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Fragile: Handle With Care

Bohuslav “Bob” Humplik serves as a pilot for the MEDUCARE Flight Team, which transfers patients by ambulance and helicopter 24/7.
Bohuslav “Bob” Humplik serves as a pilot for the MEDUCARE Flight Team, which transfers patients by ambulance and helicopter 24/7.

Risk of death remains higher for interhospital transfer patients than for patients admitted via emergency departments

By Shawn Oberrath

Seriously ill patients require serious, higher-level care and sometimes must be transferred from one hospital to another to gain access to procedures, tests or expertise that only an academic medical center can deliver. The benefits of interhospital transfer (IHT) are believed to outweigh the risks, but national studies indicate that transferred patients have a higher risk of dying than patients admitted to the hospital locally through the emergency department. And with about 1.6 million patients transferred between hospitals each year, this safety risk needs to be resolved as a top priority.

While national studies demonstrate worse outcomes for IHT patients, these studies are unable to control for patient-level details such as individual vital signs, laboratory values and specific disease processes. A few single-center studies controlling for patient-level characteristics were performed in the 1980s and 1990s, but health care has changed enormously since then.

Marc Heincelman, M.D., a hospitalist and assistant professor at MUSC, notes that patient safety has become a major target over the last two decades. As he explains, “With the implementation of electronic health records, expansion of hospitalists, and enhanced focus on quality improvement and safety, we need to look at patient-level characteristics associated with transfer.”

He led a new study, recently published in the Journal of General Internal Medicine, to examine the safety of IHT within the modern health care system. The research team separated data for about 9,000 hospital inpatients into groups based on how the patients were admitted — via IHT, the emergency department or a clinic. The team then used data modeling to examine the relationship between IHT and the risk of death in the context of individual patient details, such as the receiving hospital service, demographic information, specific disease processes, vital signs and laboratory data.

“We found two interesting things,” says Heincelman. “First, detailed patient-level variables do play a role in predicting mortality, and second, even after controlling for those variables, interhospital transfer itself is still associated with inpatient mortality.”

The study revealed that while the overall mortality risk was about two times higher for IHT patients than for patients admitted via an emergency department, that risk changed to 1.7 times after the researchers controlled for patients’ vital signs and laboratory values. But even allowing for the effect of vital signs and lab values, outcomes for transfer patients were still worse than those for patients admitted through emergency departments.

Heincelman and colleagues next plan to examine the transfer process in detail, looking at factors like the day and time of transfer, the busyness of the admitting service during transfer, the time between the hospital accepting the patient and the actual arrival time, and the accuracy and effective- ness of communications.

“I still think that the patients are inherently sicker; we just don’t have a way to measure their illness with models that we currently have,” Heincelman said. “But I also think that there are areas within the transfer process that can be improved to increase patient safety.”

He hopes that this will lead to better outcomes for patients who need to be transferred from one hospital to another.