Discharge destination following lower limb fracture: development of a prediction model to assist with decision making

A systematic literature review of predicting patient discharges using statistical methods and machine learning

Discharge planning is integral to patient flow as delays can lead to hospital-wide congestion. Because a structured discharge plan can reduce hospital length of stay while enhancing patient satisfaction, this topic has caught the interest of many healthcare professionals and researchers. Predicting discharge outcomes, such as destination and time, is crucial in discharge planning by helping healthcare providers anticipate patient needs and resource requirements. This article examines the literature on the prediction of various discharge outcomes. Our review discovered papers that explore the use of prediction models to forecast the time, volume, and destination of discharged patients. Of the 101 reviewed papers, 49.5% looked at the prediction with machine learning tools, and 50.5% focused on prediction with statistical methods. The fact that knowing discharge outcomes in advance affects operational, tactical, medical, and administrative aspects is a frequent theme in the papers studied. Furthermore, conducting system-wide optimization, predicting the time and destination of patients after discharge, and addressing the primary causes of discharge delay in the process are among the recommendations for further research in this field.

Associations with Discharge to Post-Acute Care Facilities Among Patients Undergoing Open Reduction Internal Fixation of Distal Radius Fractures

Introduction: Distal radius fractures are a common injury of the hand and wrist that often require intensive rehabilitation. We sought to identify risk factors associated with discharge to a post-acute care facility following distal radius fracture repair. Methods: The 2011 to 2016 National Surgical Quality Improvement Program® (NSQIP) database was queried for all Current Procedural Terminology (CPT) codes that corresponded with open distal radius fracture repair. Patients with concomitant traumatic injuries were excluded. Patient demographics, comorbidities, perioperative factors, laboratory data, and surgical details were collected. Our primary outcome was to determine postoperative discharge destination: home versus a post-acute care facility, and to identify factors that predict discharge to post-acute care facility. Secondary outcomes included unplanned readmission, reoperation, and complications. Results: Between 2011 and 2016, a total of 12,001 patients underwent open distal radius fracture repair and had complete information for their discharge. Of these analyzed patients, 3.24% (n  =  389) were discharged to rehabilitation facilities. The following factors were identified on multivariate analysis to have an association with discharge to a post-acute care facility: 65 years or older, White race, underweight, using steroids preoperatively, American Society of Anesthesiologists (ASA) classification > 2, admitted from a nursing home or already hospitalized, anemic, undergoing bilateral surgery, wound classification other than clean, and complications prior to discharge. Conclusion: Factors identified by our study to have associations with discharge to post-acute care facilities following distal radius fracture repair can help in appropriate patient counseling and triage from the hospital to home versus a post-acute care facility.

Using phenotypic data from the Electronic Health Record (EHR) to predict discharge

BACKGROUND

Timely discharge to post-acute care (PAC) settings, such as skilled nursing facilities, requires early identification of eligible patients. We sought to develop and internally validate a model which predicts a patient's likelihood of requiring PAC based on information obtained in the first 24 h of hospitalization.

METHODS

This was a retrospective observational cohort study. We collected clinical data and commonly used nursing assessments from the electronic health record (EHR) for all adult inpatient admissions at our academic tertiary care center from September 1, 2017 to August 1, 2018. We performed a multivariable logistic regression to develop the model from the derivation cohort of the available records. We then evaluated the capability of the model to predict discharge destination on an internal validation cohort.

RESULTS

Age (adjusted odds ratio [AOR], 1.04 [per year]; 95% Confidence Interval [CI], 1.03 to 1.04), admission to the intensive care unit (AOR, 1.51; 95% CI, 1.27 to 1.79), admission from the emergency department (AOR, 1.53; 95% CI, 1.31 to 1.78), more home medication prescriptions (AOR, 1.06 [per medication count increase]; 95% CI 1.05 to 1.07), and higher Morse fall risk scores at admission (AOR, 1.03 [per unit increase]; 95% CI 1.02 to 1.03) were independently associated with higher likelihood of being discharged to PAC facility. The c-statistic of the model derived from the primary analysis was 0.875, and the model predicted the correct discharge destination in 81.2% of the validation cases.

CONCLUSIONS

A model that utilizes baseline clinical factors and risk assessments has excellent model performance in predicting discharge to a PAC facility.

Systematic review of prediction models for postacute care destination decision-making

OBJECTIVE

This article reports a systematic review of studies containing development and validation of models predicting postacute care destination after adult inpatient hospitalization, summarizes clinical populations and variables, evaluates model performance, assesses risk of bias and applicability, and makes recommendations to reduce bias in future models.

MATERIALS AND METHODS

A systematic literature review was conducted following PRISMA guidelines and the Cochrane Prognosis Methods Group criteria. Online databases were searched in June 2020 to identify all published studies in this area. Data were extracted based on the CHARMS checklist, and studies were evaluated based on predictor variables, validation, performance in validation, risk of bias, and applicability using the Prediction Model Risk of Bias Assessment Tool (PROBAST) tool.

RESULTS

The final sample contained 28 articles with 35 models for evaluation. Models focused on surgical (22), medical (5), or both (8) populations. Eighteen models were internally validated, 10 were externally validated, and 7 models underwent both types. Model performance varied within and across populations. Most models used retrospective data, the median number of predictors was 8.5, and most models demonstrated risk of bias.

DISCUSSION AND CONCLUSION

Prediction modeling studies for postacute care destinations are becoming more prolific in the literature, but model development and validation strategies are inconsistent, and performance is variable. Most models are developed using regression, but machine learning methods are increasing in frequency. Future studies should ensure the rigorous variable selection and follow TRIPOD guidelines. Only 14% of the models have been tested or implemented beyond original studies, so translation into practice requires further investigation.

Is the Parker Mobility Score in the older patient with a traumatic hip fracture associated with discharge disposition after surgery? A retrospective cohort study

PURPOSE

The research questions for this study were as follows: (1) is the Parker Mobility Score (PMS) associated with discharge disposition and hospital length of stay (HLOS) of geriatric traumatic hip fracture patients? (2) Can the PMS be incorporated in a decision tree for the prediction of discharge disposition of geriatric traumatic hip fracture patients upon admittance.

METHODS

A dual-center retrospective cohort study was conducted at two level II trauma centers. All patients aged 70 years and older with traumatic hip fractures undergoing surgery in 2018 and 2019 were included consecutively (n = 649). A χ² automatic interaction detection analysis was performed to determine the association of the PMS (and other variables) with discharge disposition and HLOS and predict discharge destination.

RESULTS

The decision tree for discharge disposition classified patients with an overall accuracy of 82.1% and a positive predictive value of 91% for discharge to a rehabilitation facility. The PMS had the second most significant effect on discharge disposition (χ² = 22.409, p < 0.001) after age (χ² = 79.094, p < 0.001). Regarding the tree analysis of HLOS, of all variables in the analysis, PMS had the most significant association with HLOS (F = 14.891, p < 0.001). Patients who were discharged home had a mean HLOS of 6.5 days (SD 8.0), whereas patients who were discharged to an institutional care facility had a mean HLOS of 9.7 days (SD 6.4; p < 0.001).

CONCLUSION

This study shows that the PMS was strongly associated with discharge disposition and HLOS. The decision tree for the discharge disposition of geriatric traumatic hip fracture patients offers a practical solution to start discharge planning upon admittance which could potentially reduce HLOS.

LEVEL OF EVIDENCE

Level III, diagnostic.

Targeted rehabilitation may improve patient flow and outcomes: development and implementation of a novel Proactive Rehabilitation Screening (PReS) service

Rehabilitation programmes can be delivered to patients receiving acute care (‘in-reach rehabilitation’) and/or those who have completed acute care but experience ongoing functional impairments (‘subacute rehabilitation’). Access to these programmes depends on a rehabilitation assessment, but there are concerns that referrals for this assessment are often triggered too late in the acute care journey. We describe a Proactive Rehabilitation Screening (PReS) process designed to systematically screen patients during an acute hospital admission, and identify early those who are likely to require specialist rehabilitation assessment and intervention. The process is based on review of patient medical records on day 5 after acute hospital admission, or day 3 after transfer from intensive care to an acute hospital ward. Screening involves brief review of documented care needs, pre-existing and new functional disabilities, the need for allied health interventions and non-medical factors delaying discharge. From May 2017 to February 2019, the novel screening process was implemented as part of a service redesign of the rehabilitation consultation service. Four thousand consecutive screens were performed at the study site. Of those ‘ruled in’ by screening as needing a rehabilitation assessment, 86.0% went on to receive inpatient rehabilitation interventions. Of those ‘ruled out’ by screening, 92.1% did not go on to receive a rehabilitation intervention, while 7.9% did receive some form of rehabilitation intervention. Of all patients accepted into a rehabilitation programme (n=516), PReS was able to identify 53.6% (n=282) of them before the acute care teams made a referral (based on traditional criteria). In conclusion, we have designed and implemented a systematic, PReS service in one metropolitan Australian hospital. The process described was found to be time efficient and feasible to implement in an acute hospital setting. Further, it appeared to identify the majority of patients who went on to receive formal inpatient rehabilitation interventions.

Predictive Risk Factors of Nonhome Discharge Following Elective Posterior Cervical Fusion

OBJECTIVE

To identify risk factors that are predictive of nonhome discharge after elective posterior cervical fusion.

METHODS

We performed a retrospective cohort study of adult patients who underwent elective posterior cervical fusion using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014. Patients were divided into 2 groups: home discharge and nonhome discharge. Univariate analysis was performed to compare incidence of 30-day postoperative complications between groups. Multivariate analysis was performed to identify complications that were predictive of nonhome discharge.

RESULTS

The cohort included 2875 patients; 24.1% were discharged to a nonhome facility, including skilled and nonskilled care facilities, nursing homes, assisted living facilities, and rehabilitation facilities. Nonhome discharge was associated with higher rates of 30-day pulmonary complication, cardiac complication, venous thromboembolism, urinary tract infection, blood transfusion, sepsis, and reoperation. Significant predictors of nonhome discharge were wound complication (odds ratio [OR] = 1.73; 95% confidence interval [CI], 1.07-2.80; P = 0.024), pulmonary complication (OR = 3.61; 95% CI, 1.96-6.63; P < 0.001), cardiac complication (OR = 6.13; 95% CI, 1.61-23.4; P = 0.008), venous thromboembolism (OR = 2.97; 95% CI, 1.43-6.19; P = 0.004), urinary tract infection (OR = 2.69; 95% CI, 1.50-4.82; P < 0.001), blood transfusion (OR = 1.70; 95% CI, 1.20-2.39; P = 0.003), sepsis (OR = 2.75; 95% CI, 1.25-6.02; P = 0.012), and prolonged length of stay (OR = 4.07; 95% CI, 3.34-4.95; P < 0.001).

CONCLUSIONS

Early identification of patients who are at high risk for nonhome discharge is important to implement early comprehensive discharge planning protocols and minimize hospital-acquired conditions related to prolonged length of stay and associated health care costs.

Discharge from the acute hospital: trauma patients' perceptions of care

Objective The involvement of orthopaedic trauma patients in the decision-making regarding discharge destination from the acute hospital and their perceptions of the care following discharge are poorly understood. The aim of the present study was to investigate orthopaedic trauma patient experiences of discharge from the acute hospital and transition back into the community. Methods The present qualitative study performed in-depth interviews, between October 2012 and November 2013, with patients aged 18-64 years with lower limb trauma. Thematic analysis was used to derive important themes. Results Ninety-four patients were interviewed, including 35 discharged to in-patient rehabilitation. Key themes that emerged include variable involvement in decision-making regarding discharge, lack of information and follow-up care on discharge and varying opinions regarding in-patient rehabilitation. Readiness for discharge from in-patient rehabilitation also differed widely among patients, with patients often reporting being ready for discharge before the planned discharge date and feeling frustration at the need to stay in in-patient care. There was also a difference in patients' perception of the factors leading to recovery, with patients discharged to rehabilitation more commonly reporting external factors, such as rehabilitation providers and physiotherapy. Conclusion The insights provided by the participants in the present study will help us improve our discharge practice, especially the need to address the concerns of inadequate information provision regarding discharge and the role of in-patient rehabilitation. What is known about the topic? There is no current literature describing trauma patient involvement in decision-making regarding discharge from the acute hospital and the perception of how this decision (and destination choice; e.g. home or in-patient rehabilitation) affects their outcome. What does this paper add? The present large qualitative study provides information on patients' opinion of discharge from the acute hospital following trauma and how this could be improved from their perception. Patients are especially concerned with the lack of information provided to them on discharge, their lack of involvement and understanding of the choices made with regard to their discharge and describe concerns regarding their follow-up care. There is also a feeling from the patients that they are ready to leave rehabilitation before their actual planned discharge date, a concept that needs further investigation. What are the implications for practitioners? The patient insights gained by the present study will lead to a change in discharge practice, including increased involvement of the patient in the decision-making in terms of discharge from both the acute and rehabilitation hospitals and a raised awareness of the need to provide written information and follow-up telephone calls to patients following discharge. Further research into many aspects of patient discharge from the acute hospital should be considered, including the use of rehabilitation prediction tools to ensure patient involvement in decision-making and a discharge and/or follow-up coordinator to ensure patients are aware of how to access information after discharge.

Clinicians' perceptions of decision making regarding discharge from public hospitals to in-patient rehabilitation following trauma

Objective The aim of the present study was to investigate the perceptions of consultant surgeons, allied health clinicians and rehabilitation consultants regarding discharge destination decision making from the acute hospital following trauma. Methods A qualitative study was performed using individual in-depth interviews of clinicians in Victoria (Australia) between April 2013 and September 2014. Thematic analysis was used to derive important themes. Case studies provided quantitative information to enhance the information gained via interviews. Results Thirteen rehabilitation consultants, eight consultant surgeons and 13 allied health clinicians were interviewed. Key themes that emerged included the importance of financial considerations as drivers of decision making and the perceived lack of involvement of medical staff in decisions regarding discharge destination following trauma. Other themes included the lack of consistency of factors thought to be important drivers of discharge and the difficulty in acting on trauma patients' requests in terms of discharge destination. Importantly, as the complexity of the patient increases in terms of acquired brain injury, the options for rehabilitation become scarcer. Conclusions The information gained in the present study highlights the large variation in discharge practises between and within clinical groups. Further consultation with stakeholders involved in the care of trauma patients, as well as government bodies involved in hospital funding, is needed to derive a more consistent approach to discharge destination decision making. What is known about the topic? Little is known about the drivers for referral to, or acceptance at, in-patient rehabilitation following acute hospital care for traumatic injury in Victoria, Australia, including who makes these decisions of behalf of patients and how these decisions are made. What does this paper add? This paper provides information regarding the perceptions of acute hospital consultant surgeons and allied health, as well as rehabilitation clinicians, in terms of discharge destination decision making from the acute hospital following trauma. The use of case studies further highlights differences between, and within, these specialities with regard to this decision making. This research also highlights the importance of financial considerations as drivers of decision making, and the lack of consistency of the factors thought to be important drivers of discharge between these different clinical groupings. What are the implications for practitioners? This research shows that financial factors are significant drivers of discharge destination decision making for trauma patients. The present study highlights opportunities to engage with stakeholders (acute care, rehabilitation, administration, government and patients) to develop more consistent discharge processes that optimise the use of rehabilitation resources for those patients who could benefit from in-patient rehabilitation.

Predictors for Patient Discharge Destination After Elective Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective study of prospectively collected data.

OBJECTIVE

To identify risk factors for nonhome patient discharge after elective anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

ACDF is one of the most performed spinal procedures and this is expected to increase in the coming years. To effectively deal with an increasing patient volume, identifying variables associated with patient discharge destination can expedite placement applications and subsequently reduce hospital length of stay.

METHODS

The 2011 to 2014 ACS-NSQIP database was queried using Current Procedural Terminology (CPT) codes 22551 or 22554. Patients were divided into two cohorts based on discharge destination. Bivariate and multivariate logistic regression analyses were employed to identify predictors for patient discharge destination and extended hospital length of stay.

RESULTS

A total of 14,602 patients met the inclusion criteria for the study of which 498 (3.4%) had nonhome discharge. Multivariate logistic regression found that Hispanic versus Black race/ethnicity (odds ratio, OR =0.21, 0.05-0.91, P =0.037), American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander versus Black race/ethnicity (OR = 0.52, 0.34-0.80, p-value = 0.003), White versus Black race/ethnicity (OR = 0.55, 0.42-0.71), elderly age ≥65 years (OR = 3.32, 2.72-4.06), obesity (OR = 0.77, 0.63-0.93, P = 0.008), diabetes (OR = 1.32, 1.06-1.65, P = 0.013), independent versus partially/totally dependent functional status (OR = 0.11, 0.08-0.15), operation time ≥4 hours (OR = 2.46, 1.87-3.25), cardiac comorbidity (OR = 1.38, 1.10-1.72, P = 0.005), and ASA Class ≥3 (OR = 2.57, 2.05-3.20) were predictive factors in patient discharge to a facility other than home. In addition, multivariate logistic regression analysis also found nonhome discharge to be the most predictive variable in prolonged hospital length of stay.

CONCLUSION

Several predictive factors were identified in patient discharge to a facility other than home, many being preoperative variables. Identification of these factors can expedite patient discharge applications and potentially can reduce hospital stay, thereby reducing the risk of hospital acquired conditions and minimizing health care costs.

LEVEL OF EVIDENCE

3.

Return to Work After Traumatic Injury: Increased Work-Related Disability in Injured Persons Receiving Financial Compensation is Mediated by Perceived Injustice

Purpose Traumatic injury is a leading cause of work disability. Receiving compensation post-injury has been consistently found to be associated with poorer return to work. This study investigated whether the relationship between receiving compensation and return to work was associated with elevated symptoms of psychological distress (i.e., anxiety, depression, and posttraumatic stress disorder) and perceived injustice. Methods Injured persons, who were employed at the time of injury (n = 364), were recruited from the Victorian State Trauma Registry, and Victorian Orthopaedic Trauma Outcomes Registry. Participants completed the Hospital Anxiety and Depression Scale, Posttraumatic Stress Disorder Checklist, Injustice Experience Questionnaire, and appraisals of pain and work status 12-months following traumatic injury. Results Greater financial worry and indicators of actual/perceived injustice (e.g., consulting a lawyer, attributing fault to another, perceived injustice, sustaining compensable injury), trauma severity (e.g., days in hospital and intensive care, discharge to rehabilitation), and distress symptoms (i.e., anxiety, depression, PTSD) led to a twofold to sevenfold increase in the risk of failing to return to work. Anxiety, post-traumatic stress and perceived injustice were elevated following compensable injury compared with non-compensable injury. Perceived injustice uniquely mediated the association between compensation and return to work after adjusting for age at injury, trauma severity (length of hospital, admission to intensive, and discharge location) and pain severity. Conclusions Given  that perceived injustice is associated with poor return to work after compensable injury, we recommend greater attention be given to appropriately addressing psychological distress and perceived injustice in injured workers to facilitate a smoother transition of return to work.

Geriatric preinjury activities of daily living function is associated with glasgow coma score and discharge disposition: a retrospective, consecutive cohort study

The primary objective was to evaluate the associations of the Injury Severity Score (ISS), age, Glasgow Coma Score (GCS), preexisting medical conditions (PEMC), and preinjury activities of daily living (ADL) Katz score with discharge disposition in surviving geriatric trauma patients.Data were obtained from the trauma registry. The preinjury Katz ADL score was prospectively ascertained.Of 184 consecutive surviving geriatric trauma patients with an ISS of 4 to 30, age was 80 ± 8 years and 75% fell. A PEMC was present in 93%. Preinjury ADL limitation occurred in 33%. The Katz score had inverse associations with the number of PEMCs (P< .01) and dementia (P < .01). Preinjury residence was home in 93% and nursing home in 7%. Katz scores by discharge disposition were as follows: home (36%) 5.5 ± 1; nursing home (15%) 3.6 ± 2; rehabilitation (44%) 5.6 ± 1; long-term acute care (5%) 4.0 ± 3 (P < .01). Nursing home/long-term acute care discharge was independently associated (P< .01) withlower Katz score, higher age, and lower discharge GCS; dementia and the number of PEMCs had P > .05. The discharge GCS was associated with the Katz score (P < .01), head injury score (P < .01), dementia (P < .01), and admission GCS (P < .01). The discharge GCS was independently associated (P < .01) with the Katz score and admission GCS. The admission GCS was associated with the Katz score (P = .02), ISS (P < .01), head injury score (P < .01), and dementia (P < .01). The admission GCS was independently associated (P < .05) with the Katz score and ISS.The majority of geriatric trauma survivors with an ISS of 4 to 30 are not discharged home. Lower preinjury ADL function is associated with the lower admission and discharge GCS and greater care needs at discharge. Dementia and the number of PEMCs are not independent predictors of discharge disposition.

Natural history of medial clavicle fractures

BACKGROUND

Fractures of the medial third of the clavicle comprise less than 3% of all clavicle fractures. The natural history and optimal management of these rare injuries are unknown. The aim of our study is to describe the demographics, management and outcomes of patients with medial clavicle fractures treated at a Level 1 Trauma Centre.

METHODS

A retrospective review was conducted of patients presenting to our institution between January 2008 and March 2013 with a medial third clavicle fracture. Clinical and radiographic data were recorded including mechanism of injury, fracture pattern and displacement, associated injuries, management and complications. Functional outcomes were assessed using the Glasgow Outcome Scale Extended (GOS-E) scores from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Shoulder outcomes were assessed using two patient reported outcomes scores, the American Shoulder and Elbow Society Score (ASES) and the Subjective Shoulder Value (SSV).

RESULTS

Sixty eight medial clavicle fractures in 68 patients were evaluated. The majority of patients were male (n=53), with a median age of 53.5 years (interquartile range (IQR) 37.5-74.5 years). The most common mechanism of injury was motor vehicle accident (n=28). The in-hospital mortality rate was 4.4%. The fracture pattern was almost equally distributed between extra articular (n=35) and intra-articular (n=33). Fifty-five fractures (80.9%) had minimal or no displacement. Associated injuries were predominantly thoracic (n=31). All fractures were initially managed non-operatively, with a broad arm sling. Delayed operative fixation was performed for painful atrophic delayed union in two patients (2.9%). Both patients were under 65 years of age and had a severely displaced fracture of the medial clavicle. One intra-operative vascular complication was seen, with no adverse long-term outcome. Follow-up was obtained in 85.0% of the surviving cohort at an average of three years post injury (range 1-6 years). The mean ASES score was 80.3 (SD 24.8, range 10-100,), and the mean SSV score was 77.0 (SD 24.6, range 10-100).

CONCLUSION

Sixty eight patients with medial clavicle fractures were identified over a 5year period, with excellent functional results seen following conservative management.

Moderate efficiency of clinicians' predictions decreased for blurred clinical conditions and benefits from the use of BRASS index. A longitudinal study on geriatric patients' outcomes

OBJECTIVES

Accurate prognosis is an essential aspect of good clinical practice and efficient health services, particularly for chronic and disabling diseases, as in geriatric populations. This study aims to examine the accuracy of clinical prognostic predictions and to devise prediction models combining clinical variables and clinicians' prognosis for a geriatric patient sample.

STUDY DESIGN AND SETTING

In a sample of 329 consecutive older patients admitted to 10 geriatric units, we evaluated the accuracy of clinicians' prognosis regarding three outcomes at discharge: global functioning, length of stay (LoS) in hospital, and destination at discharge (DD). A comprehensive set of sociodemographic, clinical, and treatment-related information were also collected.

RESULTS

Moderate predictive performance was found for all three outcomes: area under receiver operating characteristic curve of 0.79 and 0.78 for functioning and LoS, respectively, and moderate concordance, Cohen's K = 0.45, between predicted and observed DD. Predictive models found the Blaylock Risk Assessment Screening Score together with clinicians' judgment relevant to improve predictions for all outcomes (absolute improvement in adjusted and pseudo-R(2) up to 19%).

CONCLUSION

Although the clinicians' estimates were important factors in predicting global functioning, LoS, and DD, more research is needed regarding both methodological aspects and clinical measurements, to improve prognostic clinical indices.

Validating a simple discharge planning tool following hospital admission for an isolated lower limb fracture

BACKGROUND

Early, accurate prediction of discharge destination from the acute hospital assists individual patients and the wider hospital system. The Trauma Rehabilitation and Prediction Tool (TRaPT), developed using registry data, determines probability of inpatient rehabilitation discharge for patients with isolated lower limb fractures.

OBJECTIVE

The aims of this study were: (1) to prospectively validatate the TRaPT, (2) to assess whether its performance could be improved by adding additional demographic data, and (3) to simplify it for use as a bedside tool.

DESIGN

This was a cohort, measurement-focused study.

METHODS

Patients with isolated lower limb fractures (N=114) who were admitted to a major trauma center in Melbourne, Australia, were included. The participants' TRaPT scores were calculated from admission data. Performance of the TRaPT score alone, and in combination with frailty, weight-bearing status, and home supports, was assessed using measures of discrimination and calibration. A simplified TRaPT was developed by rounding the coefficients of variables in the original model and grouping age into 8 categories. Simplified TRaPT performance measures, including specificity, sensitivity, and positive and negative predictive values, were evaluated.

RESULTS

Prospective validation of the TRaPT showed excellent discrimination (C-statistic=0.90 [95% confidence interval=0.82, 0.97]), a sensitivity of 80%, and specificity of 94%. All participants able to weight bear were discharged directly home. Simplified TRaPT scores had a sensitivity of 80% and a specificity of 88%.

LIMITATIONS

Generalizability may be limited given the compensation system that exists in Australia, but the methods used will assist in designing a similar tool in any population.

CONCLUSIONS

The TRaPT accurately predicted discharge destination for 80% of patients and may form a useful aid for discharge decision making, with the simplified version facilitating its use as a bedside tool.

Predictors of transfer to rehabilitation for trauma patients admitted to a level 1 trauma centre--a model derivation and internal validation study

OBJECTIVE

Determine the predictors of transfer to rehabilitation in a cohort of trauma patients and derive a risk score based clinical prediction tool to identify such patients during the acute phase of injury management.

METHODS

Trauma registry data at a single level one trauma centre were obtained for all patients aged between 15 and 65 years admitted due to injury between 2007 and 2011. Multivariable logistic regression with stepwise selection was performed to derive a prediction model for transfer to rehabilitation. The model was tested on a validation dataset using receiver operator characteristic analyses and bootstrap cross validation on the entire dataset. A clinical prediction risk score was developed based on the final model.

RESULTS

There were 4900 patients included in the study. Variables found to be the strongest predictors of rehabilitation after logistic regression with stepwise selection were pelvic injuries (OR 12.6 95% CI 6.2, 25.2 p<0.001), need for intensive care unit admission (OR 7.2 95% CI 4.2, 12.3 p<0.001) and neurosurgical operation (OR 10.5 95% CI 4.7, 23.1 p<0.001). After bootstrap cross validation the mean AUC was 0.86 (95% CI 0.84, 0.89). The model had a sensitivity of 89% and specificity of 64%.

CONCLUSION

Intensive unit admission, neurosurgical operation, pelvic injuries and other lower limb injuries were the most important predictors of the need for rehabilitation after trauma. The prediction model has good overall sensitivity, discrimination and could be further validated for use in clinical practice.