Patient care during interfacility transport:a narrative review of managing diverse disease states / 世界急诊医学杂志（英文）

BACKGROUND:When critically ill patients require specialized treatment that exceeds the capability of the index hospitals,patients are frequently transferred to a tertiary or quaternary hospital for a higher level of care.Therefore,appropriate and effi cient care for patients during the process of transport between two hospitals(interfacility transfer)is an essential part of patient care.While medical adverse events may occur during the interfacility transfer process,there have not been evidence-based guidelines regarding the equipment or the practice for patient care during transport.METHODS:We conducted searches from the PubMed,Cumulative Index of Nursing and Allied Health(CINAHL),and Scopus databases up to June 2022.Two reviewers independently screened the titles and abstracts for eligibility.Studies that were not in the English language and did not involve critically ill patients were excluded.RESULTS:The search identified 75 articles,and we included 48 studies for our narrative review.Most studies were observational studies.CONCLUSION:The review provided the current evidence-based management of diverse disease states during the interfacility transfer process,such as proning positioning for respiratory failure,extracorporeal membrane oxygenation(ECMO),obstetric emergencies,and hypertensive emergencies(aortic dissection and spontaneous intracranial hemorrhage).

Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection / 世界急诊医学杂志（英文）

BACKGROUND@# Acute aortic dissection (AoD) is a hypertensive emergency often requiring the transfer of patients to higher care hospitals; thus, clinical care documentation and compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) is crucial. The study assessed emergency providers (EP) documentation of clinical care and EMTALA compliance among interhospital transferred AoD patients.@*METHODS@# This retrospective study examined adult patients transferred directly from a referring emergency department (ED) to a quaternary academic center between January 1, 2011 and September 30, 2015. The primary outcome was the percentage of records with adequate documentation of clinical care (ADoCC). The secondary outcome was the percentage of records with adequate documentation of EMTALA compliance (ADoEMTALA).@*RESULTS@# There were 563 electronically identified patients with 287 included in the final analysis. One hundred and five (36.6%) patients had ADoCC while 166 (57.8%) patients had ADoEMTALA. Patients with inadequate documentation of EMTALA (IDoEMTALA) were associated with a higher likelihood of not meeting the American Heart Association (AHA) ED Departure SBP guideline (OR 1.8, 95% CI 1.03–3.2, P=0.04). Male gender, handwritten type of documentation, and transport by air were associated with an increased risk of inadequate documentation of clinical care (IDoCC), while receiving continuous infusion was associated with higher risk of IDoEMTALA.@*CONCLUSION@# Documentation of clinical care and EMTALA compliance by Emergency Providers is poor. Inadequate EMTALA documentation was associated with a higher likelihood of patients not meeting the AHA ED Departure SBP guideline. Therefore, Emergency Providers should thoroughly document clinical care and EMTALA compliance among this critically ill group before transfer.

Characteristics and outcomes of patients with septic shock who transferred to the emergency department in tertiary referral center: multicenter, retrospective, observational study

OBJECTIVE: We evaluated the clinical characteristics and prognoses of patients with septic shock who transferred to the emergency department (ED) in a tertiary referral center. METHODS: This study was performed using a prospective, multi-center registry of septic shock, with the participation of 11 tertiary referral centers in the Korean Shock Society between October 2015 and February 2017. We classified the patients as a transferred group who transferred from other hospitals after meeting the inclusion criteria upon ED arrival and a non-transferred group who presented directly to the ED. Primary outcome was hospital mortality. We conducted multiple logistic regression analysis to assess variables related to in-hospital mortality. RESULTS: A total of 2,098 patients were included, and we assigned 717 patients to the transferred group and 1,381 patients to the non-transferred group. The initial Sequential Organ Failure Assessment score was higher in the transferred group than the non-transferred group (6; interquartile range [IQR], 4–9 vs. 6; IQR, 4–8; P < 0.001). Mechanical ventilator (29% vs. 21%, P < 0.001) and renal replacement therapy (12% vs. 9%, P=0.034) within 24 hours after ED arrival were more frequently applied in the transferred group than the non-transferred group. Overall hospital mortality was 22% and there was no significant difference between transferred and non-transferred groups (23% vs. 22%, P=0.820). Multivariable analysis showed an odds ratio for in-hospital mortality of 1.00 (95% confidence interval, 0.78–1.28; P=0.999) for the transferred group compared with the non-transferred group. CONCLUSION: The transferred group showed higher severity and needed more organ support procedures than the nontransferred group. However, inter-hospital transfer did not affect in-hospital mortality.

The Relationship between Clinical Outcome in Subarachnoidal Hemorrhage Patients with Emergency Medical Service Usage and Interhospital Transfer

Prompt diagnosis and appropriate transport of patients with subarachnoid hemorrhage (SAH) is critical. We aimed to study differences in clinical outcomes by emergency medical services (EMS) usage and interhospital transfer in patients with SAH. We analyzed the CAVAS (CArdioVAscular disease Surveillance) database which is an emergency department-based, national cohort of cardiovascular disease in Korea. Eligible patients were adults with non-traumatic SAH diagnosed between January 2007 and December 2012. We excluded those whose EMS use and intershopital transfer data was unknown. The primary and secondary outcomes were mortality and neurologic status at discharge respectively. We compared the outcomes between each group using multivariable logistic regressions, adjusting for sex, age, underlying disease, visit time and social history. Of 5,461 patients with SAH, a total of 2,645 were enrolled. Among those, 258 used EMS and were transferred from another hospital, 686 used EMS only, 1,244 were transferred only, and 457 did not use EMS nor were transferred. In the regression analysis, mortality was higher in patients who used EMS and were transferred (OR 1.40, 95% CI 1.02-1.92), but neurologic disability was not meaningfully different by EMS usage and interhospital transfer. In Korea, SAH patients' mortality is higher in the case of EMS use or receiving interhospital transfer.

Prolonged neonatal interhospital transport on road: Relevance for developing countries.

Objective. To compare prolonged inter hospital long distance transports on road undertaken by a qualified transport team vs those done by the same team from shorter distances and time. Methods. Retrospective descriptive comparative study of the neonatal transports done during a period of 48 mo. All neonates transferred on road to a tertiary level pediatric hospital from various maternity and pediatric centers. The biochemical characteristics, adverse effects during transport and 24 hr survival after the transport in both the groups were compared. Results. The babies were comparable in their gestational age and ventilatory requirements (46% vs 39%). The biochemical and metabolic characteristics and 24 hr mortality rates for babies who were transported for longer times and distances were comparable (p value =0.75) to those transported for shorter times. Conclusion. Long distance neonatal transport on road is feasible and with a qualified team results can be comparable to those transported from shorter distances.

Impact of Interhospital Transfer in Mortality of Critically Ill Patients

PURPOSE: Interhospital transfer of critically ill patients is often necessary for optimal patient care. However it is known that transport of critically ill patients has been associated with high rate of potentially detrimental complications. This study was designed to determine whether mortality of critically ill patients with interhospital transfers is different from critically ill patients with direct admissions. METHODS: The retrospective cohort study was conducted at an academic medical center with 3906 critically ill patients from 2003 to 2004, of whom 1652 were direct admissions and 2254 were interhospital transfers. Death within 48 hours in interhospital transfers and direct admissions were compared using univariate and multivariate regression analyses that adjusted for severity of illness. Severity of illness was measured using Simplified Acute Physiology Score (SAPS) II and Charles comorbidity score. To measure hospital performance standardized mortality ratio (SMR) was calculated by dividing observed mortality by SAPS II-predicted mortality. RESULTS: Death within 48 hours were not significantly higher for interhospital transfer patients than for directly admitted patients (7.5% vs 8.1%, p<0.05). But directly admitted patients had significantly higher SMR than transferred patients (0.94 vs 0.81, p=0.001). Finally, transferred patients with hepatic failure had significantly higher mortality rates (odds ratio=4.636) as compared with directly admitted patients, confirming the "transfer effect"for this patients' subgroup. CONCLUSION: Admission source is not an important determinant of outcome.

Treatment of Retrohepatic Caval Injury using Total Hepatic Vascular Isolation and Venovenous Bypass / 한국간담췌외과학회지

Retrohepatic caval injuries are a difficult problem to surgeons as its mortality approaching 50~80%. Several bypass techniques was advocated to reduce operative bleeding and to improve the prognosis of the traumatized patients. We successfully managed a case of retro hepatic caval injury using venovenous bypass and total hepatic vascular isolation. A 28 year old female patients was admitted to Cheju Medical Center injured in a traffic accident. At exploration, a retrohepatic caval injury was suspected. So patient was emergently transferred to Seoul National University Hospital, after gauze packing. On arrival, vital signs were stable. Reexploration was undertaken. There was gush out of blood from retrohepatic space. After clamping suprahepatic and infrahepatic vena cava, venovenous bypass was introduced to left axillary vein and left femoral vein using Biomedicus pump. Systemic heparinization was not used. Avulsion between vena cava and common trunk of left and middle hepatic veins was repaired and left hepatectomy was done. Gauze packing was done due to ongoing oozing by coagulopathy from massive transfusion. Total venovenous bypass time was 30 min. On 10th operative day, reexploration was undertaken to assure hemostasis and to remove packed gauze. On 54th postoperative day patient discharged without any morbidity.