Characteristics and Outcomes Among Patients Transferred to a Regional Comprehensive Stroke Center for Tertiary Care

Abstract

Background and Purpose— Many patients are transferred to comprehensive stroke centers for advanced acute ischemic stroke care, especially after intravenous tissue plasminogen activator. We sought to determine differences in the baseline characteristics and outcomes between patients with acute ischemic stroke presenting directly to our academic stroke center’s front door versus transfers-in from another acute care hospital. Methods— Using our institutional Get With The Guidelines (GWTG)-Stroke registry, we analyzed all 3660 consecutively admitted patients with acute ischemic stroke (January 2005–June 2012). Univariate and multivariable models explored differences in front door versus transfer-in patients. Results— Fifty percent of all patients with acute ischemic stroke were transfer-in. Compared with front door patients, transfer-in were younger (67±16 versus 71±15 years; P <0.001), had worse median initial National Institutes of Health Stroke Scale score (7.0 versus 4.0; P <0.001), more often had limb weakness (35% versus 27%; P <0.001) or aphasia (16% versus 11%; P <0.001), and received intravenous tissue plasminogen activator (29% versus 13%; P <0.001). Despite a trend toward higher in-hospital mortality in transfer-in patients, the difference was not statistically significant (13% versus 11%; P =0.08) between the 2 groups. Transfer-in patients had a longer hospital length of stay (5 versus 4 days; P <0.001) and were more often discharged to inpatient rehabilitation (48% versus 34%; P <0.001). Independent predictors of in-hospital mortality were increasing age (odds ratio [OR], 1.38 per decade [1.23–1.55]; P <0.001), atrial fibrillation (OR, 1.47 [1.12–1.93]; P =0.006), coronary artery disease (OR, 2.02 [1.53–2.67]; P <0.001), and initial National Institutes of Health Stroke Scale (OR, 1.20 per point [1.18–1.23]; P <0.001). Transfer status was not independently associated with in-hospital mortality (OR, 0.99 [0.76–1.29]; P =0.928). Conclusions— Despite having more severe strokes on arrival at our hospital, transfer-in patients had similar in-hospital mortality versus front door patients and were more likely to be discharged to rehabilitation. These outcomes lend support to the concept of regionalized stroke care and concentrating patients who are more disabled at more advanced stroke care centers.

Characteristics and Outcomes of Stroke Patients Transferred to Hospitals Participating in the Michigan Coverdell Acute Stroke Registry

“…14,15 Similarly, a recent study of acute ischemic stroke patients transferred to a comprehensive stroke center in Boston found that despite transferred patients having higher stroke severity, mortality and discharge disposition were similar to regular admissions. 10 However, this study population was limited to a large specialized center that provides extensive tele-stroke services; the proportion of transferred cases (55%) was, therefore, substantially higher than observed in this study (19%). To our knowledge, no other registry-based studies have reported on the outcomes and characteristics of acute stroke patients who have been transferred to registry hospitals.…”

“…However, for mortality at least, the association between being transferred and higher mortality was seen only among ischemic stroke and not hemorrhagic stroke patients. Few studies have described the characteristics and outcomes of acute stroke patients who are transferred between hospital, 9,10,14,15 and most of these studies have been from single referral centers. Two studies that assessed the effect of interhospital transfer in hemorrhagic stroke patients found similar rates of mortality and complications among patients who were transferred compared with direct admissions.…”

“…16 Stroke mortality is now included as part of the Center for Medicaid and Medicare Services value-based purchasing program, 17 and concern has been raised that referral hospitals that receive a large number of transferred patients may be penalized because of their poorer patient outcomes. 10 There is a belief that by accepting more severely affected patients at presentation, hospitals will face reduced reimbursements because of their higher risk-standardized mortality. Prior studies of ICU patients have highlighted the importance of admission source (ie, interhospital transfer versus regular admission) on the effect of hospital profiling and the fact that current risk adjustment methods are unable to fully account for the poorer outcomes observed in transferred patients.…”

“…[6][7][8] Despite the growing importance of interhospital transfers to stroke systems of care, there are few reports that have described the frequency, trends, characteristics, and outcomes of stroke patients who are transferred between facilities. 9,10 Interhospital transfers of stroke patients can be categorized into either acute or delayed transfers. Acute patient transfers occur between emergency departments and most often involve patients who are candidates for urgent therapies, such as thrombolysis (tissue-type plasminogen activator [tPA]) or neurovascular surgery.…”

The capabilities and scope-of-practice requirements of advanced life support practitioners undertaking critical care transfers: A Delphi study

“…[1,9,10] International and local data have shown that outcomes improve when patients are referred to regional specialised centres where a multidisciplinary team may manage their ailment. [11][12][13] For this reason, many patients will require CCT. In SA, paramedics currently do not have additional training to undertake these specialised transfers.…”