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Stricker LG, Running A, Lucas AH, McKenzie BA. Trauma Patient-Centered Discharge Plan Form: A Pilot Study. J Trauma Nurs 2024; 31:104-108. [PMID: 38484166 DOI: 10.1097/jtn.0000000000000770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Comprehensive and multidisciplinary discharge planning can improve trauma patient throughput, decrease length of hospitalization, increase family and patient support, and expedite hospital discharge. OBJECTIVE This study aimed to assess the feasibility and acceptability of implementing a patient-centered discharge plan form for adult trauma patients. METHODS A single-center pilot study was conducted with adult trauma patients on a neurosurgical medical-surgical floor at a Level II trauma center in the Western United States from January to February 2023. The study had three phases: observation, pilot intervention, and follow-up. The key pilot intervention was the development of a standardized patient-centered discharge plan form, pilot tested by a trauma advanced practice provider and an inpatient discharge nurse. The primary outcome was the frequency of discharge orders being written before noon on the day of discharge. Qualitative and quantitative outcomes are reported. RESULTS The discharge form was used for eight patients during the pilot intervention phase; an advanced practice provider and an inpatient discharge nurse each completed the forms for four patients. Five of eight observed patients had discharge orders before noon; the incidence of orders before noon was slightly higher when the form was completed by the discharge nurse (three of four patients) than by the advanced practice provider (two of four patients). CONCLUSIONS The pilot study found that the patient-centered discharge plan form was feasible and acceptable to help improve the discharge process for trauma patients. Additional work to further refine the form's content and administration is warranted.
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Affiliation(s)
- Lisa G Stricker
- Author Affiliations: St. Vincent Healthcare, Billings, Montana (Drs Stricker and McKenzie); and Montana State University, Bozeman (Drs Running and Lucas)
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Battle C, Hutchings H, Rafferty J, Toghill H, Akbari A, Watkins A. Health care utilization outcomes in patients with blunt chest wall trauma following discharge from the emergency department: A retrospective, observational data-linkage study. J Trauma Acute Care Surg 2023; 95:868-874. [PMID: 37405800 DOI: 10.1097/ta.0000000000004086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
BACKGROUND Although much is published reporting clinical outcomes in the patients with blunt chest wall trauma who are admitted to hospital from the ED, less is known about the patients' recovery when they are discharged directly without admission. The aim of this study was to investigate the health care utilization outcomes in adult patients with blunt chest wall trauma, discharged directly from ED in a trauma unit in the United Kingdom. METHODS This was a longitudinal, retrospective, single-center, observational study incorporating analysis of linked datasets, using the Secure Anonymised Information Linkage databank for admissions to a trauma unit in the Wales, between January 1, 2016, and December 31, 2020. All patients 16 years or older with a primary diagnosis of blunt chest wall trauma discharged directly home were included. Data were analyzed using a negative binomial regression model. RESULTS There were 3,205 presentations to the ED included. Mean age was 53 years, 57% were male, with the predominant injury mechanism being a low velocity fall (50%). 93% of the cohort sustained between 0 and 3 rib fractures. Four percent of the cohort were reported to have chronic obstructive pulmonary disease, and 4% using preinjury anticoagulants. On regression analysis, inpatient admissions, outpatient appointments and primary care contacts all significantly increased in the 12-week period postinjury, compared with the 12-week period preinjury (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.33-1.99; p < 0.001; OR, 1.28; 95% CI, 1.14-1.43; p < 0.001; OR, 1.02; 95% CI, 1.01-1.02; p < 0.001, respectively). Risk of health care resource utilization increased significantly with each additional year of age, chronic obstructive pulmonary disease and preinjury anticoagulant use (all p < 0.05). Social deprivation and number of rib fracture did not impact outcomes. CONCLUSION The results of this study demonstrate the need for appropriate signposting and follow-up for patients with blunt chest wall trauma presenting to the ED, not requiring admission to the hospital. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Ceri Battle
- From the Physiotherapy Department (C.B., H.T.), Morriston Hospital; Swansea Trials Unit (H.H., J.R., A.W.); and Faculty of Medicine, Health and Life Science (A.A.), Swansea University Medical School, Swansea University, Sketty, Swansea, United Kingdom
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Shilati FM, Silver CM, Baskaran A, Jang A, Wafford QE, Slocum J, Schilling C, Schaeffer C, Shapiro MB, Stey AM. Transitional care programs for trauma patients: A scoping review. Surgery 2023; 174:1001-1007. [PMID: 37550166 PMCID: PMC10527729 DOI: 10.1016/j.surg.2023.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/16/2023] [Accepted: 06/18/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Transitional care programs establish comprehensive outpatient care after hospitalization. This scoping review aimed to define participant characteristics and structure of transitional care programs for injured adults as well as associated readmission rates, cost of care, and follow-up adherence. METHODS We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews standard. Information sources searched were Medline, the Cochrane Library, CINAHL, and Scopus Plus with Full Text. Eligibility criteria were systematic reviews, clinical trials, and observational studies of transitional care programs for injured adults in the United States, published in English since 2000. Two independent reviewers screened all full texts. A data charting process extracted patient characteristics, program structure, readmission rates, cost of care, and follow-up adherence for each study. RESULTS A total of 10 studies described 9 transitional care programs. Most programs (60%) were nurse/social-worker-led post-discharge phone call programs that provided follow-up reminders and inquired regarding patient concerns. The remaining 40% of programs were comprehensive interdisciplinary case-coordination transitional care programs. Readmissions were reduced by 5% and emergency department visits by 13% among participants of both types of programs compared to historic data. Both programs improved follow-up adherence by 75% compared to historic data. CONCLUSION Transitional care programs targeted at injured patients vary in structure and may reduce overall health care use.
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Affiliation(s)
| | - Casey M Silver
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Archit Baskaran
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Angie Jang
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Q Eileen Wafford
- Galter Health Sciences Library and Learning Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - John Slocum
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Christine Schilling
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Christine Schaeffer
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago IL
| | - Michael B Shapiro
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anne M Stey
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL. https://twitter.com/AnneMStey
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Orlas CP, Herrera-Escobar JP, Moheb ME, Velmahos A, Sanchez SE, Kaafarani HM, Salim A, Nehra D. Injury-related emergency department visits and unplanned readmissions are associated with worse long-term mental and physical health. Injury 2023; 54:110881. [PMID: 37365093 DOI: 10.1016/j.injury.2023.110881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 05/19/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND The risk factors for unplanned emergency department (ED) visits and readmission after injury and the impact of these unplanned visits on long-term outcomes are not well understood. We aim to: 1) describe the incidence of and risk factors for injury-related ED visits and unplanned readmissions following injury and, 2) explore the relationship between these unplanned visits and mental and physical health outcomes 6-12 months post-injury. METHODS Trauma patients with moderate-to-severe injury admitted to one of three Level-I trauma centers were asked to complete a phone survey to assess mental and physical health outcomes at 6-12 months. Patient reported data on injury-related ED visits and readmissions was collected. Multivariable regression analyses were performed controlling for sociodemographic and clinical variables to compare subgroups. RESULTS Of 7,781 eligible patients, 4675 were contacted and 3,147 completed the survey and were included in the analysis. 194 (6.2%) reported an unplanned injury-related ED visit and 239 (7.6%) reported an injury-related readmission. Risk factors for injury-related ED visits included: younger age, Black race, a lower level of education, Medicaid insurance, baseline psychiatric or substance abuse disorder and penetrating mechanism. Risk factors for unplanned injury-related readmission included younger age, male sex, Medicaid insurance, substance abuse disorder, greater injury severity and penetrating mechanism of injury. Injury-related ED visits and readmissions were associated with significantly higher rates of PTSD, chronic pain and new injury-related functional limitations in addition to lower SF-12 mental and physical composite scores. CONCLUSIONS Injury-related ED visits and unplanned readmissions are common after hospital discharge following treatment of moderate-severe injury and are associated with worse mental and physical health outcomes.
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Affiliation(s)
- Claudia P Orlas
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Pediatric Surgery Trials and Outcomes Research (PSTOR), MassGeneral Hospital for Children, Boston, MA, United States
| | - Juan P Herrera-Escobar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Pediatric Surgery Trials and Outcomes Research (PSTOR), MassGeneral Hospital for Children, Boston, MA, United States; Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Andriana Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sabrina E Sanchez
- Division of Trauma, Acute Care Surgery & Surgical Critical Care, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States
| | - Haytham Ma Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ali Salim
- Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Deepika Nehra
- Division of Trauma, Burn & Critical Care Surgery, Harborview Medical Center, University of Washington, Seattle, WA, United States.
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Castillo-Angeles M, Zogg CK, Jarman MP, Nitzschke SL, Askari R, Cooper Z, Salim A, Havens JM. Predictors of care discontinuity in geriatric trauma patients. J Trauma Acute Care Surg 2023; 94:765-770. [PMID: 36941228 PMCID: PMC10205689 DOI: 10.1097/ta.0000000000003961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Readmission to a non-index hospital, or care discontinuity, has been shown to have worse outcomes among surgical patients. Little is known about its effect on geriatric trauma patients. Our goal was to determine predictors of care discontinuity and to evaluate its effect on mortality in this geriatric population. METHODS This was a retrospective analysis of Medicare inpatient claims (2014-2015) of geriatric trauma patients. Care discontinuity was defined as readmission within 30 days to a non-index hospital. Demographic and clinical characteristics (including readmission diagnosis category) were collected. Multivariate logistic regression analysis was performed to identify predictors of care discontinuity and to assess its association with mortality. RESULTS We included 754,313 geriatric trauma patients. Mean age was 82.13 years (SD, 0.50 years), 68% were male and 91% were White. There were 21,615 (2.87%) readmitted within 30 days of discharge. Of these, 34% were readmitted to a non-index hospital. Overall 30-day mortality after readmission was 25%. In unadjusted analysis, readmission to index hospitals was more likely to be due to surgical infection, GI complaints, or cardiac/vascular complaints. After adjusted analysis, predictors of care discontinuity included readmission diagnoses, patient- and hospital-level factors. Care discontinuity was not associated with mortality (OR, 0.93; 95% confidence interval, 0.86-1.01). CONCLUSION More than a third of geriatric trauma patients are readmitted to a non-index hospital, which is driven by readmission diagnosis, travel time and hospital characteristics. However, unlike other surgical settings, this care discontinuity is not associated with increased mortality. Further work is needed to understand the reasons for this and to determine which standardized processes of care can benefit this population. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Manuel Castillo-Angeles
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
| | - Cheryl K. Zogg
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
- Yale School of Medicine, New Haven, CT
| | - Molly P. Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
| | - Stephanie L. Nitzschke
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Reza Askari
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Zara Cooper
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
| | - Ali Salim
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
| | - Joaquim M. Havens
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
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Smith S, McCreanor V, Watt K, Hope M, Warren J. Costs and 30-day readmission after lower limb fractures from motorcycle crashes in Queensland, Australia: A linked data analysis. Injury 2022; 53:3517-3524. [PMID: 35922339 DOI: 10.1016/j.injury.2022.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/20/2022] [Accepted: 07/17/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Lower limb trauma is the most common injury sustained in motorcycle crashes. There are limited data describing this cohort in Australia and limited international data establishing costs due to lower limb trauma following motorcycle crashes. METHODS This retrospective cohort study utilised administrative hospitalisation data from Queensland, Australia from 2011-2017. Eligible participants included those admitted with a principal diagnosis coded as lower extremity or pelvic fracture following a motorcycle crash (defined as the index admission). Multiply injured motorcyclists where the lower limb injury was not coded as the primary diagnosis (i.e. principal diagnosis was rather coded as head injury, internal organ injures etc.) were not included in the study. Hospitalisation data were also linked to clinical costing data. Logistic regression was used to determine risk factors for 30-day readmission. Costing data were compared between those readmitted and those who weren't, using bootstrapped t-tests and ANVOA. RESULTS A total of 3342 patients met eligibility, with the most common lower limb fracture being tibia/fibula fractures (40.8%). 212 participants (6.3%) were readmitted within 30-days of discharge. The following were found to predict readmission: male sex (OR 1.84, 95% CI 1.01-1.94); chronic anaemia (OR 2.19, 95% CI 1.41-3.39); current/ex-smoker (OR 1.60, 95% CI 1.21-2.12); emergency admission (OR 2.77, 95% CI 1.35-5.70) and tibia/fibula fracture type (OR 1.46, 95% CI 1.10-1.94). The most common reasons for readmission were related to ongoing fracture care, infection or post-operative complications. The average hospitalisation cost for the index admission was AU$29,044 (95% CI $27,235-$30,853) with significant differences seen between fracture types. The total hospitalisation cost of readmissions was almost AU$2 million over the study period, with an average cost of $10,977 (95% CI $9,131- $13,059). CONCLUSIONS Unplanned readmissions occur in 6.3% of lower limb fractures sustained in motorcycle crashes. Independent predictors of readmission within 30 days of discharge included male sex, chronic anaemia, smoking status, fracture type and emergency admission. Index admission and readmission hospitalisation costs are substantial and should prompt health services to invest in ways to reduce readmission.
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Affiliation(s)
- Samuel Smith
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Australia; School of Medicine, University of Queensland, Brisbane, Australia; College of Public Health, Medical and Veterinary Science, James Cook University, Townsville, Australia; Jamieson Trauma Institute, Metro North Health, Herston, Australia.
| | - Victoria McCreanor
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia; Jamieson Trauma Institute, Metro North Health, Herston, Australia
| | - Kerrianne Watt
- College of Public Health, Medical and Veterinary Science, James Cook University, Townsville, Australia; Queensland Ambulance Service, Department of Health, Brisbane, Australia
| | - Matthew Hope
- School of Medicine, University of Queensland, Brisbane, Australia; Jamieson Trauma Institute, Metro North Health, Herston, Australia; Department of Orthopaedic Surgery, Princess Alexandria Hospital, Brisbane, Australia
| | - Jacelle Warren
- Jamieson Trauma Institute, Metro North Health, Herston, Australia; Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
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Emergency department return visits and hospital admissions in trauma team assessed patients initially discharged from the emergency department: a population-based cohort study. J Trauma Acute Care Surg 2022; 93:513-520. [PMID: 35261374 DOI: 10.1097/ta.0000000000003583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many injured patients are transported directly to trauma centers, found to be minimally injured, and discharged directly home from the emergency department (ED). Our objectives were to characterize the short-term outcomes in this discharged patient population and to identify patient factors predictive of ED return visits. METHODS We conducted a retrospective population-based cohort study using linked administrative datasets involving patients assessed at trauma centers in Ontario, Canada between April 1, 2009 and March 31, 2020. Patients who were assessed by a trauma team and discharged directly home from ED were included. The primary outcome was the percentage of patients with an ED return visit within 14-days. We used multivariate logistic regression analyses to identify patient characteristics predictive of at least one ED return visit. RESULTS There were 5550 patients included in the study. 1004 (18.1%) of patients had at least one ED return visit but only 100 patients (1.8%) were admitted to hospital following initial discharge. Common reasons for ED return visits included wound care concerns (17.2%), head injury complaints (15.6%), and substance misuse (6.8%). Rural residence (OR 1.83, 95% CI: 1.45 - 2.29), history of anxiety disorder (OR 2.05, 95% CI: 1.54 - 2.73), high baseline ED usage (OR 2.58, 95% CI: 2.03 - 3.28), penetrating injury (OR 1.42, 95% CI: 1.20 - 1.68), and extremity fracture (OR 1.52, 95% CI: 1.24 - 1.88) predicted return visits. CONCLUSION Patients discharged directly have high rates of ED return visits but low rates of hospital admission or delayed surgical intervention. Trauma services should expand quality assurance initiatives to capture return visits, understand any gaps in clinical service provision, and aim to minimize unnecessary ED return visits. LEVEL OF EVIDENCE Level VI prognostic study.
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