Outcomes in nursing home patients with traumatic brain injury

Mortality and discharge disposition among older adults with moderate to severe traumatic brain injury

PURPOSE

This study examined the research on older adults with a moderate to severe traumatic brain injury (TBI), with a focus on mortality and discharge disposition.

METHOD

Systematic searches were conducted in MEDLINE, CINAHL, EMBASE and PsycINFO for studies up to April 2022 in accordance with PRISMA guidelines.

RESULTS

64 studies, published from 1992 to 2022, met the inclusion criteria. Mortality was higher for older adults ≥60 years old than for their younger counterparts; with a dramatic increase for those ≥80 yr, with rates as high as 93 %. Similar findings were reported regarding mortality in intensive care, surgical mortality, and mortality post-hospital discharge; with an 80 % rate at 1-year post-discharge. Up to 68.4 % of older adults were discharged home; when compared to younger adults, those ≥65 years were less likely to be discharged home (50-51 %), compared to those <64 years (77 %). Older adults were also more likely to be discharged to long-term care (up to 31.6 %), skilled nursing facilities (up to 46.1 %), inpatient rehabilitation (up to 26.9 %), and palliative or hospice care (up to 58 %).

CONCLUSION

Given their vulnerability, optimizing outcomes for older adults with moderate-severe TBI across the healthcare continuum is critical.

A Bayesian MultiLayer Record Linkage Procedure to Analyze Post-Acute Care Recovery of Patients with Traumatic Brain Injury

Understanding associations between injury severity and postacute care recovery for patients with traumatic brain injury (TBI) is crucial to improving care. Estimating these associations requires information on patients' injury, demographics, and healthcare utilization, which are dispersed across multiple data sets. Because of privacy regulations, unique identifiers are not available to link records across these data sets. Record linkage methods identify records that represent the same patient across data sets in the absence of unique identifiers. With a large number of records, these methods may result in many false links. Health providers are a natural grouping scheme for patients, because only records that receive care from the same provider can represent the same patient. In some cases, providers are defined within each data set, but they are not uniquely identified across data sets. We propose a Bayesian record linkage procedure that simultaneously links providers and patients. The procedure improves the accuracy of the estimated links compared to current methods. We use this procedure to merge a trauma registry with Medicare claims to estimate the association between TBI patients' injury severity and postacute care recovery.

The impact of facility-based transitional care programs on function and discharge destination for older adults with cognitive impairment: a systematic review

Background

Older adults with cognitive impairment are frequently hospitalized and discharged to facility-based transitional care programs (TCPs). However, it is unknown whether TCPs are effective in improving their functional status and promoting discharge home rather than to long-term care. The aims of this systematic review were to examine the effectiveness of facility-based TCPs on functional status, patient and health services outcomes for older adults (≥ 65 years) with cognitive impairment and to determine what proportion post TCP are discharged home compared to long-term care.

Methods

The Joanna Briggs Institute Critical Appraisal Manual for Evidence Synthesis was used to guide the methodology for this review. The protocol was published in PROSPERO (registration number CRD42021257870). MEDLINE, CINAHL, PsycINFO, the Cochrane Library, and EMBASE databases, and ClinicalTrials.gov and the World Health Organization Trials Registry were searched for English publications. Studies that met the following criteria were included: community-dwelling older adults ≥ 65 years who participated in facility-based TCPs and included functional status and/or discharge destination outcomes. Studies with participants from nursing homes and involved rehabilitation programs or transitional care in the home or in acute care, were excluded. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. Results are in narrative form.

Results

Twenty-two studies (18 cohort and four cross sectional studies) involving 4,013,935 participants met inclusion criteria. The quality of the studies was mostly moderate to good. Improvement in activities of daily living (ADLs) was reported in eight of 13 studies. Between 24.4%-68% of participants were discharged home, 20–43.9% were hospitalized, and 4.1–40% transitioned to long-term care. Review limitations included the inability to perform meta-analysis due to heterogeneity of outcome measurement tools, measurement times, and patient populations.

Conclusions

Facility-based TCPs are associated with improvements in ADLs and generally result in a greater percentage of participants with cognitive impairment going home rather than to long-term care. However, gains in function were not as great as for those without cognitive impairment. Future research should employ consistent outcome measurement tools to facilitate meta-analyses. The level of evidence is level III-2 according to the National Health and Medical Research Council for cohort and cross-sectional studies.

Adding Infectious Insult to Traumatic Injury: The Impact of Infectious Complications in End-of-Life Decision Making

Background: Trauma increases the risk for infection, but it is unknown how infection affects goals-of-care (GOC) decision making. We sought to determine how infections impact transition to comfort measures only (CMO), hypothesizing that infectious complications would expedite withdrawal of life-sustaining treatment (WOLST). Patients and Methods: We performed a retrospective review at a level-one trauma center over two years for adult patients without pre-existing advance directives who were made CMO with length of stay longer than one day. Demographics, injuries, and hospital course including infections and the GOC timeline were collected. Patients were divided on the basis of infection development, defined as an infectious complication requiring antibiotics or more invasive intervention, with subgroup analysis comparing those with single versus multiple infections. The primary end point was time to death or discharge. Results: Two hundred thirty-two patients met inclusion criteria and 72 developed an infection. Pneumonia was the most common infection (53.8%). Although those in the infection group had no substantial difference in demographics or comorbidities, they had higher emergency department Glasgow Coma Scale (GCS; 14 vs. 13), lower rate of head injury (28.6 vs. 49%), and higher time to death or discharge (12 vs. 2 days). Goals-of-care discussions were initiated later based on time to first family meeting (7 vs. 1 days), most occurring after the first infection. Subsequent analysis showed that versus those with a single infection (n = 38), those with multiple infections (n = 34) had a higher time to death or discharge (16.5 vs. 10.5 days) despite no difference in demographics, comorbidities, or trauma severity. Time to first family meeting was longer (8.5 vs. 4.5 days) with most occurring after the first infection. Conclusions: We did not find that development of an infection shortens time to WOLST. The increased time to death or discharge in the setting of multiple infections and similar patient populations may be a marker of provider approach to GOC plus family beliefs. Infectious complications play an uncertain role in end-of-life discussions after trauma.

Successful Community Discharge Among Older Adults With Traumatic Brain Injury in Skilled Nursing Facilities

OBJECTIVE

To identify patient, injury, and functional status characteristics associated with successful discharge to the community following a skilled nursing facility (SNF) stay among older adults hospitalized following traumatic brain injury (TBI).

SETTING

Skilled nursing facilities.

PARTICIPANTS

Medicare fee-for-service beneficiaries admitted to an SNF after hospitalization for TBI.

DESIGN

Retrospective cohort study using Medicare administrative data merged with the National Trauma Data Bank using a multilayered Bayesian record linkage approach.

MAIN OUTCOME MEASURE

Successful community discharge: discharged alive within 100 days of SNF admission and remaining in the community for 30 days or more without dying or admission to a healthcare facility.

RESULTS

Medicaid enrollment, incontinence, decreased independence with activities of daily living, and cognitive impairment were associated with lower odds of successful discharge, whereas race "other" was associated with higher odds of successful discharge. Injury factors including worse injury severity (Glasgow Coma Scale and Abbreviated Injury Scale scores) and fall-related injury mechanism were not associated with successful discharge.

CONCLUSION

Among older adults with TBI who discharge to an SNF, sociodemographic and functional status characteristics are associated with successful discharge and may be useful to clinicians for discharge planning. Acute injury severity indices may have limited utility in predicting discharge disposition once a patient is admitted to an SNF for post-acute care.