Background:  Direct hospital admissions from outside emergency departments and hospitals comprise a large proportion of admissions to tertiary medical centers. Clinical stability in these acutely ill patients can fluctuate, even during transport to a receiving medical center. Here, we report data obtained as part of an internal quality improvement initiative to identity clinical criteria present during patient transport from an outside institution that should prompt expedited communication with the receiving hospital team or reassessment of patient disposition within the hospital (general care vs. intensive care vs. emergency department evaluation).

Methods:  Direct hospital admissions to our medical center during the months of January through June of 2015 were cross-referenced with patients for whom rapid response team (RRT) evaluation was requested. RRT evaluation may be requested for decompensating patients to expedite critical care expertise for assessment and stabilization, or transfer to a higher level of care within the hospital. Patients who had an RRT evaluation within 24 hours of direct hospital admission were identified and electronic charts were reviewed for evidence of clinical decompensation during inter-facility transport.

Results: During the time period including January through June of 2015, our hospital accepted 5332 direct hospital admissions from clinics, outside emergency departments or other hospitals. An RRT was requested within 24 hours and evidence of clinical decompensation during transport could be found for 21 of these admissions (0.39%). RRT occurred after an average of 2.8 hours in general care (range 0 to 12 hours). During inter-facility transport, evidence of hypotension (systolic BP < 90 mmHg) was present in six (29%), tachycardia (HR>120bpm) in seven (33%), administration of IV fluids in five (24%), changes in level of supplemental oxygen therapy in five (24%), new or persistent chest pain or nitroglycerine administration in three (14%), and change in level of alertness in four (19%) of the patient records. Of the 21 patients, 15 (71%) were transferred to the intensive care unit for further care. Ten (67%) of the patients transferred to the ICU required vasopressors, eight (53%) required noninvasive positive pressure ventilation (NIPPV) or intubation and 13 (87%) required any of these interventions.

Conclusions:   Here, we report clinical developments during inter-facility transport for patients who required RRT intervention soon after direct hospital admission. Not surprisingly, abnormal vital signs, change in level of alertness and escalation of oxygen therapy were common. Most patients who transferred to intensive care required intensive-care level interventions like vasopressors, NIPPV or intubation and mechanical ventilation. These data will inform our efforts to improve the quality of communication between prehospital care providers, admission centers and hospital-based medical teams.