Transfer versus direct-visit patients in medically underserved emergency departments: a retrospective cohort study

Comprehensive Summary

This study evaluates the differences in clinical severity, resource utilization, and outcomes between transferred patients (n = 7,069, 20.0 %) and direct visit patients (n = 28,185, 80.0 %) treated in a tertiary emergency department serving a medically underserved region of South Korea. 35,254 adult ED visits were analyzed from 2023, including the triage scores, vital signs, comorbidities, diagnostic testing procedures, and outcomes. The transferred patients were significantly older (63.7 ± 16.4 as compared to 58.4 ± 17.3 years, p < 0.001), more often male (59.4% vs. 49.7%, p < 0.001), and are more likely to present with high acuity KTAS levels one to three (87.5 % v/s 31.9 %). They used substantially more ED resources including CT imaging (78.4 % v/s 34.6 %), MRI, labs, and speciality consultations. The hospital admission (55.1 % v/s 23.4 %), and ICU admission (6.1 % v/s 2.5 %) rates were also higher among the transferred patients. Surprisingly, crude in-hospital mortality was lower among transferred patients (0.47 % v/s 0.75 %, p = 0.012), a difference that disappeared after excluding out of hospital cardiac arrest cases.

Outcomes and Implications

This study is clinically relevant because it quantitatively demonstrates the disproportionate resource burden and elevated illness severity associated with transferred patients, information that is critical for capacity planning in underserved emergency departments. The adjusted analysis showed that transfer status strongly predicted hospitalization (OR 3.42) and ICU admission (OR 1.98), while lower adjusted mortality (OR 0.48) suggests survivorship as well as selection bias. These findings emphasize the requirement for improved staffing, especially at night when mortality peaked to 0.96 % during twelve A.M. to eight A.M., and for more coordinated transfer pathways between referring and receiving hospitals. While the authors do not provide a specific implementation timeline, the data indicate that the health systems with high transfer volumes could benefit immediately from reassessing resource allocation, transfer protocols, and ED operational strategies to handle the markedly higher acuity of transferred patients.