A. Ingraham1, D. Yang1, J. Havlena1, B. Hanlon1, S. Fernandes-Taylor1, J. Schumacher1, H. Santry2 1University Of Wisconsin,Madison, WI, USA 2Ohio State University,Columbus, OH, USA
Introduction: As the population ages and access to emergency surgical care declines, patients are increasingly being transferred. Most transfers originate from emergency departments (EDs). Guidelines to facilitate timely, appropriate emergency general surgery (EGS) transfers are lacking. We determined patient- and hospital-level factors associated with interhospital transfers of EGS patients originating from the ED.
Methods: Adult EGS patients (defined by American Association for the Surgery of Trauma ICD-9 diagnosis codes) were identified within the 2008-2014 Nationwide Emergency Department Sample (n=47,427,836). Patient- and hospital-level factors were examined as predictors of transfer to another acute care hospital with a multilevel, logistic regression model to assess the effect of risk factors for transfer using weights to provide national estimates. Patient-level factors considered included EGS diagnosis type indicator variables, sex, age, insurance type, zip-code level income, Charlson comorbidity index, and weekend admission. Hospital-level factors included volume (total number of ED visits), trauma center status, non-metropolitan/metropolitan teaching status, region, and hospital ownership.
Results: 893,429 (2%) encounters resulted in a transfer. Transferred patients were on average 56.7±0.4 years old and more likely to have Medicare (45%) than private insurance (27%) or Medicaid (14%). EGS diagnoses most commonly associated with transfer were general abdominal (29% of transferred encounters) and upper gastrointestinal tract (21%) conditions. Transfer was significantly more likely for encounters with select EGS diagnosis groups [resuscitation (Odds Ratio [OR] 23.53, 95% Confidence Interval [CI] 19.56-28.31); cardiothoracic (OR=8.46, CI=7.42-9.65); intestinal obstruction (OR=4.62, CI=4.10-5.19)] than encounters for patients without those conditions. (Table) Hospital-level factors associated with increased odds of transfer included non-metropolitan (vs. metropolitan non-teaching hospitals), Midwestern (vs. Northeastern region), and level III or non-trauma center (vs. levels I or II). Patient factors included older age, male gender, higher comorbidity scores, either Medicare or private insurance, and patients living in zip codes with lower levels of income.
Conclusion: The odds of transfer varies widely by EGS diagnosis even after controlling for important patient and hospital-level factors. Consideration of these factors is a starting point for developing EGS triage criteria based on presenting symptoms as is currently done for myocardial infarctions or cerebrovascular accidents in our nation’s EDs.
