Quantifying the risk of unplanned transfer from subacute to acute care
Patients who require an emergency interhospital transfer from subacute to acute hospital care have high hospital admission rates and in-hospital mortality. Clinical instability during the first acute care admission, such as serious adverse events or increased surveillance, may prompt reassessment of patient suitability for movement to a separate subacute care hospital.
The aim of this study was to describe characteristics and outcomes of emergency interhospital transfers from subacute to acute hospital care, and develop an internally validated predictive model to identify features associated with high risk of emergency interhospital transfer.
A prospective case-time-control study design was used in acute and subacute healthcare facilities from five Victorian health services. Cases were patients with an emergency interhospital transfer from subacute to acute hospital care and for every case, two inpatients from the same subacute care ward on the same day of emergency transfer were randomly selected as controls.
The main outcome measures were patient and admission characteristics, transfer characteristics and outcomes (cases), serious adverse events and mortality. Medical record audit data was collected for 603 transfers in 557 patients and 1160 control patients.
When adjusted for health service, cases had significantly higher in-patient mortality and were more likely to have unplanned intensive care unit admissions, and rapid response team calls during their entire hospital admission.
When adjusted for health service, vital sign abnormalities in subacute care and serious adverse events during the first acute care admission were the clinical factors associated with increased risk of emergency interhospital transfer. During subacute care, 15.7% of cases had vital signs fulfilling organisational rapid response team activation criteria, yet missed rapid response team activations were common.
An internally validated predictive model showed that vital sign abnormalities can fairly predict emergency interhospital transfers from subacute to acute care hospitals.
Further consideration of the criteria and strategies to optimise recognition and response to clinical deterioration in subacute care patients is needed to ensure the safety of this vulnerable population.
This project was funded by Deakin’s School of Nursing and Midwifery and undertaken by Professor Julie Considine, Dr Maryann Street, Professor Trisha Dunning, Alfred Deakin Professor Tracey Bucknall, Alfred Deakin Professor Alison Hutchinson, Dr Helen Rawson, Associate Professor Anastasia Hutchinson, Alfred Deakin Professor Mari Botti, Alfred Deakin Professor Maxine Duke and Dr Mohammadreza Mohebbi with partners Eastern Health, Alfred Health, Barwon Health, Epworth HealthCare, Monash Health, QPS and Deakin.