Risk events during intrahospital transport of patients from the emergency department: a prospective observational study.

BACKGROUND: We aimed to determine the incidence, nature of and predisposing factors for risk events (REs) that occur during the intrahospital transport of patients from the ED. METHODS: We undertook a prospective, observational study of intrahospital patient transports from a single ED between 30 January and 20 March 2020. An investigator attended each transport and recorded any RE on a specifically designed data collection document. An RE was any mishap, even if not foreseen, that had the potential to cause the patient harm. A patient equipment number was assigned based on the number of pieces of equipment required during the transport. Poisson regression generated incidence rate ratios (IRRs) and determined risk factors for REs. RESULTS: Of 738 transports, 289 (39.1%, 95% CI 35.6% to 42.8%) had at least one RE. The total of 521 REs comprised 125 patient-related, 279 device-related and 117 line/catheter-related REs. The most common included trolley collisions (n=142), intravenous fluid line catching/tangling (n=93), agitation/aggression events (n=31) and cardiac monitoring issues (n=31). Thirty-four (6.5%) REs resulted in an undesirable patient outcome, most commonly distress and pain. Predisposing factors for REs included an equipment number ≥3 (IRR 5.68, 95% CI 3.95 to 8.17), transport to a general ward (IRR 2.68, 95% CI 2.12 to 3.39), hypertension (IRR 1.93, 95% CI 1.07 to 3.50), an abnormal temperature and a GCS<14. CONCLUSIONS: REs are common in transport of patients from the ED and can result in undesirable patient outcomes. Adequate pre-transfer preparation, especially securing equipment and lines, would result in a reduced risk.

Discerning Post Anesthesia Readiness for Transition (DPART): A Measurement Tool.

PURPOSE: To develop a valid reliable measurement tool that accurately quantifies postanesthesia recuperation in adult and pediatric patients. DESIGN: A descriptive factor-isolating design guided by measurement theory. METHODS: Instrument development was based on collaborative discussions of professional evidence. A five-person expert panel was consulted for content and face validity. Reliability testing took place in the adult and pediatric postanesthesia care units. FINDINGS: The expert panel's final review yielded a kappa statistic of 1 and scale content validity index based on universal agreement between raters of 1, suggesting high content validity. Reliability testing yielded a kappa statistic of 1, demonstrating complete agreement for all items. CONCLUSIONS: The Discerning Post Anesthesia Readiness for Transition measurement tool is a valid and reliable instrument that can be used in practice or future research to assess postanesthesia recuperation in pediatric and adult patients.

The Origin of Present-on-admission Pressure Ulcers/Injuries Among Patients Admitted from the Community: Results of a Retrospective Study.

Research about community-acquired pressure ulcer/injuries (CAPU/I) remains limited. PURPOSE: The aim of this descriptive, retrospective study was to quantify the number of patients with pressure ulcers/injuries (PU/Is) present on admission (POA), with particular attention to patient residence (home or skilled/long-term care facility [SNF]). METHODS: Data from the electronic medical records (EMR) and the incident reporting system of a 620-bed integrated health system in northern California from January 1, 2017, to December 31, 2017, were examined and used to create a registry that included patient demographics, length of stay (LOS), source of admission (home versus SNF), co-existing conditions, and documentation on end of life and death. A manual chart review was conducted to confirm the accuracy of data entered into the registry. All patients at least 18 years old and with a nurse-reported incident and EMR-documented PU/I that was listed as POA were included; pediatric, pregnant, or incarcerated patients were excluded. Extracted variables included demographic data, stage of PU/I on admission, and major diagnosis (or co-existing condition) by groups (spinal cord injuries [tetraplegia, paraplegia], neurological conditions, end-stage renal disease, cardiac and vascular disease, end of life [EOL], and death while in hospital during the year 2017). Descriptive analysis was used to examine the data. RESULTS: Of the 2340 records of patients with an PU/I POA, 477 were complete and analyzed. The majority (336, 70.4%) originated from home. Patients admitted from home were younger than those admitted from SNF (average age 62.9 and 71.5 years, respectively) and had a higher proportion of co-existing paraplegia/tetraplegia (24.4% vs 12.8%). More than 60% of all patients had a stage 3, stage 4, or unstageable PU/I. CONCLUSION: The majority of patients with a PU/I POA were admitted from home. Additional research and improved efforts to help high-risk individuals living at home prevent and manage PU/Is are needed.

Accuracy of inter-hospital transfer information in Australian hospital administrative databases.

Inter-hospital transfers improve care delivery for which sending and receiving hospitals both accountable for patient outcomes. We aim to measure accuracy in recorded patient transfer information (indication of transfer and hospital identifier) over 2 years across 121 acute hospitals in New South Wales, Australia. Accuracy rate for 127,406 transfer-out separations was 87 per cent, with a low variability across hospitals (10% differences); it was 65 per cent for 151,978 transfer-in admissions with a greater inter-hospital variation (36% differences). Accuracy rate varied by departure and arrival pathways; at receiving hospitals, it was lower for transfer-in admission via emergency department (incidence rate ratio = 0.52, 95% confidence interval: 0.51-0.53) versus direct admission. Transfer-out data were more accurate for transfers to smaller hospitals (incidence rate ratio = 1.06, 95% confidence interval: 1.03-1.08) or re-transfers (incidence rate ratio > 1.08). Incorporation of transfer data from sending and receiving hospitals at patient level in administrative datasets and standardisation of documentation across hospitals would enhance accuracy and support improved attribution of hospital performance measures.

Risk factors for avoidable transfer to a pediatric trauma center among patients 2 years and older.

BACKGROUND: Effective and sustainable pediatric trauma care requires systems of regionalization and interfacility transfer. Avoidable transfer, also known as secondary overtriage, occurs when a patient is transferred to a regional trauma center after initial evaluation at another facility that is capable of providing definitive care. The purpose of this study was to identify risk factors for avoidable transfer among pediatric trauma patients in southwest Florida. METHODS: All pediatric trauma patients 2 years and older transferred from outlying hospitals to the emergency department of a single state-designated pediatric trauma center between 2009 and 2017 were obtained from the institutional registry. Transfers were classified as avoidable if the patient suffered only minor injuries (International Classification of Diseases-9th Rev. Injury Severity Score > 0.9), did not require invasive procedures or intensive care unit monitoring, and was discharged within 48 hours. Demographics and injury characteristics were compared for avoidable and nonavoidable transfers. Logistic regression was used to estimate the independent effects of age, sex, insurance type, mechanism of injury, diagnosis, within region versus out-of-region residence, suspected nonaccidental trauma, and abnormal Glasgow Coma Scale score on the risk of avoidable transfer. RESULTS: A total of 3,876 transfer patients met inclusion criteria, of whom 1,628 (42%) were classified as avoidable. Among avoidable transfers, 29% had minor head injuries (isolated skull fractures, concussions, and mild traumatic brain injury not otherwise specified), and 58% received neurosurgery consultation. On multivariable analysis, the strongest risk factors for avoidable transfer were diagnoses of isolated skull fracture or concussion. Suspected nonaccidental trauma was predictive of nonavoidable transfer. CONCLUSION: Among injured children 2 years and older, those with minor head injuries were at greatest risk for avoidable transfer. Many were transferred because of a perceived need for evaluation by a pediatric neurosurgeon. Future projects seeking to reduce avoidable transfers should focus on children with isolated skull fractures and concussions, in whom there is no suspicion of nonaccidental trauma. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Challenges of the Transition from Pediatric Care to Care of Adults: "Say Goodbye, Say Hello".

Transition has been defined as "the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centered to adult-oriented health care systems." We will here describe the challenges of such a process: challenges coming from the pediatrician, from the adolescent, linked to the disease itself, and those from the parents. We will outline how to overcome those fears and challenges to provide a successful transition process. A key factor to underline that process is that a relationship based on confidence should be established between the pediatrician and the physician for adults, in order for that relationship, based on trust, to be the basis for the transfer of the adolescent from the pediatric system of care to the adult one.

Traslado de pacientes críticos / Critical care transport

Critical care transport is a raising need in health care because patients who have medical conditions that exceed the capabilities of the initial treating facility require timely safe transport to referral centers. Therefore, indications for inter-hospital transfer include the need for specialist intervention, a critical bed not available or ongoing support not provided in the referring hospital. The aim of transferring a critically ill patient to a reference center is to improve prognosis, and this potential benefit must outweigh potential harm derived of eventual complications or adverse events that could happen during transportation, because critically ill patients have a high risk of morbidity and mortality during transport. The most frequent indications of transfer involve time-dependent pathologies, such as Cardiovascular and Neurologic Emergencies. Pre-transport evaluation and stabilization is critical, as it contributes to minimize in-transport risks, and it must consider aspects as adequate monitoring, transportation times and conditions...

Utilizing electronic health record data to determine the health of the medication process after the relocation of a children's hospital.

UNLABELLED: Hospital relocation is a highly complex undertaking, which has the potential to interrupt operations and poses risks for patients, staff, and providers. Little is known how hospital relocation impacts on workflow and communication. METHODS: Using existing Electronic Health Record (EHR) data we determined time from medication ordering to first dose administration as a proxy for well-being of the medication process during a five months window surrounding the relocation of a 205-bed children's hospital. RESULTS: Overall performance of the medication process has declined slightly. We identified regional (unit) differences with the pediatric intensive care unit, which had the most significant changes to its workflow, experiencing a more than doubling of the time from ordering to medication administration. Overall, there was no significant difference in time-sensitive medication administration times. Evaluating the medication ordering-dispensing-administration process through readily available EHR data demonstrated that the impact of a hospital' s relocation on workflow and communication can be successfully monitored.

Accuracy of the new ICD-9-CM code for "drip-and-ship" thrombolytic treatment in patients with ischemic stroke.

A new International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code, V45.88, was approved by the Centers for Medicare and Medicaid Services (CMS) on October 1, 2008. This code identifies patients in whom intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is initiated in one hospital's emergency department, followed by transfer within 24 hours to a comprehensive stroke center, a paradigm commonly referred to as "drip-and-ship." This study assessed the use and accuracy of the new V45.88 code for identifying ischemic stroke patients who meet the criteria for drip-and-ship at 2 advanced certified primary stroke centers. Consecutive patients over a 12-month period were identified by primary ICD-9-CM diagnosis codes related to ischemic stroke. The accuracy of V45.88 code utilization using administrative data provided by Health Information Management Services was assessed through a comparison with data collected in prospective stroke registries maintained at each hospital by a trained abstractor. Out of a total of 428 patients discharged from both hospitals with a diagnosis of ischemic stroke, 37 patients were given ICD-9-CM code V45.88. The internally validated data from the prospective stroke database demonstrated that a total of 40 patients met the criteria for drip-and-ship. A concurrent comparison found that 92% (sensitivity) of the patients treated with drip-and-ship were coded with V45.88. None of the non-drip-and-ship stroke cases received the V45.88 code (100% specificity). The new ICD-9-CM code for drip-and-ship appears to have high specificity and sensitivity, allowing effective data collection by the CMS.

Reshuffling the DRG deck. New cardiac DRGs praised for more equitable reimbursements while post-acute-transfer changes are generating some worries.

The CMS' changes to its DRGs, which took effect Oct. 1, could alter hospitals' bottom lines significantly. The addition of 16 DRGs makes a total of 526 classifications that will dictate payments and determine hospital services and patient mix. Tom Watson, left, a partner with accounting firm BKD, which specializes in healthcare reimbursement, says it's unlikely the changes will put any hospitals out of business, but they will feel a pinch.

Expansion of Medicare's definition of post-acute care transfers.

In October 1998, the definition of a transfer in Medicare's hospital prospective payment system was expanded to include several post-acute care (PAC) providers in 10 high-volume PAC diagnosis-related groups (DRGs). In this methodological article, the authors respond to a congressional mandate to consider more DRGs in the definition. Empirical results support expansion to many more DRGs that are split in ways that understate total PAC volumes, including 25 DRG pairs (with/without complications) and DRG bundles (e.g., infections) that together exhibit high PAC volumes. By contrast, some DRGs (e.g., craniotomy) are questionable PAC candidates because of their heterogenous procedure mix.

Transport of the critically ill patient: an example of an integrated model.

AIMS: To demonstrate a model for the transport of critically ill patients between hospitals, and the aiding of primary emergency responses (A-Zeros). METHOD: A review of a model based on Waikato Hospital is carried out. RESULTS: Categories of transport, modes of transport, standards, and the funding model are described. The total Waikato experience includes over 2500 patients transported between hospitals and 325 A-Zeros. A detailed analysis of cases between 1988-94 is presented. CONCLUSIONS: The Waikato model has worked well. A formal system needs to be instituted in New Zealand to handle interhospital transport of the critically ill and also to provide medical help at the scene of emergencies based on advanced trauma and intensive care centres.

Intrahospital transport of critically ill patients.

Intrahospital transport of critically ill patients must be considered as part of the critical care continuum. The level of care provided must be commensurate with the severity of illness. These transfers are intensive in terms of utilization of personnel and resources. Advance preparation and optimal coordination of the transport process go a long way toward safer transfers of the critically ill.