Dataset Information

A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage.

ABSTRACT:

Goal

Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers' perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage.

Materials and methods

We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method.

Findings

The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers' questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions.

Conclusions

The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians' voices.

SUBMITTER: Finn EB

PROVIDER: S-EPMC8354217 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:IntroductionNontraumatic intracranial hemorrhage (ICH) is a neurological emergency of research interest; however, unlike ischemic stroke, has not been well studied in large datasets due to the lack of an established administrative claims-based definition. We aimed to evaluate both explicit diagnosis codes and machine learning methods to create a claims-based definition for this clinical phenotype.MethodsWe examined all patients admitted to our tertiary medical center with a primary or secondary International Classification of Disease version 9 (ICD-9) or 10 (ICD-10) code for ICH in claims from any portion of the hospitalization in 2014-2015. As a gold standard, we defined the nontraumatic ICH phenotype based on manual chart review. We tested explicit definitions based on ICD-9 and ICD-10 that had been previously published in the literature as well as four machine learning classifiers including support vector machine (SVM), logistic regression with LASSO, random forest and xgboost. We report five standard measures of model performance for each approach.ResultsA total of 1830 patients with 2145 unique ICD-10 codes were included in the initial dataset, of which 437 (24%) were true positive based on manual review. The explicit ICD-10 definition performed best (Sensitivity = 0.89 (95% CI 0.85-0.92), Specificity = 0.83 (0.81-0.85), F-score = 0.73 (0.69-0.77)) and improves on an explicit ICD-9 definition (Sensitivity = 0.87 (0.83-0.90), Specificity = 0.77 (0.74-0.79), F-score = 0.67 (0.63-0.71). Among machine learning classifiers, SVM performed best (Sensitivity = 0.78 (0.75-0.82), Specificity = 0.84 (0.81-0.87), AUC = 0.89 (0.87-0.92), F-score = 0.66 (0.62-0.69)).ConclusionsAn explicit ICD-10 definition can be used to accurately identify patients with a nontraumatic ICH phenotype with substantially better performance than ICD-9. An explicit ICD-10 based definition is easier to implement and quantitatively not appreciably improved with the additional application of machine learning classifiers. Future research utilizing large datasets should utilize this definition to address important research gaps.

Project description:BackgroundNo consensus based national standard for interhospital transports of critically ill patients exists in Norway. The local hospitals are responsible for funding, organizing and performing these transports, resulting in potentially different level of care for the critically ill patients depending on local hospital resources and not the level of severity in the patient's condition. The aim of this study was to examine how these transports are executed and to discover challenges during transports and potentials of improvement.MethodsA qualitative study with 20 semi-structured interviews of doctors, nurses and ambulance personnel representing a wide range in experience and formal education, reflecting the different compositions of crews performing interhospital transports was conducted. A systematic text condensation of the interviews was performed to describe personal experiences and values.ResultsFew interviewees reported special adverse events when asked. Instead they chose to describe more general characteristics of the working environment, their own positive emotions or fears and the strengths and weaknesses of the organizational system. The prehospital working environment was described as different from the in-hospital environment. The personnel experienced being on their own during transports, lack of procedures and checklists and often no systematic education or demanded preparedness for participating. The resident doctors described pressure from elderly colleagues to participate in the transports. At the same time, all interviewees reported a self-interest in participating in these transports.ConclusionsSafe interhospital transports of the critically ill patients are challenged by the characteristics of the out of hospital environment. The transports are described as potentially unsafe for both patients and personnel. Systematic education is warranted, highlighting the use of checklists and special educational programs in prehospital critical care medicine. The strong personal interest to participate in these transports may serve as a barrier against changing todays system. To ensure the right level of competence and safety for each unique patient, it is imperative to standardize the interhospital transports on a national level, built on consensus from experienced prehospital personnel.Trial registrationThe trial is approved and registered by the local representative for the Norwegian Data Protection Authority as trial 13-7751.

Project description:BackgroundSuboptimal triage of critically ill patients with surgical sepsis may contribute to adverse outcomes. Patients transferred to a tertiary care center after spending 24 hours or longer at an outside facility were compared with patients who had early triage to a tertiary care center with the null hypothesis that management parameters and outcomes would be similar between groups.MethodsThis prospective observational cohort study included 308 patients treated for surgical sepsis in a surgical intensive care unit at a tertiary care center. Patients transferred after spending more than 24 hours at an outside facility (n = 69) were compared with patients who were directly admitted or transferred within 24 hours (n = 239). Patient characteristics, management parameters, and outcomes were compared between groups. This study was registered at ClinicalTrials.gov (NCT02276066).ResultsAverage outside facility length of stay in the delayed transfer group was 43 hours. Delayed transfer patients had higher sequential organ failure assessment (7 vs. 5, p = 0.003) and APACHE II scores (19 vs. 16, p = 0.007) on admission. The interval between admission and source control was significantly longer in the delayed transfer group (12.1 hours vs. 1.0 hours, p = 0.009). The incidence of nosocomial infection was significantly higher in the delayed transfer group (41% vs. 23%, p = 0.005). Delayed transfer was independently associated with a 10-day increase in hospital length of stay. Delayed transfer patients were less likely to be discharged home (22% vs. 59%, p < 0.001) and suffered twofold higher in-hospital mortality (14.5% vs. 7.1%, p = 0.056).ConclusionPatients with surgical sepsis who spent more than 24 hours at an outside facility prior to transfer had greater initial illness severity, longer intervals between admission and source control, and more nosocomial infections compared with patients who had early triage to a tertiary care center.Level of evidenceCare management/therapeutic, Level IV; Epidemiologic/prognostic, Level III.

Project description:Background Previous studies of patients with nontraumatic subarachnoid hemorrhage (SAH) suggest better outcomes at hospitals with higher case and procedural volumes, but the shape of the volume-outcome curve has not been defined. We sought to establish minimum volume criteria for SAH and aneurysm obliteration procedures that could be used for comprehensive stroke center certification. Methods and Results Data from 8512 discharges in the National Inpatient Sample (NIS) from 2010 to 2011 were analyzed using logistic regression models to evaluate the association between clinical outcomes (in-hospital mortality and the NIS-SAH Outcome Measure [NIS-SOM]) and measures of hospital annual case volume (nontraumatic SAH discharges, coiling, and clipping procedures). Sensitivity and specificity analyses for the association of desirable outcomes with different volume thresholds were performed. During 8512 SAH hospitalizations, 28.7% of cases underwent clipping and 20.1% underwent coiling with rates of 21.2% for in-hospital mortality and 38.6% for poor outcome on the NIS-SOM. The mean (range) of SAH, coiling, and clipping annual case volumes were 30.9 (1-195), 8.7 (0-94), and 6.1 (0-69), respectively. Logistic regression demonstrated improved outcomes with increasing annual case volumes of SAH discharges and procedures for aneurysm obliteration, with attenuation of the benefit beyond 35 SAH cases/year. Analysis of sensitivity and specificity using different volume thresholds confirmed these results. Analysis of previously proposed volume thresholds, including those utilized as minimum standards for comprehensive stroke center certification, showed that hospitals with more than 35 SAH cases annually had consistently superior outcomes compared with hospitals with fewer cases, although some hospitals below this threshold had similar outcomes. The adjusted odds ratio demonstrating lower risk of poor outcomes with SAH annual case volume ≥35 compared with 20 to 34 was 0.82 for the NIS-SOM (95% CI, 0.71-094; P=0.0054) and 0.80 (95% CI, 0.68-0.93; P=0.0055) for in-hospital mortality. Conclusions Outcomes for patients with SAH improve with increasing hospital case volumes and procedure volumes, with consistently better outcomes for hospitals with more than 35 SAH cases per year.

Project description:Patients with acute spontaneous intracerebral hemorrhage (ICH) develop secondary neuroinflammation and cerebral edema that can further damage the brain and lead to increased risk of neurologic complications. Preclinical studies in animal models of acute brain injury have shown that a novel small-molecule drug candidate, MW01-6-189WH (MW189), decreases neuroinflammation and cerebral edema and improves functional outcomes. MW189 was also safe and well tolerated in phase 1 studies in healthy adults. The proof-of-concept phase 2a Biomarker and Edema Attenuation in IntraCerebral Hemorrhage (BEACH) clinical trial is a first-in-patient, multicenter, randomized, double-blind, placebo-controlled trial. It is designed to determine the safety and tolerability of MW189 in patients with acute ICH, identify trends in potential mitigation of neuroinflammation and cerebral edema, and assess effects on functional outcomes. A total of 120 participants with nontraumatic ICH will be randomly assigned 1:1 to receive intravenous MW189 (0.25 mg/kg) or placebo (saline) within 24 h of symptom onset and every 12 h for up to 5 days or until hospital discharge. The 120-participant sample size (60 per group) will allow testing of the null hypothesis of noninferiority with a tolerance limit of 12% and assuming a "worst-case" safety assumption of 10% rate of death in each arm with 10% significance and 80% power. The primary outcome is all-cause mortality at 7 days post randomization between treatment arms. Secondary end points include all-cause mortality at 30 days, perihematomal edema volume after symptom onset, adverse events, vital signs, pharmacokinetics of MW189, and inflammatory cytokine concentrations in plasma (and cerebrospinal fluid if available). Other exploratory end points are functional outcomes collected on days 30, 90, and 180. BEACH will provide important information about the utility of targeting neuroinflammation in ICH and will inform the design of future larger trials of acute central nervous system injury.