Guidelines for Transfer to Specialized Centers



Fig. 10.1
Time from admission to death for untreated ruptured abdominal aortic aneurysms (Adapted from Lloyd et al. [1])





Current State



Emergency Department Deaths for Ruptured Abdominal Aortic Aneurysm


One of the perceived limitations in achieving a successful outcome for a patient requiring transfer is the potential opportunity cost of awaiting transfer. When no organized system of care exists specifically for the care of ruptured abdominal aortic aneurysm, emergency department (ED) death can occur when local treatment is unavailable. Although some of these ED deaths encompass those who arrive in extremis, a percentage of these deaths also reflect those who deteriorate while awaiting definitive care [2]. A recent study using the Nationwide Emergency Department Sample (NEDS) data found 7 % of patients died in the ED and another 6 % admitted to the presenting hospital died without treatment. It is not possible from the NEDS dataset to determine exactly why patients died in the ED or were not offered transfer; however, one can hypothesize that these patients were either in extremis on presentation precluding transfer or worsened while awaiting transfer. The study suggests that the later explanation may be a larger factor as those more likely to have an ED death included those who were older and who presented to nonmetropolitan hospitals (Table 10.1). Nonmetropolitan hospitals were also most likely to transfer patients. The high ED death rate and transfer rate may imply that these facilities were not able to provide local care. Without a rapid and reliable transfer process, a percentage of these deaths are likely preventable with better regional systems of care.


Table 10.1
Predictors of ED death for ruptured abdominal aortic aneurysm
















































































Factor

Adjusted ORa

95 % CI

P-value

Rural vs. urban teaching hospital

1.9

1.2–2.9

0.001

Rural vs. urban nonteaching hospital

1.4

0.9–2.1

0.12

Low-volume ED

1.3

0.8–2.2

0.25

Moderate-volume ED

1.0

0.7–1.4

0.92

High-volume ED

1.0

Referent
 

Region

East

0.5

0.3–0.8

0.008
 
South

0.4

0.3–0.7

0.001
 
Midwest

0.6

0.4–0.9

0.02
 
West

1.0

Referent
 

Trauma designation
 
0.9

0.5–1.4

0.54

Age (per decade)

1.9

1.6–2.2

<0.0001

Male gender

0.7

0.5–0.9

0.008


aAdjusted for comorbidity and insurance status

The need for predefined transfer plans may be even more important in geographic regions where the land mass to hospital facility ratio is greatest. The NEDS study also identified differences in ED death by region. The West had almost double the ED death rate even after adjusting for demographic and hospital factors. Further underscoring the difficulties with transfer across larger geographic constraints, the West was also the least likely to transfer patients. As the Western Region of the United States has approximately 25 % of the US population but 50 % of the land mass, our findings suggest that patients who have greater travel distances and travel times to the initial ED may be more likely to become clinically unstable upon arrival or before transfer can be arranged (REF).


Transfer for Treatment of Ruptured Abdominal Aortic Aneurysm


In the current era of publically reported outcomes, many centers remain concerned about the implications on overall institutional mortality when accepting high-risk patient transfers. In the case of ruptured abdominal aortic aneurysms, single-center studies have reported equivalent outcomes for treatment of ruptured abdominal aortic aneurysm after transfer [37]. However, in these studies only those receiving treatment for their aneurysm were included. Thus, those transferred who did not undergo treatment or who died prior to reaching the receiving hospital were not captured These studies suffer from survivor bias given that patients had to survive transfer and be stable enough for treatment on arrival.

This limitation was addressed in a follow-up study using an intent-to-treat analysis linking State Inpatient Databases and Emergency Department Databases for New York, California, and Florida to compare outcomes for ruptured abdominal aortic aneurysm between those transferred for care with those treated at the presenting institution [8]. Almost 20 % of patients were transferred for definitive care (REF). Most patients were transferred a short distance (median, 27 miles), and few (<8 %) traveled great distances defined as >100 miles. The study found equivalent mortality rates for those transferred (45 %) patients to those treated without transfer (43 %). Unfortunately, among those transferred, 17 % still died without receiving treatment. When accounting for these patients in the intent-to-treat analysis, transfer was actually associated with an increased mortality (Table 10.2).


Table 10.2
Inter-facility transfer and ruptured abdominal aortic aneurysm mortality























 
Adjusted odds ratioa

95 % CI

P-value

Nonoperative deaths excluded

0.81

0.68–0.97

0.02

Nonoperative deaths included

1.30

1.05–1.60

0.01


aAdjusted for age, gender, weekend presentation, admission year, state, comorbidity, and insurance status

Although transfers were more common on weekends, mortality was independent of time of presentation. One of the interesting findings was the annual increase in transfer rates over time from 15 % in 2005 to 24 % in 2010. Transferred patients had fewer comorbid medical conditions and were more likely to present to smaller nonteaching hospitals. These findings further support the hypothesis that those most likely to benefit from transfer are those that are stable enough to receive an operation when they arrive at the receiving facility. Establishing transfer guidelines is unlikely to benefit those who are in extremis at the initial treating facility, but likely will have the greatest impact on those patients who are harmed by delays in care that convert them from stable to potentially unstable while awaiting transfer. The key finding thus far is that the benefits of the current de facto transfer process seen on a population level could be interpreted that transfer is associated with a higher mortality; the alternative and likely more accurate summation is that attention should be focused on improving the transfer process to increase the likelihood of clinical stability during transfer and consequently improve overall survival [9].


Patient Selection


Although under the development by the Western Vascular Society, no current guidelines or standards exist in the United States for selecting the ruptured abdominal aortic aneurysm patient suitable for repair, especially when inter-facility transfer is needed. Clinical algorithms [1015] for predicting death have been reported, but clinical utility is still questioned. Hospitals and clinicians considering the acceptance of transferred patients are often faced with patients who are not hemodynamically stable or have a large burden of preexisting comorbidities making survival from repair even more challenging. Prior studies have hypothesized that transferred patients who die without a repair were either not candidates for repair or were those who would have been candidates but decline during the transfer process. Included in the unsuitable repair group are patients that have forgone prior elective repair often due to extensive comorbidities. Not uncommonly, these patients request repair when presented with the life-threatening realization that they are dying from a ruptured aneurysm.

Electing to proceed with transfer of these types of patients including the unstable patient is a difficult decision point for both the clinicians and the patient where the default is often to initiate transfer. A recent survey of vascular surgeons in the Western United States revealed that most had few if any exclusion criteria for accepting transfers for ruptured abdominal aortic aneurysm [16]. Specifically, age was not a consideration. Only 7 % reported age greater than 90 years as preclusion for transfer. Similarly, 19 % did not consider transfer for those with severe underlying systemic disease and 34 % for those unable to perform activities of daily living [2].

The approach of US vascular surgeons is in stark contrast to those that practice in a socialized medical system with a recent survey of the United Kingdom providers citing underlying health and lifestyle considerations as major factors in the decision-making process [17]. Both groups identified cardiac arrest requiring CPR as a contraindication to transfer, but hypotension requiring inotropic support was not.

Without established guidelines for patient selection, current transfer decisions vary across institutions, regions, and on a case-by-case basis. This likely increases time delay as the request for clinical evaluation, diagnostic laboratory tests, or radiographic imaging may be extensive, time intensive, and ultimately unnecessary. For example, respondents in the US study were far more likely to require evaluation by a surgeon or a CT scan prior to transfer compared with the UK respondents [16]. In summary, there is a growing need as transfer has become more common to provide guidance on who clearly will not benefit, while maintaining liberal criteria for those in whom transfer would be advantageous when combined with an efficient and efficacious overall approach to treatment.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Nov 11, 2017 | Posted by in ABDOMINAL MEDICINE | Comments Off on Guidelines for Transfer to Specialized Centers

Full access? Get Clinical Tree

Get Clinical Tree app for offline access