Emergency Transfers: An Important Predictor of Adverse Outcomes in Hospitalized Children
In-hospital arrests are uncommon in pediatrics, making it difficult to identify the risk factors for unrecognized deterioration and to determine the effectiveness of rapid response systems. An emergency transfer (ET) is a transfer from an acute care floor to an intensive care unit (ICU) where the patient received intubation, inotropes, or ≥3 fluid boluses in the first hour after arrival or before transfer. Improvement science work has reduced ETs, but ETs have not been validated against important health outcomes. This case–control study aimed to determine the predictive validity of an ET for outcomes in a free-standing children’s hospital. Controls were matched in terms of age, hospital unit, and time of year. Patients who experienced an ET had a significantly higher likelihood of in-hospital mortality (22% vs 9%), longer ICU length of stay (4.9 vs 2.2 days), and longer posttransfer length of stay (26.4 vs 14.7 days) compared with controls (P < .03 for each).
© 2019 Society of Hospital Medicine
Cases
We identified all ET cases from an existing situation awareness database in which each RRS call is entered by the hospital nursing supervisor, whose role includes responding to each RRS activation. If the patient transfer meets the ET criteria, the nurse indicates this in the database. Each ET entry is later confirmed for assurance purposes by the nurse leader of the RRS committee (RG). For the purposes of this study, all records were again reviewed and validated using manual chart review in the electronic health record (Epic Systems, Verona, Wisconsin).
Controls
We identified nonemergent ICU transfers to serve as controls and matched those to ET in cases to limit the impact of confounders that may increase the likelihood of both an ET and a negative outcome such as ICU mortality. We identified up to three controls for each case from our database and matched in terms of age group (within five years of age), hospital unit before transfer, and time of year (within three months of ET). These variables were chosen to adjust for the impact of age, diversity of disease (as hospital units are generally organized by organ system of illness), and seasonality on outcomes.
Outcome Measures
Posttransfer LOS in the ICU, posttransfer hospital LOS, and in-hospital mortality were the primary outcome measures. Patient demographics, specific diagnoses, and number of medical conditions were a priori defined as covariates of interest. Data for each case and control were entered into a secure, web-based Research Electronic Data Capture (REDCap) database.
Analysis
Descriptive data were summarized using counts and percentages for categorical variables and medians and ranges for continuous variables due to nonnormal distributions. Chi-square test was used to compare in-hospital mortality between the ETs and the controls. The Wilcoxon rank-sum test was used to compare LOS between ETs and controls. All data analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina).
RESULTS
A total of 45 ETs were identified, and 110 controls were matched. Patient demographics were similar among all cases and controls (P > .05). Patients with ETs had a median age of seven years (interquartile range: 3-18 years), and 51% of them were males. The majority of patients among our examined cases were white (68%) and non-Hispanic (93%). There was no statistical difference in insurance between the ETs and the controls. When evaluating the hospital unit before the transfer, ETs occurred most commonly in the Cardiology (22%), Hematology/Oncology (22%), and Neuroscience (16%) units.
ETs stayed longer in the ICU than non-ETs [median of 4.9 days vs 2.2 days, P = .001; Figure (A)]. Similarly, ET cases had a significantly longer posttransfer hospital LOS [median of 35 days vs 21 days, P = .001; Figure (B)]. ETs had a 22% in-hospital mortality rate, compared with 9% in-hospital mortality in the matched controls (P = .02; Table).
DISCUSSION
Children who experienced an ET had a significantly longer ICU LOS, a longer posttransfer LOS, and a higher in-hospital mortality than the matched controls who were also transferred to the ICU. Researchers and improvement science teams at multiple hospitals have demonstrated that interventions targeting improved situation awareness can reduce ETs; we have demonstrated that reducing ETs may reduce subsequent adverse outcomes.8,10
