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ORIGINAL RESEARCH: 2021 AAST PODIUM PAPERS

Emergency general surgery transfer to lower acuity facility: The role of right-sizing care in emergency general surgery regionalization

Baimas-George, Maria MD, MPH; Schiffern, Lynnette MD, FACS; Yang, Hongmei PhD; Paton, Lauren MD, FACS; Barbat, Selwan MD; Matthews, Brent MD, FACS; Reinke, Caroline E. MD, MSHP, FACS

Author Information
Journal of Trauma and Acute Care Surgery: January 2022 - Volume 92 - Issue 1 - p 38-43
doi: 10.1097/TA.0000000000003435
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Emergency general surgery (EGS) represents a public health predicament with over four million annual admissions in the United States, accounting for more than 10% of all hospitalizations.1 As this number only continues to rise, projected cost of care by 2060 will increase by 45% to over 40 billion dollars annually.2 With this considerable, and escalating, burden on the healthcare system, widespread study has ensued in hopes of improved comprehension of factors contributing to perioperative outcomes. Research has found the EGS population to be a uniquely vulnerable, high acuity cohort at particular risk for death and complications, accounting for 50% of all national surgical mortality.3,4

With an inability to optimize or alter patient factors because of the urgent or emergent nature of pathologic presentation, research has centered in on system and facility factors and processes of care. Data from the Nationwide Inpatient Sample have demonstrated lower risk of mortality at high-volume centers and those with higher trauma level designation.5–7 With over 15% of patients requiring readmission, other associated factors include care fragmentation, hospital bed-size, teaching status, and quality.8,9 Similar to the transformation witnessed in trauma regionalization, this has led to the concept of EGS regionalization to triage and redefine patient management to designated centers.10,11 Regionalization offers treatment expedition for high acuity patients through interfacility transfers to higher levels of care.12

Unfortunately, interfacility transfers are not independent of challenges, introducing additional costs, significant resource use, capacity constraints, and often delays and/or duplication of care. As such, trauma research has focused on opportunities for improvement by evaluating factors associated with overtriage, aiming to decrease unnecessary transfers and, subsequently, unneeded hospital resources for cost-effective care.13,14 This is particularly salient with the COVID-19 pandemic compounding an already escalating dilemma of hospital capacity.15 Emergency department (ED) overcrowding has been associated with delays in critical interventions and care, and while overcrowding is a multifactorial issue the primary cause is inadequate inpatient capacity resulting in an inability to move admitted patients from the ED to an inpatient bed.16–19

Another avenue for improvement that has yet to be studied is through safe triage of low-risk EGS patients. Expedient identification of such patients with common, low-risk pathology presenting at tertiary centers for transfer to lower-level centers could significantly benefit overcrowding and resource burden, without sacrificing care or outcomes. We sought to evaluate this hypothesis by evaluation of a 16-month experience of a five-surgeon team triaging EGS patients at a tertiary care, Level I trauma center to an affiliated community hospital.

MATERIALS AND METHODS

Atrium Health encapsulates over 40 hospital and acute care facilities across three states. Within the Charlotte metropolitan region, there are 13 hospitals of which Carolinas Medical Center (CMC) is the tertiary referral center and the only Level I trauma center, with 847 beds and 74 operating rooms (ORs). Atrium Health Mercy (AHM) is an affiliated, community hospital located only 1.3 miles distant from CMC with 185 beds and 12 ORs. Resources, personnel training, and availability vary between CMC and AHM with CMC having sub-surgical specialists and an in-house intensive care unit (ICU). Although AHM does have interventional radiology and advanced gastroenterology, there is a limited blood bank, a virtual intensive care unit (ICU) overnight, and no general surgery subspecialities. The general surgery section is comprised of five surgeons who specialize in both EGS and advanced laparoscopic surgery, with four having completed a minimally-invasive fellowship. This group covers EGS at both CMC and AHM, operating emergently and electively at both facilities.

Beginning in December of 2019, to offset hospital capacity at CMC, a protocol was initiated to assess the safety and efficacy of low-risk EGS patient triage from CMC to AHM. For this study, EGS patients are defined as patients who presented to the CMC ED who required surgical consult for a general surgery diagnosis. No patients transferring from any other centers, including tertiary centers, free-standing EDs, or urgent care facilities, were included. All EGS patients who presented to the CMC ED were screened remotely by one of the EGS surgeons for transfer appropriateness. This screening assessment was based on both patient and system factors which included hemodynamics, comorbidity profile, diagnostic testing, ED provider evaluation, and potential hospital resource needs. Reasons not to transfer included need for immediate in-person evaluation, comorbidity burden, OR availability, need for surgical or medical subspecialist, and established care with a surgical team at CMC. If deemed low risk and appropriate for transfer, patients were transferred to AHM and assessed in-person by the surgical team after the decision to transfer was made. This algorithm was based off the success of a similar approach with the free-standing EDs in the Charlotte metro region. For more than 10 years, this group of EGS surgeons has performed similar virtual triage, discussing patient disposition with free-standing ED providers to either community hospitals or the tertiary referral center. In addition, in collaboration with the ED providers, a standardized framework for discussion with the patient and their family was created, expressing that the patient's information had been reviewed for clinical appropriateness, that the group of surgeons provided surgical care at both hospitals, and that their care would likely be expedited with the transfer.

All EGS patients, identified through ED physician assessment, who presented during this time period (01/2020 to April 2021) were analyzed. Patient encounters were identified retrospectively and linked to demographic and clinical data through our Electronic Data Warehouse. Patients were separated into three disposition categories: (1) transfer admission to AHM; (2) admission to CMC; or (3) discharge from ED. Variables included were age, sex, body mass index, Charlson Comorbidity Index (CCI), and EGS diagnosis. Minutes to disposition was calculated using ED arrival time and ED discharge time. For patients admitted to either CMC or AHM, additional variables collected included the need for surgical intervention, length of stay (LOS), 30-day readmission rate from discharge, and 30-day mortality rate from transfer admission or tertiary admission. Patients who underwent surgical intervention were grouped into either laparoscopic or open procedures. Reasons that patients were not candidates for transfer to AHM were collected for the final 6 months of the study period and were categorized as: (1) acuity of disease/physiological status, (2) need for consultation with surgical or medical specialists not available at AHM, (3) established with surgeon at CMC, (4) limited resources at AHM (ORs, beds, or surgical support).

The STrengthening the Reporting of OBservational studies in Epidemiology statement was used to guide reporting of this research.20 All data were analyzed using Statistical Analysis Software, version 9.4 (SAS Institute, Inc., Cary, NC), with approval from the CMC Institutional Review Board. Descriptive statistics were reported as means with standard deviations or medians with interquartile range for continuous variables and percentages for categorical variables. Categorical variables were evaluated using Pearson's χ2 test or Fisher's exact test when appropriate. Continuous variables were evaluated using two-sample t test. Statistical significance was set at p less than 0.05, and all p values were two-tailed.

RESULTS

From January 2020 to April 2021, there were 987 EGS patients who presented to the ED and reviewed for transfer from CMC to AHM. The mean response time of the EGS physician to provide disposition to the ED was 8.32 minutes (±11.17 minutes). The most common diagnoses were biliary disease, bowel obstruction, and appendicitis. After review, 311 (31.5%) were transferred to the affiliated community hospital, 159 (16.1%) were discharged home, and 517 (52.4%) were admitted to CMC.

Patients who were transferred to AHM were on average significantly younger and with significantly lower CCI score than patients remaining at CMC (Table 1). Diagnoses that were more common in transferred patients included acute appendicitis, and acute cholecystitis. Compared with AHM, a higher percentage of patients admitted to CMC presented with bowel obstruction, incarcerated hernia, or postoperative complication.

TABLE 1 - The Difference in Patient Factors and Outcomes between Transferred Patients and Patients Remaining at Tertiary Care Center
Transferred Patients Remained at Tertiary Care Center p*
n = 311 (31.5%) n = 517 (52.4%)
Age (± STD), y 43.92 ± 16.71 54.76 ± 18.33 <0.001
BMI** (kg/m2 ± STD) 30.42 ± 7.91 29.01 ± 8.48 0.018
Male sex 121 (38.9%) 261 (50.5%) 0.001
CCI score 1.89 ± 2.76 4.45 ± 4.01 <0.001
Diagnosis
 Acute appendicitis 92 (29.6%) 44 (8.5%) <0.001
 Acute cholecystitis 98 (31.5%) 55 (10.6%) <0.001
 Choledocholithiasis 1 (0.3%) 8 (1.6%) 0.165†
 Gallstone pancreatitis 5 (1.6%) 3 (0.6%) 0.160†
 Bowel obstruction 40 (12.9%) 107 (20.7%) 0.004
 Incarcerated hernia 6 (1.9%) 32 (6.2%) 0.005
 Perforated viscus 6 (1.9%) 18 (3.5%) 0.197
 Postoperative complication 1 (0.3%) 29 (5.6%) <0.001
Surgical intervention
 All surgery‡ 210 (67.5%) 259 (50.1%) <0.001
 Laparoscopy 195 (62.7%) 136 (26.3%) <0.001
 Laparotomy 3 (1.0%) 46 (8.9%) <0.001
Length of stay, d 2.23 ± 2.72 5.49 ± 7.30 <0.001
30-d readmission rate 26 (8.4%) 79 (15.3%) 0.004
30-d mortality rate 2 (0.6%) 26 (5.0%) <0.001
30-d readmission rate§ 22 (11.5%) 68 (16.4%) 0.115
Minutes wait before the call 267 ± 132 249 ± 144 0.063
Minutes wait after the call 172 ± 118 228 ± 215 <0.001
Admission status
 Inpatient 192 (61.7%) 417 (80.7%)
 OBS 103 (33.1%) 100 (19.3%)
 Outpatient 16 (5.1%) 0 (0%) <0.001
Note: *χ2 test for categorical variables and t-test for numeric variables unless specified differently.
**11 cases had no information on BMI, 7 from transferred and 4 from the remaining. Seven cases were capped at 65 kg/m2.
†Fisher's exact test.
‡The remaining surgeries included other procedures, such as incision and drainage of abscess.
§Readmission rate among inpatients only—192 inpatients from transferred and 417 inpatients from the remaining.
BMI, body mass index; STD, standard deviation.

Transferred patients had a higher rate of surgical intervention which was more likely to be performed using a minimally invasive approach. There were higher rates of laparotomies in patients who remained at CMC. Length of stay was shorter for transferred patients as was 30-day readmission rates and 30-day mortality rates. After the surgical service was consulted, minutes to disposition from the ED were significantly less in the transferred patient group.

There were no transferred patients who were undertriaged or requiring transfer back to the higher level of care (0.0%). Bed days saved at CMC were 693, of which 591 were inpatient bed days. Total OR minutes saved were 24,008, of which 16,919 minutes were between the hours of 7:00 am and 5:00 pm.

Table 2 presents nontransferring reasons based on data from the final 6 months of the study period. The most common reasons patients were not transferred included acuity of disease/physiological status, previously known to care teams at the tertiary care hospital, need for consultation with specialists only available at CMC.

TABLE 2 - Transfer Denial Reasons to AHM over a 6-month Period
Acuity of disease/physiological status 154 (34%)
Need for consultation with specialists only at CMC 56 (12%)
Established care with team at CMC 132 (29%)
Limited OR resources at AHM 32 (7%)
Possibility for discharge from ED 54 (12%)
Other 23 (5%)
Note: Data reported as n (%).

DISCUSSION

Emergency general surgery patients are a high-acuity, vulnerable cohort that represents a significant and increasing number of hospital admissions. As such, the population offers, if not demands, opportunity for intervention to help offset worsening ED and hospital capacity at tertiary care centers. This study, representing the first literature evaluation of low-risk patient triage, demonstrates preservation of high-quality care and outcomes with appropriate EGS patient transfer. Achievements in improvement of OR and bed capacity, as well as resource utilization at tertiary centers highlights that low-risk patient triage should become an additional focus for EGS regionalization efforts.

The EGS population is a difficult group to study because of the urgent and emergent nature of presentation and their increased risk of mortality.3 As such, developing a triage strategy to a lower-acuity hospital can be risky particularly with studies citing improved survival at higher-volume centers.21 Upon further investigation, however, the reported relationship between hospital volume and mortality may be heavily influenced by individual surgical volume.7,22 Surgeon procedural frequency resulting in improved technical expertise and experience in perioperative care is potentially a direct mediator of this observation. Our study maintained high-volume surgical care for each transfer as the surgeons involved operate at both hospitals. Performing on average 650 annual elective, urgent and emergent procedures at AHM and 800 at CMC, the same surgical team provides care for patients at both facilities and thus is familiar with the resources and limitations. Therefore, outcomes are not sacrificed; and, in fact, because of the intent to identify low-risk patients, it was not surprising that transferred patients had a shorter LOS, decreased readmission rate, and decreased mortality rate. While the transferred population is by design not comparable to the population admitted to CMC, the findings nevertheless demonstrate conservation of high-quality care, particularly with an observed under-triage rate of zero patients. Quite remarkably, none of the 311 patients required transfer back to CMC, suggesting that consideration of higher acuity transfers should be explored. Extrapolating from the trauma literature guidelines deeming overtriage rates acceptable at less than 35%, there is potentially significant room for triage and transfer growth.23

This triage of care to offload tertiary care centers can additionally have significant benefit on ED volume and patient care. Prolonged ED boarding and disposition are associated with worse outcomes (including mortality) and decreased quality of care, particularly in the critically ill.24,25 Resulting in longer LOS, prolonged ED boarding serves to not only exacerbate the negative consequences of ED crowding but compounds a situation of environmental disarray comprised of high provider turnover resulting in employee inexperience and poor patient satisfaction.26 These results have spurred hospitals to work on developing systems aimed at improving ED bed traffic. Successful programs demonstrate improved patient satisfaction, less ambulance diversion, and less patients leaving without being seen while maintaining, and often increasing, ED and inpatient hospital volumes.26,27 In our study, EGS surgeons were contacted directly by ED providers through a remote paging system, allowing for an immediate virtual chart review that, for low-risk patients, and in conjunction with the ED provider's assessment, allowed an efficient disposition that on average took 8.32 minutes ± 11.17 minutes. After this consultation, transferred patients had a significantly faster disposition from the ED of nearly 1 hour decreased wait time (172 minutes vs. 228 minutes). For patients who were transferred, disposition was not delayed by physician- or hospital-dependent time intervals, such as consult-to-evaluation time and/or inpatient bed availability at the often-filled CMC, allowing expeditious door-to-room or door-to-OR intervals. While ED patient satisfaction was not assessed, there may be improvement possible in conjunction with prior studies' results.28,29

Low-risk patient triage can also benefit hospital capacity and resources which have only become increasingly more sparce as COVID-19 has persisted.15 Before the pandemic, the American healthcare infrastructure was already strained with increasing annual patient encounters and healthcare costs soaring above predicted outputs.30 The arrival of the COVID-19 virus served to place exceptional and sustained stresses on many hospitals and health systems, considered already overburdened. This predicament, issued in an expeditious manner discussions and actions, aimed at equitable allocation of scant resources in the setting of a global shortage. Even in a hopeful aftermath of this pandemic, preparation for future global public health crises and simply the American health system as it stands today demands solutions. In an attempt to offload the tertiary care flagship hospital (CMC), our study of low-risk patient triage to community hospitals has improved disposition time from the ED, saved nearly 700 bed days, and saved 400 operative hours. This has had significant cost-savings effect, irrespective of the immeasurable gains from additional availability of elective surgical block time opening at CMC. Although there is inherent cost associated with patient transport, this cost was absorbed by the hospital. Without sacrificing outcomes, our protocol allowed patients without high-acuity needs to still receive the appropriate standard of care at AHM while offloading bed capacity. With this expansion of available beds at CMC, more critically ill patients and those requiring advanced resources and/or subspecialty consultation can receive appropriate care more expeditiously.

With considerable variation in readmission destination, care discontinuity has been found to be associated with increased morbidity and mortality in the EGS population with nearly a quarter of all readmissions receiving care at a nonindex hospital.8 This care fragmentation is associated with higher failure to rescue and mortality rates, subsequent readmissions, LOS, and cost.31 Interestingly, while factors at play are speculated to include incomplete record transfer, delay in postoperative complication recognition and thus overall treatment, and inaccurate medicine reconciliation, there is no demonstrated association with EGS hospital volume. As such, triaging primary admissions to community hospitals may present opportunity to improve care fragmentation rates as community hospitals are often less burdened than tertiary referral centers.31 Atrium Health Mercy, for instance, has on average 18.2% (± 8.0%) unoccupied inpatient beds on a given day which is nearly twice as many as CMC (10.2% [± 4.5%]) and therefore, may have more flexibility to accept readmissions from free-standing EDs or direct admissions from home or clinic.

The limitations of our study include the unique model and environment specific to this EGS surgical practice. The existence of a group practice that provides surgical care at both the tertiary care referral center and the 1.3 miles distant community hospital allowed for easy ED triage and transfer and sustainment of high surgical volume. This model will inevitably vary based on practices and unique patient and hospital factors at other institutions which must be considered. Patient transfer denials (Table 2) was captured for only a portion of the study population as we initially were not collecting this data until the final 6 months of the study period. Therefore, these data do not provide a complete picture of the reasons; however, we predict the overall trend for the entire study population to be similar.

This prospective cohort trial demonstrates that triage of EGS patients with low-risk pathologies is safe and may benefit overcrowding and resource burden, without sacrificing outcomes. Future directions include prospective validation at multiple centers and across multiple disciplines with addition of cost analysis and severity of illness at the tertiary care hospital.

AUTHORSHIP

M.B.-G., L.S., C.E.R. participated in the literature search. L.S., L.P., S.B., B.M., C.E.R. participated in the study design. M.B.-G., L.S. H.Y., C.R. participated in the data collection. M.B-.G., L.S., H.Y., C.E.R. participated in the data analysis. M.B.-G, L.S., H.Y., C.E.R. participated in the data interpretation. M.B.-G., L.S., H.Y., C.E.R. participated in the writing. M.B.-G., L.S., H.Y., L.P., S.B., B.M., C.E.R. participated in the critical revision.

DISCLOSURE

The authors declare no conflicts of interest.

REFERENCES

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DISCUSSION

LILLIAN S. KAO, M.D., M.S. (Houston, Texas): Thank you. Thank you to Drs. Spain and Reilly for the honor of discussing this paper. Like everyone has expressed before me, it really is a pleasure to be at this meeting in person.

So I’d like to congratulate Dr. Baimas-George and coauthors on the successful ability to offload a busy Level I trauma center without sacrificing quality of care through the effective triage and transfer of low-acuity EGS patients to a nearby, affiliated community hospital.

As the authors alluded to, the need to efficiently care for patients with all emergency conditions has become an even greater challenge during this COVID pandemic.

I do have a few questions.

The authors explained their criteria for triage to the community hospital. What amount of “wiggle room” was there for surgeon judgment? And do the authors have any recommendations for criteria should other hospitals want to implement a similar process?

The authors alluded to in their paper additional metrics such as door-to-room time, door-to-OR time, and costs. Do the authors have any preliminary data on these metrics for transferred versus non-transferred patients? And while differences in the patient populations may affect these metrics, even adjusted data would be useful.

Based on the authors’ experience, should these low-risk patients be transferred regardless of the Level I trauma center’s capacity for a given day? Or is there a threshold capacity at which transfer becomes the preferred strategy?

And, lastly, the authors alluded to this as a future area but do they have any preliminary data on stakeholder perception of these transfers such as patient or even surgeon satisfaction?

Thank you and congratulations, again, to the authors on an excellent paper.

KIMBERLY A. DAVIS, M.D., M.B.A. (New Haven, Connecticut): Excellent presentation. I have several questions.

The first is, as alluded to by Dr. Kao, the resource availability at the main hospital versus the smaller hospital. Do you have the same number of surgeons? Can cases be done in the middle of the night or is patient care delayed until the following day?

My second question focuses on patient satisfaction and, more importantly, patient cost. If patients experience interfacility transfer, do they have the added costs of ambulance transfer and evaluation at the second facility? Are the fee structures similar at the two institutions?

For my final question, I wonder if rather than transferring patients for emergent or urgent disease, have you given any thought to try to offloading some of the less-complicated elective surgeries so that you maintain the ability to do the urgent cases at your center?

Excellent presentation. A huge area of interest for those of us who provide acute care surgery. Thanks very much.

JAMES M. BETTS, M.D. (Oakland, California): I enjoyed your presentation. Were pediatric patients considered when you reviewed those who were transferred to another facility? Specifically, was the population of less than 16 years included in your series of transfers? A significant number of our trauma population, all pediatrics, are sent to us from a wide catchment area. Did any of your transfers out include children?

Thank you.

ANGELA M. INGRAHAM, M.D. (Madison, Wisconsin): Angie Ingraham, University of Wisconsin. I’m curious about the ability of your Level I trauma center to get patients into your center because you’re able to move other patients out. Any data you may have from your transfer center regarding how many patients were able to be transferred in would be illustrative and useful to include.

The other question I have is that at Wisconsin, under the leadership of Dr. Savage, we’ve set up an expedient pathway to allow patients with diagnoses that do not require admission but would benefit from expedited surgical care, such as biliary colic, to obtain their surgery as early as the next-day. This has allowed patients to receive expedient care without being admitted. Have you looked into that as well?

ROBERT A. MAXWELL, M.D. (Chattanooga, Tennessee): Great paper. Wonderful model if that’s what you want to do with your “bread and butter” patients and probably good for an employed system.

But I was curious about what impact this has on the OR schedule at the small hospital. Do these patients all get pushed to the end of the day? Or is there accommodations made to add these on in a timely fashion?

What we’ve done at our facility – and we have a small hospital that will occasionally get patients diverted to it and these patients do usually get put on at the end of the day after all the orthopedic and GYN elective stuff gets done.

But what we’ve done is create a surgical admissions unit and we have an acute care surgery room and these patients come to the admissions unit and get teed up for surgery the next day at 8 a.m. if they don’t need to go in the middle of the night.

Thank you.

MARIA BAIMAS-GEORGE, M.D. (Charlotte, North Carolina): Thank you. For triage criteria, we have no objective criteria; only subjective based off of expert surgeon chart review, hemodynamics, comorbidities, diagnostic testing, and input from our ED colleagues. Objective criteria is something we would like to eventually create as we move forward with this research such that similar studies could be assessed at other centers.

In terms of metrics, we were not able to measure all of those. We were able to assess disposition from the ED which was significantly faster in the transferred patient group than the patients that stayed at the tertiary care center. We plan to assess the other metrics when we perform our prospective multicenter validation study.

In terms of whether triage should only happen when a Level I center is at capacity, I, personally, have nearly never experienced our Level I center not at capacity. And I’m sure a lot of Level I centers probably exist in the same state. Regardless, we can never predict mass casualty events or influx of emergency general surgery patients. We further often have patients in the ICU waiting for floor beds to become available. In summary, I believe this protocol should be followed pretty consistently, regardless of where your center stands in percent capacity.

For stakeholders, we did not look at this data, but, anecdotally and the opinions we were given the ED providers and from our colleagues at Mercy, was all very positive and encouraging. There were of course some patients who were not happy with transfer but the vast majority were happy with the experience. Mercy is a Planetree hospital, dedicated to patient outcomes and satisfaction.

In regards to resource utilization, operating room, and patient care differences between our tertiary care center and our community hospital, the big difference includes a virtual ICU overnight at the community hospital and limited subspecialists. The same surgical team does operate and care for these patients at both hospitals so it is the same level of expertise and clinical experience at both centers.

We did not assess patient satisfaction however we plan to address it moving forward in our prospective validation as this is an incredibly important metric.

The patient’s cost of transport was covered by our hospital. This was an ED to inpatient transfer; not an ED to ED transfer.

Consideration of transferring elective cases there, I think is a great idea. We have started to offload certain services to some of our community hospitals. And algorithms are being trialed and laid into place. We hope to continue to expand on these as we move forward.

We did not transfer any pediatric patients as Mercy hospital is not a pediatric hospital.

In regards to the opportunity costs obtained by transferring these patients out, and getting more complicated patients into the tertiary care center, this is not a metric we examined in the current study but again, are hoping to evaluate in future trials.

The schedule at our community hospital is permissive to this algorithm. We have block time allocated several days of the week and, very rarely, do these cases go later than the afternoon or evening after admission. This additionally allows cases to become outpatient rather than requiring an admission at the tertiary center due to operating room availability.

Thank you.

Keywords:

Emergency general surgery; regionalization; transfers; acute care surgery; triage

Copyright © 2021 American Association for the Surgery of Trauma.