Analysis of Factors Affecting the Length of Stay in the Emergency Department for Critically Ill Patients Transferred to Regional Emergency Medical Centers

BackgroundTransferring an emergency patient to another emergency department (ED) is necessary when she/he is unable to receive necessary treatment from the first visited ED, although the transfer poses potential risks for adverse clinical outcomes and lowering the quality of emergency medical services by overcrowding the transferred ED. This study aimed to understand the factors affecting the ED length of stay (LOS) of critically ill patients and to investigate whether they are receiving prompt treatment through Interhospital Transfer (IHT).MethodsThis study analyzed 968 critically ill patients transferred to the ED of the study site in 2019. Machine learning based prediction models were built to predict the ED LOS dichotomized as greater than 6 hours or less. Explanatory variables in patient characteristics, clinical characteristics, transfer-related characteristics, and ED characteristics were selected through univariate analyses.ResultsAmong the prediction models, the Logistic Regression (AUC 0.85) model showed the highest prediction performance, followed by Random Forest (AUC 0.83) and Naïve Bayes (AUC 0.83). The Logistic Regression model suggested that the need for emergency operation or angiography (OR 3.91, 95% CI=1.65–9.21), the need for Intensive Care Unit (ICU) admission (OR 3.84, 95% CI=2.53–5.83), fewer consultations (OR 3.57, 95% CI=2.84–4.49), a high triage level (OR 2.27, 95% CI=1.43–3.59), and fewer diagnoses (OR 1.32, 95% CI=1.09–1.61) coincided with a higher likelihood of 6-hour-or-less stays in the ED. Furthermore, an interhospital transfer handoff led to significantly shorter ED LOS among the patients who needed emergency operation or angiography, or ICU admission, or had a high triage level.ConclusionsThe results of this study suggest that patients prioritized in emergency treatment receive prompt intervention and leave the ED in time. Also, having a proper interhospital transfer handoff before IHT is crucial to provide efficient care and avoid unnecessarily longer stay in ED.

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out‐of‐Hospital Cardiac Arrest: A Systematic Review and Meta‐Analysis

Background The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm ( P =0.006) and without prehospital return of spontaneous circulation ( P =0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.

Abstract 11759: Survival Among Medicare Beneficiaries After Out-of-Hospital Cardiac Arrest Undergoing Interhospital Transfer

Intro: Among individuals treated for out-of-hospital cardiac arrest (OHCA), there is hospital-level variability in mortality, but the relationship between interhospital transfer (IHT) OHCA volume and survival remain unclear. We sought to examine the association of OHCA volume and survival for individuals undergoing IHT. Methods: Utilizing age-eligible Medicare fee-for-service claims, we identified an emergency department treated OHCA cohort using ICD-9/10 diagnosis codes. Hospital OHCA volume was defined as the total number of index (first-treated) OHCA claims during the study period and were binned into quartiles. Each claim was assigned the OHCA volume quartile of the index hospital and the index volume of the receiving hospital. Multiple logistic regression was conducted to assess the association between initial and receiving hospital volume categories and survival to 30 days among IHT patients while controlling for patient-level characteristics (age, sex, race), comorbidity index, urbanicity of index hospital and days to transfer. Results: We identified a cohort of 222,018 claims at 4,461 hospitals between 1/2013-12/2015. Median age was 78 years (IQR 71-85); 44% were female; 11% of the cohort was alive at 30 days. IHT occurred in 12,245 cases (5.5%) and 59% of transfers occurred on the day of admission or day 1. Transfers originated from 3411 index hospitals and 1566 receiving hospitals. Median OHCA hospital index volume was 25 [IQR 9, 67]. Adjusted odds of survival at 30 days was significantly lower at index hospitals with lower OHCA volumes compared to the highest volume category (aOR [95%CI] Q2: 0.71 [0.6, 0.83] p<0.001). Additionally, odds of survival at 30 days was significantly lower at low volume receiving hospitals (aOR [95%CI] Q1: 0.73 [0.55, 0.99] p<0.001), and increased for higher OHCA volume receiving hospitals, but these groups did not achieve statistical significance. Conclusion: For Medicare beneficiaries who suffer an OHCA and undergo IHT, lower index and receiving hospital OHCA volume was significantly associated with decreased adjusted odds of 30-day survival. Further exploration of hospital characteristics, timing, and transfer patterns is needed to understand differences in benefit for OHCA patients undergoing IHT.

Interhospital transfer of COVID-19 patients treated with high-flow nasal oxygen therapy

At the start of the COVID-19 pandemic, early intubation was recommended on the basis of worldwide observations of severe hypoxemia. However, some patients were ultimately able to benefit from high-flow nasal cannula (HFNC) and thus avoid intubation. During the “second wave” (September to December 2020 in France), some emergency departments implemented HFNC in patients with severe COVID-19. The question then arose regarding the transfer of these most serious patients to intensive care units (ICU) and of the respiratory modalities to be used during this transfer. To assess the feasibility of interhospital transfers of COVID-19 patients needing HFNC, we conducted a bi-centric prospective observational study of all medical transfers of patients needing HFNC with the Chambéry and Angers (France) mobile emergency and intensive care service (SMUR) during the “second wave” of the COVID-19 pandemic in France. Analysis of these 42 patients showed no significant variation in the respiratory requirements during the transfer. Overall, 52% of patients were intubated during their stay in ICU, including three patients intubated before or during transfer. Interhospital transfer with HFNC is very high-risk, and intubation remains indicated in the most unstable patients. However, 48% of patients benefited from HFNC and were thus able to avoid intubation during their transfer and ICU stay; for these patients, intubation would probably have been indicated in the absence of available HFNC techniques.

Assessment of a novel marker of ICU strain, the ICU Activity Index, during the COVID-19 pandemic in Victoria, Australia

OBJECTIVES: To validate a real-time Intensive Care Unit (ICU) Activity Index as a marker of ICU strain from daily data available from the Critical Health Resource Information System (CHRIS), and to investigate the association between this Index and the need to transfer critically ill patients during the coronavirus disease 2019 (COVID-19) pandemic in Victoria, Australia. DESIGN: Retrospective observational cohort study. SETTING: All 45 hospitals with an ICU in Victoria, Australia. PARTICIPANTS: Patients in all Victorian ICUs and all critically ill patients transferred between Victorian hospitals from 27 June to 6 September 2020. MAIN OUTCOME MEASURE: Acute interhospital transfer of one or more critically ill patients per day from one site to an ICU in another hospital. RESULTS: 150 patients were transported over 61 days from 29 hospitals (64%). ICU Activity Index scores were higher on days when critical care transfers occurred (median, 1.0 [IQR, 0.4–1.7] v 0.6 [IQR, 0.3–1.2]; P < 0.001). Transfers were more common on days of higher ICU occupancy, higher numbers of ventilated or COVID-19 patients, and when more critical care staff were unavailable. The highest ICU Activity Index scores were observed at hospitals in north-western Melbourne, where the COVID-19 disease burden was greatest. After adjusting for confounding factors, including occupancy and lack of available ICU staff, a rising ICU Activity Index score was associated with an increased risk of a critical care transfer (odds ratio, 4.10; 95% CI, 2.34–7.18; P < 0.001). CONCLUSIONS: The ICU Activity Index appeared to be a valid marker of ICU strain during the COVID-19 pandemic. It may be useful as a real-time clinical indicator of ICU activity and predict the need for redistribution of critical ill patients.