Hospital Readmissions After Pediatric Trauma

Risk of Injury-Related Readmission Varies by Initial Presenting-Hospital Type Among Children at High Risk for Physical Abuse

OBJECTIVES

Children experiencing physical abuse may initially present to hospitals with underappreciated minor injuries, only to experience more severe injuries in the future. The objectives of this study were to 1) describe young children presenting with high-risk diagnoses for physical abuse, 2) characterize the hospitals to which they initially presented, and 3) evaluate associations of initial presenting-hospital type with subsequent admission for injury.

METHODS

Patients aged younger than 6 years from the 2009-2014 Florida Agency for Healthcare Administration database with high-risk diagnoses (codes previously associated with >70% risk of child physical abuse) were included. Patients were categorized by the hospital type to which they initially presented: community hospital, adult/combined trauma center, or pediatric trauma center. Primary outcome was subsequent injury-related hospital admission within 1 year. Association of initial presenting-hospital type with outcome was evaluated with multivariable logistic regression, adjusting for demographics, socioeconomic status, preexisting comorbidities, and injury severity.

RESULTS

A total of 8626 high-risk children met inclusion criteria. Sixty-eight percent of high-risk children initially presented to community hospitals. At 1 year, 3% of high-risk children had experienced subsequent injury-related admission. On multivariable analysis, initial presentation to a community hospital was associated with higher risk of subsequent injury-related admission (odds ratio, 4.03 vs level 1/pediatric trauma center; 95% confidence interval, 1.83-8.86). Initial presentation to a level 2 adult or combined adult/pediatric trauma center was also associated with higher risk for subsequent injury-related admission (odds ratio, 3.19; 95% confidence interval, 1.40-7.27).

CONCLUSIONS

Most children at high risk for physical abuse initially present to community hospitals, not dedicated trauma centers. Children initially evaluated in high-level pediatric trauma centers had lower risk of subsequent injury-related admission. This unexplained variability suggests stronger collaboration is needed between community hospitals and regional pediatric trauma centers at the time of initial presentation to recognize and protect vulnerable children.

Pediatric trauma center vs. adult trauma center: which is better?

PURPOSE OF REVIEW

Pediatric trauma centers (PTCs) have been championed as multidisciplinary facilities specializing in the care of pediatric trauma, the leading cause of childhood mortality in the United States. 1 However, the vast majority of pediatric trauma is still seen in trauma centers focused on treating adults. This article reviews the latest evidence comparing the relative strengths of PTCs and adult trauma centers (ATCs) in treating childhood injury.

RECENT FINDINGS

Recent multicenter studies comparing outcomes of pediatric injury in PTCs and ATCs have found no differences in mortality or hospital length of stay, contradicting earlier findings. However, fewer invasive procedures and CT scans were performed at PTCs, and more children were discharged back to their homes.

SUMMARY

It is difficult to demonstrate a difference in outcomes for children treated at PTCs vs. ATCs. However, PTCs do offer a multidisciplinary, nuanced approach to pediatric trauma care, which may result in long term benefits and offer opportunities for regional collaboration.

Factors associated with new mental health diagnoses and resource utilization among pediatric patients following trauma admission

PURPOSE

Injured children are at risk for a variety of physical and emotional sequelae that may impair their ability to return to prior function. The effect of traumatic injury on mental health in children is not well characterized or understood. We sought to determine factors associated with new mental health diagnoses and/or mental health resource utilization following admission to a Level 1 pediatric trauma center for traumatic injury.

METHODS

A retrospective chart review of patients admitted for accidental trauma between 2016 and 2019 was performed. Demographic data, injury characteristics, new mental health diagnoses and/or mental health resource utilization following hospitalization were extracted. Patients with prior mental health diagnosis, psychotropic prescription(s), or resource utilization were excluded from this cohort. A multivariable logistic regression model was used to examine predictors of new mental health diagnoses and/or resource utilization.

RESULTS

The prevalence of new mental health diagnoses or resources utilization was 9.5% (363/3828). The most common diagnoses were anxiety disorders and nonbipolar depression. The most common psychotropic medication prescribed was antidepressants. Patients with new mental illness were older (odds ratio [OR] 1.1 [95% CI: 1.06, 1.12]), more likely to sustain burn injuries (OR 6.3 [4.2, 9.5]), have non-sports related injuries (OR 3.5 [2.1, 6.0]), and be pedestrian struck (OR 2.7 [1.5, 4.8]). They additionally were more likely to sustain head, neck, and spine injuries (OR 3.8 [2.9, 5.1], 2.4 [1.1, 5.5], and 2.1 [1.3, 3.3], respectively).

CONCLUSIONS

There are a variety of demographic and injury specific factors associated with new mental health diagnoses and/or resource utilization in children following admission for trauma. Knowledge of these risk factors may ensure patients are allocated adequate resources to promote timely access to appropriate mental health services after hospitalization.

TYPE OF STUDY

Retrospective comparative study LEVEL OF EVIDENCE: III.

Unplanned Admissions, Emergency Department Visits, and Epilepsy After Critical Neurological Illness Requiring Prolonged Mechanical Ventilation in Children

Background and Purpose

Long-term outcomes after pediatric neurocritical illness are poorly characterized. This study aims to characterize the frequency and risk factors for post-discharge unplanned health resource use in a pediatric neurocritical care population using insurance claims data.

Methods

Retrospective cohort study evaluating children who survived a hospitalization for an acute neurologic illness or injury requiring mechanical ventilation for >72 hours and had insurance eligibility in Colorado's All Payers Claims database. Insurance claims identified unplanned readmissions and emergency department [ED] visits during the post-discharge year. For patients without pre-existing epilepsy/seizures, we evaluated for post-ICU epilepsy identified by claim(s) for a maintenance anti-seizure medication during months 6-12 post-discharge. Multivariable logistic regression identified factors associated with each outcome.

Results

101 children, median age 3.7 years (interquartile range (IQR) .4-11.9), admitted for trauma (57%), hypoxic-ischemic injury (17%) and seizures (15%). During the post-discharge year, 4 (4%) patients died, 26 (26%) were readmitted, and 48 (48%) had an ED visit. Having a pre-existing complex chronic condition was independently associated with readmission and emergency department visit. Admission for trauma was protective against readmission. Of those without pre-existing seizures (n = 86), 25 (29%) developed post-ICU epilepsy. Acute seizures during admission and prolonged ICU stays were independently associated with post-ICU epilepsy.

Conclusions

Survivors of pediatric neurocritical illness are at risk of unplanned healthcare use and post-ICU epilepsy. Critical illness risk factors including prolonged ICU stay and acute seizures may identify cohorts for targeted follow up or interventions to prevent unplanned healthcare use and post-ICU epilepsy.

Financial and Safety Impact of Simulation-based Clinical Systems Testing on Pediatric Trauma Center Transitions

Simulation offers multiple tools that apply to medical settings, but little is known about the application of simulation to pediatric trauma workflow changes. Our institution recently underwent significant clinical changes in becoming an independent pediatric trauma center. We used a simulation-based clinical systems testing (SbCST) approach to manage change-associated risks. The purpose of this study was to describe our SbCST process, evaluate its impact on patient safety, and estimate financial costs and benefits.

Novel Claims-Based Outcome Phenotypes in Survivors of Pediatric Traumatic Brain Injury

OBJECTIVE

For children hospitalized with acute traumatic brain injury (TBI), to use postdischarge insurance claims to identify: (1) healthcare utilization patterns representative of functional outcome phenotypes and (2) patient and hospitalization characteristics that predict outcome phenotype.

SETTING

Two pediatric trauma centers and a state-level insurance claim aggregator.

PATIENTS

A total of 289 children, who survived a hospitalization after TBI between 2009 and 2014, were in the hospital trauma registry, and had postdischarge insurance eligibility.

DESIGN

Retrospective cohort study.

MAIN MEASURES

Unsupervised machine learning to identify phenotypes based on postdischarge insurance claims. Regression analyses to identify predictors of phenotype.

RESULTS

Median age 5 years (interquartile range 2-12), 29% (84/289) female. TBI severity: 30% severe, 14% moderate, and 60% mild. We identified 4 functional outcome phenotypes. Phenotypes 3 and 4 were the highest utilizers of resources. Morbidity burden was highest during the first 4 postdischarge months and subsequently decreased in all domains except respiratory. Severity and mechanism of injury, intracranial pressure monitor placement, seizures, and hospital and intensive care unit lengths of stay were phenotype predictors.

CONCLUSIONS

Unsupervised machine learning identified postdischarge phenotypes at high risk for morbidities. Most phenotype predictors are available early in the hospitalization and can be used for prognostic enrichment of clinical trials targeting mitigation or treatment of domain-specific morbidities.

Post-discharge healthcare utilization in infants with neonatal opioid withdrawal syndrome

The opioid epidemic in the United States has led to a significant increase in the incidence of neonatal opioid withdrawal syndrome (NOWS); however, the understanding of long-term consequences of NOWS is limited. The objective of this study was to evaluate post-discharge healthcare utilization in infants with NOWS and examine the association between NOWS severity and healthcare utilization. A retrospective cohort design was used to ascertain healthcare utilization in the first year after birth-related discharge using the CERNER Health Facts® database. ICD-9/ICD-10 diagnostic codes were used to identify live births and to classify infants into two study groups: NOWS and uncomplicated births (a 25% random sample). Evaluated outcomes included rehospitalization, emergency department (ED) visits within 30-days and one-year after discharge, and a composite one-year utilization event (either hospitalization or emergency department visit during that year). NOWS severity was operationalized as pharmacologic treatment, length of hospitalization, and medical conditions often associated with NOWS. In 3,526 infants with NOWS (restricted to gestational age ≥ 33 weeks), NOWS severity was associated with an increase in composite one-year utilization (OR: 1.1; 95% CI: 1.04-1.2) after adjusting for prematurity, sepsis, jaundice, use of antibiotics, infant sex, insurance status, race, hospital bed size, year of birth, and census division. In a subset of full-term infants (3008 with NOWS and 88,452 uncomplicated births), having a NOWS diagnosis was associated with higher odds of a 30-day (OR: 1.6; 95% CI: 1.03-2.4) and one-year rehospitalization (OR: 1.6; 95% CI: 1.1-2.4) after adjusting for infant sex, race, type of medical insurance, hospital location, census division, year of primary encounter, hospital bed size, and medical conditions. This study found higher healthcare utilization during the first year of life in infants diagnosed with NOWS, especially those with severe NOWS. Findings suggest a need for closer post-discharge follow-up and management of infants with NOWS.

Prediction of 7-Day Readmission Risk for Pediatric Trauma Patients

BACKGROUND

Pediatric patients admitted for trauma may have unique risk factors of unplanned readmission and require condition-specific models to maximize accuracy of prediction. We used a multicenter data set on trauma admissions to study risk factors and predict unplanned 7-day readmissions with comparison to the 30-day metric.

METHODS

Data from 28 hospitals in the United States consisting of 82,532 patients (95,158 encounters) were retrieved, and 75% of the data were used for building a random intercept, mixed-effects regression model, whereas the remaining were used for evaluating model performance. The variables included were demographics, payer, current and past health care utilization, trauma-related and other diagnoses, medications, and surgical procedures.

RESULTS

Certain conditions such as poisoning and medical/surgical complications during treatment of traumatic injuries are associated with increased odds of unplanned readmission. Conversely, trauma-related conditions, such as trauma to the thorax, knee, lower leg, hip/thigh, elbow/forearm, and shoulder/upper arm, are associated with reduced odds of readmission. Additional predictors include the current and past health care utilization and the number of medications. The corresponding 7-day model achieved an area under the receiver operator characteristic curve of 0.737 (0.716, 0.757) on an independent test set and shared similar risk factors with the 30-day version.

CONCLUSIONS

Patients with trauma-related conditions have risk of readmission modified by the type of trauma. As a result, additional quality of care measures may be required for patients with trauma-related conditions that elevate their risk of readmission.

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.

Teenage Trauma Patients Are at Increased Risk for Readmission for Mental Diseases and Disorders

BACKGROUND

Most studies of readmission after trauma are limited to single institutions or single states. The purpose of this study was to determine the risk factors for readmission after trauma for mental illness including readmissions to different hospitals across the United States.

MATERIALS AND METHODS

The Nationwide Readmission Database for 2013 and 2014 was queried for all patients aged 13 to 64 y with a nonelective admission for trauma and a nonelective readmission within 30 d. Multivariable logistic regression was performed for readmission for mental diseases and disorders.

RESULTS

During the study period, 53,402 patients were readmitted within 30 d after trauma. The most common major diagnostic category on readmission was mental diseases and disorders (12.1%). The age group with the highest percentage of readmissions for mental diseases and disorders was 13 to 17 y (38%). On multivariable regression, the teenage group was also the most likely to be readmitted for mental diseases and disorders compared to 18-44 y (odds ratio [OR] 0.45, P < 0.01) and 45-64 y (OR 0.24, P < 0.01). Other high-risk comorbidities included HIV infection (OR 2.4, P < 0.01), psychosis (OR 2.2, P < 0.01), drug (OR 2.0, P < 0.01), and alcohol (OR 1.4, P < 0.01) abuse.

CONCLUSIONS

Teenage trauma patients are at increased risk for hospital readmission for mental illness. Efforts to reduce these admissions should be targeted toward individuals with high-risk comorbidities such as HIV infection, psychosis, and substance abuse.