The impact of trauma case management on patient outcomes

Psychological and psychosocial aspects of major trauma care: A survey of current practice across UK and Ireland

Introduction

Psychological and psychosocial impacts of major trauma, defined as any injury that has the potential to be life-threatening and/or life changing, are common, far-reaching and often enduring. There is evidence that these aspects of major trauma care are often underserved. The aim of this research was to gain insight into the current provision and operationalisation of psychological and psychosocial aspects of major trauma care across the UK and Ireland.

Methods

A cross-sectional online survey, open to health professionals working in major trauma network hospitals was undertaken. The survey had 69 questions across six sections: Participant Demographics, Psychological First Aid, Psychosocial Assessment and Care, Assessing and Responding to Distress, Clinical Psychology Services, and Major Trauma Keyworker (Coordinator) Role.

Results

There were 102 respondents from across the regions and from a range of professional groups. Survey findings indicate a lack of formalised systems to assess, respond and evaluate psychological and psychosocial aspects of major trauma care, most notably for patients with lower-level distress and psychosocial support needs, and for trauma populations that don't reach threshold for serious injury or complex health need. The findings highlight the role of major trauma keyworkers (coordinators) in psychosocial aspects of care and that although major trauma clinical psychology services are increasingly embedded, many lack the capacity to meet demand.

Conclusion

Neglecting psychological and psychosocial aspects of major trauma care may extend peritraumatic distress, result in preventable Years Lived with Disability and widen post-trauma health inequalities. A stepped psychological and psychosocial care pathway for major trauma patients and their families from the point of injury and continuing as they move through services towards recovery is needed. Research to fulfil knowledge gaps to develop and implement such a model for major trauma populations should be prioritised along with the development of corresponding service specifications for providers.

Evaluation of the criteria for trauma activation in the paediatric emergency department

BACKGROUND

Trauma team activation criteria have a variable performance in the paediatric population. We aimed to identify predictors for high-level resource utilisation during trauma resuscitation in the ED.

METHODS

A retrospective study was conducted in the ED of a tertiary paediatric hospital. Patient data were collected from trauma surveillance registry and analysis was performed to identify significant predictors. We then assessed the sensitivity and specificity of proposed models with respect to observed patient outcomes.

RESULTS

Among 11 282 cases, the mean age was 6.1±4.9 (SD) years old. Fall was the most common mechanism of injury in 7364 (65.3%) patients. Eighty-eight (0.8%) patients required at least one high-level resource. Significant predictors for high-resource utilisation were overall GCS of <14 (relative risk (RR) 38.841, 95% CI 21.328 to 70.739, p<0.001), high-risk mechanisms of fall from height and motor vehicle collision (RR 7.863, 95% CI 4.687 to 13.192, p<0.001), as well as age-specific tachycardia (RR 1.796, 95% CI 1.145 to 2.817, p=0.0108). A model consisting of GCS and high-risk mechanism would under-triage 21 (0.2%) patients and over-triage 681 (6.0%) patients. When age-specific tachycardia was added, 8 (0.1%) less patients would be under-triaged but an additional 3251 (28.9%) patients would be over-triaged.

CONCLUSION

As utilisation of high-level resources in paediatric trauma was rare, it was difficult to find an appropriate balance between under-triage and over-triage. Between the two, minimising the proportion of under-triage is more important as patient safety is paramount in paediatric trauma care.

Effectiveness of trauma team on medical resource utilization and quality of care for patients with major trauma

BACKGROUND

Trauma is one of the leading causes of death in Taiwan, and its medical expenditure escalated drastically. This study aimed to explore the effectiveness of trauma team, which was established in September 2010, on medical resource utilization and quality of care among major trauma patients.

METHODS

This was a retrospective study, using trauma registry data bank and inpatient medical service charge databases. Study subjects were major trauma patients admitted to a medical center in Tainan during 2009 and 2013, and was divided into case group (from January, 2011 to August, 2013) and comparison group (from January, 2009 to August, 2010).

RESULTS

Significant reductions in several items of medical resource utilization were identified after the establishment of trauma team. In the sub-group of patients who survived to discharge, examination, radiology and operation charges declined significantly. The radiation and examination charges reduced significantly in the subcategories of ISS = 16 ~ 24 and ISS > 24 respectively. However, no significant effectiveness on quality of care was identified.

CONCLUSIONS

The establishment of trauma team is effective in containing medical resource utilization. In order to verify the effectiveness on quality of care, extended time frame and extra study subjects are needed.

The trauma nurse coordinator in England: a survey of demographics, roles and resources

INTRODUCTION

Following the introduction of the regional trauma system in 2012 the role of the trauma nurse coordinator (TNC) has been rolled out. This study aims to determine the demographic and practice profile of nurses performing the TNC role in England.

METHODS

An electronic survey of TNCs across the 18 trauma networks in England was conducted.

RESULTS

Fifty-three TNCs responded (62%) to the survey. Seventeen different role titles identified. The majority of TNCs had an emergency or trauma/orthopaedics clinical background. The largest proportion of time spent was clinical (38%). Least amount of time was spent in the education (7%), and research (3%). Nearly a quarter of respondents (23%) had some form of formal research training, nearly half (47%) were assisting others in research. Over half (55%) of respondents felt that they did not have adequate human resources to conduct their role.

DISCUSSION

This research has provided baseline information about nurses in the role of TNC, their role titles and domains of the role 18 months after the formal introduction of trauma networks in England. There are some marked similarities and differences in the time spent in the different domains of the role between these findings and those published internationally.

Complication rates as a trauma care performance indicator: a systematic review

Introduction

Information on complication rates is essential to trauma quality improvement efforts. However, it is unclear which complications are the most clinically relevant. The objective of this study was to evaluate whether there is consensus on the complications that should be used to evaluate the performance of acute care trauma hospitals.

Methods

We searched the Medline, EMBASE, Cochrane Central, CINAHL, BIOSIS, TRIP and ProQuest databases and included studies using at least one nonfatal outcome to evaluate the performance of acute care trauma hospitals. Data were extracted in duplicate using a piloted electronic data abstraction form. Consensus was considered to be reached if a specific complication was used in ≥ 70% of studies (strong recommendation) or in ≥ 50% of studies (weak recommendation).

Results

Of 14,521 citations identified, 22 were eligible for inclusion. We observed important heterogeneity in the complications used to evaluate trauma care. Seventy-nine specific complications were identified but none were used in ≥ 70% of studies and only three (pulmonary embolism, deep vein thrombosis, and pneumonia) were used in ≥ 50% of studies. Only one study provided evidence for the clinical relevance of complications used and only five studies (23%) were considered of high methodological quality.

Conclusion

Based on the results of this review, we can make a weak recommendation on three complications that should be used to evaluate acute care trauma hospitals; pulmonary embolism, deep vein thrombosis, and pneumonia. However, considering the observed disparity in definitions, the lack of clinical justification for the complications used, and the low methodological quality of studies, further research is needed to develop a valid and reliable performance indicator based on complications that can be used to improve the quality and efficiency of trauma care.

The cumulative effect of multiple critical care protocols on length of stay in a geriatric trauma population

The elderly individuals are the most rapidly growing cohort within the US population, and a corresponding increase is being seen in elderly trauma patients. Elderly patients are more likely to have a hospital length of stay (LOS) in excess of 10 days. They account for 60% of total ICU days. Length of stay is frequently used as a proxy measure for improvement in injury outcomes, changes in quality of care, and hospital outcomes. Patient care protocols are typically created from evidence-based guidelines that serve to reduce variation in care from patient to patient. Patient care protocols have been found to positively impact patient care with reduced duration of mechanical ventilation, shorter LOS in the ICU and shorter overall hospitalization time, reduced mortality, and reduced health care costs. The following study was designed to assess the impact of the implementation of 4 patient care protocols within an elderly trauma population. We hypothesized that the implementation of these protocols would have a beneficial impact on patient care that could be measured by a decrease in hospital LOS. An archival, retrospective pretest/posttest study was performed on elderly trauma patients. The new protocols helped guide practical changes in care that resulted in a 32% decrease in LOS for our elderly trauma patients which exceeds the 25% decrease found in other studies. Additionally, the "Other" category for each variable was less frequently used in the post-protocol phase than in the pre-protocol phase, suggesting a spillover effect on the level of detail recorded in the patient chart. With less variation in practices in the post-protocol phase, Injury Severity score, and admission systolic blood pressure emerged as significant predictors of LOS.

Comparison of quality control for trauma management between Western and Eastern European trauma center

Background

Quality control of trauma care is essential to define the effectiveness of trauma center and trauma system. To identify the troublesome issues of the system is the first step for validation of the focused customized solutions. This is a comparative study of two level I trauma centers in Italy and Romania and it has been designed to give an overview of the entire trauma care program adopted in these two countries. This study was aimed to use the results as the basis for recommending and planning changes in the two trauma systems for a better trauma care.

Methods

We retrospectively reviewed a total of 182 major trauma patients treated in the two hospitals included in the study, between January and June 2002. Every case was analyzed according to the recommended minimal audit filters for trauma quality assurance by The American College of Surgeons Committee on Trauma (ACSCOT).

Results

Satisfactory yields have been reached in both centers for the management of head and abdominal trauma, airway management, Emergency Department length of stay and early diagnosis and treatment. The main significant differences between the two centers were in the patients' transfers, the leadership of trauma team and the patients' outcome. The main concerns have been in the surgical treatment of fractures, the outcome and the lacking of documentation.

Conclusion

The analyzed hospitals are classified as Level I trauma center and are within the group of the highest quality level centers in their own countries. Nevertheless, both of them experience major lacks and for few audit filters do not reach the mmum standard requirements of ACS Audit Filters. The differences between the western and the eastern European center were slight. The parameters not reaching the minimum requirements are probably occurring even more often in suburban settings.

The trauma nurse coordinator in Australia and New Zealand: a progress survey of demographics, role function, and resources

An initial profile of the demographics and current practice of Australian trauma nurse coordinators (TNCs) was conducted in 2003. The study identified common and differing role components, provided information to assist with establishing national parameters for the role, and identified the resources perceived necessary to enable the role to be performed effectively. This article compares the findings of the 2003 study with a 2007 survey, expanded to include New Zealand trauma coordinators. Forty-nine people, identified as working in a TNC capacity in Australia and New Zealand, were invited to participate in February 2007. The survey consisted of a 3-part questionnaire of respondents' demographics, the percentage of time allocated to 10 defined role functions (components), and the TNCs' perceived required resources to fulfill their role effectively. Feedback from the 2003 survey was incorporated in the redesign. Participation in the research enabled an update of the previously compiled Australia/New Zealand trauma network list. Thirty-six surveys (71.5% response rate) were returned. Descriptive statistics were undertaken for each item, and comparisons were made among states, territories, and countries. The mean age of respondents was 41+/-7.7, range 27 to 57, and 92% were female. They averaged 11.1 years of postregistration critical care or trauma experience, and 50% (n=18) reported working unpaid overtime (decreased from 56% (n=19) since 2003). Participants reported that most of their time was spent fulfilling the trauma registry component of the role (27% of total hours), followed by quality and clinical activities (19% of total hours), education, and administration. The component associated with the least amount of time was outreach (3% of total hours). Although the proportion of time has almost halved since 2003, TNCs still spend the most time maintaining trauma registries. Compared to the 2003 survey, Australian and New Zealand TNCs are working more unpaid overtime, spending more time performing quality and clinical activities and less time doing data entry. Despite where one works, the role components identified are fulfilled to a certain extent. However, trauma centers need to provide the TNC with adequate resources if trauma care systems are to be optimally effective.

Trauma case management: improving patient outcomes

BACKGROUND

The purpose of the study was to measure the effect of trauma case management (TCM) on patient outcomes, using practice-specific outcome variables such as in-hospital complication rates, length of stay, resource use and allied health service intervention rates.

METHODS

TCM was provided 7 days a week to all trauma patient admissions. Data from 754 patients were collected over 14 months. These data were compared with 777 matched patients from the previous 14 months.

RESULTS

TCM greatly improved time to allied health intervention (p<0.0001). Results demonstrated a decrease in the occurrence of deep vein thrombosis (p<0.038) and a trend towards decreased patient morbidity, unplanned admissions to the intensive care unit and operating suite. A reduced hospital stay LOS, particularly in the paediatric and 45-64 years age group was noted. Six thousand six hundred twenty-one fewer pathology tests were performed and the total number of bed days was 483 days less than predicted from the control group.

CONCLUSION

The introduction of TCM improved the efficiency and effectiveness of trauma patient care in our institution. This initiative demonstrates that TCM results in improvements to quality of care, trauma patient morbidity, financial performance and resource use.

Trauma Case Management

The care of a critically ill trauma patient is complex and requires the expertise and skill of many healthcare providers. Delays in injury identification and the development of a treatment plan without considering comorbid conditions impede the patient's resuscitation and recovery from the acute injury, delay the rehabilitative phase, and increase the costs. This article will discuss a strategy using an advanced practice nurse as a case manager to assist in prompt identification of the patients' pathologic and physiologic changes and psychosocial and rehabilitative needs and to orchestrate a comprehensive and consistent plan through the continuum of care.

Maintaining Patient Throughput on an Evolving Trauma/Emergency Surgery Service

BACKGROUND

The case-management team (CMT) has been an effective tool to decrease denied days and improve hospital throughput on a trauma service. With the addition of emergency general surgery (EGS) to our practice, we reviewed the ability of the case management team to absorb EGS patients on the inpatient trauma service while maintaining the improvements initially realized.

METHODS

An interdisciplinary CMT was implemented in January 1999. CRNPs were added in August 2003 to address the Accreditation Council for Graduate Medical Education resident work-hour restrictions. "Key communications" for each CMT member are reported three times per week as defined by a hospital-approved policy. Beginning in August 2001, the trauma service was expanded to include EGS patients. Data from the trauma registry, hospital utilization review, and finance office were analyzed before (1998 and 1999) and after (2003 and 2004) the addition of EGS. Tests of proportion were used to evaluate questions of interest.

RESULTS

The number of injured patients admitted to the trauma service remained relatively constant during the study periods, ranging from a high of 1,365 in 1999 to a low of 1,116 in 2003. Beginning in 2003, the influx of emergency surgery patients to the service was marked. By 2004, there were 561 emergency surgery admissions, representing more than 30% of the total service admissions. As a result, the total number of service admissions has dramatically increased, reaching 1,833 in CY 2004, a 56% increase from CY 1998 levels. Hospital length of stay data varied from a low of 5.5 days in CY 1999 to a high of 6.9 days in CY 2003. Length of stay appeared to be associated with injury severity (mean Injury Severity Score 11.8 in 1999 and 13.1 in 2003) and case mix, but not associated with denied days. The percent of denied days decreased over the study periods, from 4.6% in 1998 (before the implementation of the CMT) to 0.5% in 2004 (p<0.01). The percent of readmissions also fell significantly over the study periods (4.0% in 1998 to 1.8% in 2004; p<0.01).

CONCLUSIONS

The initial improvements in patient throughput noted after the introduction of a CMT in January 1999 have been maintained in recent years despite the addition of an EGS component to the trauma service. Percent denied days and readmissions have continued to decrease. The length of stay for these patients remains, in part, dependent on other factors. The CMT plays an integral role in maintaining the efficiency of a trauma/emergency surgery service.

Differences in survival, length of stay, and discharge disposition of older trauma patients admitted to trauma centers and nontrauma center hospitals

PURPOSE

To examine the relationship of level of care (trauma center [TC], nontrauma center [NTC] hospitals) on three outcomes: survival, length of stay, and discharge disposition.

DESIGN

Retrospective secondary analysis of a subset of data (1,418 patients age 65 to 99 years) from a large statewide study in which the purpose was to compare admission patterns (TCs and NTCs) of motor vehicle (MV) trauma patients according to age and sex. The New Jersey UB-92 Patient Discharge Data for 2000 were used in this analysis.

METHODS

Demographic and clinical variables were compared using descriptive data, independent samples t tests, Pearson chi square, and Mann-Whitney U analyses. Logistic regression and multiple regression analyses were performed to examine relationships between level of care and three outcome variables, survival, length of stay, and discharge disposition, while controlling for age and severity of injury.

RESULTS

NTC admission was the only predictor of survival and discharge to home, but injury severity was the strongest predictor of length of stay, followed by NTC care. The odds of survival and discharge home decreased slightly as age and injury severity increased.

CONCLUSIONS

This analysis indicated preliminary evidence that level of care influences survival, length of stay, and discharge disposition. Studies are warranted for researchers to examine the influence of postinjury variables, including complications, stress reaction, and depression on outcomes.