Characteristics and outcomes of patients discharged home from the Emergency Department following trauma team activation

Mobile Phone-Based Telemonitoring for Improving Adherence to Analgesic Treatment in Trauma Patients After Emergency Department Discharge: A Randomized Controlled Trial

OBJECTIVE

To determine the impact of mobile-phone telemonitoring on patients' adherence and satisfaction with posttrauma pain treatment.

MATERIALS AND METHODS

We conducted a prospective randomized clinical trial including patients with minor trauma discharged from the emergency department (ED) with analgesic treatment. Patients were randomized to one of 3 groups, the control group, where patients received a phone call on day-7, the short message service (SMS) group, where patients received a daily text message to remind them to take their treatment during 7 days, and the mobile-phone based telemonitoring (TLM) group. Patients' adherence to analgesic treatments using the Morisky Medication Adherence Scale, current pain by using a visual analogue scale, and patients' satisfaction were assessed. For the TLM group, the assessment was performed at day-2, 4 and 7.

RESULTS

Good adherence was observed in 418 patients (92.9%) in the TLM group versus 398 patients (88.6%) in the SMS group and 380 patients (84.8%) in the control group ( P <0.001). The factor mostly associated with adherence was telemonitoring (OR 2.40 95% CI 1.55-3.71). The decrease in pain visual analogue scale was highest in the TLM group compared with SMS and control groups ( P <0.001). The percentage of patients' satisfaction at 7 days post-ED discharge was 93% in the TLM group versus 88% in the SMS group and 84% in the standard group ( P =0.02).

DISCUSSION

Our findings suggest that mobile-phone-based telemonitoring is beneficial in the treatment of pain in trauma patients after ED discharge. This approach improved patients' adherence and satisfaction.

Emergency department return visits and hospital admissions in trauma team assessed patients initially discharged from the emergency department: a population-based cohort study

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.

Event centrality following treatment for physical injury in the emergency department: Associations with posttraumatic outcomes

BACKGROUND

The relationship between event centrality (i.e., the degree to which a stressful event is integrated into one's identity) and acute posttraumatic outcomes after relatively minor physical injury is unknown. We examined pre-injury and Emergency Department (ED) predictors of event centrality at 6-weeks post-injury, and whether event centrality is uniquely associated with 6-week posttraumatic outcomes.

METHODS

In the EDs of two Level I trauma centers, 149 patients completed surveys regarding demographic, psychological and injury-related factors within 24 h post-injury; 84 patients (51% male) completed 6-week surveys of event centrality, posttraumatic stress symptoms (PTSS) and trauma-specific QOL (T-QoL). Data were analyzed using linear regression modeling.

RESULTS

At least 20% of patients agreed or strongly agreed that the injury changed their life. Hospitalization status and peritraumatic dissociation were significant predictors of event centrality at 6-weeks. After controlling for demographics, ED-related factors and pre-injury PTSS, event centrality was uniquely associated with PTSS (p < .001) and T-QOL (p < .001) at 6 weeks.

CONCLUSION

Over and above the effects of the injury itself, event centrality conveyed important information for posttraumatic outcomes at 6 weeks post-injury. The centrality scale is brief and feasible to administer; future work is needed to determine the predictive utility of event centrality on post-injury outcomes.

Early Screening for Posttraumatic Stress Disorder and Depression Among Injured Emergency Department Patients: A Feasibility Study

BACKGROUND

Despite the risk of developing posttraumatic stress disorder (PTSD) and associated comorbidities after physical injury, few emergency departments (EDs) in the United States screen for the presence of psychological symptoms and conditions. Barriers to systematic screening could be overcome by using a tool that is both comprehensive and brief. This study aimed to determine 1) the feasibility of screening for posttraumatic sequelae among adults with minor injury in the ED and 2) the relationship between ED screening and later psychological symptoms and poor quality of life (QOL) at 6 weeks postinjury.

METHODS

In the EDs of two Level I trauma centers, we enrolled injured patients (n = 149) who reported serious injury and/or life threat in the past 24 hours. Subjects completed the Posttraumatic Adjustment Scale (PAS) to screen for PTSD and depression in the ED, and 6 weeks later they completed assessments for symptoms of PTSD, depression, and trauma-specific QOL (T-QoL).

RESULTS

Our retained sample at 6 weeks was 84 adults (51.2% male; mean ± SD age = 33 ± 11.88 years); 38% screened positive for PTSD, and 76% screened positive for depression in the ED. Controlling for age, hospital admission, and ED pain score, regression analyses revealed that a positive ED screen for both PTSD and depression was significantly associated with 6 weeks PTSD (p = 0.027, 95% confidence interval [CI] = 0.92 to 15.14) and depressive symptoms (p = 0.001, 95% CI = 2.20 to 7.74), respectively. Further, a positive ED screen for depression (p = 0.043, 95% CI = -16.66 to -0.27) and PTSD (p = 0.015, 95% CI = -20.35 to -2.24) was significantly associated with lower T-QoL.

CONCLUSIONS

These results suggest that it is feasible to identify patients at risk for postinjury sequelae in the ED; screening for mental health risk may identify patients in need of early intervention and further monitoring.

The Association between Daily Posttraumatic Stress Symptoms and Pain over the First 14-days after Injury: An Experience Sampling Study

OBJECTIVES

Psychosocial factors and responses to injury modify the transition from acute to chronic pain. Specifically, posttraumatic stress disorder symptoms (PTSS; reexperiencing, avoidance, and hyperarousal symptoms) exacerbate and co-occur with chronic pain. Yet no study has prospectively considered the associations among these psychological processes and pain reports using experience sampling methods (ESM) during the acute aftermath of injury. This study applied ESM via daily text messaging to monitor and detect relationships among psychosocial factors and post-injury pain across the first 14-days after emergency department (ED) discharge.

METHODS

We recruited 75 adults (59% male; M age = 33) who experienced a potentially traumatic injury (i.e., involving life threat or serious injury) in the past 24-hours from the EDs of two Level 1 trauma centers. Participants received 5 questions per day via text messaging from Day-1 to Day-14 post-ED discharge; three questions measured PTSS, one question measured perceived social support, and one question measured physical pain.

RESULTS

Sixty-seven participants provided sufficient data for inclusion in the final analyses, and the average response rate per subject was 86%. Pain severity score decreased from a mean of 7.2 to 4.4 over 14 days and 50% of the variance in daily pain scores was within-person. In multilevel structural equation models, pain scores decreased over time, and daily fluctuations of hyperarousal (b = 0.22, 95% CI [0.08, 0.36]) were uniquely associated with daily fluctuations in reported pain level within each person.

CONCLUSIONS

Daily hyperarousal symptoms predict same-day pain severity over the acute post-injury recovery period. We also demonstrated feasibility to screen and identify patients at risk for pain chronicity in the acute aftermath of injury. Early interventions aimed at addressing hyperarousal (e.g. anxiolytics) could potentially aid in reducing experience of pain. This article is protected by copyright. All rights reserved.

Risk Factors Associated With Emergency Department Return Visits Following Trauma System Discharge

OBJECTIVES

Little evidence exists in the pediatric trauma literature regarding what factors are associated with re-presentation to the hospital for patients discharged from the emergency department (ED).

METHODS

This was a retrospective cohort study of trauma system activations at a pediatric trauma center from June 30, 2007, through June 30, 2013, who were subsequently discharged from the ED or after a brief inpatient stay. Returns within 30 days were reviewed. χ, Student t test, and univariate logistical regression were used to compare predictive factors for those returning and not.

RESULTS

One thousand eight hundred sixty-three patient encounters were included in the cohort. Seventy-two patients (3.9%) had at least 1 return visit that was related to the original trauma activation. Age, sex, language, race/ethnicity, ED length of stay, arrival mode, level of trauma activation, and transfer from an outside hospital did not vary significantly between the groups. Patients with public insurance were almost 2 times more likely to return compared with those with private insurance (odds ratio, 1.92; 95% confidence interval, 1.11-3.35). Income by zip code was associated with the risk of a return visit, with patients in neighborhoods at less than the 50th percentile income twice as likely to return to the ED (odds ratio, 2.15; 95% confidence interval, 1.30-3.54).

CONCLUSIONS

Patients with public insurance and those from low-income neighborhoods were significantly more likely to return to the ED after trauma system activation. These data can be used to target interventions to decrease returns in high-risk trauma patients.

Does use of a trauma checklist increase discharges from the emergency department?

Introduction

Emergency department (ED) discharge is appropriate for patients with minor traumatic injuries. The objective of this study is to determine if use of a trauma checklist increases identification of patients with minor trauma who are safe for discharge.

Methods

Data were collected on trauma patients evaluated between 1 April 2015 and 31 January 2016 in two groups before and after introduction of a trauma checklist. The two groups were compared using age, mechanism of injury, and Injury Severity Score (ISS) using unpaired Student t-tests and Fisher’s exact test.

Results

A total of 841 trauma patients were included; 197 prior to the introduction of the checklist and 644 afterwards. Following the implementation of the trauma checklist, significantly more patients were discharged from the ED (18.2% vs. 7.6%, p = 0.0004). Discharged patients in the pre- and post-checklist groups had similar ISS (1.93 ± 1.49 vs. 1.87 ± 1.90, p = 0.90) and were of similar age (35.27 ± 11.06 vs. 41.99 years ± 18.20, p = 0.17). There was no increase in ‘bounce-backs’ to the ED in the post checklist group despite a significantly higher rate of discharge.

Conclusion

Use of a trauma checklist allows for better identification of those trauma patients who are safe to discharge from the ED and widespread use may decrease healthcare costs.

Incidence, Intensity, and Impact of Pain in Recently Discharged Adult Trauma Patients: An Exploratory Study

The long-term implications of pain following injury are well known; however, the immediate posthospitalization incidence and impact of pain is less understood. Inadequate pain relief during this time can delay return to work, leading to psychological stress and chronic pain. This exploratory study aimed to identify the incidence, intensity, and impact of injury-related pain in recently discharged adult trauma patients. During July to December 2014, 82 recently discharged adult trauma patients completed a questionnaire about their injury-related pain experience approximately 2 weeks posthospital discharge from a Level 1 trauma center. The questionnaire was developed using the Brief Pain Inventory, assessing severity, and impact of pain through a score from 0 to 10. The average age of participants was 52 years, the median Injury Severity Score was 6, and almost all (n = 80, 98%) experienced a blunt injury. The majority of participants reported pain since discharge (n = 80, 98%), with 65 (81%) still experiencing pain on the day of data collection. Normal work was most affected by pain, with an average score of 6.6 of 10, closely followed by effect on general activity (6.1 of 10) and enjoyment of life (5.7 of 10). The highest pain severity was reported by those with injuries from road trauma, with low Injury Severity Scores, who were female, and did not speak English at home. Pain in the recently discharged adult trauma patient is common, intense and interferes with quality of life. Identification of barriers to effective pain management and interventions to address these barriers are required.

Is a two-tier trauma team activation system the most effective way to manage trauma in the UK?

This review describes the evidence exploring the use of a two-tier trauma team activation system, reviewing the background, history, data available and potential benefits and downsides. The current evidence suggests that a two-tier system may be a lean, cost-effective system, focussed on patient outcome, which could be implemented throughout the UK. Despite its current use in some hospitals, there is limited data from similar systems supporting this in a UK setting. Specific activation criteria need to be validated to ensure appropriate activation of trauma teams, ensuring optimal patient outcome and ensuring best practice.

Association between a single-pass whole-body computed tomography policy and survival after blunt major trauma: a retrospective cohort study

INTRODUCTION

Single-pass, whole-body computed tomography (pan-scan) remains a controversial intervention in the early assessment of patients with major trauma. We hypothesized that a liberal pan-scan policy is mainly an indicator of enhanced process quality of emergency care that may lead to improved survival regardless of the actual use of the method.

METHODS

This retrospective cohort study included consecutive patients with blunt trauma referred to a trauma center prior to (2000 to 2002) and after (2002 to 2007) the introduction of a liberal single-pass pan-scan policy. The overall mortality between the two periods was compared and stratified according to the availability and actual use of the pan-scan. Logistic regression analysis was employed to adjust mortality estimates for demographic and injury-related independent variables.

RESULTS

The study comprised 313 patients during the pre-pan-scan period, 223 patients after the introduction of the pan-scan policy but not undergoing a pan-scan and 608 patients undergoing a pan-scan. The overall mortality was 23.3, 14.8 and 7.9% (P < 0.001), respectively. By univariable logistic regression analysis, both the availability (odds ratio (OR) 0.57, 95% confidence interval (CI): 0.36 to 0.90) and the actual use of the pan-scan (OR 0.28, 95% CI: 0.19 to 0.42) were associated with a lower mortality. The final model contained the Injury Severity Score, the Glasgow Coma Scale, age, emergency department time and the use of the pan-scan. 2.7% of the explained variance in mortality was attributable to the use of the pan-scan. This contribution increased to 7.1% in the highest injury severity quartile.

CONCLUSIONS

In this study, a liberal pan-scan policy was associated with lower trauma mortality. The causal role of the pan-scan itself must be interpreted in the context of improved structural and process quality, is apparently moderate and needs further investigation with regard to the diagnostic yield and changes in management decisions. (The Pan-Scan for Trauma Resuscitation [PATRES] Study Group, ISRCTN35424832 and ISRCTN41462125).