Interfacility neurosurgical transfers: an analysis of nontraumatic inpatient and emergency department transfers with implications for improvements in care

Abstract

OBJECTIVE Interfacility neurosurgical transfers to tertiary care centers are driven by a number of variables, including lack of on-site coverage, limited available technology, insurance factors, and patient preference. The authors sought to assess the timing and necessity of surgery and compared transfers to their institution from emergency departments (ED) and inpatient units at other hospitals. METHODS Adult neurosurgical patients who were transferred to a single tertiary care center were analyzed over 12 months. Patients with traumatic injuries or those referred from skilled nursing facilities or rehabilitation centers were excluded. RESULTS A total of 504 transferred patients were included, with mean age 55 years (range 19-92 years); 53% of patients were women. Points of origin were ED in 54% cases and inpatient hospital unit in 46%, with a mean distance traveled for most patients of 119 miles. Broad diagnosis categories included brain tumors (n = 142, 28%), vascular lesions, including spontaneous and hypertensive intracerebral hemorrhage (n = 143, 28%), spinal lesions (n = 126, 25%), hydrocephalus (n = 45, 9%), wound complications (n = 29, 6%), and others (n = 19, 4%). Patients transferred from inpatient units had higher rates of surgical intervention (75% vs 57%, p < 0.001), whereas patients transferred from the ED had higher rates of urgent surgery (20% vs 8%, p < 0.001) and shorter mean time to surgery (3 vs 5 days, p < 0.001). Misdiagnosis rates were higher among ED referrals (11% vs 4%, p = 0.008). Across the same timeframe, patients undergoing elective admission (n = 1986) or admission from the authors' own ED (n = 248) had significantly shorter lengths of stay (p < 0.001) and ICU days (p < 0.001) than transferred patients, as well as a significantly lower total cost ($44,412, $46,163, and $72,175, respectively; p < 0.001). CONCLUSIONS The authors present their 12-month experience from a single tertiary care center without Level I trauma designation. In this cohort, 65% of patients required surgery, but the rates were higher among inpatient referrals, and misdiagnosis rates were higher among ED transfers. These data suggest that admitting nonemergency patients to local hospitals may improve diagnostic accuracy of patients requiring urgent care, more precisely identify patients in need of transfer, and reduce costs. Referring facilities may lack necessary resources or expertise, and the Emergency Medical Treatment and Active Labor Act (EMTALA) obligates tertiary care centers to accept these patients under those circumstances. Telemedicine and integration of electronic medical records may help guide referring hospitals to pursue additional workup, which may eliminate the need for unnecessary transfer and provide additional cost savings.

Inter-facility transfer of patients with traumatic intracranial hemorrhage and GCS 14–15: The pilot study of a screening protocol by neurosurgeon to avoid unnecessary transfers

“…Avoidance of interfacility transfer is associated with potential cost savings [1] , [2] , [3] , [4] , [5] , [6] , [7] , [8] , [22] . Arnold et al retrospectively reviewed the records of TBI patients with GCS 13–15 transferred to a level 1 trauma center in their respective hospital system.…”

“…Traumatic brain injury (TBI) is a common reason for transfer to trauma centers for neurosurgical evaluation [1] , [2] , [3] , [4] , [5] , [6] . Results from a recent TRACK-TBI study revealed that less than 50% of patients with so-called “mild” TBI (i.e., Glasgow Coma Score (GCS), 13–15) reported full return to pre-injury levels of day-to-day function at one-year post-injury [7] , highlighting the need for further study of long-term functional limitations in this group of patients.…”

Demographics and Outcomes of Interhospital Transfer Patients Undergoing Intracranial Tumor Resection: A Retrospective Cohort Analysis

“…This holds true emphatically for neurosurgical patients, for whom both avoidable IHT and inefficient transfer infrastructure leave room for quality improvement. In one series of neurosurgical patients, 57.4% of IHT led to no surgical intervention and in another one 34.5% IHTs were non-operative [1,2]. The direct transportation costs for avoidable transfers amounted to $1.46 million over two years in a study of neurosurgical IHT [2].…”

“…In one series of neurosurgical patients, 57.4% of IHT led to no surgical intervention and in another one 34.5% IHTs were non-operative [1,2]. The direct transportation costs for avoidable transfers amounted to $1.46 million over two years in a study of neurosurgical IHT [2].…”

Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies

“…6 Prior systematic studies have described general patterns of EMTALA enforcement, 6 resulting fines, [7][8][9][10] impact of the law on on-call coverage, 11 and patterns of EMTALA transfers for surgical subspecialty care. [12][13][14][15][16][17] Despite the fact that labor is the only medical condition named in the title of the law, EMTALA violations related to labor and other OB emergencies have not previously been systematically described in the peer-reviewed medical literature.…”