Stroke transfers, order volume

Summaries from ACP Hospitalist Weekly.

Transferred stroke patients had higher mortality, more severe disability than front-door patients

Patients with acute ischemic stroke who were transferred to specialized stroke centers had more severe strokes on arrival and higher in-hospital mortality compared to those who were admitted directly to such hospitals, a recent study found.

Researchers analyzed 970,390 cases of acute ischemic stroke in the Get With The Guidelines-Stroke registry from January 2010 to March 2014 to determine variation in baseline characteristics and clinical outcomes between patients presenting directly to the front door of stroke centers versus transfers from another hospital. Patients were discharged from 1,646 hospitals in the U.S. Researchers compared hospitals with high transfer-in rates (≥15%) versus those with low transfer-in rates (<5%) and compared the front-door versus transfer-in patients admitted to hospitals with high transfer-in rates. Results were published online on Sept. 1, 2018, by Circulation: Cardiovascular Quality and Outcomes.

Image by Getty Images
Image by Getty Images

Overall, 87% of cases initially presented to the ED and 13% were a transfer-in from another hospital. Hospitals with more transfers in were larger, had a median 31% transfer-in rate among all stroke discharges, had higher annual volume of acute ischemic stroke and intravenous tissue-type plasminogen activator rates, and were more often Midwest teaching hospitals and stroke centers.

Compared to front-door patients, transfer-in patients had higher in-hospital mortality (7.9% vs. 4.9%; standardized difference, 12.4%), were younger, were more often white, had higher median National Institutes of Health Stroke Scale scores, and less often had hypertension and previous stroke/transient ischemic attack. After adjustment for multiple variables, transfer-in patients had higher in-hospital mortality and more severe disability, with higher discharge Modified Rankin Scale scores.

Given these differences, the transfer-in patients “have the potential to negatively influence institutional mortality rates and should be accounted for explicitly in hospital risk-profiling measures,” the authors concluded. They noted that there was also significant regional variability in transfer rates. Limitations of the study include the site-level, retrospective method of data collection, as well as a lack of additional information (e.g., specific reasons for transfer, transfer times), the study authors noted.

“Although [CMS] currently assigns mortality to the hospital where the patient was first admitted, transfers from emergency departments may represent a loophole, wherein first admission occurs at the receiving hospital,” an accompanying editorial noted.

In addition to suggesting an impact of interhospital stroke transfers on hospital mortality metrics, the study findings show an opportunity for quality improvement, although the best model of care remains unknown, the editorial said. “A better understanding of the ins and outs of doors in stroke care will be a big step towards ensuring that the right patients are treated at the right centers and the right time,” the editorialist wrote.

Order volume may be associated with increased patient complexity

Electronic order volume may be significantly associated with patient complexity and could therefore represent a potential marker of resident physician workload, a recent study suggested.

Researchers retrospectively assessed admissions to the internal medicine teaching service of an academic medical center during a 13-month period. They tested the association between electronic order volume and patient level of care and severity of illness category. They also used multivariable logistic regression to determine the association between daily team orders and two discharge-related quality metrics (receipt of a high-quality patient after-visit summary and timely discharge summary), adjusting for team census, patient severity of illness, and patient demographics. Results were published online on Aug. 29, 2018, by the Journal of Hospital Medicine and appeared in the December 2018 issue.

Overall, clinicians entered 929,153 orders for 5,032 inpatient admissions, and the median daily number of orders per team was 343. Mean daily order volume correlated with patient severity of illness, with those in the lowest quartile of Medicare Severity-Diagnosis Related Group weight receiving an average of 98 orders in the first three days of hospitalization, compared to 105 orders in the second quartile, 132 orders in the third quartile, and 149 orders in the fourth and highest quartile (P<0.001 for all comparisons). In addition, mean daily order volume was higher for patients in the ICU than for those in step-down units and general medical wards (40 vs. 24 vs. 19, respectively; P<0.001).

Of 5,032 discharged patients, 3,657 (73%) received a high-quality after-visit summary. After adjustment, there was no significant association between total orders on the day of discharge and the odds of receiving a high-quality after-visit summary.

Among 3,835 patients with data on timing of discharge summary, 3,455 (91.2%) had a discharge summary completed within 24 hours. After adjustment, there was no significant association between total team orders on the day of discharge and odds of receiving a timely discharge summary. However, patients were 12% less likely to receive a timely discharge summary for every 100 additional team orders placed on the day before discharge (odds ratio, 0.88 [95% CI, 0.82 to 0.95]; P=0.002).

The study authors noted limitations, such as the many factors that influence resident workload and the fact that they focused on team orders as opposed to individual work, which may be more directly linked to discharge-related quality metrics.