SLR - July 2021 - Stephanie N. Campbell

Optimizing Safety for Surgical Patients Undergoing Interhospital Transfer

Reference: Ingraham A & Reinke CE. Optimizing Safety for Surgical Patients Undergoing Interhospital Transfer. Surg Clin of N Am. 2021 Jan 31; 101(1). 

Level of Evidence: IV

Scientific Literature Review 

Reviewed By: Stephanie N. Campbell, DPM
Residency Program: West Penn Hospital – Pittsburgh, PA

Podiatric Relevance: Time sensitive procedures have developed standardized practices of care and intervention that are best practice to improve time to urgent treatment and thus prognosis. This is not true of surgical transfers due to complexity of diagnoses, interventional procedures/surgeries and available treating physicians. As such, it is important to note that surgical patients are transferred more frequently, and outcomes vary with increased rates of adverse outcomes in most studies. 

Most acute needs surgeries involving transfer reviewed in this study are for general surgery, noting increased mortality risk. One reason of particular interest to the Podiatric Surgeon is increased mortality in the treatment of necrotizing fasciitis when transferred for surgical intervention.

Podiatric surgeons consulted to care for patients in the hospital setting should remain aware of the increased risks and care gaps associated with transferred surgical patients to identify and prevent medical errors to improve patient safety. 

Methods: Current literature review and National Inpatient Sample database focusing on patient transition of care due to urgent or emergent medical and specific surgical needs.

Results: Patients who undergo interhospital transfer have increased rates of adverse outcomes, with seven papers reviewed observing increased mortality among transferred surgical patients. The patient population for interhospital transfer are more ill. Hospital level characteristics more strongly predict the need for patient transfer than patient-related factors and include small or medium size hospital centers, government based and rural or urban nonteaching. Patient transfers are inherently associated with increased resource use, repeat imaging and laboratory testing. 

Conclusions: The interhospital transferred surgical patient is identified as uniquely vulnerable. Surgical patients are at a higher risk of care issues and poor outcomes as compared to non-surgical patient transfers or the surgical patient that is directly admitted to the same institution. 

It is important to note the many factors that contribute to patient transfers, from institutional, procedural and physician accessibility to medical complexity and social preference. Patient hospital relationship, family expectation, resource availability – particularly imaging, operating room facilities, procedural services and suites, and providers not available at current facility can initiate transfer. The process of referring and accepting providers with different medical and surgical perspectives coordinating transfer, time to transfer, mismatched or incomplete medical records and surgical transcript, pending culture or pathology data needing forwarded, lack of family expectation as plans develop between hospitals, and deteriorating patient status compound over the transfer process. We can infer, and anticipate, poor outcomes with problems at any point during this transfer.

Opportunities to standardize acute patient transfer models between various health care centers can benefit the patient, surgeons, hospitals, if done with a conscientious mindset to fill in care gaps, ensure safety and patient outcomes. 

Further research remains necessary to understand what portion of adverse medical outcomes are caused by the details of patient transfer, inter-institutional communication, patient comorbidities and severity of disease, or ultimately overall poor prognosis despite institution care resources and surgeons. 

Educational Opportunities