Interfacility transfer: an indicator of delay in fracture care
Authors: Gregory L Peck
Journal: The Lancet Global Health (2020)

The Three Delays framework was introduced in 1994 by Thaddeus and Maine1Thaddeus S Maine D Too far to walk: maternal mortality in context.Soc Sci Med. 1994; 38: 1091-1110Crossref PubMed Scopus (1709) Google Scholar to present obstetric obstacles that lead to pregnancy-related death and has since been adapted to categorise delays in accessing timely surgical care, forming the basis of the study reported in The Lancet Global Health by Panthea Pouramin and colleagues.2Pouramin P Li CS Busse JW et al.Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study.Lancet Glob Health. 2020; 8: e711-e720Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar The framework's theory included three groups of health-care delivery factors to assess the timeliness of care—seeking care, reaching care, and receiving care—by measuring patient, provider system, and social determinants of health-care delay.3Gabrysch S Campbell OM Still too far to walk: literature review of the determinants of delivery service use.BMC Pregnancy Childbirth. 2009; 9: 34Crossref PubMed Scopus (757) Google Scholar Together the three groups of factors contextualised a continuum of delay that spans precare, prehospital, and intrahospital environments. Importantly, if all three delays were addressed systematically, 75–90% of maternal deaths were purported to be preventable and regionally disparate maternal mortality avertable.4Hogan MC Foreman KJ Naghavi M et al.Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5.Lancet. 2010; 375: 1609-1623Summary Full Text Full Text PDF PubMed Scopus (1442) Google Scholar, 5WHOMother-Baby Package: implementing Safe Motherhood in countries. Wold Health Organization, Geneva1996Google Scholar In their Article,2Pouramin P Li CS Busse JW et al.Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study.Lancet Glob Health. 2020; 8: e711-e720Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar Pouramin and colleagues apply The Lancet Commission on Global Surgery's Three Delays framework in the largest prospective, observational, hospital-level study of open and closed fractures across 49 hospitals in 18 low-income and middle-income countries. The authors' categorical analysis of the Three Delays and related factors establishes an empirical association between delay in fracture care and interfacility transfer. They found that 27·5% of patients with closed fractures were delayed by more than 24 h in their admission to a treating hospital and 71·9% of patients with open fractures were delayed by more than 2 h. Interfacility (47·7%) and Third Delays (50·5%) were the most common reasons for delays of more than 24 h, whereas Second Delays (delays in reaching care) were the least common (5·4%). Pouramin and colleagues define interfacility transfer as a Third Delay, as do previous reports,6Khan S Zafar H Zafar SN Haroon N Inter-facility transfer of surgical emergencies in a developing country: effects on management and surgical outcomes.World J Surg. 2014; 38: 281-286Crossref PubMed Scopus (17) Google Scholar going onto conclude that interfacility transfer is the most common factor within the most commonly occurring category of delay—Third Delay. The study raises some questions, such as, is it accurate to define interfacility transfer as a Third Delay?7Bagguley D Fordyce A Guterres J et al.Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste's national referral hospital.BMJ Open. 2019; 9e029812Crossref PubMed Scopus (12) Google Scholar Pouramin and colleagues' outcomes measurement for delay in admittance to an orthopaedic unit after injury was defined as 2 h for open fractures and 24 h for closed fractures. Whether or not timely surgical intervention occurred when needed was not determined and, as Pouramin and colleagues state, “assessing the time to treatment was beyond the scope of this analysis.”2Pouramin P Li CS Busse JW et al.Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study.Lancet Glob Health. 2020; 8: e711-e720Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar Would a more comprehensive, standard analysis of Third Delay include time to actual surgical intervention? Such a definition would differentiate between delays to surgical intervention and just admission to the treating hospital. Time to surgical intervention is especially important in the case of an open fracture, for which washout is needed to prevent sepsis. The primary outcome of the study by Pouramin and colleagues2Pouramin P Li CS Busse JW et al.Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study.Lancet Glob Health. 2020; 8: e711-e720Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar was the number of patients with open and closed fractures who were admitted to a treating hospital, and the secondary outcome was the reason for delay in admission, stratified by First, Second, and Third Delay. However, these outcomes must be put into the context of the clinical relevance of each of the three delay categories, noting that reaching a facility or unit capable of care (ie, admission [Second Delay]) and receiving surgical care when needed (Third Delay), are nuanced definitions that should always be accurately defined in the interpretation of Second and Third Delay analyses. For example, when a patient reaches a first hospital but is then sent to a second hospital which is able to provide treatment—ie, an interhospital transfer—the patient has not actually reached care until arriving at the second hospital. Then, admission by itself to an orthopaedic unit at the second hospital might or might not include surgical intervention or even definitive surgeon-patient consultation. And so, is this study highlighting a more upstream Second Delay if the study design does not determine whether a definitive intervention was achieved?7Bagguley D Fordyce A Guterres J et al.Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste's national referral hospital.BMJ Open. 2019; 9e029812Crossref PubMed Scopus (12) Google Scholar Finally, is the 47·7% interfacility transfer rate high or the expected mean considering the infrastructure of prehospital health-care systems in low-income and middle-income countries, contract constraints between hospitals and emergency medical systems, and potential work-arounds that circumvent greater delay? The authors found that 3778 (71·9%) of 5256 people with open fractures were not admitted to a treating hospital within 2 h of injury. The proportion of the cohort that was not admitted to hospital within 2 h of injury is nearly a reciprocal of indicator two of The Lancet Commission on Global Surgery 2030 target, that 80% of the population can access emergency and essential care within 2 h when needed, unrestricted by geographical location. Although the authors measure time to admission to a treating hospital, a measure that has Berkson's bias, their work highlights a difference between geographical (possible) and physical (actual) fracture care by Bellwether procedure specifically—ie, open fracture in low-income and middle-income countries.7Bagguley D Fordyce A Guterres J et al.Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste's national referral hospital.BMJ Open. 2019; 9e029812Crossref PubMed Scopus (12) Google Scholar With respect to moving forward in research of delay, in the case of Second Delays, hypothesis testing is anchored in prehospital location as the unit of analysis. For example, factors associated with prehospital teams' decision to deliver patients to the first hospital reached without objective information on the number of surgeon providers in-house and capacity of operating rooms could increase the rate of interfacility transfer. Although these decision and information factors contributing to Second Delays will inevitably also contribute to Third Delays downstream, they are specifically upstream factors that require upstream hypothesis and intervention testing. By contrast, the definition of a Third Delay, and related hypothesis testing, would target definitive surgical intervention received at the second hospital reached after interfacility transfer has transported the patient to a facility with definitive capacity. Although Pouramin and colleagues' regional analysis of Latin America is based on convenience sampling and limited to two hospitals in two countries with different health-care systems, the substantial delays in admission to a hospital in the region (173 [88·7%] of 195 patients with open fractures and 426 [44·7%] of 952 with closed fractures) and the association between such delays and regional interfacility transfer are concerning. For Latin America, such transfers might be associated with deterioration in patient outcomes and historical disparity might still exist in requirements of prehospital quality assurance programmes if interfacility transfer is not included in emergency system assessments; therefore, population-level mortality due to trauma is likely to remain regionally disparate.6Khan S Zafar H Zafar SN Haroon N Inter-facility transfer of surgical emergencies in a developing country: effects on management and surgical outcomes.World J Surg. 2014; 38: 281-286Crossref PubMed Scopus (17) Google Scholar, 8Peralta LM The prehospital emergency care system in Mexico City: a system's performance evaluation.Prehosp Disaster Med. 2006; 21: 104-111Crossref PubMed Scopus (8) Google Scholar In a densely populated Colombian city, our group found over a 13-month study period that 21 790 (69%) of 31 659 patient transports by the public ambulance system were interfacility transfers.9Truche P, NeMoyer R, Patiño-Franco S, Torres M, Pino LF, Peck GL. Burden of surgical disease on interfacility ambulance transfers in a middle-income country. Academic Surgical Congress; Houston TX, USA; Feb 26, 2019 (abstr 90.07).Google Scholar 7808 (35·8%) of 21 790 patients required interfacility transfer for surgical conditions and the most common diagnosis was fracture (1227 [5·6%]). Interfacility transfer might be a surrogate of the bureaucratic barriers that contribute to community, transport, or hospital-based factors in delay in definitive care. If true, interfacility transfer should then be evaluated as an independent predictor of the strength of emergency and essential surgical systems' delivery processes, structures, and outcomes. Several key messages should be taken from this Article. First, interfacility transfer might serve as a health-care system indicator of timely fracture care in low-income and middle-income countries. Robust multilevel health system interventions are needed to impact the where and why (ie, factors) of interfacility transfer. Second, the rate of interfacility transfer for fracture care might be as high as 50% in some low-income and middle-income countries. An observed-to-expected interfacility transfer rate ratio is needed for regional benchmarking. Finally, the proportion of patients reaching any hospital is different from the proportion reaching a second hospital, and still different from the proportion that reaches a second hospital that can provide definitive surgical treatment when needed. This definitive care factor has important implications in the analysis of preparedness for care versus delivery of care and implementation of interdependent clinical-policy solutions.10Alkire BC Raykar NP Shrime MG et al.Global access to surgical care: a modelling study.Lancet Glob Health. 2015; 3: e316-e323Summary Full Text Full Text PDF PubMed Scopus (345) Google Scholar I declare no competing interests. Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational studyIn low-income and middle-income countries, timely hospital admission remains largely inaccessible, especially among patients with open fractures. Reducing hospital-based delays in receiving care, and, in particular, improving interfacility referral systems are the most substantial tools for reducing delays in admissions to hospital. Full-Text PDF Open Access