Timing of emergency interhospital transfers from subacute to acute care and patient outcomes: A prospective cohort study

Background: Australian and international data show that transfer from inpatient rehabilitation to acute care hospitals occurs in one in ten patients. Early unplanned transfers from subacute to acute care hospitals raises questions about the safety of patient transitions between health sectors. Objectives: To explore the characteristics of early and late emergency interhospital transfers from subacute to acute care. The investigators defined early transfers as occurring within 1 day and late transfers occurring after 1 day after subacute care admission. Design: This prospective, exploratory cohort study is a subanalysis of data from a larger case-time-control study. Setting: Twenty-two wards of eight subacute care hospitals in five major health services in Victoria, Australia. All subacute care hospitals were geographically separate from their health services' acute care hospitals. Participants: All patients with an emergency transfer from inpatient rehabilitation or geriatric evaluation and management wards to an acute care hospital within the same health service were included. Patients receiving palliative care were excluded. Methods: Data were collected between 22 August 2015 and 30 October 2016 by record audit. To compare patient and admission characteristics between early and late transfers Cochran-Mantel-Haenszel test (CMH) or logistic regression were used to account for health service clustering effect. Results: There were 602 transfers: 54 early (48 patients) and 548 late transfers (505 patients). There was no difference in median age (79.5 vs 80, p=0.680) or Charlson Comorbidity index (both groups=3, p=0.933). Early transfer patients had lower functional independence measure scores on subacute care admission (median 45 vs 66, p < 0.001). Prior to transfer, fewer early transfers had a limitation of medical treatment order in place during their subacute care admission (25.9% vs 48.7%, p < 0.001). The majority ofboth early and late transfers resulted in acute care hospital readmission (85.1% vs 77.7%, p=0.204). For patients admitted to acute care, there was no difference in median acute care length of stay (6.5 vs 8 days, p=0.367). Early transfer patients had fewer in-hospital deaths than late transfer patients (3.8% vs 16.1%, p=0.004). Conclusions: The high rates of acute care readmission in both groups suggest that transfer was warranted. Early transfer patients had lower in-patient mortality so emergency interhospital transfers, while resource intensive, appear to have a safety benefit. Early transfer patients were less likely than late transfer patients to have limitation of medical treatment orders, so the influence of resuscitation status and patient goals of care on transfer decisions warrants further investigation. (C) 2019 Elsevier Ltd. All rights reserved.