles was conducted for studies comparing outcome at the receiving hospital for critically ill adult or pediatric patients transported by dedicated transport crews or tertiary-based specialists with other forms of transport personnel including referring house staff. All potentially relevant articles were retrieved in full and reviewed independently by 2 reviewers to determine eligibility for inclusion. Data were tabulated and results were summarized. RESULTS Six cohort studies (n = 4534) were included. When patients of equal severity were assessed, only 1 study demonstrated an improvement in outcome at the receiving hospital (survival to 6 hours) when specialist personnel transported the patients. Methodological limitations and interstudy differences in participants and transport personnel precluded pooling of results. CONCLUSIONS Current data are insufficient. The study designs used create opportunity for significant bias, preventing any useful inferences to be drawn. Further study is warranted.
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Affiliation(s)
- Dean Belway
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada V6Z 1Y6
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Markakis C, Dalezios M, Chatzicostas C, Chalkiadaki A, Politi K, Agouridakis PJ. Evaluation of a risk score for interhospital transport of critically ill patients. Emerg Med J 2006; 23:313-7. [PMID: 16549583 PMCID: PMC2579512 DOI: 10.1136/emj.2005.026435] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Interhospital transfer imposes essential risk for critically ill patients. The Risk Score for Transport Patients (RSTP) scale can be used as a triage tool for patient severity. METHODS In total, 128 transfers of critically ill patients were classified in two groups of severity according to the RSTP. Statistical analysis was performed using the receiver operating characteristic (ROC) curve and goodness of fit statistics. RESULTS In total, 66 patients (51.5%) were classified as group I and 62 (48.4%) as group II. Major en route complications were more common in group II patients (19.3% v 3%, p<0.001). Haemodynamic instability was the most common complication. There were significant differences in the mean risk scores between group I and II patients (mean (SD) 4.48 (1.01) v 11.04 (3.47), p<0.001). Discrimination power of RSTP was acceptable (area under the ROC curve 0.743; cutoff value > or =8). Goodness of fit was adequate (p = 0.390). CONCLUSION The RSTP had acceptable discrimination and adequate goodness of fit and could be considered as a triage tool. Haemodynamic instability is the most common problem encountered during transfer.
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Affiliation(s)
- C Markakis
- ICU, General Hospital of Rethymnon, Crete, Greece
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Abstract
The organizational structure of critical care services likely affects the quality of patient care, and ultimately, patient outcomes. Based on the available data, the ideal intensive care unit would be a closed-unit staffed by dedicated intensivists. Whether or not around-the-clock intensivist staffing is necessary, however, is debatable. Because financial realities preclude all units from being ideal, alternative strategies for organization must be explored.
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Affiliation(s)
- Steven Y Chang
- Department of Medicine, New York University School of Medicine, North Shore University Hospital, 300 Community Drive, 4 Levitt Manhasset, NY 11030, USA.
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