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Publicly funded interfacility ambulance transfers for surgical and obstetrical conditions: A cross sectional analysis in an urban middle-income country setting.

ABSTRACT: INTRODUCTION:Interfacility transfers may reflect a time delay of definitive surgical care, but few studies have examined the prevalence of interfacility transfers in the urban low- and middle-income (LMIC) setting. The aim of this study was to determine the number of interfacility transfers required for surgical and obstetric conditions in an urban MIC setting to better understand access to definitive surgical care among LMIC patients. METHODS:A retrospective analysis of public interfacility transfer records was conducted from April 2015 to April 2016 in Cali, Colombia. Data were obtained from the single municipal ambulance agency providing publicly funded ambulance transfers in the city. Interfacility transfers were defined as any patient transfer between two healthcare facilities. We identified the number of transfers for patients with surgical conditions and categorized transfers based on patient ICD-9-CM codes. We compared surgical transfers from public vs. private healthcare facilities by condition type (surgical, obstetric, nonsurgical), transferring physician specialty, and transfer acuity (code blue, emergent, urgent and nonurgent) using logistic regression. RESULTS:31,659 patient transports occurred over the 13-month study period. 22250 (70.2%) of all transfers were interfacility transfers and 7777 (35%) of transfers were for patients with surgical conditions with an additional 2,244 (10.3%) for obstetric conditions. 49% (8660/17675) of interfacility transfers from public hospitals were for surgical and obstetric conditions vs 32% (1466/4580) for private facilities (P<0.001). The most common surgical conditions requiring interfacility transfer were fractures (1,227, 5.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), trauma (652, 2.9%), and acute abdomen (271, 1.2%). CONCLUSION:Surgical and obstetric conditions account for nearly half of all urban interfacility ambulance transfers. The most common reasons for transfer are basic surgical conditions with public healthcare facilities transferring a greater proportion of patient with surgical conditions than private facilities. Timely access to an initial healthcare facility may not be a reliable surrogate of definitive surgical care given the substantial need for interfacility transfers.

SUBMITTER: Truche P

PROVIDER: S-EPMC7647066 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Publicly funded interfacility ambulance transfers for surgical and obstetrical conditions: A cross sectional analysis in an urban middle-income country setting.

Truche Paul P NeMoyer Rachel E RE Patiño-Franco Sara S Herrera-Escobar Juan P JP Torres Myerlandi M Pino Luis F LF Peck Gregory L GL

PloS one 20201106 11

<h4>Introduction</h4>Interfacility transfers may reflect a time delay of definitive surgical care, but few studies have examined the prevalence of interfacility transfers in the urban low- and middle-income (LMIC) setting. The aim of this study was to determine the number of interfacility transfers required for surgical and obstetric conditions in an urban MIC setting to better understand access to definitive surgical care among LMIC patients.<h4>Methods</h4>A retrospective analysis of public in ...[more]

PMID: 33156837

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Project description:BackgroundHealthcare spending has grown over the last decades in all developed countries. Making hard choices for investments in a rational, evidence-informed, systematic, transparent and legitimate manner constitutes an important objective. Yet, most scientific work in this area has focused on developing/improving prescriptive approaches for decision making and presenting case studies. The present work aimed to describe existing practices of priority setting and resource allocation (PSRA) within the context of publicly funded health care systems of high-income countries and inform areas for further improvement and research.MethodsAn online qualitative survey, developed from a theoretical framework, was administered with decision-makers and academics from 18 countries. 450 individuals were invited and 58 participated (13% of response rate).ResultsWe found evidence that resource allocation is still largely carried out based on historical patterns and through ad hoc decisions, despite the widely held understanding that decisions should be based on multiple explicit criteria. Health technology assessment (HTA) was the tool most commonly indicated by respondents as a formal priority setting strategy. Several approaches were reported to have been used, with special emphasis on Program Budgeting and Marginal Analysis (PBMA), but limited evidence exists on their evaluation and routine use. Disinvestment frameworks are still very rare. There is increasing convergence on the use of multiple types of evidence to judge the value of investment options.ConclusionsEfforts to establish formal and explicit processes and rationales for decision-making in priority setting and resource allocation have been still rare outside the HTA realm. Our work indicates the need of development/improvement of decision-making frameworks in PSRA that: 1) have well-defined steps; 2) are based on multiple criteria; 3) are capable of assessing the opportunity costs involved; 4) focus on achieving higher value and not just on adoption; 5) engage involved stakeholders and the general public; 6) make good use and appraisal of all evidence available; and 6) emphasize transparency, legitimacy, and fairness.

Project description:IntroductionIn Uganda, 2% of women die from maternal causes with a mortality rate of 336 maternal deaths per 100,000 live births. According to the World Health Organization Uganda is one of the top three contributors to maternal mortality in sub-Saharan Africa. Uganda has parallel weak ambulance systems, government, and non-government-owned, that transport obstetric emergencies to higher-level facilities. These two operations lack standards of medical care and inter-facility transfer (IFT) protocols to direct care. Limited studies exist which assess the state of Emergency Care Services in Uganda and none has been performed to assess the ambulance referral services utilized to address obstetric emergencies.ObjectiveThe present study was performed to describe the ambulance transfer processes of obstetric emergencies by analyzing cases arriving at Kawempe National Referral Hospital (KNRH) from outlying health facilities.MethodsThe study was based at KNRH in Kampala, Uganda. It was a descriptive and analytic cross-sectional study. Trained research assistants enrolled participating patients who met the inclusion criteria consecutively on arrival by ambulance at the hospital. Utilizing a questionnaire, quantitative data was collected from the ambulance driver, the sending facility referral form, and the receiving hospital's ambulance log book for each case. The sample size was 215.ResultsThe median age was 27 years and the majority of patients were referred because of hypertensive disorders (34.9%), obstructed labor (26.5%) and hemorrhage (20.9%). The median total response time for transfer of obstetric emergencies was 50 min, from ambulance activation until the mother was received at KNRH. Differences were identified between government and non-government-owned ambulances in regards to the method of activation, medical escort staffing, number of vital signs recorded, and ambulance onboard medical care. Ambulances parked at the facility took the shortest transfer time and EMT-supported ambulances had the greatest number of vital signs taken.ConclusionsRecommendations are to develop an integrated ambulance system for both government and non-government ambulances with standards especially in regards to standardized scripted call-center calls analysis, dispatch activation time, response-to-patient time, and trained ambulance professional staffing and medical care whenever in patient transport mode.

Project description:Study designSecondary overtriage is a burden to the medical system. Unnecessary transfers overload trauma centers, occupy emergency transfer resources, and delay definitive patient care. Craniomaxillofacial (CMF) trauma, especially in isolation, is a frequent culprit.ObjectiveThe aim of this study is to assess the perspectives of facial trauma surgeons regarding the interfacility transfer of patients with isolated CMF trauma.MethodsA 31-item survey was developed using Likert-type scale and open-ended response systems. Internal consistency testing among facial trauma surgeons yielded a Cronbach's α calculation of .75. The survey was distributed anonymously to the American Society of Maxillofacial Surgeons, the North American Division of AO Craniomaxillofacial, and the American Academy of Facial Plastic and Reconstructive Surgery. Statistical significance in response plurality was determined by nonoverlapping 99.9% confidence intervals (P < .001). Sum totals were reported as means with standard deviations and z scores with P values of less than .05 considered significant.ResultsThe survey yielded 196 responses. Seventy-seven percent of respondents did not believe that most isolated CMF transfers required emergency surgery and roughly half (49%) thought that most emergency transfers were unnecessary. Fifty-four percent of respondents agreed that most patients transferred could have been referred for outpatient management and 87% thought that transfer guidelines could help decrease unnecessary transfers. Twenty-seven percent of respondents had no pre-transfer communication with the referring facility. Perspectives on the transfer of specific fracture patterns and their presentations were also collected.ConclusionMost facial trauma surgeons in this study believe that emergent transfer for isolated CMF trauma is frequently unnecessary. Such injuries rarely require emergent surgery and can frequently be managed in the outpatient setting without activating emergency transfer services. The fracture-specific data collected are a representation of the national, multidisciplinary opinion of facial trauma surgeons and correlate with previously published data on which specific types of facial fractures are most often transferred unnecessarily. The results of this study can serve as the foundation for interfacility transfer guidelines, which may provide a valuable resource in triaging transfers and decreasing associated health-care costs.

Project description:BackgroundCOVID-19, the pandemic caused by the severe acute respiratory syndrome coronavirus-2, is challenging healthcare systems worldwide. Little is known about problems faced by emergency medical services-particularly helicopter services-caring for suspected or confirmed COVID-19 patients. We aimed to describe the issues faced by air ambulance services in Europe as they transport potential COVID-19 patients.MethodsNine different HEMS providers in seven different countries across Europe were invited to share their experiences and to report their data regarding the care, transport, and safety measures in suspected or confirmed COVID-19 missions. Six air ambulance providers in six countries agreed and reported their data regarding development of special procedures and safety instructions in preparation for the COVID-19 pandemic. Four providers agreed to provide mission related data. Three hundred eighty-five COVID-19-related missions were analysed, including 119 primary transport missions and 266 interfacility transport missions.ResultsAll providers had developed special procedures and safety instructions in preparation for COVID-19. Ground transport was the preferred mode of transport in primary missions, whereas air transport was preferred for interfacility transport. In some countries the transport of COVID-19 patients by regular air ambulance services was avoided. Patients in interfacility transport missions had a significantly higher median (range) NACA Score 4 (2-5) compared with 3 (1-7), needed significantly more medical interventions, were significantly younger (59.6 ± 16 vs 65 ± 21 years), and were significantly more often male (73% vs 60.5%).ConclusionsAll participating air ambulance providers were prepared for COVID-19. Safe care and transport of suspected or confirmed COVID-19 patients is achievable. Most patients on primary missions were transported by ground. These patients were less sick than interfacility transport patients, for whom air transport was the preferred method.

Project description:ImportancePediatric referral centers are increasingly using telemedicine to provide consultations to help care for acutely ill children presenting to rural and community emergency departments (EDs). These pediatric telemedicine consultations may help improve physician decision-making and may reduce the frequency of overtriage and interfacility transfers.ObjectiveTo examine the use of pediatric critical care telemedicine vs telephone consultations associated with risk-adjusted transfer rates of acutely ill children from community and rural EDs.Design, setting, and participantsA cluster-randomized crossover trial was conducted between November 18, 2015, and March 26, 2018. Analyses were conducted from January 19, 2018, to July 23, 2022, 2022. Participants included acutely ill children aged 14 years and younger presenting to a participating ED in 15 rural and community EDs in northern California.InterventionsParticipating EDs were randomized to use telemedicine or telephone for consultations with pediatric critical care physicians according to 1 of 4 unbalanced (3 telemedicine:1 telephone) crossover treatment assignment sequences.Main outcomes and measuresIntention-to-treat, treatment-received, and per-protocol analyses were performed to determine the risk of transfer using mixed effects Poisson regression analyses with random intercepts for presenting EDs to account for hospital-level clustering.ResultsA total of 696 children (392 boys [56.3%]; mean [SD] age, 4.2 [4.6] years) were enrolled. Of the 537 children (77.2%) assigned to telemedicine, 251 (46.7%) received the intervention. In the intention-to-treat analysis, patients assigned to the telemedicine arm were less likely to be transferred compared with patients assigned to the telephone arm after adjusting for patient age, severity of illness, and hospital study period (risk rate [RR], 0.93; 95% CI, 0.88-0.99). The adjusted risk of transfer was significantly lower in the telemedicine arm compared with the telephone arm in both the treatment-received analysis (RR, 0.81; 95% CI, 0.71-0.94) and the per-protocol analysis (RR, 0.79; 95% CI, 0.68-0.92).Conclusions and relevanceIn this randomized trial, the use of telemedicine to conduct consultations for acutely ill children in rural and community EDs resulted in less frequent overall interfacility transfers than consultations done by telephone.Trial registrationClinicalTrials.gov Identifier: NCT02877810.

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Publicly funded interfacility ambulance transfers for surgical and obstetrical conditions: A cross sectional analysis in an urban middle-income country setting.

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Publicly funded interfacility ambulance transfers for surgical and obstetrical conditions: A cross sectional analysis in an urban middle-income country setting.

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