The Impact of Timing on Clinical and Economic Outcomes During Inter-ICU Transfer of Acute Respiratory Failure Patients: Time and Tide Wait for No One

Approximately one in 30 patients with acute respiratory failure (ARF) undergoes an inter-ICU transfer. Our objectives are to describe inter-ICU transfer patterns and evaluate the impact of timing of transfer on patient-centered outcomes. Retrospective, quasi-experimental study. We used the Healthcare Cost and Utilization Project State Inpatient Databases in five states (Florida, Maryland, Mississippi, New York, and Washington) during 2015-2017. We selected patients with , 9th and 10th Revision codes of respiratory failure and mechanical ventilation who underwent an inter-ICU transfer ( = 6,718), grouping as early (≤ 2 d) and later transfers (3+ d). To control for potential selection bias, we propensity score matched patients (1:1) to model propensity for early transfer using a priori defined patient demographic, clinical, and hospital variables. Inhospital mortality, hospital length of stay (HLOS), and cumulative charges related to inter-ICU transfer. Six-thousand seven-hundred eighteen patients with ARF underwent inter-ICU transfer, 68% of whom ( = 4,552) were transferred early (≤ 2 d). Propensity score matching yielded 3,774 well-matched patients for this study. Unadjusted outcomes were all superior in the early versus later transfer cohort: inhospital mortality (24.4% vs 36.1%; < 0.0001), length of stay (8 vs 22 d; < 0.0001), and cumulative charges ($118,686 vs $308,977; < 0.0001). Through doubly robust multivariable modeling with random effects at the state level, we found patients who were transferred early had a 55.8% reduction in risk of inhospital mortality than those whose transfer was later (relative risk, 0.442; 95% CI, 0.403-0.497). Additionally, the early transfer cohort had lower HLOS (20.7 fewer days [13.0 vs 33.7; < 0.0001]), and lower cumulative charges ($66,201 less [$192,182 vs $258,383; < 0.0001]). Our study is the first to use a large, multistate sample to evaluate the practice of inter-ICU transfers in ARF and also define early and later transfers. Our findings of favorable outcomes with early transfer are vital in designing future prospective studies evaluating evidence-based transfer procedures and policies.