Early unplanned hospital readmission after acute traumatic injury: the experience at a state-designated level-I trauma center

Predictors of hospital readmission after trauma: A retrospective cohort study in New Zealand

INTRODUCTION

Understanding predictors of hospital readmission following major trauma is important as readmissions are costly and some are potentially avoidable. This study describes the incidence of, and sociodemographic, injury-related and treatment-related factors predictive of, hospital readmission related to: a) all-causes, b) the index trauma injury, and c) subsequent injury events in the 30 days and 12 months following discharge for major trauma patients nationally in New Zealand.

METHODS

Data from the New Zealand Trauma Registry (NZTR) was linked with Ministry of Health hospital discharge data. Hospital readmissions were examined for all patients entered into the NZTR for an injury event between 1 January and 31 December 2018. Readmissions were examined for the 12-months following the discharge date for participant's index trauma injury.

RESULTS

Of 1986 people, 42% had ≥1 readmission in the 12 months following discharge; 15% within 30 days. Seven percent had ≥1 readmission related to the index trauma within 30 days of discharge; readmission was 3.43 (95% CI 1.87, 6.29) times as likely if the index trauma was self-inflicted compared to unintentional, and 1.64 (95% CI 1.15, 2.34) times as likely if the index trauma involved intensive care unit admission. Those admitted to hospital for longer for their index trauma were less likely to be readmitted due to their index trauma injury within 30 days compared to those admitted for 0-1 day. Seventeen percent were readmitted for a subsequent injury event within 12 months, with readmission more likely for older people (>65 years), those with comorbidities, Māori compared with non-Māori and those with higher trauma injury severity.

CONCLUSION

A substantial proportion of people are readmitted after discharge for major trauma. Factors identified in this study will be useful to consider when developing interventions to reduce preventable readmissions including those related to the index trauma injury, readmissions from other causes and subsequent injury-related readmissions. Further research specifically examining planned and unplanned readmissions is warranted.

Emergency department visit patterns in the recently discharged, violently injured patient: Retrospective cohort review

BACKGROUND

Analysis of the costs associated with emergency department (ED) visits after discharge for violent injury could highlight subgroups for the development of cost-effective interventions to support healing and prevent treatment failures in violently injured patients.

METHODS

A retrospective cohort review was conducted of all patients with return ED visits within 90 days of discharge after treatment for a violent injury occurring between July 1, 2016, and June 30, 2018. Hospital costs were calculated for each incidence and analyzed against demographic and injury type variables to identify trends.

RESULTS

218 return ED visits were identified. Hospital costs showed a high frequency of low-cost visits. For more complex visits, distinct cost patterns were observed for Black and LatinX males compared to White males as a function of age.

CONCLUSIONS

Analysis of hospital cost per visit identified trends among different subgroups. Underlying etiologies presumably vary between groups, but hypothesis-driven further investigation and needs assessment is required. Understanding the driving forces behind these cost trends may aid in developing effective interventions.

Victims of Violence and Post-Discharge Adverse Events: A Prospective Modified Trauma Quality Improvement Program (TQIP) Study

Introduction

Trauma patients frequently return to an emergency department (ED) soon after discharge; often for non-urgent reasons. Social factors contribute to higher ED usage. At present, there is no standardized system for reporting of ED visits and readmissions among trauma care. We hypothesized that victims of violent crime suffer from many early post-discharge adverse events that has not been captured by current methods.

Methods

We prospectively consented and enrolled injured patients from January 1st, 2019 to December 31st, 2019. We documented 30-day post-discharge events using post-discharge phone calls and detailed chart abstraction. Patients were categorized as victims of violence (VV) or unintentional traumatic injury (UT).

Results

During the study period, 444 patients were enrolled. Fifty-one (11.5%) were victims of violence and 393 (88.5%) experienced unintentional injuries. The VV patients were younger (40.10 vs 60.36; p<0.0001), and more predominantly male (92.16% vs 57.51%; p<0.0001). Total injury severity score (ISS), critical care length of stay (LOS), and total LOS were similar. VV patients were more likely discharged home (70.59% vs 55.47%; p=0.0403). They were significantly more likely to return to an emergency department (47.06% vs 23.16%; p<0.0005) and had more total number of ED visits per patient. Readmission rates, however, were not different (21.57% vs 16.28%; p=NS). The VV patients more frequently were underinsured (72.5%, vs 20.6%, p<0.005).

Discussion

Victims of violence presented to the ED significantly more often, despite similar injury scores, LOS, and being of younger age. Of these patients, only 26.2% of ED presentations resulted in readmission, suggesting the majority of patient complaints may have been able to be managed in an office-based setting. VV had significantly more underinsured or subsidized patients. Victims of violence are vulnerable and may benefit from more resources provided in the early post-discharge period.

Readmission following surgical stabilization of rib fractures: Analysis of incidence, cost, and risk factors using the Nationwide Readmissions Database

BACKGROUND

Surgical stabilization of rib fractures (SSRF) has become increasingly common for the treatment of traumatic rib fractures; however, little is known about related postoperative readmissions. The aims of this study were to determine the rate and cost of readmissions and to identify patient, hospital, and injury characteristics that are associated with risk of readmission in patients who underwent SSRF. The null hypotheses were that readmissions following rib fixation were rare and unrelated to the SSRF complications.

METHODS

This is a retrospective analysis of the 2015 to 2017 Nationwide Readmission Database. Adult patients with rib fractures treated by SSRF were included. Univariate and multivariate analyses were used to compare patients readmitted within 30 days with those who were not, based on demographics, comorbidities, and hospital characteristics. Financial information examined included average visit costs and national extrapolations.

RESULTS

A total of 2,522 patients who underwent SSRF were included, of whom 276 (10.9%) were readmitted within 30 days. In 36.2% of patients, the reasons for readmissions were related to complications of rib fractures or SSRF. The rest of the patients (63.8%) were readmitted because of mostly nontrauma reasons (32.2%) and new traumatic injuries (21.1%) among other reasons. Multivariate analysis demonstrated that ventilator use, discharge other than home, hospital size, and medical comorbidities were significantly associated with risk of readmission. Nationally, an estimated 2,498 patients undergo SSRF each year, with costs of US $176 million for initial admissions and US $5.9 million for readmissions.

CONCLUSION

Readmissions after SSRF are rare and mostly attributed to the reasons not directly related to sequelae of rib fractures or SSRF complications. Interventions aimed at optimizing patients' preexisting medical conditions before discharge should be further investigated as a potential way to decrease rates of readmission after SSRF.

LEVEL OF EVIDENCE

Epidemiological study, level III.

Association of Psychosocial Factors and Hospital Complications with Risk for Readmission After Trauma

BACKGROUND

Unplanned hospital readmissions are associated with morbidity and high cost. Existing literature on readmission after trauma has focused on how injury characteristics are associated with readmission. We aimed to evaluate how psychosocial determinants of health and complications of hospitalization combined with injury characteristics affect risk of readmission after trauma.

MATERIALS AND METHODS

We conducted a retrospective cohort study of adult trauma admissions from July 2015 to September 2017 to Harborview Medical Center in Seattle, Washington. We assessed patient, injury, and hospitalization characteristics and estimated associations between risk factors and unplanned 30-d readmission using multivariable generalized linear Poisson regression models.

RESULTS

Of 8916 discharged trauma patients, 330 (3.7%) had an unplanned 30-d readmission. Patients were most commonly readmitted with infection (41.5%). Independent risk factors for readmission among postoperative patients included public insurance (adjusted Relative Risk (aRR) 1.34, 95% CI 1.02-1.76), mental illness (aRR 1.39, 1.04-1.85), and chronic renal failure (aRR 2.17, 1.39-3.39); undergoing abdominal, thoracic, or neurosurgical procedures; experiencing an index hospitalization surgical site infection (aRR 4.74, 3.00-7.50), pulmonary embolism (aRR 3.38, 2.04-5.60), or unplanned ICU readmission (aRR 1.74, 1.16-2.62); shorter hospital stay (aRR 0.98/d, 0.97-0.99), and discharge to jail (aRR 4.68, 2.63-8.35) or a shelter (aRR 4.32, 2.58-7.21). Risk factors varied by reason for readmission. Injury severity, trauma mechanism, and body region were not independently associated with readmission risk.

CONCLUSIONS

Psychosocial factors and hospital complications were more strongly associated with readmission after trauma than injury characteristics. Improved social support and follow-up after discharge for high-risk patients may facilitate earlier identification of postdischarge complications.

Readmission rates and associated factors following rib cage injury

BACKGROUND

There remains a lack of knowledge about readmission characteristics after sustaining rib fractures. We aimed to determine rates, characteristics, and predictive/protective factors associated with unexpected reevaluation and readmission after rib cage injury.

METHODS

A retrospective review was performed based on trauma patients evaluated at an urban Level I trauma center from January 2014 to December 2016. Adult patients sustaining blunt trauma with more than one rib fracture or a sternomanubrial fracture were defined as having moderate to severe rib cage injury. Exclusion criteria included penetrating injury, death during initial hospitalization, and only one rib fracture. Reevaluation was defined as presenting at a hospital within 90 days of discharge urgently or emergently. Demographics, injury characteristics, comorbidities, complications, imaging, and readmission data were collected. Univariate and multivariate analysis was performed with a significance of p less than 0.05.

RESULTS

During the study period, 11,667 patients underwent trauma evaluation, of which 1,717 patients were found to have a moderate to severe rib cage injury. Within 90 days, 397 (23.1%) of patients underwent reevaluation, while 177 (10.3%) required readmission. One hundred forty-two (8.3%) patients were reevaluated specifically for chest-related complaints, and 55 (3.2%) required readmission. On univariate analysis, Injury Severity Score greater than 15, hospital length of stay longer than 7 days, intensive care unit (ICU) length of stay longer than 3 days, a worsened chest x-ray at discharge, a psychiatric comorbidity, a smoking comorbidity, deep vein thrombosis, unplanned readmission to the ICU, and unplanned intubation were higher in the overall reevaluation cohort. On multivariate analysis, age of 15 years to 35 years, Risk Assessment Profile score greater than 8, hypertension, psychiatric comorbidity, current smoker, and unplanned return to the ICU on index admission were predictive of reevaluation of overall reevaluation.

CONCLUSION

Moderate to severe rib cage injury is associated with high rates of reevaluation and readmission. Younger patients who smoke and required a return to the ICU are at greater risk for readmission.

LEVEL OF EVIDENCE

Level IV, Prognostic and Epidemiologic.

Unplanned readmission after traumatic injury: A long-term nationwide analysis

BACKGROUND

Long-term outcomes after trauma admissions remain understudied. We analyzed the characteristics of inpatient readmissions within 6 months of an index hospitalization for traumatic injury.

METHODS

Using the 2010 to 2015 Nationwide Readmissions Database, which captures data from up to 27 US states, we identified patients at least 15 years old admitted to a hospital through an emergency department for blunt trauma, penetrating trauma, or burns. Exclusion criteria included hospital transfers, patients who died during their index hospitalizations, and hospitals with fewer than 100 trauma patients annually. After calculating the incidences of all-cause, unplanned inpatient readmissions within 1 month, 3 months, and 6 months, we used multivariable logistic regression models to identify predictors of readmissions. Analyses adjusted for patient, clinical, and hospital factors.

RESULTS

Among 2,763,890 trauma patients, the majority had blunt injuries (92.5%), followed by penetrating injuries (6.2%) and burns (1.5%). Overall, rates of inpatient readmissions were 11.1% within 1 month, 21.6% within 6 months, and 29.8% within 6 months, with limited variability by year. After adjustment, the following were associated with all-cause 6 months inpatient readmissions: male sex (adjusted odds ratio [aOR], 1.10; 95% confidence interval [95% CI], 1.09-1.10), comorbidities (aOR, 1.21; 95% CI, 1.21-1.22), low-income quartiles (first and second) (aOR, 1.08; 95% CI, 1.07-1.10 and aOR, 1.04; 95% CI, 1.03-1.06, respectively), Medicare (aOR, 1.65; 95% CI, 1.62-1.69), Medicaid (aOR, 1.51; 95% CI, 1.48-1.53), being treated at private, investor-owned hospitals (aOR, 1.15; 95% CI, 1.12-1.18), longer hospital length of stay (aOR, 1.01; 95% CI, 1.01-1.01) and patient disposition to short-term hospital (aOR, 1.55; 95% CI, 1.49-1.62), skilled nursing facility (aOR, 1.43; 95% CI, 1.42-1.45), home health care (aOR, 1.27; 95% CI, 1.25-1.28), or leaving against medical advice (aOR, 1.85; 95% CI, 1.78-1.92).

CONCLUSION

Unplanned readmission after trauma is high and remains this way 6 months after discharge. Understanding the factors that increase the odds of readmissions within 1 month, 3 months, and 6 months offer a focus for quality improvement and have important implications for hospital benchmarking.

LEVEL OF EVIDENCE

Epidemiological study, level III.

[Analysis of causes and factors associated with hospital readmission in mild and moderate polythraumatism: An observational study]

BACKGROUND

Early readmissions (ER) occur during the 30 days after discharge, ER are common and expensive, associated with a decrease in the quality of care. The rate of ER in polytraumatic patients (PTP) is estimated between 4.3-15%. Our objective was to identify those factors associated with ER and its characteristics after suffering mild-moderate trauma in our area.

MATERIAL AND METHOD

This is a retrospective observational study, including data of patients with (PTP) mild or moderate admitted between July 2012 and June 2017 in our institution and their ER in public hospitals and/or outpatient centers. Demographic variables, diagnoses, procedures and characteristics of readmissions were collected. After a bivariant analysis was done, a Logistic regression had benn performed to determine risk factors for ER.

RESULTS

1013 patients were included, with median age of 38 years, ISS of 3 points and initial hospital stay of 1 day. 185 patients were readmitted (18.3%). Independent factors associated with ER were: injury mechanism, especially bicycle accident (OR 2.26), comorbidities highlighting HBP (OR 1.83) and COPD (OR 1.98), fracture immobilization (OR 1.99) and hospital admission in the initial care (OR 0.56). The causes of ER were: pain 61.6%, wound infection 15.1%, scheduled cures and deferred interventions 12.97%, medical 6.4% and psychiatric decompensation. 2.7% CONCLUSION: The ERs in mild-moderate PTP are multifactorial, our results show an association between factors such as injury mechanism, the presence of comorbidities and the procedures performed in the sentinel episode and the rate of ER. The implementation of simple interventions at discharge could reduce its incidence clearly.

Back so soon? Characterizing emergency department use after trauma

BACKGROUND

Trauma readmissions have been well studied but little data exists regarding Emergency Department (ED) utilization following an injury. This study was performed to determine the factors associated with a return to the ED after trauma.

METHODS

A retrospective review of all adult trauma patients evaluated between January and December of 2014 was performed. Demographics, follow-up plan, and characteristics of ED visits within 30 days of discharge were recorded. Predictive factors of ED utilization were identified using univariate analysis and multi-logistic regression.

RESULTS

Fourteen percent of 1836 consecutive patients returned to the ED within 30 days of initial trauma. On multi-logistic regression, penetrating trauma (OR 2.15 p = 0.001), and scheduled follow-up (OR 1.81 p = 0.046) remained significant predictors.

CONCLUSIONS

Penetrating trauma victims are at increased risk of returning to the ED, most often because of wound or pain issues. Recognizing these factors allows for targeted interventions to decrease ED resource utilization.

Hospital readmissions in paediatric trauma patients: A 10-year Australian review

AIM

Readmission of paediatric trauma patients is associated with increased hospital length of stay, additional operative procedures and significant costs to the health-care system. The rates and causes of readmission of paediatric trauma patients are not well reported outside of the USA or single centres. This nation-wide study is the first in Australia to examine the readmission rates, costs and characteristics of Australian paediatric trauma patients.

METHODS

This was a retrospective examination of linked hospitalisation and mortality data for injured children aged 16 or younger from 1 July 2001 to 30 June 2012, readmitted to hospital within 28 days of discharge. Data including injury severity, nature of injury, episodes of care and costs were extracted from hospitalisation data.

RESULTS

There were 37 603 injury children aged ≤16 years readmitted to hospital within 28 days during the 10-year period, a readmission rate of 5.5%. The most common principal injury requiring readmission was fracture (52.6%) and burns (19.3%). A total of 66% of all patients had a readmission diagnosis of injury, complication of their initial injury or complication of surgical and medical care; 30% were readmitted for a specific procedure or follow-up care. The total cost of readmissions was AU$108 million.

CONCLUSIONS

Hospital readmission rates of paediatric trauma patients in Australia are due to injury or a complication of injury and are associated with significant costs. Early identification of at-risk patients and the prevention of complications are needed to prevent the ongoing burden of readmission.

Using clinical analysis to classify 30-day trauma readmissions

BACKGROUND

Unplanned hospital readmissions are common across specialties. Descriptive readmission studies commonly query large administrative databases, which some speculate lack clinical granularity. This article provides the framework for a process improvement initiative aimed at identifying clinically meaningful reasons for trauma readmission. Our study hypothesizes an expected difference between the clinically abstracted reasons for readmission and those documented by the data processing staff in the trauma registry and that those differences will be the starting point to target performance improvement.

METHODS

This is a retrospective, cohort study from 2014 to 2016 involving 18,998 trauma evaluations at a Level I trauma center. The systematic categorization of trauma readmissions was completed via clinical chart review. Readmissions were categorized following an organizational flowchart. The chart reviews ultimately resulted in two readmission categories: primary and secondary reasons for 30-day trauma readmission.

RESULTS

There were 413 readmissions, an overall readmission rate of 2.7%. The highest rate of readmission, by mechanism of injury, was gunshot wounds (11%). Secondary reasons for readmission predominated (76.1%). Complications led (41%), followed by observation (8.8%) and pain (8.6%). Following readmission chart review and categorization, the trauma registry data were queried and categorized via the same method. When the two methods of data collection were compared, there was a significant difference (p < 0.0001).

CONCLUSIONS

The granular dissection of readmission charts proved to assist in isolating clinically significant readmission variables, providing clarity into the reasons behind trauma readmission. If determined solely by the trauma registry data, our performance and quality improvement initiatives would be misguided. We recommend clinical oversight of databases, with clinical review of key areas in order to guide performance improvement.

Trauma transitional care coordination: A mature system at work

BACKGROUND

We have previously demonstrated effectiveness of a Trauma Transitional Care Coordination (TTCC) Program in reducing 30-day readmission rates for trauma patients most at risk. With program maturation, we achieved improved readmission rates for specific patient populations.

METHODS

TTCC is a nursing driven program that supports patients at high risk for 30-day readmission. The TTCC interventions include calls to patients within 72 hours of discharge, complete medication reconciliation, coordination of medical appointments, and individualized problem solving. Account IDs were used to link TTCC patients with the Health Services Cost Review Commission database to collect data on statewide unplanned 30-day readmissions.

RESULTS

Four hundred seventy-five patients were enrolled in the TTCC program from January 2014 to September 2016. Only 10.5% (n = 50) of TTCC enrollees were privately insured, 54.5% had Medicaid (n = 259), and 13.5% had Medicare (n = 64). Seventy-three percent had Health Services Cost Review Commission severity of injury ratings of 3 or 4 (maximum severity of injury = 4). The most common All Patient Refined Diagnosis Related Groups for participants were: lower-extremity procedures (n = 67, 14%); extensive abdominal/thoracic procedures (n = 40, 8.4%); musculoskeletal procedures (n = 37, 7.8%); complicated tracheostomy and upper extremity procedures (n = 29 each, 6.1%); infectious disease complications (n = 14, 2.9%); major chest/respiratory trauma, major small and large bowel procedures and vascular procedures (n = 13 each, 2.7%). The TTCC participants with lower-extremity injury, complicated tracheostomy, and bowel procedures had 6-point reduction (10% vs. 16%, p = 0.05), 11-point reduction (13% vs. 24%, p = 0.05), and 16-point reduction (11% vs. 27%, p = 0.05) in 30-day readmission rates, respectively, compared to those without TTCC.

CONCLUSION

Targeted outpatient support for high-risk patients can decrease 30-day readmission rates. As our TTCC program matured, we reduced 30-day readmission in patients with lower-extremity injury, complicated tracheostomy and bowel procedures. This represents over one million-dollar savings for the hospital per year through quality-based reimbursement.

LEVEL OF EVIDENCE

Therapeutic/care management, level III.

Readmissions after Firearm Injury Requiring Vascular Repair

BACKGROUND

Firearm injuries can be morbid and potentially have high resource utilization. Historically, trauma and vascular surgery patients are at higher risk for readmissions. Our goal was to assess the risk for readmission among patients undergoing vascular repair after a firearm injury.

METHODS

The National Readmission Database was queried from 2011 to 2014. All firearm injuries with or without vascular repair were analyzed. Multivariable analysis was conducted to assess the effect of concurrent vascular repair on readmissions at 30, 90, and 180 days.

RESULTS

There were 42,184 firearm injury admissions identified, where 93.3% did not undergo vascular repair and 6.7% required vascular repair. The overall in-hospital death rate was 8.2%. Average age was 29.9 ± 0.2 years, and 89.2% were male. Intent was most frequently assault (61.2%) followed by unintentional injury (26.5%), suicide (5.2%), and legal intervention (3.1%). Patients with vascular repair compared to those without vascular repair were more frequently admitted at teaching hospitals (85.2% vs. 81.8%, P = 0.042), had higher Agency for Healthcare Research and Quality (AHRQ) extreme severity of illness, AHRQ risk of mortality, New Injury Severity Score (NISS), and had more diagnoses and procedures (P < 0.0001). Patients with vascular repair compared to those without vascular repair also more frequently sustained abdominal/pelvis injury (40.4% vs. 23.4%, P < 0.0001) and were more likely to have anemia (5.9% vs. 3.6%, P = 0.009). Patients undergoing vascular repair had a higher rate for 30-day (8.9% vs. 5.5%, P = 0.0001), 90-day (18.1% vs 9.5%, P < 0.0001), and 180-day (22.3% vs. 13%, P < 0.0001) readmission. Kaplan-Meier analysis of unadjusted data showed a higher readmission rate over time with vascular repair. Multivariable analysis demonstrated that vascular repair was not associated with higher 30-day readmission (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.92-1.72, P = 0.14) but was for 90-day (OR 1.38, 95% CI 1.14-1.68, P = 0.001) and 180-day readmission (OR 1.24, 95% CI 1.06-1.45, P = 0.009). Additional factors associated with 30-day readmission were higher NISS, discharge to a care facility, and Elixhauser score. Other factors associated with 90-day readmission were unintentional intent of injury, NISS, discharge to a care facility, and Elixhauser score. Factors also associated with 180-day readmission were insurance type, unintentional intent of injury, NISS, care facility discharge, and Elixhauser score.

CONCLUSIONS

Firearm injury resulting in vascular injury was associated with increased readmissions at 90 and 180 days. This study establishes baseline rates for readmission after vascular repair for firearm traumas and allows opportunity for improvement through targeted interventions for these patients. Vascular surgeons can have a more active role in managing this high-profile public health issue.

US pediatric trauma patient unplanned 30-day readmissions

PURPOSE

We sought to determine readmission rates and risk factors for acutely injured pediatric trauma patients.

METHODS

We produced 30-day unplanned readmission rates for pediatric trauma patients using the 2013 National Readmission Database (NRD).

RESULTS

In US pediatric trauma patients, 1.7% had unplanned readmissions within 30days. The readmission rate for patients with index operating room procedures was no higher at 1.8%. Higher readmission rates were seen in patients with injury severity scores (ISS)=16-24 (3.4%) and ISS ≥25 (4.9%). Higher rates were also seen in patients with LOS beyond a week, severe abdominal and pelvic region injuries (3.0%), crushing (2.8%) and firearm injuries (4.5%), and in patients with fluid and electrolyte disorders (3.9%). The most common readmission principal diagnoses were injury, musculoskeletal/integumentary diagnoses and infection. Nearly 39% of readmitted patients required readmission operative procedures. Most common were operations on the musculoskeletal system (23.9% of all readmitted patients), the integumentary system (8.6%), the nervous system (6.6%), and digestive system (2.5%).

CONCLUSIONS

Overall, the readmission rate for pediatric trauma patients was low. Measures of injury severity, specifically length of stay, were most useful in identifying those who would benefit from targeted care coordination resources.

LEVEL OF EVIDENCE

This is a Level III retrospective comparative study.

Continuing Trauma Care After Discharge, the Experience of Outpatient Trauma Clinics in British Columbia

The recovery process from traumatic injuries, and the potential for complications, extends beyond the time of hospital discharge. In 2014, the Fraser Health Trauma Network established outpatient clinics to provide follow-up care for trauma patients after discharge from hospital. The following research questions were asked: Which services were commonly performed by our trauma clinics and how satisfied were patients with the care they received at our clinics? A survey was distributed to patients after their clinic visit to assess overall satisfaction and areas for improvement. A retrospective medical record review was performed to illustrate and quantify the interventions provided during clinic visits. During the first 22 months of clinic operation, a total of 412 appointments were scheduled and the attendance rate was 88%. The provided services included obtaining additional imaging (41% of visits), providing wound and brace care (16%), and initiating referrals to specialists (12%). Seventy-seven patient satisfaction surveys were returned during the study period, 34 in 2014 and 43 in 2015. Seventy-four percent of respondents strongly agreed, and 21% agreed that they were satisfied with the care they received in the clinic. Ninety percent found their visit helpful, and only 10% reported having additional medical issues that were not addressed during the appointment. At trauma clinic follow-up, discharged patients have ongoing care requirements, including a need for further investigation, specialist referral, and wound or brace issues that are likely to benefit from specialist trauma care. Patients were satisfied with the care provided by a postdischarge trauma clinic.

Trauma Transitional Care Coordination: protecting the most vulnerable trauma patients from hospital readmission

Background

Unplanned hospital readmissions increase healthcare costs and patient morbidity. We hypothesized that a program designed to reduce trauma readmissions would be effective.

Methods

A Trauma Transitional Care Coordination (TTCC) program was created to support patients at high risk for readmission. TTCC interventions included call to patient (or caregiver) within 72 hours of discharge to identify barriers to care, complete medication reconciliation, coordination of appointments, and individualized problem solving. Information on all 30-day readmissions was collected. 30-day readmission rates were compared with center-specific readmission rates and population-based, risk-adjusted rates of readmission using published benchmarks.

Results

260 patients were enrolled in the TTCC program from January 2014 to September 2015. 30.8% (n=80) of enrollees were uninsured, 41.9% (n=109) reported current substance abuse, and 26.9% (n=70) had a current psychiatric diagnosis. 74.2% (n=193) attended outpatient trauma appointments within 14 days of discharge. 96.3% were successfully followed. Only 6.6% (n=16) of patients were readmitted in the first 30 days after discharge. This was significantly lower than both center-specific readmission rates before start of the program (6.6% vs. 11.3%, P=0.02) and recently published population-based trauma readmission rates (6.6% vs. 27%, P<0.001).

Discussion

A nursing-led TTCC program successfully followed patients and was associated with a significant decrease in 30-day readmission rates for patients with high-risk trauma. Targeted outpatient support for these most vulnerable patients can lead to better utilization of outpatient resources, increased patient satisfaction, and more consistent attainment of preinjury level of functioning or better.

Level of evidence

Level IV.

Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care

BACKGROUND

Modern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC).

METHODS

For this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed.

RESULTS

The USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p<0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17-29] vs. 21 [17-26], p<0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61-1.48, p=0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2-11] vs. 2 [2-7] days, p=0.006) but had a shorter hospital stay (median [IQR] 6 [3-13] vs. 8 [4-16] days, p<0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p<0.0001), and had a higher readmission rate (8% vs. 4%, p=0.01).

CONCLUSION

Although several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.

Universal Health Insurance and its association with long term outcomes in Pediatric Trauma Patients

BACKGROUND

Racial disparities in mortality exist among pediatric trauma patients; however, little is known about disparities in outcomes following discharge.

METHODS

We conducted a longitudinal cohort study of children admitted for moderate to severe trauma, covered by TRICARE from 2006 to 2014. Patients were followed up to 90days after discharge. All children <18 years with a primary trauma diagnosis, an Injury Severity Score >9 and 90days of follow-up after discharge were included. Complications, readmissions and utilization of healthcare services up to 90days after discharge were compared between Black and White patients.

RESULTS

Of the 5192 children included, majority were White (74.6%, n=3871), with 15.4% Black (n=800) and 10.0% Other (n=521). Most common injuries involved the extremities or the pelvic girdle followed by the head or neck. Complication and readmission rates were 3.6% and 8.9% within 30days of discharge respectively and 4.4% and 9.3% within 90days of discharge. 99.0% of children had at least one outpatient visit by 90days. After adjusting for patient and injury characteristics no significant differences were detected between Black and White children in outcomes after discharge.

CONCLUSIONS

Universal insurance may help mitigate disparities in post discharge care in pediatric trauma populations by increasing access to outpatient services overall and within each racial group. Further studies are required to determine the appropriate timing and frequency of follow up care in order to achieve maximum reduction in use of acute care services after discharge.

Preinjury ASA score as an independent predictor of readmission after major traumatic injury

Background

Patients with trauma have a high predisposition for readmission after discharge. Unplanned solicitation of medical services is a validated quality of care indicator and is associated with considerable economic costs. While the existing literature emphasizes the severity of the injury, there is heterogeneity in defining preinjury health status. We evaluate the validity of the American Society of Anesthesiologists (ASA) Physical Status score as an independent predictor of readmission and compare it to the Charlson Comorbidity Index (CCI).

Methods

This is a single center, retrospective cohort study based on adult patients (>18 years of age) with trauma admitted to the Ottawa Hospital from January 1, 2004 to November 1, 2014. A multivariate logistic regression model is used to control for confounding and assess individual predictors. Outcome is readmission to hospital within 30 days, 3 months and 6 months.

Results

A total of 4732 adult patients were included in this analysis. Readmission rates were 6.5%, 9.6% and 11.8% for 30 days, 3 months and 6 months, respectively. Higher preinjury ASA scores demonstrated significantly increased risk of readmission across all levels in a dose-dependent manner for all time frames. The effect of preinjury ASA scores on readmission is most striking at 30 days, with patients demonstrating a 2.81 (1.88–4.22, P<0.0001), 3.59 (2.43–5.32, P<0.0001) and 7.52 (4.72–11.99, P<0.0001) fold odds of readmission for ASA class 2, 3 and 4, respectively, as compared with healthy ASA class 1 patients. The ASA scores outperformed the CCI at 30 days and 3 months.

Conclusions

The preinjury ASA score is a strong independent predictor of readmission after traumatic injury. In comparison to the CCI, the preinjury ASA score was a better predictor of readmission at 3 and 6 months after a major traumatic injury.

Level of Evidence

Prognostic and Epidemiological Study, Level III.

Functional outcomes after inpatient rehabilitation for trauma-improved but unable to return home

BACKGROUND

Twenty-five percent of trauma patients are discharged to postacute care, indicating a loss of physical function and need for rehabilitation. The purpose of this study was to quantify the functional improvements in trauma patients discharged from inpatient rehabilitation facility (IRF) and identify predictors of improvement.

MATERIALS AND METHODS

A retrospective cohort study of trauma patients aged ≥ 18 years were admitted to an IRF after discharge from a level-1 trauma center. Data included demographics, injury characteristics, hospital, and IRF course. The functional independence measure (FIM) was used to measure change in physical and cognitive function.

RESULTS

There were 245 patients with a mean age of 55.8 years and mean injury severity score (ISS) of 14.7. Fall was the leading mechanism of injury (45.7%). On IRF admission, 50.7% of patients required moderate or greater assistance. On discharge, the mean intraindividual change in FIM score was 29.9; 85.4% of the patients improved by ≥1 level of functioning. Before injury, 99.6% of patients were living at home, but only 56.0% were discharged home from the IRF, despite 81.8% requiring minimal assistance at most (23.5% to skilled nursing; 19.7% readmitted). Increasing age and lower ISS were associated with less FIM improvement, and increasing ISS was associated with increased FIM improvement.

CONCLUSIONS

More than 80% of the trauma patients experienced meaningful functional improvements during IRF admission. However, only half were discharged home, and a quarter required further institutional care. Further research is needed to identify the additional impediments to return to preinjury functioning.

Risk factors and costs associated with nationwide nonelective readmission after trauma

BACKGROUND

Most prior studies of readmission after trauma have been limited to single institutions, whereas multi-institutional studies have been limited to single states and an inability to distinguish between elective and nonelective readmissions. The purpose of this study was to identify the risk factors and costs associated with nonelective readmission after trauma across the United States.

METHODS

The Nationwide Readmission Database was queried for all patients with nonelective admissions in 2013 and 2014 with a primary diagnosis of trauma. Univariate and multivariate logistic regression identified risk factors for 30-day nonelective same- and different-hospital readmission. The diagnosis groups on readmission were evaluated, and the total cost of readmissions was calculated.

RESULTS

There were 1,180,144 patients admitted for trauma, the 30-day readmission rate was 9.4%, and 26.4% of readmissions occurred at a different hospital. The median readmission cost for patients readmitted to the same hospital was $8,298 (interquartile range, $4,899-$14,911), whereas the median readmission cost for patients readmitted to a different hospital was $8,568 (interquartile range, $4,935-$16,078; p < 0.01). Multivariate regression revealed that patients discharged against medical advice were at increased risk of readmission (odds ratio, 2.79; p < 0.01) and readmission to a different facility (odds ratio, 1.58; p < 0.01). Home health care was associated with a decreased risk of readmission to a different hospital (odds ratio, 0.74; p < 0.01). Septicemia and disseminated infections were the most common diagnoses on readmission (8.4%) and readmission to a different hospital (8.6%).

CONCLUSIONS

A significant portion of US readmissions occur at different hospitals with implications for continuity of care, quality metrics, cost, and resource allocation. Home health care reduces the likelihood of nonelective readmission to a different hospital. Infection was the most common reason for readmission, with ramifications for outcomes research and quality improvement.

LEVEL OF EVIDENCE

Care management/epidimeological, level IV.

Early unplanned trauma readmissions in a safety net hospital are resource intensive but not due to resource limitations

BACKGROUND

In an era of decreasing reimbursements, the incentive to decrease readmissions has never been greater. It has been suggested that trauma readmission is an indicator of poor hospital care or fragmented discharge. Even though trauma readmissions are relatively low, readmissions add significant cost, tie up already limited resources and lead to worse outcomes, including mortality. The literature on trauma readmissions is sparse, and the reasons and risk factors for readmission are inconsistent across studies. If readmissions are to serve as useful indicators of quality of care, we must elucidate factors that may predict readmissions.

METHODS

We performed a retrospective review of all admissions to our urban Level I trauma center from July 1, 2012, to June 30, 2015. All patients aged 16 years or older who were discharged alive were included. We identified all unplanned readmissions that occurred within 30 days of discharge and performed an extensive chart review to determine the reasons for readmission. We performed univariate and multivariable analyses.

RESULTS

We identified 6,026 index trauma admissions, with 158 (2.6%) unplanned readmissions within 30 days of discharge. The most common reasons for readmission were disease/symptom progression (30.2%), wound complications (28.9%), and pain control (11.8%). On multivariate analysis, only Injury Severity Score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.05; p=0.016), penetrating injuries (OR, 1.9; 95% CI, 1.12-3.24; p=0.018), and smoking (OR, 1.73; 95% CI, 1.05-2.86; p=0.031) were found to be significant. Hospital length of stay, insurance status, and race were not significant.

CONCLUSION

In a resource-limited environment, we expected a lack of access to care would lead to increased trauma readmissions; however, we were still able to achieve similar readmission rates, irrespective of insurance status and race. Our trauma readmission rate is low and consistent with previously published studies. Our results at our Level I trauma center support previously published studies that found Injury Severity Score and penetrating injury to be risk factors for readmission; however, more ubiquitous risk factors, such as hospital length of stay and discharge destination, were not significant. With no consensus on the risk factors for unplanned early trauma readmission, individual trauma centers should evaluate their specific risk factors for readmission to improve patient outcomes and decrease hospital costs.

LEVEL OF EVIDENCE

Care management, level IV; Epidemiologic, level IV.

Risk factors for 30-day reoperation and 3-month readmission: analysis from the Quality and Outcomes Database lumbar spine registry

OBJECTIVE

The aim of this paper was to use a prospective, longitudinal, multicenter outcome registry of patients undergoing surgery for lumbar degenerative disease in order to assess the incidence and factors associated with 30-day reoperation and 90-day readmission.

METHODS

Prospectively collected data from 9853 patients from the Quality and Outcomes Database (QOD; formerly known as the N2QOD [National Neurosurgery Quality and Outcomes Database]) lumbar spine registry were retrospectively analyzed. Multivariate binomial regression analysis was performed to identify factors associated with 30-day reoperation and 90-day readmission after surgery for lumbar degenerative disease. A subgroup analysis of Medicare patients stratified by age (< 65 and ≥ 65 years old) was also performed. Continuous variables were compared using unpaired t-tests, and proportions were compared using Fisher’s exact test.

RESULTS

There was a 2% reoperation rate within 30 days. Multivariate analysis revealed prolonged operative time during the index case as the only independent factor associated with 30-day reoperation. Other factors such as preoperative diagnosis, body mass index (BMI), American Society of Anesthesiologists (ASA) class, diabetes, and use of spinal implants were not associated with reoperations within 30 days. Medicare patients < 65 years had a 30-day reoperation rate of 3.7%, whereas those ≥ 65 years had a 30-day reoperation rate of 2.2% (p = 0.026). Medicare beneficiaries younger than 65 years undergoing reoperation within 30 days were more likely to be women (p = 0.009), have a higher BMI (p = 0.008), and have higher rates of depression (p < 0.0001). The 90-day readmission rate was 6.3%. Multivariate analysis demonstrated that higher ASA class (OR 1.46 per class, 95% CI 1.25–1.70) and history of depression (OR 1.27, 95% CI 1.04–1.54) were factors associated with 90-day readmission. Medicare beneficiaries had a higher rate of 90-day readmissions compared with those who had private insurance (OR 1.43, 95% CI 1.17–1.76). Medicare patients < 65 years of age were more likely to be readmitted within 90 days after their index surgery compared with those ≥ 65 years (10.8% vs 7.7%, p = 0.017). Medicare patients < 65 years of age had a significantly higher BMI (p = 0.001) and higher rates of depression (p < 0.0001).

CONCLUSIONS

In this analysis of a large prospective, multicenter registry of patients undergoing lumbar degenerative surgery, multivariate analysis revealed that prolonged operative time was associated with 30-day reoperation. The authors found that factors associated with 90-day readmission included higher ASA class and a history of depression. The 90-day readmission rates were higher for Medicare beneficiaries than for those who had private insurance. Medicare patients < 65 years of age were more likely to undergo reoperation within 30 days and to be readmitted within 90 days after their index surgery.

Missed injuries and unplanned readmissions in pediatric trauma patients

BACKGROUND

We sought to determine the incidence and characteristics of missed injuries and unplanned readmissions at a Level-1 pediatric trauma center.

METHODS

We conducted a retrospective review of all trauma patients who presented to our ACS-verified Level-1 pediatric trauma center from 2009 to 2014.

RESULTS

Overall, there were 27 readmissions and 27 missed injuries (0.38%). Patients who were unplanned readmissions had a greater Injury Severity Score (ISS) (8.6 vs 5.2, p=0.03), had longer hospitalizations (4.9 vs 2.5days, p=0.02), and were more likely to have required operative intervention (51.9% vs 32.3%, p=0.04). Similarly, patients identified with missed injuries had a higher ISS (15.2 vs 5.2, p<0.0001), greater length of stay (12.7 vs 2.5days, p<0.0001), and were also more likely to be intubated (25.9% vs 3.6%, p<0.0001) or require critical care (48.1% vs 10.3%, p<0.0001). Seven missed injuries were in patients who were deemed nonaccidental trauma (25.9%) and significantly altered their hospital course while 10 patients (37%) required operative intervention. On multivariate analysis, only ISS was found to be an independent risk factor for readmissions and missed injuries.

CONCLUSIONS

Missed injuries and unplanned readmissions were rare occurrences among our pediatric patient population. These events, however, did result in longer hospitalizations and additional procedures. Patients with multisystem injuries and compromised physical exam are at higher risk.

LEVEL OF EVIDENCE

IV.

Trauma advanced practice provider programme development in an academic setting to optimize care coordination

Background

Benchmark data from the Trauma Quality Improvement Program (TQIP) identified an opportunity for improvement in our trauma programme. Our unexpected return to the intensive care unit (ICU) was found to be higher than the national averages and we also noticed that our readmission rate had increased. We chose to address these complications as continuous quality improvement projects. It was hypothesized that restructuring the workflow of the trauma advanced practice providers (APPs) to focus on the delivery of comprehensive clinical care would decrease return to ICU and readmission rates of trauma patients.

Methods

The development of the APP programme occurred from 2012 to 2014. First, APP daily shifts were extended to mirror the resident physicians’ coverage. Second, the APPs’ original job description was expanded from ‘task-oriented’ workflow to providing comprehensive clinical care. Third, the APPs were involved in the evaluation and decision-making process for transferring trauma patients from the ICU. Finally, the APPs implemented a new discharge process that included all information in a standardized format and a follow-up phone call 24–48 hours after discharge. The trauma registry at our verified, academic level I trauma center was use to assess our ICU and hospital readmission rates during the time we instituted the new APP workflow programme.

Results

In 2012, our ICU readmission rate was 5.7% (TQIP=1.9%) but then decreased to 4.4% in 2013 (TQIP=2.5%) and 2.1% in 2014 (TQIP=2.8%). Our hospital readmission rate was 2.0% in 2012 but then decreased to 1.38% and 0.96% over the next 2 years.

Conclusions

After extending the APP service coverage, implementing a comprehensive clinical care model and standardizing the discharge process, our unplanned return to ICU rates have decreased to below the TQIP national average and hospital readmission rates have also decreased by half.

Level of evidence

III.

Review: Immunology of sinusitis, trauma, asthma, and sepsis

Background:

This review article is important for allergists/immunologists and otolaryngologists. It discussed chronic rhinosinusitis, epidemiology, pathogenesis, innate adaptive immunology, nuclear factor–kappa B related to inflammation, sepsis, complement, reactive oxygen species, asthma, sinusitis, elderly pathogenesis, oxidative stress, depression, seasonal variation, vitamin D, genetic susceptibility and sepsis, hereditary angioedema related to trauma and stress.

Objective:

The objective of this review is to link chronic rhinosinusitis, epidemiology, innate and adaptive immunology, NF-kappa B related to inflammation, sepsis, complement, reactive oxygen species, asthma and sinusitis.

Methods:

A literature search was conducted from several articles, prospective studies, recent reviews and earlier reports. A synergistic relationship develops between activation of the innate immune system and the loss of organ barrier functions. Many complex factors, such as genetics, physical agents, mediators in the development of organ failure both in asthma, sinusitis, stress, depression and trauma, leading to posttraumatic organ failure. Asthma and sepsis, a common condition encountered in hospital environments remains an important cause of death at intensive care units where allergists/immunologists and otolaryngologists are frequently consulted. The patient's immune surveillance could fail to eliminate the pathogen, allowing it to spread and there is a proinflammatory mediator release with inappropriate activation.

Conclusion:

This review discussed chronic rhinosinusitis, sinusitis related to trauma, the innate and adaptive immunology, NF-kappa B related to inflammation, sepsis, complement, inflammation, reactive oxygen species, asthma pathogenesis, and asthma in the elderly, oxidative stress, depression, seasonal variation and vitamin D, cytokines, genetic susceptibility related to sepsis, hereditary angioedema related to trauma and stress.