Subarachnoid hemorrhage patients: to transfer or not to transfer?

Introduction and Methods Prompt management of aneurysmal subarachnoid hemorrhage (SAH) is critical. Literature is inconclusive regarding outcomes for patients directly-admitted to specialized centers versus transferred from lower-volume hospitals. Providers are often unclear about the safety of transferring critical patients. This study evaluated the “transfer effect” in a large sample of aneurysmal SAH patients undergoing treatment. Using NIS 20022007 data, we analyzed outcomes of SAH patients treated with coil or clip procedures. Analyses studied the effect of direct-admit versus transfer admission on mortality, discharge disposition, complications, Length of stay (LOS) and total charges. Results Of 47,114 patients, 31,711 (67.3%) were directadmits and 15,403 (32.7%) were transfers. More transfer patients were coiled than direct-admits (45.3% vs. 33.7%, p<.0001) and fewer underwent ventriculostomy (26.6% vs. 31.5%, p=.003). Older age (OR 1.2, p<.0001), higher disease severity (OR 1.4, p<.0001), lower volume (OR 1.5, p<.0001), and ventriculostomy (OR 2.1, p<.0001) increased mortality and predicted non-routine discharge, complications, LOS, and charges. Transfer patients had similar mortality (OR 0.9, p=.13) and complications (OR 0.9, p=.22) as direct-admits but incurred higher non-routine discharge (OR 1.3, p=.002). Analysis of grade V patients demonstrated similar outcomes between direct-admits and transfers; however, charges for treating transfer patients were notably higher ($401,386 vs. $242,774, p=.03). Conclusions Patients treated in lowest volume hospitals were 1.6 times more likely to die than those treated at the highest quintile hospitals. Among the critically-ill grade V patients, transfer to higher volume specialized centers did not increase the likelihood of a poor prognosis. Figure 1a/1b