The Scope and Impact of a Novel, Urban, Rapid Patient Interhospital Transfer System to Improve Neuroemergent Care: The Design and Development of the Neuroemergency Transfer Program

Original Article

Austin J Clin Neurol 2021; 8(2): 1151.

The Scope and Impact of a Novel, Urban, Rapid Patient Interhospital Transfer System to Improve Neuroemergent Care: The Design and Development of the Neuroemergency Transfer Program

John S¹*, Woodward J², Keegan KC², Tchalukov K², Koro L², Brahimaj BC², Eddelman D², Munoz L² and Byrne RW²

¹Department of Neurology, Rush University Medical Center, Chicago, Illinois, USA

²Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA

*Corresponding author: Sayona John, Department of Neurology, Rush University Medical Center, 1725 W. Harrison St., Suite 1121, Chicago, IL 60612, USA

Received: July 20, 2021; Accepted: August 09, 2021; Published: August 16, 2021


Background: Access to neuroemergent care in the United States represents a significant public health concern, with limited neurosurgery and/ or neurocritical care coverage in both rural and urban settings. Inadequate access to neuroemergent providers, even in urban settings, may result in prolonged patient transfer time, associated neurological decline and translate into increased morbidity and mortality.

Methods: A single center retrospective analysis of prospectively collected data of interhospital patient transfers to a neuroscience ICU between 2008-2018 was performed.

Results: 9637 patients were included for analysis. A substantial increase in transfer requests were observed, 610 to 1221 from 2008 to 2018 respectively, with concurrent increase in the number and geographic distribution of referral centers. Ultimately, 7726 (80.2%) patients were discharged home or to outpatient or acute rehabilitation while 1820 (18.9%) were discharged to a long-term acute care facility (LTAC), hospice, or expired during the index admission. The leading diagnoses for transfer were: 1. intracerebral hemorrhage, 2. subarachnoid hemorrhage, 3. ischemic stroke, 4. subdural hematoma and 5. brain tumor. Transfer from an ED or ICU constituted 93.3% of requests. Mean total transfer time between 2012-2018 was < 155 minutes annually (range 128-155 minutes). In 2018, 91.5% of patients had health insurance with 68.7% covered by some form of Medicaid or Medicare.

Conclusions: The ongoing evolution and overall success of the NTP draws chiefly from the designation of an easily accessible central operator to orchestrate transfer, establishing a network of community referral centers and optimization of regional patient transportation - all with the solitary goal of improving patient outcomes.

Keywords: Neurosurgery/economics; Neurosurgery/epidemiology; Neurology/classification; Neurology/economics; Patient transfer; Critical care outcomes


Limited access to neurosurgical and neurocritical care in the United States represents a significant and growing public health concern [1,2]. It is well recognized that healthcare infrastructure, investment and training deficiencies limit access to neuroemergent care in rural communities [3-10]. However, a discrepancy in the geographic distribution of patients and neuroemergent providers also exists in urban settings and may translates into increased transfer referrals to tertiary medical centers [1,11]. As a result of increased patient volume, medical liability exposure and essential infrastructure or resources shortfalls, gaps in neurosurgery and/ or neurocritical care coverage are increasing [1,12,13]. As such, the importance of providing critically ill neurologic patient’s access to pathology-specific expert guided emergent evaluation and treatment underlies the necessity of establishing rapid and reliable interhospital patient transfer systems [1,3,12]. Prior studies have reported mean transfer times for neuroemergent patients between 180 and 300 minutes [1,12,14]. In 2005, Byrne et al. showed a mean transfer time of 310 minutes among 230 transfers to 5 universities in Chicago, IL. Of the 29 patients that experienced a decline in Glasgow Coma Scale score, mean transfer time still exceeded 300 minutes. As a recognized risk factor for progressive neurological decline, prolonged or delayed patient transfer may translate into increased morbidity and mortality [1,3,15-21]. To address the limitations in healthcare providers, as well as inefficient means of patient transfer, we developed a novel interhospital transfer system for the neuroemergent patient.

In the present study, the consistent increase in the annual volume of transfer requests reiterates the need and underlies the importance of optimizing the interhospital transfer process. Herein, we describe the development of the Neuroemergency Transfer Program (NTP) and the clinical implications for patient care and associated healthcare outcomes.


An IRB approved (IRB # 17112802) retrospective analysis of prospectively collected data was performed on patient transfers accepted between 2008-2018 at Rush University Medical Center in Chicago, IL. Patients ≥18 years of age transferred via the NTP were eligible for inclusion. No prior screening for the presence, absence of type of healthcare insurance is performed prior to transfer acceptance. Paper documentation was reviewed for relevant clinical information and patient characteristics until the incorporation of an Electronic Healthcare Record (EHR) in 2012. 2019 United States Census Bureau and Illinois Department of Public Health data were evaluated for socioeconomic and demographic data. Characteristics of referral centers were assessed via the American Hospital Directory. A review of each referral center’s website was performed for determination of the presence or absence of neurosurgical coverage. Statistical analysis of continuous variables was performed using either two-tailed t-test or one-way analysis of variance for determination of statistical significance, with p <0.05 establishing significance (JMP®, Version 14. SAS Institute Inc., Cary, NC, 1989-2019). Raw data is presented using descriptive statistics, continuous variables as means with standard deviation and categorical data as frequencies with percentages.

In the current study, a number of clinical parameters were assessed and include: total transfer time, transfer distance, transfer diagnosis, procedures performed and disposition at discharge. Total transfer time was calculated as the interval between initial acceptance and patient arrival in the Intensive Care Unit (ICU) for the years an EHR was available (2012-2018). In all instances, transfer distance was calculated using the shortest ground route. Categorical determination of transfer diagnosis was based on the visit primary discharge diagnosis indicated in the EHR as this was the most informed and accurate diagnosis. Total and neurosurgical specific procedures and interventions were enumerated from 2008-2018. Neurosurgical specific interventions included: endovascular, bedside and general Operating Room (OR) procedures. Binary determination of patient outcome was undertaken, a “good” clinical outcome included disposition to home, acute or outpatient rehabilitation. A “poor” clinical outcome included discharge to a Long-Term Acute Care facility (LTAC), hospice or death from any causes during the index admission.


In total, 9637 patients were included for analysis with a male predominance of 51.1% and a mean age of 60.3 years (range 18- 111 years) (Table 1). Overall, the leading diagnoses for transfer were: intracranial hemorrhage (23.8%), subarachnoid hemorrhage (14.9%), ischemic stroke (14.8%), subdural hematoma (11.5%), intracranial tumor (8.0%), seizure and/or status epilepticus (4.4%), central nervous system infection (3.2%), spine fracture (1.5%) and spine tumor (0.6%). A substantial increase in annual transfer volume, from 610 transfers in 2008 to 1221 transfers in 2018 with a concurrent increase in the number of referral centers from 79 institutions in 2012, to 97 institutions in 2018 was observed (Figure 1). Relative trends in transfer diagnoses were maintained from year-to-year with minimal variation (Figure 2) and are stratified by race and ethnicity in Table 2. Annual mean total transfer time was <155 minutes (range 128-155 minutes) with no significant annual variation (p <0.05) (Figure 1). The most frequent categorical distance for transfer was ≥20 miles, followed by 5-9.9 miles, 10-19.9 miles and finally <5 miles.