A QASM PERSPECTIVE

A QASM December 2023 (Volume 5) Delayed interhospital transfers Two Queensland Audit of Surgical Mortality (QASM) assessors have stated that: “The delay in transfer to another hospital contributed to the patient’s poor outcome” and “Delay in transfer of an elderly comorbid patient resulted in loss of opportunity for early surgery that may have reduced the risk of death.”

PURPOSE

This report highlights the challenges of interhospital transfers in Queensland. Important recommendations and resources are provided below.

BACKGROUND

Interhospital transfers and delayed interhospital transfers both contribute to delayed surgery and longer hospital stays with increased clinical management issues (CMIs).1, 2 This is particularly so in emergency general surgery patients.2–5 Despite hospital transfer guidelines, surgical mortality audit data show that 10% of patients experienced delayed hospital transfers 1, 2, 6 and 11% had CMIs that contributed to patient mortality.2 Surgical mortality audit data define delayed hospital transfer as a subjective assessment made by the reporting surgeon, who felt the patient transfer did not occur within a clinically expected and safe timeframe for the patient’s condition.1 In Queensland public and private hospitals, between January 2018 and December 2022, 93,115 patients had interhospital transfers during their last hospital admission. Transfers included 24,517 surgical patients (26.3%; median age 51 years, interquartile range [IQR] 28–67), 63,207 medical patients (67.9%; median age 61 years, IQR 30–77) and 5,391 patients admitted for other interventions (5.8%; median age 62 years, IQR 48–74). Of the surgical patients, most (63%; n = 15,517) were male (female 37%; n = 9,000).

For QASM during this same period, 1,430 patients had interhospital transfers (median age 73 years, IQR 60–82). The median transfer distance for all patients was 88 km (IQR 25–250; transfer distance not recorded for 50 patients). Transfers were delayed for 146 patients (10.2%). For all patient transfers 7.5% (44/584) were delayed from metropolitan hospitals (<50 km); 11.8% (50/423) were delayed from rural hospitals (50–200 km) and 13.9% (52/373) were delayed from remote hospitals (>200 km). Most delayed patients (43.8%; 46/146) were classified ASA 4 (American Society of Anesthesiologists physical status classification system) and had a median age of 73 years (IQR 62–81). In 42 instances (28.8%) the delayed patient was a trauma victim.

QASM assessors identified CMIs in 40 patients with delayed transfers; 28 CMIs in these patients were preventable, including 3 adverse events, 13 areas of concern and 12 areas of consideration. Intensive Care Unit (ICU) bed availability was flagged as a contributor to delayed transfers for 11 patients; this affected one patient in 2018, one patient in 2020, 3 patients in 2021 and 6 patients in 2022.

Themed factors contributing to delayed interhospital transfers were classified based on publications using surgical mortality audit data and clinicians’ views. Themes were independently classified by 3 investigators; consensus was reached for each case and verified by a clinician. When more than one theme emerged from a case, the most significant was reported. Table 1 shows the preventable and non-preventable delay in transfers as a proportion of each dominant theme.

Table 1. Preventable and non-preventable delay in transfers THEME

Preventable (n = 92; 63%)

Non-preventable (n = 54; 37.0%)

Patient factors (unstable, unexpected deterioration, delay seeking healthcare)

14 (29.8%)

33 (70.2%)

Local facility factors (under-resourced, radiology access issues, missing expertise or experience, inadequate clinical management)

44 (91.7%)

4 (8.3%)

Logistical factors (Retrieval Services Queensland [RFDS] or Queensland Ambulance Service [QAS] delayed by other jobs, insufficient aircraft/ambulance or staff, weather conditions, after hours transfer or multiple transfers)

14 (50.0%)

14 (50.0%)

Communication factors (issues with decision-making for transfers, finding an accepting team, too many phone calls, unclear about referral pathways, questionable transfer, no operation after transfers)

20 (87.0%)

3 (13.0%)

The following case studies and vignettes highlight themes which contribute to delay in interhospital transfers in Queensland.* QASM CASE STUDY 1 A nursing-home patient had been complaining of a sore throat for several days. He presented to the local emergency department (ED) because he was distressed and had stopped eating. A computed tomography (CT) scan performed that morning was reported on late in the day. The initial review missed a denture in the pharynx. The airway oedema around the denture was underestimated.

The local hospital had no Otolaryngology Head and Neck service. When the denture was recognised and reported, a tertiary referral hospital was contacted. The patient was transferred that evening.

On arrival, the patient was unable to swallow and had stridor. Later that evening, he was taken to theatre but swelling made intubation difficult.

On removal of the denture, a large volume of pus was released from the related abscess. He remained intubated and was transferred to ICU. Family discussions took place and a one-way trial of extubation followed. The patient had ongoing airway compromise and died with comfort measures.

Lesson: This death was avoidable. The nursing home staff did not communicate a missing denture, and the delayed adverse findings on CT scan delayed the patient’s transfer for surgery. These circumstances resulted in airway compromise.

A QASM QASM CASE STUDY 2 An elderly patient sustained traumatic crush injuries. Bilateral lower limb tourniquets were applied at the scene. He arrived at the regional hospital 40 minutes after sustaining the injuries. The vascular and orthopaedic surgeons declined to operate because of the complex injuries, so arranged transfer to a tertiary referral hospital. The tourniquets were not to be removed.

The helicopter arrived approximately one hour after the retrieval call. Two and half hours later, it left for the tertiary referral hospital. One hour later it arrived with the trauma team in attendance. The patient had X-rays and was transferred to theatre, where 4 consultant surgeons were present. The bilateral tourniquets were released 6 hours post-application. Active arterial bleeding was not found. A left through-knee amputation was completed. The degloving injury was debrided and dressings were applied. The patient subsequently had multiple surgeries and progressively deteriorated. A right above-knee amputation was performed. At the fourth debridement, the left through-knee amputation progressed to an above-knee amputation. Ongoing wound issues became overwhelming. The patient entered renal failure and died from sepsis.

Lesson: Surgical management at the regional hospital would have benefited the patient and may have made the interhospital transfer a lifesaving option. There was delayed transfer to the tertiary referral hospital and the patient had 6 hours of bilateral tourniquets to his lower limbs, resulting in long-term ischaemia.

QASM CASE STUDY 3 An elderly patient had a fall and sustained a left distal femoral peri-prosthetic fracture.

The patient was admitted to a regional hospital, but because of anaesthetic risks was referred to a tertiary referral hospital. The transfer was accepted; however, she arrived 5 days later. Planning for surgery was further delayed because of insufficient work-up for surgery from the anaesthetic department. Her surgery was performed 8 days after the fall. Appropriate postoperative care plans were made.

The morning after surgery, repeat chest X-rays were performed due to the patient’s deteriorating condition. The palliative care team was notified.

She died 24 hours post-surgery. The cause of death was multiple organ failure on a background of multiple cardiovascular and respiratory comorbidities.

Lesson: Earlier transfer to the tertiary referral hospital, and faster work-up and decision to operate with the anaesthetic department could have potentially changed this patient’s outcome.

QASM CASE STUDY 4 An elderly patient with right pyelonephritis was on antibiotics for a diabetic foot infection. He was admitted for sepsis and acute kidney injury. A CT of kidneys, ureters and bladder showed hydronephrosis of unclear cause. He was clinically stable.

The urology team discussed the patient, who would be transferred to a nearby tertiary referral hospital if he deteriorated. This eventuated over the weekend. Urology planned for a category B stent once the patient was well enough for transfer.

On the Sunday (prior to transfer), he tested positive for COVID-19, which delayed the transfer due to short staffing and the need for increased staffing to meet COVID-19 protocols. The transfer was delayed until the Monday. COVID-19 protocols for surgery were implemented once the patient was at the tertiary referral hospital. These protocols were also complicated by short staffing (2 scrub teams were required).

There were no intraoperative delays or complications. Postoperatively, the patient had ongoing delirium and fatigue. There was an inability to administer intravenous antibiotics. The patient and his family requested palliative care.

Lesson: Considering the circumstances, this case highlights unpreventable issues. However, with no COVID-19 nor staffing issues, an earlier transfer would have been more efficient with a better outcome.

QASM VIGNETTES 1: A patient fell at home and sustained C5-6 fracture dislocation with complete cord injury and multiple rib fractures. An interhospital transfer from hospital A to a spinal team at a tertiary referral hospital was arranged. When the helicopter arrived at hospital A, there was a last-minute destination change to a different tertiary referral hospital due to notification of a lack of ICU beds at the first tertiary referral hospital.

2: A patient was discussed with Vascular Surgery and accepted for transfer at hospital B. The transfer occurred 2 days after accepting the patient due to bed pressures.

3: A trauma patient was admitted to a peripheral hospital (without a trauma team or 24-hour onsite theatre staff) and underwent a damage control laparotomy within 3 hours of presentation. At the completion of the procedure there was no active bleeding. Prior to the operation a massive transfusion protocol had been initiated and immediate contact was made with hospital B to provide appropriate ongoing care. The RFDS transfer took 9 hours. (This is not unusual considering that patient transfer logistics are beyond the control of the doctors or the hospitals.

RFDS or QAS transfers are dependent on staff availability to provide safe care during transport.)

4: T his patient should probably have stayed at hospital A to die peacefully in the presence of family. Instead, the patient was transferred a long distance to hospital B, suffered cardiac arrest and was then transferred to hospital C. If sufficient or accurate information had been provided to hospital C, there would have been no transfer and no operation.

5: A patient with a known infected total hip replacement had been an inpatient in an orthopaedic unit for 3 weeks prior to transfer. The patient was not transferred to the final treating unit until renal and hepatic failure necessitated ICU care.

6: A patient presented from home to a private hospital ED with acute worsening of chronic abdominal pain and a syncopal/hypotensive episode.

The CT angiography identified a ruptured type 1A endoleak. A private vascular surgeon was unavailable. The patient and imaging were discussed with hospital B and accepted for cuff insertion. There were no ICU beds at hospital B; nearby hospital C was also on bypass. Hospital D, although further away, accepted the patient for transfer at 17:00. The patient was too heavy for a rotary wing plane, necessitating RFDS transfer. The patient was hypotensive and being resuscitated until arrival at hospital D theatre at about 22:30.

7: A patient was admitted with a ruptured aortic arch aneurysm and a large right haemothorax. The patient was accepted for urgent transfer to the cardiothoracic team at hospital B. There was a considerable delay in transfer due to poor weather rendering the flight unsafe. During the delay, the patient suffered several arrests with resuscitation requiring a high-dose adrenaline infusion to maintain output, and a massive transfusion protocol was enacted.

8: A 2-month-old patient sustained a severe closed head injury. There was a significant delay in aeromedical retrieval due to difficulties with ventilation and instability, and the initial retrieval team feeling they were ill-equipped to transfer the child. This required a second retrieval team with a paediatric ICU consultant, which inevitably delayed transfer.

A QASM LIMITATIONS

Delay in transfer data are from surgeons’ clinical judgements. A surgeon may not report each delay in transfer because these delays occur frequently.

Therefore, this QASM report represents the minimum data for delay in transfer. Consistently, all mortality audits in Australia report 10% delay in transfer.

DISCUSSION

Review of QASM data shows that patient factors is the most frequent theme related to delay in transfers. This includes delay in patients seeking healthcare and unexpected patient deterioration. Local facility factors, largely due to inadequate clinical management, resource issues and radiology access issues, were predominantly preventable. ICU bed availability was highlighted as a contributor to delay in transfers for 11 patients.

This affected 3 patients in 2021 and 6 patients in 2022, possibly due to COVID-19-infected patients occupying ICU beds. Preventable and nonpreventable delays in transfer were equal within the theme of logistical factors, while delay in transfers were largely preventable within the theme of communication factors. Within this theme, 'questionable transfers' and 'no operation after transfer' were less frequent than outright communication issues.

Best practice for each patient remains a priority. When contemplating transferring a patient, each patient's needs and their presenting circumstances should be considered.

RECOMMENDATIONS

• Encourage the Royal Australasian College of Surgeons and other specialty colleges to provide support for surgeons who may have to refuse a futile transfer but who experience pressure to administratively admit patients under their care only for palliative reasons.

• Develop guidelines to enable retrieval services to transfer patients to the best facility rather than the closest.

• Develop clear pathways to enable peripheral hospitals to expedite transfers to tertiary centres.

• Improve support for clinicians and services at smaller hospitals.

• Improve communication between senior clinicians prior to initiation of patient transfer.

RESOURCES

Healthcare Improvement Unit, Clinical Excellence Queensland Protocol for the management of inter-hospital transfers. Queensland Health, 2021.

Available from: https://www.health.qld.gov.au/system-governance/policies-standards/health-service-directives/patient-access-to-care/ protocol-for-management-of-inter-hospital-transfers Queensland Audit of Surgical Mortality. Distance, delays and deterioration – improving surgical care in regional Queensland [seminar recording].

Townsville Hospital, 2019. Available from: URL: https://www.youtube.com/playlist?list=PLnAHK9sihHOJtNr_baqXCvxuIfmLzjFg6 Clinical Excellence Commission. Clinical Focus Report: Retrieval and inter-hospital transfer. New South Wales Government, 2013. Available from: https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0019/259210/Clinical-Focus-Report-Retrieval-and-Inter-Hospital-Transfer.pdf

ACKNOWLEDGMENTS

• Dr Martin Wullschleger, Queensland trauma surgeon • Queensland Surgical Advisory Committee *These case studies and vignettes are edited from QASM cases, and first- or second-line assessments that have been generated by expert surgeons in the field. Any recommendations relate to the cases as they were presented.

REFERENCES

1. Young E, Kopunic HS, Trochsler MI, Maddern GJ. Predictors of interhospital transfer delays in acute surgical patient deaths in Australia: a retrospective study. ANZ J Surg. 2022;92(6):1322-31. Available from: https://onlinelibrary.wiley.com/doi/10.1111/ans.17669 2. Murshed I, Gupta AK, Camilos AN, Sabab A, Bacchi S, Kovoor JG, et al. Surgical interhospital transfer mortality: national analysis. Br J Surg.

2023;110(5):591-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10364502/ 3. Young E, Khoo T-W, Trochsler MI, Maddern GJ. Factors influencing interhospital transfer delays in emergency general surgery: a systematic review and narrative synthesis. ANZ J Surg. 2022;92(6):1314-21. Available from: https://academic.oup.com/bjs/article/110/5/591/7060325 4. Cave B, Najafali D, Gilliam W, Barr JF, Cain C, Yum C, et al. Predicting outcomes for interhospital transferred patients of emergency general surgery. Crit Care Res Pract. 2022;2022:8137735. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9033401/ 5. Emanuelson RD, Brown SJ, Termuhlen PM. Interhospital transfer (IHT) in emergency general surgery patients (EGS): A scoping review. Surg Open Sci. 2022;9:69-79. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9190042/ 6. Queensland Audit of Surgical Mortality. Distance, delays and deterioration – improving surgical care in regional Queensland [seminar recording].

Townsville Hospital: Queensland Audit of Surgical Mortality; 2019. Available from: https://www.youtube.com/playlist?list=PLnAHK9sihHOJtNr_ baqXCvxuIfmLzjFg6

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