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Time is ticking: The post-operative impact of inter-facility transfers on acute surgical patients in rural America
*Raphael J Louie, Horace F Henriques, III, *Brent C White
Dartmouth-Hitchcock Medical Center, Lebanon, NH

Objective: In rural community hospitals, where general surgeons may be unavailable, patients diagnosed with acute perforated viscus may require transfer to a tertiary care center for surgical intervention. Delays may lead to adverse outcomes. We aim to quantify the average time from diagnosis to surgical intervention and identify differences in outcomes in patients requiring inter-facility transfer.
Design: Single institution retrospective chart review from July 1, 2009-June 30, 2014
Setting: Rural tertiary care center
Patients: Patients requiring emergent exploratory laparotomy for perforated viscus as diagnosed on radiographic imaging.
Interventions: Initial admission to the tertiary care center or transfer to a tertiary care center for emergent exploratory laparotomy
Main Outcome Measures: Time to OR from diagnosis as defined by time stamp on confirmatory radiographic imaging, hospital length of stay, ICU admission, 30-day mortality and 30-day readmission.
Results: There were no differences in patient demographics, risk factors, or surgical diagnoses between the tertiary-admitted (n =21) and the tertiary-transferred (n = 38) groups. Average time from diagnosis to OR was 3:44 for tertiary-admitted and 6:55 for tertiary-transferred, p<0.0001. Average transport time for transfers was 57 minutes. Rate of ICU admission was significantly higher in tertiary-transferred (55.3 %) vs tertiary-admitted patients (19.5%), p=0.01. Average length of stay, mortality, and readmission were similar between both groups.
Conclusions: We found a significant difference in time from diagnosis to operative intervention depending on where patients initially presented. Given a significantly higher rate of ICU utilization and increased time to surgery in tertiary-transferred patients, efforts should be made to improve transfer efficiency and streamline transfer logistics to potentially reduce postoperative morbidity in these acute patients.


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