Interhospital Transfer Delays Appropriate Treatment for Patients With Severe Sepsis and Septic Shock

Faine, Brett; Noack, Joseph; Wong, Terrance; Messerly, Jeffrey T.; Ahmed, Azeemuddin; Fuller, Brian M.; Mohr, Nicholas M.

doi:10.1097/ccm.0000000000001301

Cited by 78 publications

(67 citation statements)

References 31 publications

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“…We have shown previously that transferred sepsis patients have lower adherence with Surviving Sepsis Campaign Guidelines and that inter-hospital transfer itself is associated with significant delays in sepsis care. 14, 27 Our findings may simply be a reflection that delays in sepsis care translate to worse clinical outcomes, and that transferred patients have systematic delays in their resuscitation. This justification also may explain why inpatient transfers were at even higher risk of mortality: if sepsis resuscitation were delayed further, patients may have decompensated prior to transfer and experienced worse outcomes.…”

Section: Discussionmentioning

confidence: 85%

“…Early resuscitation is critical to survival, and inter-hospital transfer during the critical period of resuscitation may delay appropriate time-sensitive therapy for a benefit that is not as time-critical. 14 …”

Section: Discussionmentioning

confidence: 99%

“…Currently, national adherence with Surviving Sepsis Campaign guidelines is low, and rural sepsis patients often do not receive guideline-adherent sepsis care. 14, 28-32 We showed previously that transferred patients had hospital admission delayed nearly 6 hours, and that appropriate empiric antibiotics were administered prior to transfer in only one-third of cases. 14 If inter-hospital transfer is to be the most effective strategy for improving population-based outcomes, perhaps transfer must occur more rapidly (median time in ED prior to transfer was 3.6 h).…”

Section: Discussionmentioning

confidence: 99%

“…14, 28-32 We showed previously that transferred patients had hospital admission delayed nearly 6 hours, and that appropriate empiric antibiotics were administered prior to transfer in only one-third of cases. 14 If inter-hospital transfer is to be the most effective strategy for improving population-based outcomes, perhaps transfer must occur more rapidly (median time in ED prior to transfer was 3.6 h). Alternatively, bolstering rural resuscitation algorithms, either through standard care pathways, electronic order sets, or telemedicine may improve the quality of rural resuscitation.…”

Section: Discussionmentioning

confidence: 99%

“…Many transferred sepsis patients in rural states have low adherence with national sepsis resuscitation guidelines. 14 As sepsis survival depends in large part on time-sensitive interventions, the transfer process associated with regionalization could also cause harm to patients, driven by the administrative and time-consuming processes associated with inter-hospital transfer. Because both early resuscitation and later hospital care are important to improving patient outcomes, it is unclear what role inter-hospital transfer plays in improving sepsis survival.…”

Section: Introductionmentioning

confidence: 99%

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Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: An instrumental variables approach

Mohr

Harland

Shane

et al. 2016

Journal of Critical Care

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Purpose The objective of this study was to evaluate the impact of regionalization on sepsis survival, to describe the role of inter-hospital transfer in rural sepsis care, and to measure the cost of inter-hospital transfer in a predominantly rural state. Materials and Methods Observational case-control study using statewide administrative claims data from 2005-2014 in a predominantly rural Midwestern state. Mortality and marginal costs were estimated with multivariable generalized estimating equations (GEE) models and with instrumental variables models. Results A total of 18,246 patients were included, of which 59% were transferred between hospitals. Transferred patients had higher mortality and longer hospital length-of-stay than non-transferred patients. Using a multivariable GEE model to adjust for potentially confounding factors, inter-hospital transfer was associated with increased mortality (aOR 1.7, 95%CI 1.5 – 1.9). Using an instrumental variables model, transfer was associated with a 9.2% increased risk of death. Transfer was associated with additional costs of $6,897 (95%CI $5,769-8,024). Even when limiting to only those patients who received care in the largest hospitals, transfer was still associated with $5,167 (95%CI $3,696-6,638) in additional cost. Conclusions The majority of rural sepsis patients are transferred, and these transferred patients have higher mortality and significantly increased cost of care.

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Section: Discussionmentioning

confidence: 85%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: An instrumental variables approach

Mohr

Harland

Shane

et al. 2016

Journal of Critical Care

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Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis

França

McManus

2018

JAMA Netw Open

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Key Points Question How often do children transferred for management of abdominal pain and appendicitis require specialized pediatric services? Findings This cohort study found that children with abdominal pain or suspected appendicitis were regularly transferred from hospitals with a wide range of capabilities to a small subset of highly capable centers. Although more than half (54.2%) required surgery, nearly one-third (29.9%) were discharged from the receiving hospital without intervention. Meaning Improved coordination between high-capability and lower-capability hospitals may decrease the cost and increase the quality of care for children with abdominal pain and suspected appendicitis.

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Rural-Urban Disparities in Hospital Services and Outcomes for Children With Medical Complexity

Leyenaar,

Freyleue,

Arakelyan

et al. 2024

JAMA Netw Open

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ImportanceLimited availability of inpatient pediatric services in rural regions has raised concerns about access, safety, and quality of hospital-based care for children. This may be particularly important for children with medical complexity (CMC).ObjectivesTo describe differences in the availability of pediatric services at acute care hospitals where rural- and urban-residing CMC presented for hospitalization; identify rural-urban disparities in health care quality and in-hospital mortality; and determine whether the availability of pediatric services at index hospitals or the experience of interfacility transfer modified rural-urban differences in outcomes.Design, Setting, and ParticipantsThis retrospective cohort study examined all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 to 2017. Analysis was conducted from May 2023 to July 2024. Participants included CMC younger than 18 years residing in these states and hospitalized during the study period.ExposuresRural or urban residence was determined using Rural-Urban Commuting Area codes. Hospitals were categorized as children’s hospitals or general hospitals with comprehensive, limited, or no dedicated pediatric services using American Hospital Association survey data. Interfacility transfers between index and definitive care hospitals were identified using health care claims.Main Outcomes and MeasuresIn-hospital mortality, all-cause 30-day readmission, medical-surgical safety events, and surgical safety events were operationalized using Agency for Healthcare Research and Quality measure specifications.ResultsAmong 36 943 CMC who experienced 79 906 hospitalizations, 16 525 (44.7%) were female, 26 034 (70.5%) were Medicaid-insured, and 34 008 (92.1%) were urban-residing. Rural-residing CMC were 6.55 times more likely to present to hospitals without dedicated pediatric services (rate ratio [RR], 6.55 [95% CI, 5.86-7.33]) and 2.03 times more likely to present to hospitals without pediatric beds (RR, 2.03 [95% CI, 1.88-2.21]) than urban-residing CMC, with no significant differences in interfacility transfer rates. In unadjusted analysis, rural-residing CMC had a 44% increased risk of in-hospital mortality (RR, 1.44 [95% CI, 1.03-2.02]) with no significant differences in other outcomes. Adjusting for clinical characteristics, the difference in in-hospital mortality was no longer significant. Index hospital type was not a significant modifier of observed rural-urban outcomes, but interfacility transfer was a significant modifier of rural-urban differences in surgical safety events.Conclusions and RelevanceIn this cohort study, rural-residing CMC were significantly more likely to present to hospitals without dedicated pediatric services. These findings suggest that efforts are justified to ensure that all hospital types are prepared to care for CMC.

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Interhospital Transfer Delays Appropriate Treatment for Patients With Severe Sepsis and Septic Shock

Cited by 78 publications

References 31 publications

Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: An instrumental variables approach

Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: An instrumental variables approach

Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis

Rural-Urban Disparities in Hospital Services and Outcomes for Children With Medical Complexity

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