​Nearly 6 percent of seizure-related emergency department visits resulted in patients being transferred to another facility, and the rate of medically unnecessary moves is high and possibly growing, according to a study published Oct. 11 online in Neurology.

Lead author Emily K. Acton, MSCE, of the [EF1] University of Pennsylvania Perelman School of Medicine in Philadelphia, and her colleagues said their study offers previously unreported data that “may help inform strategies to minimize unnecessary interfacility transfers.”

“While some interfacility transfers are necessary and unavoidable due to the intentional concentration of scarce resources such as subspecialty expertise into tertiary centers, unnecessary transfers remain undesirable,” researchers said.

According to the study, seizure-related emergencies make up about 1 percent of all US emergency department visits and result in $1 billion in annual associated costs for prehospital and emergency department care, making interfacility transfer protocols more important. Because of a lack of data about current practices related to these transfers, researchers aimed to evaluate the prevalence, temporal trends, and patterns of interfacility transfers.

“Appropriate triage and interfacility transfer protocols are of critical importance for this population given the highly specialized expertise and equipment essential in a critical subset of these visits, particularly the [6 percent to 7 percent] attributable to status epilepticus, the life-threatening neurologic emergency,” researchers said.

Using the Nationwide Emergency Department Sample (NEDS), the biggest all-payer emergency department health care database in the US, the investigators conducted a retrospective longitudinal cross-sectional analysis of emergency department dispositions for children and adult seizure-related emergencies.

They looked at the transfer rate from 2007 to 2018 and used logistic regression models to analyze data from 2016 to 2018, exploring the patient- and hospital-level factors associated with transfer versus admission. They also applied sampling weights to account for the complex survey design of NEDS.

Researchers found 7,372,065 weighted emergency department visits for seizure-related emergencies occurred between 2007 and 2018, with 2.3 percent to 5.6 percent resulting in an interfacility transfer.

“Transferred patients were more likely to be children (AOR 1.5 CI 1.3-1.6 for those 1-4 years old; AOR 1.5 (1.3-1.7) for ages 5-14), have acute cerebrovascular disease (AOR 1.4, CI 1.1-1.8) and have received mechanical ventilation (AOR 1.5, CI 1.4-1.7),” the study found.

Of the more than 7 million visits, 419,368 (5.6 percent) were for a primary diagnosis of status epilepticus, and 19.8 percent to 23.24 percent of those visits led to interfacility transfers; those transferring hospitals were more likely to be in nonmetropolitan areas (adjusted odds ratio (AOR) 2.2, 95 percent confidence interval (CI) 1.6-2.9), and less likely to have continuous EEG (cEEG) capabilities (AOR 0.3, CI 0.3-0.4), the study noted.

The number of interfacility transfers among seizure-related emergency department visits also rose from 4.7 percent in 2007 to 5.3 percent in 2018, researchers said, “with a flatter but increasing trend observed when only assessing the [emergency department] visits for status epilepticus.”

“Since our study was limited to data from 2007-2018, ongoing evaluations of these trends to present day will be important to better contextualize the magnitude of temporal changes,” they added.

Factors that led to a patient’s admission to a facility included illness severity, emergency department seizure volume, comorbid meningitis and traumatic brain injury, non-rural location, cEEG capabilities, and pediatric. Factors that resulted in their transfer, meanwhile, included rural location, lack of cEEG capabilities, and comorbid stroke.

Researchers pointed out that thoughtful use of novel EEG technologies and teleneurology tools to care for seizure patients may offer “an opportunity to update triage procedures and disposition protocols, with the aim of reducing unnecessary transfers, optimizing resource allocation, and preventing avoidable financial and emotional hardship on patients from inter-hospital transport.”

In an accompanying editorial, Olga Taraschenko, MD, Ph.D., of the Comprehensive Epilepsy Program in the department of neurological sciences of the University of Nebraska Medical Center, Omaha, said the study “highlights important patterns and trends of transfers” and “provides an assessment of barriers that should be addressed to allow prompt triage of patients with seizure emergencies and reduction of the cost of their care.”

“In resource poor areas and emergency departments … where such care [ (cEEG) monitoring] cannot be provided, transfers are undertaken to the facilities with advanced monitoring capabilities, and this may lead to delays in the initiation of advanced care for patients with seizures,” Dr. Taraschenko wrote. “Moreover, it amounts to a high burden of substantial medical and travel costs to patients and their families.”


Source: journals.lww.com, Caitlin West