Original Article
The Effect of Treatment Delays Associated with Inpatient Inter-hospital Transfer from Peripheral to Tertiary Hospitals for the Surgical Treatment of Cardiology Patients

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Background

Nearly 100,000 presentations to non-tertiary hospitals per year result in an inpatient transfer [1]. The timely inter-hospital transfer of patients for cardiothoracic surgery is significant to their overall outcomes. We hypothesised that patients with a prolonged pre-operative admission were at risk of nosocomial infection, leading to prolonged hospitalisation, morbidity and mortality.

Methods

Patients admitted to a non-tertiary centre (Frankston Hospital, Group 1) and requiring transfer to tertiary centres for cardiac surgery were compared to patients presenting directly to tertiary centres (Alfred Hospital, Group 2; St Vincent's Hospital, Group 3) from June 2011–July 2012. Data was obtained from medical records and the National Cardiac Surgery Database.

Results

Eighty-seven patients in Group 1, 78 patients in Group 2 and 65 patients in Group 3 were identified. A higher proportion of total admission time was spent awaiting surgery in Group 1 compared to Group 2 (52.8% vs. 38.3%, p≤0.001) and Group 3 (52.8% vs. 26.3%, p≤0.001). Nosocomial infections occurred more frequently in Group 1 compared to Group 2 (20.7% vs. 5.1%, p=0.04) and Group 3 (20.7% vs. 6%, p<0.001).

Conclusion

Presentation to a non-tertiary centre requiring inpatient cardiothoracic surgery is associated with longer pre-operative waiting time and higher rates of hospital-acquired infections.

Introduction

A significant number of patients present to non-tertiary hospitals and then require definitive inpatient surgical treatment at a tertiary centre. Thirty-two per cent of all Australian public hospital emergency department presentations are to hospitals not classified as principal referral centres, accounting for over two million presentations per year. From this group, nearly 100,000 presentations per year result in an inpatient transfer, further emphasising the role of initial management and referral by non-tertiary centres [1].

In order to properly service this demand, services such as coronary angiography and angioplasty are now readily available in peripheral centres, despite the lack of on-site cardiothoracic services. Recent studies have demonstrated the procedural safety of this approach with no increased risk of adverse outcomes [2]. Yet, for a variety of clinical and logistical reasons, a subset of patients treated at such peripheral sites will require definitive surgical treatment in an inpatient setting. Specialised cardiothoracic surgery (CTS) requires significant human and technological resources, resulting in such services congregating in larger, usually metropolitan based, tertiary centres. Thus increasingly, inter-hospital transfers between peripheral and tertiary centres are required for definitive management of these patients. This is particularly the case in the Australian health system where large cities such as Sydney and Melbourne have geographically vast greater metropolitan areas, serviced by relatively sparse peripheral centres, with a clustering of tertiary referral centres in and around the CBD [11]. The inter-hospital transfer of such patients consequently becomes an important component of the patient's overall management. Previous studies have focussed on the timely transfer of critically ill patients such as those with ST elevation acute myocardial infarction [3], or severe sepsis but have not specifically looked at the effect of inter-hospital transfer for definitive treatment in patients already partially evaluated. This population is growing, particularly in cardiology (both locally and worldwide), as peripheral catheter laboratories undertake initial evaluation of presenting patients [2], [5], [6], [7].

We sought to assess the outcomes of patients initially presenting to a cardiology unit in a peripheral Melbourne non-tertiary centre who required inpatient transfer to a tertiary centre for cardiothoracic surgery. We hypothesised that patients with a prolonged pre-operative admission were at risk of acquiring a nosocomial infection, leading to prolonged hospitalisation and increasing risk of morbidity and mortality.

Section snippets

Methods

We evaluated all patients admitted to Frankston Hospital (Group 1), a non-tertiary centre, over a 14-month period (1st June 2011 to 31st July 2012) who then required inpatient transfer to a tertiary centre for definitive cardiothoracic surgical treatment. For comparison, similar data was obtained from patients presenting directly to the tertiary centres, the Alfred (Group 2) and St Vincent's Hospitals (SVH) (Group 3) who required inpatient cardiothoracic surgical treatment over the same

Results

Of the 8024 cardiology admissions across the three study hospitals during the study period, 230 patients met the inclusion criteria – 87 patients in Group 1, 78 patients in Group 2 and 65 patients in Group 3 (see Figure 1). There were no significant differences between the groups with regards to baseline demographics (age and sex), Euroscore score and the presence of major cardiovascular risk factors. Patients in Group 1 were more likely to undergo isolated CABG, than patients in Groups 2 and

Discussion

This research found that patients presenting to a peripheral cardiology centre and requiring inpatient transfer to a tertiary centre for definitive surgical treatment experienced significantly longer pre-operative inpatient stays, largely due to the delays associated with inpatient transfer. This group of patients were also almost five times more likely to suffer a hospital-acquired infection (most commonly pneumonia) then their counterparts presenting directly to tertiary centres.

A major

Conclusion

In conclusion, this study demonstrated that initial presentation to a non-tertiary centre of patients requiring inpatient cardiothoracic surgery is associated with significantly longer pre-operative waiting time and higher rates of hospital acquired infections than their counterparts presenting to a tertiary centre. Further research in this area is needed, however these findings suggest that a streamlined process facilitating transfer of such patients may improve outcomes and reduce treatment

Acknowledgements

There has been no financial, technical or other assistance to be acknowledged in this project.

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