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The Transfer Center as Mode of Access to Vascular Care at a Southeast Academic Medical Health System
Elizabeth H Weissler, Zachary F. Williams, Kevin W. Southerland, Adam P. Johnson, Chandler Long, Dawn M Coleman, Young Kim
Duke University, Durham, NC
Background: A growing body of evidence lends credence to the anecdotal observation that vascular surgeons are essential to the safe and efficient delivery of care in tertiary hospital systems. We have previously shown that vascular surgeons provide operative assistance to every surgical service in the hospital on both elective and urgent/emergent bases in addition to caring for patients with urgent/emergent vascular conditions, a resource intensive response resulting in a significant burden of after-hours and weekend cases. Many hospitals cannot support full-time vascular surgery coverage; therefore, patients who present to those hospitals requiring vascular surgical care may require transfer to sites where care can be provided. This study aims to explore patterns in transfer requests to an academic healthy system as a way to understand the role of vascular surgeons as a regional referral resource.
Methods: We retrospectively queried electronic medical records for all transfer center requests and external consultations to a vascular surgery service at our tertiary/quaternary-care academic health system (inclusive of 3 hospitals) between January 2021 and December 2023. Data were collected on request status, transfer type, reason for transfer, timing, location of referring hospital, and total number of communications. Transfer-related cases were defined as those occurring within 30 days after transfer. Statistics were descriptive.
Results: From 2021 to 2023, a total of 16,340 transfer center requests were made to surgical specialties at our institution, of which 1,033 (6.3%) requested vascular surgery assistance. The median age of these patients was 67 years old and most were male (n=581, 56.2%). Almost half of patients were white (n=453, 43.9%) and more than a third were Black (n=354, 34.3%). These transfer center requests included 800 (77.4%) requests for transfer and 233 (22.6%) external consultations for potential transfer. Over the three-year period, the median number of transfer center requests was 28 per month (interquartile range [IQR], 23-34), with five communications (IQR 4-7) accompanying each transfer request. Of all transfer requests, 556 (53.8%) were received after-hours (n=296), on a weekend (n=156), or both (n=104). The most common reasons for transfer included needing a higher level of care (n=695, 67.3%) and lack of on-call vascular surgeons (n=78, 7.6%;
Table 1). Requests originated from a total of 104 referring hospitals across 13 states, including a total of 211 (20.4%) requests from out-of-state facilities. Half of all requests were accepted for transfer (n=488, 47.2%). Most transfers were to an inpatient floor from either an outside emergency department (n=262, 25.7%) or an outside hospital’s inpatient floor (n=265, 25.7%), but a third of transfers were from one emergency department to another (n=346, 33.5%). Of 488 accepted transfers, 351 resulted in cases (71.9%) - 331 of these cases were done by vascular surgeons and 20 were done by other surgical or procedural specialists. The median time from transfer request to operating room was 1 day [IQR 0,4]. The most common indications for operation were acute limb ischemia (N=70) and chronic limb-threatening ischemia (N=70), followed by aortoiliac disease (N=54) and hemodialysis access complications (N=43). Mesenteric ischemia was present in 22 patients, cerebrovascular disease in 17 patients, and iliofemoral venous thrombus in 11 patients (Table 2)
Conclusions: Modern vascular surgical practice at referral centers requires around-the-clock surgeon availability to care for patients with vascular pathologies as well as to assist other specialists in providing safe care. There are many hospitals, especially in more rural areas, that are not able to support continuous vascular surgical coverage - yet patients continuously present to these hospitals with vascular diseases. External consultations and requests for transfer fill an important gap in care for patients at hospitals without adequate personnel or resources. Though most of the cases resulting from transfer were done on an urgent or emergent basis, a significant number of cases were done for more chronic conditions, suggesting that some patients are accessing elective vascular care through transfers. As demonstrated, these consultations and transfer requests also absorb significant resources at the accepting hospitals, carrying with them a significant volume of communications that often occur at night and on weekends. These findings contribute to the growing body of work in accurately assessing the value of the vascular surgeon in modern-day practice.
Table 1. Details regarding transfer center requests to vascular surgery.
| |
| Transfer requests (n=1033) |
| Communications per request | 5 (4-7) |
| Request type | |
| Request for transfer | 800 (77.4%) |
| Consult for potential transfer | 233 (22.6%) |
| Request status | |
| Transfer accepted | 488 (47.2%) |
| Transfer declined | 344 (33.3%) |
| Consult only | 157 (15.2%) |
| Not reported | 44 (4.3%) |
| Transfer request type | |
| ED to ED | 346 (33.5%) |
| ED to IP | 262 (25.7%) |
| IP to ED | 2 (0.2%) |
| IP to IP | 265 (25.7%) |
| Consult only | 158 (15.3%) |
| Transfer reason | |
| Higher level of care | 695 (67.3%) |
| Continuity of care | 70 (6.8%) |
| Patient or family preference | 19 (1.8%) |
| No vascular surgery service | 78 (7.6%) |
| Hospital capacity | 2 (0.2%) |
| Insurance/financial reasons | 2 (0.2%) |
| Other/not reported | 167 (16.2%) |
Abbreviations used: ED, emergency department; IP, inpatient.
Table 2. Vascular transfer-related case indications
| |
| Indication | N (331) |
| Acute limb ischemia | 70 |
| Revascularization | 67 |
| Amputation or diagnostic | 3 |
| Chronic limb-threatening ischemia | 70 |
| Amputation | 37 |
| Diagnostic | 7 |
| Revascularization | 26 |
| Aortoiliac disease | 54 |
| Ruptured/other hemorrhage | 18 |
| Impending rupture/symptomatic | 20 |
| Infection | 11 |
| Dissection | 3 |
| Asymptomatic | 2 |
| Hemodialysis access | 43 |
| Hemorrhage | 25 |
| Infection | 10 |
| Steal | 3 |
| Need for access | 5 |
| Mesenteric ischemia | 22 |
| Acute | 16 |
| Chronic | 6 |
| Carotid disease | 17 |
| Symptomatic | 13 |
| Near occlusion | 3 |
| Hemorrhage | 1 |
| Upper extremity disease | 14 |
| Wound complication | 14 |
| Iliofemoral DVT | 11 |
| Iatrogenic injury | 6 |
| Mesenteric aneurysm or pseudoaneurysm | 4 |
| Graft infection | 3 |
| Chronic great vessel disease | 1 |
| Renal Ischemia | 1 |
| SVC syndrome | 1 |
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