Timing of emergency interhospital transfers from subacute to acute care and patient outcomes: A prospective cohort study

https://doi.org/10.1016/j.ijnurstu.2018.12.008Get rights and content

Abstract

Background

Australian and international data show that transfer from inpatient rehabilitation to acute care hospitals occurs in one in ten patients. Early unplanned transfers from subacute to acute care hospitals raises questions about the safety of patient transitions between health sectors.

Objectives

To explore the characteristics of early and late emergency interhospital transfers from subacute to acute care. The investigators defined early transfers as occurring within 1 day and late transfers occurring after 1 day after subacute care admission.

Design

This prospective, exploratory cohort study is a subanalysis of data from a larger case-time-control study.

Setting

Twenty-two wards of eight subacute care hospitals in five major health services in Victoria, Australia. All subacute care hospitals were geographically separate from their health services’ acute care hospitals.

Participants

All patients with an emergency transfer from inpatient rehabilitation or geriatric evaluation and management wards to an acute care hospital within the same health service were included. Patients receiving palliative care were excluded.

Methods

Data were collected between 22 August 2015 and 30 October 2016 by record audit. To compare patient and admission characteristics between early and late transfers Cochran-Mantel-Haenszel test (CMH) or logistic regression were used to account for health service clustering effect.

Results

There were 602 transfers: 54 early (48 patients) and 548 late transfers (505 patients). There was no difference in median age (79.5 vs 80, p = 0.680) or Charlson Comorbidity index (both groups = 3, p = 0.933). Early transfer patients had lower functional independence measure scores on subacute care admission (median 45 vs 66, p < 0.001). Prior to transfer, fewer early transfers had a limitation of medical treatment order in place during their subacute care admission (25.9% vs 48.7%, p < 0.001). The majority of both early and late transfers resulted in acute care hospital readmission (85.1% vs 77.7%, p = 0.204). For patients admitted to acute care, there was no difference in median acute care length of stay (6.5 vs 8 days, p = 0.367). Early transfer patients had fewer in-hospital deaths than late transfer patients (3.8% vs 16.1%, p = 0.004).

Conclusions

The high rates of acute care readmission in both groups suggest that transfer was warranted. Early transfer patients had lower in-patient mortality so emergency interhospital transfers, while resource intensive, appear to have a safety benefit. Early transfer patients were less likely than late transfer patients to have limitation of medical treatment orders, so the influence of resuscitation status and patient goals of care on transfer decisions warrants further investigation.

Section snippets

What is already known about the topic?

  • Despite the important role of subacute care in the Australian healthcare system, there is a dearth of research related to the care and outcomes of patients in the subacute care sector

  • Approximately 10% of rehabilitation care admissions result in transfer to an acute care hospital, however issues related to transition between acute and subacute sectors and patient movement between acute and subacute care hospitals is poorly understood

  • Unexpected transfers from inpatient rehabilitation hospitals to

What this paper adds

  • Patients with early and late emergency interhospital transfers from subacute to acute care had similar demographic and comorbidity profiles and similar acute care admission characteristics prior to subacute care admission

  • Readmission to acute care hospital was the most common transfer outcome in both groups suggesting that transfer was warranted and the lower mortality in early transfer patients suggests emergency interhospital transfers have a patient safety benefit

  • Early transfer patients had

Method

This prospective, exploratory cohort study is a subanalysis of data derived from a larger case-time-control study (Suissa, 1995) conducted across 21 wards of eight subacute care facilities located within five major health services in Victoria, Australia (Considine et al., 2018). All subacute care hospitals in this study were geographically separate from their health services’ acute care hospitals. The inclusion criterion was all patients with an emergency interhospital transfer from inpatient

Results

There were 54 early transfers in 48 patients (four patients had two transfers and one patient had three transfers) and 548 late transfers in 505 patients (39 patients had two transfers and two patients had three transfers) and there was one transfer in which the exact timing could not be accurately determined, leaving a sample of 602 transfers. The median length of stay in subacute care prior to transfer time was 16.3 h for early transfers and 211 h (8.8 days) for late transfers. The patient

Discussion

In this study, two transitions in care: subacute care admission (planned movement of the patient from an acute care to a subacute care hospital) and emergency interhospital transfer from the subacute care to an acute care hospital were analysed in relation to time of emergency interhospital transfer from the subacute care facility. Key differences between early and late transfer patients were that early transfer patients were less likely to have a limitation of treatment order at any time

Conclusion

Patients with early and late emergency interhospital transfers from subacute to acute care had similar demographic and comorbidity profiles and similar acute care admission characteristics prior to transition to subacute care hospitals. Acute care hospital readmission was the most common transfer outcome in both groups suggesting that transfer was warranted. Further, early transfer patients had lower in-patient mortality so emergency interhospital transfers, while resource intensive, appear to

Funding

This work was supported by a Deakin University School of Nursing and Midwifery grant.

Competing interests

There are no conflicts of interest to declare. No author had any financial or professional relationships which may pose a competing interest to the study or decision to submit the manuscript for publication.

Acknowledgements

The authors wish to thank Adjunct Professors David Plunkett, Cheyne Chalmers, Sharon Donovan, Janet Weir-Phyland and Lucy Cuddihy for their support of this work and Renata Mistarz RN, Sam Xenos RN, Sue Streat RN, Joanne Stafford RN, Kath Colvin RN and Lee Hughes RN for their assistance with data collection.

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