ICULocation of patients before transfer to a tertiary care intensive care unit: Impact on outcome
Introduction
Intensive care units (ICUs) at tertiary care hospitals may receive a significant portion of their patients from outside referring institutions. Several studies have compared the outcome of patients transferred to tertiary care ICUs with those directly admitted to the ICU at these institutions. Although data reports by Duke and Green [1], Surgenor et al [2], and Golestanian et al [3] did not demonstrate any difference in mortality between such patients, Durairaj et al [4] and Rosenberg et al [5] found higher mortality rates among patients transferred from outside facilities when compared to those admitted directly to the ICU at tertiary care centers. Even after adjustment for case mix and severity of illness, it has been demonstrated that there may be a significantly higher mortality rate in transfer patients than in those admitted directly to a tertiary care ICU. Investigators at the University of Michigan found that, in benchmarking analyses, a tertiary care facility with a 25% transfer rate would be “penalized” by 14 excess deaths per 1000 admissions unless the source of admission was taken into account [5]. No data have been evaluated until now specifically comparing outcomes in transfer patients based on their location before transfer, an outside hospital's emergency department (ED) vs an outside hospital's ICU.
The purpose of this study was to determine whether the location of patients at a referring hospital before transfer to the medical surgical intensive care unit (MSICU) of a tertiary care hospital has an impact on the outcome of these patients.
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Materials and methods
This study was performed as a retrospective analysis of closed records within the Project Impact (PI) database (Cerner Corporation, Kansas City, Mo) of a medical-surgical ICU (MSICU) in an urban, tertiary care teaching hospital. Project Impact is a critical care data system, which incorporates clinical, demographic, and acuity data on critically ill patients. Approval was granted for the performance of this study by the Cooper University Hospital Institutional Review Board. Adult patients
Results
A total of 503 patients transferred from outside EDs (283 patients) or ICUs (220 patients) were identified in the period studied, accounting for approximately 15.4% of the 3267 admissions during that time. In the analysis of all transferred patients, despite being older, EDtx had better overall survival, as well as lower ICU and HLOS than ICUtx (Table 1).
Among patients in group 1 (ICH), no differences were identified in any of the demographic or outcome parameters measured (Table 1).
Among
Discussion
Our findings indicate that transfer from an ED to a tertiary care ICU with a diagnosis other than an acute intracerebral event (ICH or nonhemorrhagic CVA) is associated with better outcomes when compared to transfer from an outside ICU. The explanation for this difference is speculative at the present time, but may involve factors such as differences in the acuity of patients transferred from different sources and/or the ability to deliver a higher level of care to critically ill patients at
Conclusion
Our findings indicate that transfer to a tertiary care ICU from the ED of a referring hospital is associated with better outcomes when compared with transfers from outside ICUs. There are several potential clinical implications of these findings. The application of standard acuity scoring systems to transferred patients may not be appropriate and may result in underestimations of the severity of illness of such patients. Such underestimations may erroneously negatively impact outcome data at
References (16)
- et al.
Effect on ICU mortality of a full-time critical care specialist
Chest
(1989) Leapfrog and critical care: evidence- and reality-based intensive care for the 21st century
Am J Med
(2004)- et al.
Outcome of critically ill patients undergoing interhospital transfer
Med J Aust
(2001) - et al.
Survival of patients transferred to tertiary intensive care from rural community hospitals
Crit Care
(2001) - et al.
Effect of interhospital transfer on resource utilization and outcomes at a tertiary care referral center
Crit Care Med
(2007) - et al.
Prognostic factors for mortality following interhospital transfers to the medical intensive care unit of a tertiary referral center
Crit Care Med
(2003) - et al.
Accepting critically ill transfer patients: adverse effect on a referral center's outcome and benchmark measures
Ann Intern Med
(2003) - et al.
Treatment and prevention of primary intracerebral hemorrhage
Semin Neurol
(2005)