Disparities in triage and management of the homeless and the elderly trauma patient

Association of houselessness and outcomes after traumatic injury: A retrospective, matched cohort study at an urban, academic level-one trauma center

BACKGROUND

Houselessness is associated with increased mortality and unmet health needs. Current understanding of traumatic injury in houseless patients is limited.

METHODS

This is a retrospective matched cohort study among houseless and housed adults, admitted to an urban, safety net, level I trauma center from 1/1/2018-12/31/2021. Houseless patients were matched with their housed counterparts 1:2 based on age, sex, injury severity score (ISS) and nature of injury. The primary outcome was in-hospital adverse events. Secondary outcomes included hospital length of stay (LOS), outpatient follow-up, emergency department (ED) utilization post-injury, and readmission. Conditional multivariable regression was used to determine associations between the exposure and outcomes.

RESULTS

1413 patients were included; 471 houseless patients and 942 matched controls. Median [IQR] age was 42 years [31-58] and median [IQR] ISS was 9 [5-13] for all patients. About 30 % of traumatic injuries were violent in nature. Median [IQR] total LOS was longer for houseless patients (4.4 days [2.0-8.3] vs. 3.1 days [1.4-6.5], p < 0.001). Houseless patients were more frequently admitted to the ICU (5 % versus 3 %, p = 0.045). The rate of any in-hospital adverse event was similar (houseless 17 % vs. housed 16 %, p = 0.537). Adjusting for age, sex, language, insurance, ISS, nature of injury, injury mechanism, ICU admission, and operative intervention, houselessness was inversely associated with outpatient follow-up (OR 0.60, 95 % CI 0.46-0.79) and positively associated with ED representation (OR 2.49, 95 % CI 1.64-3.78) and hospital readmission (OR 4.35, 95 % CI 3.19-5.92).

CONCLUSIONS

Housing status was not associated with increased in-hospital morbidity or mortality in trauma patients in a single institution cohort of trauma patients. Unhoused patients had lower odds of completing outpatient injury-specific follow-up and higher odds of utilizing the ED within 30 days of discharge. These findings highlight gaps in post-discharge care coordination and underscore opportunities to improve discharge services for this population.

Emergency department visits for undiagnosed pelvic organ prolapse

OBJECTIVES

To describe women presenting to the emergency department (ED) for previously undiagnosed pelvic organ prolapse (POP). Secondary objective was to determine rates of outpatient specialty follow-up and factors associated with accessing follow-up care.

STUDY DESIGN

Retrospective study of patients who presented at 3 EDs affiliated with an urban academic health system that received a new diagnosis of POP between January 2016 and September 2022. Data on demographics, chief complaint, evaluation and interventions performed in the ED, and follow-up care within 3 months post-ED discharge were abstracted from the medical chart. Descriptive statistics and bivariate analyses were used to compare characteristics of women who did and did not follow-up for specialty or subspecialty care.

RESULTS

56 patients met inclusion criteria. Mean age was 61.2 ± 17.1 years. The majority identified as either non-Hispanic Black (51.8 %) or Hispanic or Latino (25.0 %). 57.1 % of patients had public insurance. Less than half (42.8 %) of patients underwent follow-up care with a urogynecologist or gynecologist within 3 months after ED discharge. Race was found to be significantly associated with follow-up rates (P = 0.03), with non-Hispanic Black women experiencing the lowest rates (20.7 %) of follow-up.

CONCLUSIONS

POP causes sufficient distress to prompt an ED encounter. A subset of women overrepresented by Black and publicly insured women utilize the ED for initial POP evaluation, when compared to patients who access initial outpatient POP care. A minority of patients underwent outpatient follow-up. Further research is needed to understand care-seeking behaviors for POP and barriers to timely outpatient follow-up care.

Outcomes and characteristics differ between homeless and housed trauma patients following the COVID-19 pandemic

BACKGROUND

Americans experiencing homelessness are uniquely vulnerable to traumatic injuries and morbidity. Despite a high and increasing number of persons experiencing homelessness (PEH), American researchers have not comprehensively described the impact of this social problem on trauma patients in recent years.

STUDY DESIGN

Retrospective cohort study using the American College of Surgeons TQIP 2021-2022 data. We performed descriptive statistics and multivariable modeling to test for differences in clinical characteristics and discharge dispositions between adult trauma patients experiencing homelessness (n = 20,692) and housed trauma patients (n = 1,927,159).

RESULTS

Trauma patients experiencing homelessness are more likely to be male, younger, and belong to different racial / ethnic groups. Homeless trauma patients have 37 % longer hospital stays than housed trauma patients and are more likely to experience an assault (adjusted OR: 2.92) or self-inflicted injury (adjusted OR: 1.50) and less likely to experience an unintentional injury (adjusted OR: 0.33). Homeless trauma patients' mechanisms of injury differ from those of housed trauma patients. They are similarly likely to have an ISS score of 12 or higher (adjusted OR: 1.01). They are slightly less likely to experience in-hospital mortality than housed trauma patients (adjusted OR: 0.85). They are more likely to be discharged to court or law enforcement (adjusted OR: 1.89); to a psychiatric facility or unit (adjusted OR: 2.99); leave against medical advice (adjusted OR: 3.89); or to a skilled nursing facility (adjusted OR: 2.01) than housed trauma patients. They are less likely to be discharged to inpatient rehab or home health than housed trauma patients.

CONCLUSIONS

This study describes differences in injury outcomes and clinical characteristics affecting homeless trauma patients compared to housed trauma patients since the COVID-19 pandemic, such as longer lengths of hospital stay, greater propensity to have violent injuries, and different discharge dispositions.

Utility of an Artificial Intelligence Language Model for Post-Operative Patient Instructions Following Facial Trauma

Study Design

Qualitative Descriptive Study.

Objective

To evaluate the utility of post-operative instructions (POIs) for facial trauma provided by the language model ChatGPT as compared to those from electronic medical record (EMR) templates and Google search engine.

Methods

POIs for four common facial trauma procedures (mandibular fracture, maxillary fracture, nasal fracture, and facial laceration) were generated by ChatGPT, extracted from EMR templates, or obtained from Google search engine. The POIs were evaluated by a panel of surgeons using the Patient Education Materials Assessment Tool (PEMAT-P).

Results

Average PEMAT-P understandability scores across all 3 sources ranged from 55% to 94%. Actionability scores ranged from 33% to 94%, and procedure-specific scores ranged from 50% to 92%. ChatGPT-generated POIs ranged from 82% to 88% for understandability, 60% to 80% for actionability, and 50% to 75% for procedure-specific items.

Conclusions

ChatGPT has great potential to be a useful adjunct in providing post-operative instructions for patients undergoing facial trauma procedures. Detailed and patient-specific prompts are necessary to output tailored instructions that are accurate, understandable, and actionable.

Back on the Streets: Examining Emergency Department Return Rates for Unhoused Patients Discharged After Trauma

BACKGROUND

The unhoused population is at high risk for traumatic injuries and faces unique challenges in accessing follow-up care. However, there is scarce data regarding differences in Emergency Department (ED) return rates and reasons for return between unhoused and housed patients.

METHODS

We conducted a 3-year retrospective cohort study at a level-1 trauma center in a large metropolitan area. All patients who presented to the ED with traumatic injuries and were discharged without hospital admission were included in the study. The primary outcome was ED returns for trauma-related complications or new traumatic events <6 months after discharge. Patient characteristics and study outcomes were compared between housed and unhoused groups.

RESULTS

A total of 4184 patients were identified, of which 20.3% were unhoused. Compared to housed, unhoused patients were more likely to return to the ED (18.8% vs 13.9%, P < .001), more likely to return for trauma-related complications (4.6% vs 3.1%, P = .045), more likely to return with new trauma (7.1% vs 2.8%, P < .001), and less likely to return for scheduled wound checks (2.5% vs 4.3%, P = .012). Of the patients who returned with trauma-related complications, unhoused patients had a higher proportion of wound infection (20.5% vs 5.7%, P = .008). In the regression analysis, unhoused status was associated with increased odds of ED return with new trauma and decreased odds of return for scheduled wound checks.

CONCLUSIONS

This study observed significant disparities between unhoused and housed patients after trauma. Our results suggest that inadequate follow-up in unhoused patients may contribute to further ED return.

Unhoused and Injured: Injury Characteristics and Outcomes in Unhoused Trauma Patients

INTRODUCTION

The unhoused population is known to be at high risk for traumatic injury. However, there are scarce data regarding injury patterns and outcomes for this patient group. This study aims to investigate any differences in injury characteristics and hospital outcomes between unhoused and housed patients presenting with traumatic injuries.

METHODS

We conducted a 3-y retrospective cohort study at a level 1 trauma center in a metropolitan area with a large unhoused population. All adult trauma patients who were identified as unhoused or housed underinsured (HUI) were included in the study. Injury characteristics, comorbidities, and hospital outcomes were compared between the two groups.

RESULTS

A total of 8450 patients were identified, of which 7.5% were unhoused. Compared to HUI patients, unhoused patients were more likely to sustain minor injuries (65.2% versus 59.1%, P = 0.003) and more likely to be injured by assault (17.9% versus 12.4%, P < 0.001), stab wound (17.7% versus 10.8%, P < 0.001), and automobile versus pedestrian or bike (21.0% versus 15.8% P < 0.001). We found that unhoused patients had higher odds of mortality (adjusted odds ratio [AOR]: 1.93, 95% confidence interval [CI]: 1.10-3.36, P = 0.021), brain death (AOR: 5.40, 95% CI: 2.11-13.83, P < 0.001), bacteremia/sepsis (AOR: 4.36, 95% CI: 1.20-15.81, P = 0.025), and increased hospital length of stay (regression coefficient: 0.08, 95% CI: 0.03-0.12, P = 0.003).

CONCLUSIONS

This study observed significant disparities in injury characteristics and hospital outcomes between the unhoused and HUI groups. Our results suggest that these disparities are impacted by social determinants of health unique to the unhoused population.

Prospective validation of a hospital triage predictive model to decrease undertriage: an EAST multicenter study

Background

Tiered trauma team activation (TTA) allows systems to optimally allocate resources to an injured patient. Target undertriage and overtriage rates of <5% and <35% are difficult for centers to achieve, and performance variability exists. The objective of this study was to optimize and externally validate a previously developed hospital trauma triage prediction model to predict the need for emergent intervention in 6 hours (NEI-6), an indicator of need for a full TTA.

Methods

The model was previously developed and internally validated using data from 31 US trauma centers. Data were collected prospectively at five sites using a mobile application which hosted the NEI-6 model. A weighted multiple logistic regression model was used to retrain and optimize the model using the original data set and a portion of data from one of the prospective sites. The remaining data from the five sites were designated for external validation. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used to assess the validation cohort. Subanalyses were performed for age, race, and mechanism of injury.

Results

14 421 patients were included in the training data set and 2476 patients in the external validation data set across five sites. On validation, the model had an overall undertriage rate of 9.1% and overtriage rate of 53.7%, with an AUROC of 0.80 and an AUPRC of 0.63. Blunt injury had an undertriage rate of 8.8%, whereas penetrating injury had 31.2%. For those aged ≥65, the undertriage rate was 8.4%, and for Black or African American patients the undertriage rate was 7.7%.

Conclusion

The optimized and externally validated NEI-6 model approaches the recommended undertriage and overtriage rates while significantly reducing variability of TTA across centers for blunt trauma patients. The model performs well for populations that traditionally have high rates of undertriage.

Level of evidence

2.

Morbidity and Length of Stay After Injury Among People Experiencing Homelessness in North America

Importance

Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. However, hospital course among this population is unknown.

Objective

To evaluate whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury and whether associations between homelessness and LOS were moderated by age and/or Injury Severity Score (ISS).

Design, Setting, and Participants

This retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) included patients 18 years or older who were hospitalized after an injury and discharged alive from 787 hospitals in North America from January 1, 2017, to December 31, 2018. People experiencing homelessness were propensity matched to housed patients for hospital, sex, insurance type, comorbidity, injury mechanism type, injury body region, and Glasgow Coma Scale score. Data were analyzed from February 1, 2022, to May 31, 2023.

Exposures

People experiencing homelessness were identified using the TQP's alternate home residence variable.

Main Outcomes and Measures

Morbidity, hemorrhage control surgery, and intensive care unit (ICU) admission were assessed. Associations between homelessness and LOS (in days) were tested with hierarchical multivariable negative bionomial regression. Moderation effects of age and ISS on the association between homelessness and LOS were evaluated with interaction terms.

Results

Of 1 441 982 patients (mean [SD] age, 55.1 [21.1] years; (822 491 [57.0%] men, 619 337 [43.0%] women, and 154 [0.01%] missing), 9065 (0.6%) were people experiencing homelessness. Unmatched people experiencing homelessness demonstrated higher rates of morbidity (221 [2.4%] vs 25 134 [1.8%]; P < .001), hemorrhage control surgery (289 [3.2%] vs 20 331 [1.4%]; P < .001), and ICU admission (2353 [26.0%] vs 307 714 [21.5%]; P < .001) compared with housed patients. The matched cohort comprised 8665 pairs at 378 hospitals. Differences in rates of morbidity, hemorrhage control surgery, and ICU admission between people experiencing homelessness and matched housed patients were not statistically significant. The median unadjusted LOS was 5 (IQR, 3-10) days among people experiencing homelessness and 4 (IQR, 2-8) days among matched housed patients (P < .001). People experiencing homelessness experienced a 22.1% longer adjusted LOS (incident rate ratio [IRR], 1.22 [95% CI, 1.19-1.25]). The greatest increase in adjusted LOS was observed among people experiencing homelessness who were 65 years or older (IRR, 1.42 [95% CI, 1.32-1.54]). People experiencing homelessness with minor injury (ISS, 1-8) had the greatest relative increase in adjusted LOS (IRR, 1.30 [95% CI, 1.25-1.35]) compared with people experiencing homelessness with severe injury (ISS ≥16; IRR, 1.14 [95% CI, 1.09-1.20]).

Conclusions and Relevance

The findings of this cohort study suggest that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS. These findings underscore the need to reduce disparities in trauma outcomes and improve hospital resource use among people experiencing homelessness.

Resource Deployment in Response to Trauma Patients

Background Variance in the deployment of the trauma team to the emergency department (ED) can result in patient treatment delays and excess burden on ED personnel. Characteristics of trauma patients, including mechanism of injury, injury type, and age, have been associated with differences in trauma resource deployment. Therefore, this retrospective, single-site study aimed to examine the deployment patterns of trauma resources, the characteristics of the trauma patients associated with levels of trauma resource deployment, and the deployment impact on ED workforce utilization and non-trauma ED patients. Methodology This was an investigator-initiated, single-institution, retrospective cohort study of all patients designated as a trauma response and admitted to a community hospital's ED from July 01, 2019, through July 01, 2022. Results Resource deployment for trauma patients varied by mechanism of injury (p < 0.001), injury type (p < 0.001), and patient age groups (p < 0.001). Specifically, there was a lower average trauma activation for geriatric trauma patients with a fall as a mechanism of injury compared to all younger patient groups with any mechanism of injury (F(5) = 234.49, p < 0.001). In the subsample, there was an average of 3.35 ED registered nurses (RNs) allocated to each trauma patient. Additionally, the ED RNs were temporarily reallocated from an average of 4.09 non-trauma patients to respond to trauma patients, despite over a third of the trauma patients in the subsample being the trauma patients being discharged home from the ED. Conclusions Trauma activation responses need to be standardized with a specific plan for geriatric fall patients to ensure efficient use of trauma and ED personnel resources.

Prehospital Chest Pain Management: Disparity Based on Homeless Status

BACKGROUND

People experiencing homelessness may use emergency medical services to access health care. We sought to examine the relationship between homelessness and prehospital evaluation and treatment of chest pain.

METHODS

We obtained 2019 data of all emergency medical services activations from a single 9-1-1 provider in San Francisco, California with a clinician's primary impression of chest pain. Using chart review, we categorized patients as experiencing homelessness or not and determined treatment rates between the two groups based on local chest pain/acute coronary syndrome protocol. We then stratified the two groups based on primary impression subcategories: "chest pain-not cardiac" and "chest-pain-cardiac/STEMI"; ST elevation myocardial infarction (STEMI).

RESULTS

A total of 601 chest pain calls were analyzed after excluding non-transports and pediatric patients. 120 incidents (20%) involved patients experiencing homelessness. Across all chest pain impressions, people experiencing homelessness were less likely to receive aspirin (35% vs 53%; p < 0.001), intravenous access (38% vs 62%; p < 0.001), and nitroglycerin (21% vs 39%; p < 0.001). No patients experiencing homelessness received analgesic medication, though only 4% of other patients received this intervention (0% vs 4%; p = 0.020). People experiencing homelessness were more likely to receive a clinical impression of "chest pain-not cardiac" compared to "chest pain-cardiac/STEMI" (68% vs 32%; p < 0.001). Results were less significant in most fields when adjusted for impression sub categorizations: "chest pain-not cardiac" versus "chest pain-cardiac/STEMI." Greater than 97% of all patients received 12 lead electrocardiograms.

CONCLUSIONS

Significant disparities were observed between patients experiencing and not experiencing homelessness in the prehospital treatment of chest pain. Larger scale evaluations are needed to further assess potential disparities in care for people experiencing homelessness in the prehospital setting. Using prehospital clinician impression as a proxy for acuity may mask existing bias and disparity; however, 12-lead ECG acquisition, the key diagnostic tool, was appropriately performed in more than 97% of all chest pain patients.

Health disparities in orthopedic trauma: a qualitative study examining providers' perspectives on barriers to care and recovery outcomes

Social workers involved in interdisciplinary orthopedic trauma care can benefit from the knowledge of providers' perspectives on healthcare disparities in this field. Using qualitative data from focus groups conducted on 79 orthopedic care providers at three Level 1 trauma centers, we assessed their perspectives on orthopedic trauma healthcare disparities and discussed potential solutions. Focus groups originally aimed to detect barriers and facilitators of the implementation of a trial of a live video mind-body intervention to aid in recovery in orthopedic trauma care settings (Toolkit for Optimal Recovery-TOR). We used the Socio-Ecological Model to analyze an emerging code of "health disparities" during data analysis to determine at which levels of care these disparities occurred. We identified factors related to health disparities in orthopedic trauma care and outcomes at the Individual (Education- comprehension, health-literacy; Language Barriers; Psychological Health- emotional distress, alcohol/drug use, learned helplessness; Physical Health- obesity, smoking; and Access to Technology), Relationship (Social Support Network), Community (Transportation and Employment Security), and Societal level (Access- safe/clean housing, insurance, mental health resources; Culture). We discuss the implications of the findings and provide recommendations to address these issues, with a specific focus on their relevance to the field of social work in health care.