Original Article

Effect of Delirium on Interhospital Transfer Outcomes

Authors: Meghan K. Thomas, MD, MPH, Benjamin Kalivas, MD, Jingwen Zhang, MS, Justin Marsden, MS, Patrick D. Mauldin, PhD, William P. Moran, MD, MS, Kelly Hunt, PhD, Marc Heincelman, MD, MPH

Abstract

Objectives: Interhospital transfer (IHT) and in-hospital delirium are both independently associated with increased length of stay (LOS), mortality, and discharge to facility. Our objective was to investigate the joint effects between IHT and the presence of in-hospital delirium on the outcomes of LOS, discharge to a facility, and in-hospital mortality.

Methods: This was a single-center retrospective cohort study of 25,886 adult hospital admissions at a tertiary-care academic medical center. Staged multivariable logistic and linear regression models were used to evaluate the association between IHT status and the outcomes of discharge to a facility, LOS, and mortality while considering the joint impact of delirium. The joint effects of IHT status and delirium were evaluated by categorizing patients into one of four categories: emergency department (ED) admissions without delirium, ED admissions with delirium, IHT admissions without delirium, and IHT admissions with delirium. The primary outcomes were LOS, in-hospital mortality, and discharge disposition.

Results: The odds of discharge to a facility were 4.48 times higher in admissions through IHT with delirium when compared with ED admissions without delirium. IHT admissions with delirium had a 1.97-fold (95% confidence interval 1.88–2.06) longer LOS when compared with admission through the ED without delirium. Finally, admissions through IHT with delirium had 3.60 (95% confidence interval 2.36–5.49) times the odds of mortality when compared with admissions through the ED without delirium.

Conclusions: The relationship between IHT and delirium is complex, and patients with IHT combined with in-hospital delirium are at high risk of longer LOS, discharge to a facility, and mortality.

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References

1. Mueller SK, Zheng J, Orav EJ, et al. Rates, predictors and variability of interhospital transfers: a national evaluation. J Hosp Med 2017;12:435–442.
 
2. Usher M, Sahni N, Herrigel D, et al. Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. J Gen Intern Med 2018;33:1447–1453.
 
3. Mueller S, Zheng J, Orav EJ, et al. Inter-hospital transfer and patient outcomes: a retrospective cohort study. BMJ Qual Saf 11 2019;28:e1.
 
4. Heincelman M, Gebregziabher M, Kirkland E, et al. Impact of patient-level characteristics on in-hospital mortality after interhospital transfer to medicine services: an observational study. J Gen Intern Med 2020;35:1127–1134.
 
5. Flabouris A, Hart GK, George C. Outcomes of patients admitted to tertiary intensive care units after interhospital transfer: comparison with patients admitted from emergency departments. Crit Care Resusc 2008;10:97–105.
 
6. Snow K, Galaviz K, Turbow S. Patient outcomes following interhospital care fragmentation: a systematic review. J Gen Intern Med 2020;35:1550–1558.
 
7. Sokol-Hessner L, White AA, Davis KF, et al. Interhospital transfer patients discharged by academic hospitalists and general internists: characteristics and outcomes. J Hosp Med 2016;11:245–250.
 
8. Arthur KR, Kelz RR, Mills AM, et al. Interhospital transfer: an independent risk factor for mortality in the surgical intensive care unit. Am Surg 2013;79: 909–913.
 
9. Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994;97:278–288.
 
10. Jones RN, Cizginer S, Pavlech L, et al. Assessment of instruments for measurement of delirium severity: a systematic review. JAMA Intern Med 2019;179:231–239.
 
11. Mattison MLP. Delirium. Ann Intern Med 2020;173:ITC49–ITC64.
 
12. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 2006;35:350–364.
 
13. Thomas MK, Heincelman ME, Zhang J, et al. Understanding the association between admission source and in-hospital delirium: a cross-sectional study. J Investig Med 2023;71:32–37.
 
14. Thomas AJ, Eberly LE, Davey Smith G, et al. ZIP-code-based versus tract-based income measures as long-term risk-adjusted mortality predictors. Am J Epidemiol 2006;164:586–590.
 
15. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286:2703–2710.
 
16. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;29:1370–1379.
 
17. Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 2013; 62:457–465.
 
18. US Census Bureau. American fact finder. https://factfinder.census.gov/bkmk/table/1.0/en/ACS/10_3YR/S1701/0100000US.05000.003. Accessed February 12, 2021.
 
19. Stelmokas J, Gabel N, Flaherty JM, et al. Delirium detection and impact of comorbid health conditions in a post-acute rehabilitation hospital setting. PLoS One 2016;11:e0166754.
 
20. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005; 43:1130–1139.
 
21. LaHue SC, Maselli J, Rogers S, et al. Outcomes following implementation of a hospital-wide, multicomponent delirium care pathway. J Hosp Med 2021; 16:397–403.
 
22. Deschodt M, Braes T, Flamaing J, et al. Preventing delirium in older adults with recent hip fracture through multidisciplinary geriatric consultation. J Am Geriatr Soc 2012;60:733–739.