Characteristics and Timing of Interhospital Transfers of Emergency General Surgery Patients

Philip, Jennifer L.; Saucke, Megan C.; Schumacher, Jessica R.; Fernandes‐Taylor, Sara; Havlena, Jeffrey; Greenberg, Caprice C.; Ingraham, Angela M.

doi:10.1016/j.jss.2018.06.017

Cited by 25 publications

(42 citation statements)

References 32 publications

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“…Third, NSQIP has no information about transferred cases managed nonoperatively, which account for 45% to 65% of the cases in some studies. 5,7,10 The current study also has several areas of strength. We used two robust methods to adjust for differences in the two study groups: multivariable logistic regression and propensity score using IPTW and ATT.…”

Section: Discussionmentioning

confidence: 97%

“…Inadequate access to EGS care is affected by many factors, including, but not limited to, heterogeneity in human and technical resource availability, current trends in the development and training of the surgical workforce, and patient complexity requiring care in highly specialized centers. These factors have led to an increased number of EGS patients requiring transfer to a higher level of care 5–8 …”

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confidence: 99%

“…Unquestionably, increased mortality and complication rates, likely because of patient complexity (disease severity and comorbidities), have been reported by many authors studying the impact of transfers on EGS outcomes. An interesting component of this discussion is that approximately 10% to 25% of all transfers are deemed unnecessary, and many patients never undergo a surgical procedure at the definitive care facility 5–10 …”

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confidence: 99%

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The unequal impact of interhospital transfers on emergency general surgery patients: Procedure risk and time to surgery matter

Coimbra¹,

Barrientos²,

Allison-Aipa³

et al. 2021

J Trauma Acute Care Surg

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BACKGROUND:The impact of interhospital transfer on outcomes of patients undergoing emergency general surgery (EGS) procedures is incompletely studied. We set out to determine if transfer before definitive surgical care leads to worse outcomes in EGS patients. METHODS:Using the National Surgical Quality Improvement Project database (2013-2019), a retrospective cohort study was conducted including nine surgical procedures encompassing 80% of the burden of EGS diseases, performed on an urgent/emergent basis. The procedures were classified as low risk (open and laparoscopic appendectomy and laparoscopic cholecystectomy) and high risk (open cholecystectomy, laparoscopic and open colectomy, lysis of adhesions, perforated ulcer repair, small bowel resection, and exploratory laparotomy). Time to surgery was recorded in days. The impact of interhospital transfer on outcomes (mortality, major complications, 30-day reoperations, and 30-day readmissions) and length of stay, according to procedure risk and time to surgery, were analyzed by multivariate logistic regression and inverse probability treatment of the weighting with treatment effect in the treated. RESULTS:A total of 329,613 patients were included in the study (284,783 direct admission and 44,830 transfers). Adjusted mortality (3.1% vs. 10.4%; adjusted odds ratio [AOR], 1.28; p < 0.001), major complications (6.7% vs. 18.9%; AOR, 1.39; p < 0.001), 30-day reoperations (3.1% vs. 6.4%; AOR, 1.22; p < 0.001), and length of stay (2 vs. 5) were higher in transferred patients. Transfer had no effect on 30-day readmissions (6% vs. 8.5%; AOR, 1.04; p = 0.063). These results were also observed in high-risk surgery patients and in the late surgery group. The results were further confirmed after robust propensity score weighting was performed. CONCLUSION:We have demonstrated that delays to surgical intervention affect outcomes and that interhospital transfer of EGS patients for definitive surgical care has a negative impact on mortality, development of postoperative complications, and reoperations in patients undergoing high-risk EGS procedures. These findings may have important implications for regionalization of EGS care.

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Section: Discussionmentioning

confidence: 97%

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confidence: 99%

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confidence: 99%

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The unequal impact of interhospital transfers on emergency general surgery patients: Procedure risk and time to surgery matter

Coimbra¹,

Barrientos²,

Allison-Aipa³

et al. 2021

J Trauma Acute Care Surg

View full text Add to dashboard Cite

show abstract

“…Our findings are comparable to those found by Philip et al and Broman et al from the University of Wisconsin and Vanderbilt University, respectively. 15 , 16 However, these were retrospective studies and did not include surgeon discomfort as a transfer reason.…”

Section: Discussionmentioning

confidence: 99%

An evaluation of emergency general surgery transfers and a call for standardization of practices

Bruenderman

Block

Kehdy

et al. 2021

Surgery

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Background There is an increasing trend toward regionalization of emergency general surgery, which burdens patients. The absence of a standardized, emergency general surgery transfer algorithm creates the potential for unnecessary transfers. The aim of this study was to evaluate clinical reasoning prompting emergency general surgery transfers and to initiate a discussion for optimal emergency general surgery use. Methods Consecutive emergency general surgery transfers (December 2018 to May 2019) to 2 tertiary centers were prospectively enrolled in an institutional review board–approved protocol. Clinical reasoning prompting transfer was obtained prospectively from the accepting/consulting surgeon. Patient outcomes were used to create an algorithm for emergency general surgery transfer. Results Two hundred emergency general surgery transfers (49% admissions, 51% consults) occurred with a median age of 59 (18 to 100) and body mass index of 30 (15 to 75). Insurance status was 25% private, 45% Medicare, 21% Medicaid, and 9% uninsured. Weekend transfers (Friday to Sunday) occurred in 45%, and 57% occurred overnight (6:00 pm to 6:00 am). Surgeon-to-surgeon communication occurred with 22% of admissions. Pretransfer notification occurred with 10% of consults. Common transfer reasons included no surgical coverage (20%), surgeon discomfort (24%), or hospital limitations (36%). A minority (36%) underwent surgery within 24 hours; 54% did not require surgery during the admission. Median length of stay was 6 (1 to 44) days. Conclusion Conditions prompting emergency general surgery transfers are heterogeneous in this rural state review. There remains an unmet need to standardize emergency general surgery transfer criteria, incorporating patient and hospital factors and surgeon availability. Well-defined requirements for communication with the accepting surgeon may prevent unnecessary transfers and maximize resource allocation.

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“…1,2 Emergency general surgury conditions are also associated with high mortality and costs, placing substantial burden on the health care system. 1,[3][4][5][6][7][8][9][10][11] Interhospital transfers of patients with EGS conditions are common, occurring in up to 13% of all EGS encounters, but little is known about the transfer patterns within the network. 1,12 Acute care hospitals with EGS services are not evenly distributed with regard to population density or need for care and, at present, there are no standardized guidelines in place to direct patients to those hospitals.…”

Section: Introductionmentioning

confidence: 99%

Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions

et al. 2021

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IMPORTANCE Although patients with emergency general surgery (EGS) conditions frequently undergo interhospital transfers, the transfer patterns and associated factors are not well understood. OBJECTIVE To examine whether patients with EGS conditions are consistently directed to hospitals with more resources and better outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study performed a network analysis of interhospital transfers among adults with EGS conditions from January 1 to December 31, 2016. The analysis used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in 8 states. A total of 728 hospitals involving 85 415 transfers of 80 307 patients were included. Patients were eligible for inclusion if they were 18 years or older and had an acute care hospital encounter with a diagnosis of an EGS condition as defined by the American Association for the Surgery of Trauma. Data were analyzed from January 1, 2020, to June 17, 2021.EXPOSURES Hospital-level measures of size (total bed capacity), resources (intensive care unit[ICU] bed capacity, teaching status, trauma center designation, and presence of trauma and/or surgical critical care fellowships), EGS volume (annual EGS encounters), and EGS outcomes (riskadjusted failure to rescue and in-hospital mortality). MAIN OUTCOMES AND MEASURESThe main outcome was hospital-level centrality ratio, defined as the normalized number of incoming transfers divided by the number of outgoing transfers. A higher centrality ratio indicated more incoming transfers per outgoing transfer. Multivariable regression analysis was used to test the hypothesis that a higher hospital centrality ratio would be associated with more resources, higher volume, and better outcomes. RESULTS Among 80 307 total patients, the median age was 63 years (interquartile range [IQR], 50-75 years); 52.1% of patients were male and 78.8% were White. The median number of outgoing and incoming transfers per hospital were 106 (IQR, 61-157) and 36 (IQR, 8-137), respectively. A higher log-transformed centrality ratio was associated with more resources, such as higher ICU capacity (eg,

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Characteristics and Timing of Interhospital Transfers of Emergency General Surgery Patients

Cited by 25 publications

References 32 publications

The unequal impact of interhospital transfers on emergency general surgery patients: Procedure risk and time to surgery matter

The unequal impact of interhospital transfers on emergency general surgery patients: Procedure risk and time to surgery matter

An evaluation of emergency general surgery transfers and a call for standardization of practices

Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions

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