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Published on: November 10, 2023
Characterizing Avoidable Transfer Admissions in Infants Hospitalized for Bronchiolitis
Tehnaz P Boyle1, Charles G Macias2, Susan Wu3
1Boston Medical Center, Boston, Massachusetts; tehnaz.boyle@bmc.org.
Insights
One in four interfacility transfer admissions for infant bronchiolitis may be avoidable. These transfers often involve children of color and originate from smaller emergency departments (EDs), suggesting potential inefficiencies in care coordination.
Area of Science:
- Pediatric critical care
- Respiratory infections
- Healthcare systems research
Background:
- The necessity of transferring infants with bronchiolitis to pediatric centers is often unclear.
- Understanding avoidable transfers is crucial for optimizing resource allocation and patient care pathways.
- This study investigates the characteristics and predictors of potentially unnecessary interfacility transfers for bronchiolitis.
Purpose of the Study:
- To characterize avoidable interfacility transfer admissions for infants hospitalized with bronchiolitis.
- To test the hypothesis that a higher proportion of transferred infants are discharged within 48 hours with minimal intervention compared to direct admissions.
Main Methods:
- A prospective cohort study of 1007 infants (<1 year) hospitalized for bronchiolitis across 17 centers (2011-2014).
- An 'avoidable transfer admission' was defined as hospitalization <48 hours without interventions for severe illness where pediatric specialists are beneficial.
- Multivariable logistic regression identified factors associated with avoidable transfer admissions, comparing transfer and non-transfer groups.
Main Results:
- Of 1007 infants, 164 (16%) were transfer admissions. Fewer transferred infants (24%) were hospitalized <48 hours with minimal intervention compared to non-transferred infants (36%) (P = .007).
- Avoidable transfer admissions were more common in children of color, those with non-private insurance, and transfers from small emergency departments (EDs).
- Minority race/ethnicity, normal oxygenation, and small ED origin independently predicted higher odds of avoidable transfer admission.
Conclusions:
- While most transferred infants with bronchiolitis require significant interventions, approximately 25% of transfer admissions may be potentially avoidable.
- Factors such as patient demographics and originating ED size are associated with avoidable transfers, highlighting areas for improved care coordination.
- Further research should focus on refining transfer criteria and improving primary care or community ED management of bronchiolitis to reduce unnecessary transports.
Objectives:
The appropriateness of interfacility transfer admissions for bronchiolitis to pediatric centers is uncertain. We characterized avoidable transfer admissions for bronchiolitis. We hypothesized that a higher proportion of hospitalized infants transferred from a community emergency department (ED) or hospital (transfer admission) would be discharged within 48 hours with little or no intervention, compared with direct admissions from an enrolling ED (nontransfer admission).
Methods:
We analyzed a 17-center, prospective infant cohort (age <1 year) hospitalized for bronchiolitis (2011-2014). An avoidable transfer admission (primary outcome) was hospitalization for <48 hours without an intervention for severe illness in which a pediatric specialist could be beneficial (oxygen, advanced airway management, life support). Parenteral fluids and routine medications were excluded. We compared admissions by patient, ED, inpatient, and transferring hospital characteristics to identify factors associated with avoidable transfer admissions. Multivariable logistic regression was used to identify predictors of avoidable transfer admission.
Results:
Among 1007 infants, 558 (55%) were nontransfer admissions, 164 (16%) were transfer admissions, and 204 (20%) were referrals from clinics; 81 (8%) were missing referral type. Significantly fewer transferred infants were hospitalized for <48 hours with little or no intervention (40 of 164; 24% [95% confidence interval 18%-32%]) than nontransferred infants (199 of 558; 36% [95% confidence interval 32%-40%]; P = .007). Avoidable transfer admissions were more likely to be children of color, have nonprivate insurance, receive fewer ED interventions, and originate from small EDs. A multivariable model revealed that minority race and/or ethnicity, normal oxygenation, and small ED transfers increased odds of avoidable transfer admission.
Conclusions:
Although most transferred infants hospitalized for bronchiolitis required interventions for severe illness, 1 in 4 admissions were potentially avoidable.
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