Missed injuries and unplanned readmissions in pediatric trauma patients

The Tertiary Survey as a Quality Improvement Initiative in Pediatric Trauma Care

BACKGROUND

Patients are at risk of missed or delayed injuries in the setting of multisystem trauma, which may be identified with a tertiary trauma survey (TTS). There is limited literature to support the utilization of a TTS in pediatric trauma population. We aim to assess the impact of the TTS as a quality and performance improvement tool in identifying missed or delayed injuries and improving the quality of care among pediatric trauma population.

METHODS

A retrospective study assessing a quality improvement/performance improvement (QI/PI) project focusing on the administration of tertiary surveys to pediatric trauma patients was conducted at our level 1 trauma center between 08-2020 and 08-2021. Patients with injury severity scores (ISS) greater than 12 and/or an anticipated hospital stay greater than 72 hours met inclusion criteria and were included.

RESULTS

Of the 535 trauma patients admitted to the pediatric trauma service during the study period, 85 (16%) patients met the criteria and received a TTS. Thirteen unaddressed or undertreated injuries were found in 11 patients: 5 cervical spine injuries, 1 subdural hemorrhage, 1 bowel injury, 1 adrenal hemorrhage, 1 kidney contusion, 2 hematomas, and 2 full thickness abrasions. Following TTS, 13 patients (15%) had additional imaging, which identified 6 of the 13 injuries.

CONCLUSION

The TTS is a valuable quality and performance improvement tool in the comprehensive care of trauma patients. Standardization and implementation of a tertiary survey have the potential to facilitate the prompt detection of injuries and improve the quality of care for pediatric trauma patients.

LEVEL OF EVIDENCE

III.

Analysis of Missed Skeletal Injuries Detected Using Whole-Body Bone Scan Applied to Trauma Patients: A Case-Control Study

(1) Background: Skeletal injuries may be missed in patients presenting multiple traumas during initial assessment. A whole-body bone scan (WBBS) may aid the detection of missed skeletal injuries, but the current level of research in this regard is insufficient. Thus, this study aimed to investigate whether a WBBS is useful for the detection of missed skeletal injuries in patients with multiple traumas. (2) Methods: This retrospective, single-region, trauma center study was conducted at a tertiary referral center from January 2015 to May 2019. The rate of missed skeletal injuries detected via WBBSs was evaluated, and factors that could influence the outcome were analyzed and divided into missed and not-missed groups. (3) Results: A total of 1658 patients with multiple traumas who underwent WBBSs were reviewed. In the missed group, the percentage of cases with an Injury Severity Score (ISS) ≥ 16 was higher than the not-missed group (74.66% vs. 45.50%). The rate of admission route through surgery and embolization was high in the missed group. Moreover, the proportion of patients that experienced shock in the missed group was higher than that in the not-missed group (19.86% vs. 3.51%). In univariate analysis, ISS ≥ 16, admission route through surgery and embolization, orthopedic surgery involvement, and shock were related to missed skeletal injuries. ISS ≥ 16 was determined to be statistically significant in multivariate analysis. Additionally, a nomogram was constructed based on multivariable analysis. (4) Conclusions: Missed skeletal injuries were significantly associated with several statistical factors, and a WBBS can be used as a screening method to detect missed skeletal injuries in patients with multiple blunt traumas.

Common and Consequential Fractures That Should Not Be Missed in Children

Missed or delayed diagnosis of fractures in children is not uncommon owing to their immature skeletons, unique fracture patterns, and distinctive radiologic findings. The term occult is used to describe radiographically subtle fractures. Some of these fractures can be associated with excellent outcomes despite the pitfalls of delayed diagnosis. However, a subset of these injuries have more guarded prognoses when missed, despite their harmless radiographic appearance. A high index of suspicion should be maintained when treating pediatric extremity injuries with clinical findings disproportionate to a benign-appearing radiograph. Moreover, overreliance on radiology reports can perpetuate diagnostic error. In cases of discrepancy, timely follow-up for repeat examination or immediate advanced imaging can help avoid missed diagnoses. Most critically, the one diagnosis not to miss is nonaccidental trauma, as continued exposure to abuse puts the child at risk of further injury and death. [Pediatr Ann. 2022;51(9):e357-e363.].

Prediction of 7-Day Readmission Risk for Pediatric Trauma Patients

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hospital readmissions in paediatric trauma patients: A 10-year Australian review

AIM

Readmission of paediatric trauma patients is associated with increased hospital length of stay, additional operative procedures and significant costs to the health-care system. The rates and causes of readmission of paediatric trauma patients are not well reported outside of the USA or single centres. This nation-wide study is the first in Australia to examine the readmission rates, costs and characteristics of Australian paediatric trauma patients.

METHODS

This was a retrospective examination of linked hospitalisation and mortality data for injured children aged 16 or younger from 1 July 2001 to 30 June 2012, readmitted to hospital within 28 days of discharge. Data including injury severity, nature of injury, episodes of care and costs were extracted from hospitalisation data.

RESULTS

There were 37 603 injury children aged ≤16 years readmitted to hospital within 28 days during the 10-year period, a readmission rate of 5.5%. The most common principal injury requiring readmission was fracture (52.6%) and burns (19.3%). A total of 66% of all patients had a readmission diagnosis of injury, complication of their initial injury or complication of surgical and medical care; 30% were readmitted for a specific procedure or follow-up care. The total cost of readmissions was AU$108 million.

CONCLUSIONS

Hospital readmission rates of paediatric trauma patients in Australia are due to injury or a complication of injury and are associated with significant costs. Early identification of at-risk patients and the prevention of complications are needed to prevent the ongoing burden of readmission.

Unwarranted clinical variation in the care of children and young people hospitalised for injury: a population-based cohort study

INTRODUCTION

Injury is a leading cause of death and disability among children and young people. Recovery may be negatively affected by unwarranted clinical variation such as representation to an emergency department (ED), readmission to a hospital, and mortality. The aim of this study was to examine unwarranted clinical variation across providers of care of children and young people who were hospitalised for injury in New South Wales (NSW).

MATERIALS AND METHODS

Retrospective population-based cohort study using linked ED, hospital, and mortality data of all children and young people aged ≤25 years who were injured and hospitalised during 1 January 2010-30 June 2014 in NSW. Unwarranted clinical variation across providers was examined using three indicators. That is, for each hospital that treated ≥100 cases per year, risk standardised ratios were calculated with 95% and 99.8% confidence limits using the number of observed and expected events of (1) representations to ED within 72 h, (2) unplanned readmissions to hospital within 28 days, and (3) all-cause mortality within 30 days.

RESULTS

There were 189,990 injury-related hospitalisations of children and young people. Of these, 4.4% represented to an ED, 8.7% were readmitted to hospital, and 0.2% died. Of the 45 public hospitals that treated ≥100 cases per year, higher than expected rates of ED representations, hospital readmissions, and mortality were observed in eleven, six, and two hospitals, respectively.

CONCLUSION

The rates of ED representations, hospital readmissions, and mortality among children and young people hospitalised for injury in NSW were similar to the rates reported in other countries. However, unwarranted clinical variation across public hospitals was observed for all three indicators. These findings suggest that by improving routine follow-up support services post-discharge for children and young people and their families, it may be possible to reduce unwarranted clinical variation and improve health outcomes.

US pediatric trauma patient unplanned 30-day readmissions

PURPOSE

We sought to determine readmission rates and risk factors for acutely injured pediatric trauma patients.

METHODS

We produced 30-day unplanned readmission rates for pediatric trauma patients using the 2013 National Readmission Database (NRD).

RESULTS

In US pediatric trauma patients, 1.7% had unplanned readmissions within 30days. The readmission rate for patients with index operating room procedures was no higher at 1.8%. Higher readmission rates were seen in patients with injury severity scores (ISS)=16-24 (3.4%) and ISS ≥25 (4.9%). Higher rates were also seen in patients with LOS beyond a week, severe abdominal and pelvic region injuries (3.0%), crushing (2.8%) and firearm injuries (4.5%), and in patients with fluid and electrolyte disorders (3.9%). The most common readmission principal diagnoses were injury, musculoskeletal/integumentary diagnoses and infection. Nearly 39% of readmitted patients required readmission operative procedures. Most common were operations on the musculoskeletal system (23.9% of all readmitted patients), the integumentary system (8.6%), the nervous system (6.6%), and digestive system (2.5%).

CONCLUSIONS

Overall, the readmission rate for pediatric trauma patients was low. Measures of injury severity, specifically length of stay, were most useful in identifying those who would benefit from targeted care coordination resources.

LEVEL OF EVIDENCE

This is a Level III retrospective comparative study.

Universal Health Insurance and its association with long term outcomes in Pediatric Trauma Patients

BACKGROUND

Racial disparities in mortality exist among pediatric trauma patients; however, little is known about disparities in outcomes following discharge.

METHODS

We conducted a longitudinal cohort study of children admitted for moderate to severe trauma, covered by TRICARE from 2006 to 2014. Patients were followed up to 90days after discharge. All children <18 years with a primary trauma diagnosis, an Injury Severity Score >9 and 90days of follow-up after discharge were included. Complications, readmissions and utilization of healthcare services up to 90days after discharge were compared between Black and White patients.

RESULTS

Of the 5192 children included, majority were White (74.6%, n=3871), with 15.4% Black (n=800) and 10.0% Other (n=521). Most common injuries involved the extremities or the pelvic girdle followed by the head or neck. Complication and readmission rates were 3.6% and 8.9% within 30days of discharge respectively and 4.4% and 9.3% within 90days of discharge. 99.0% of children had at least one outpatient visit by 90days. After adjusting for patient and injury characteristics no significant differences were detected between Black and White children in outcomes after discharge.

CONCLUSIONS

Universal insurance may help mitigate disparities in post discharge care in pediatric trauma populations by increasing access to outpatient services overall and within each racial group. Further studies are required to determine the appropriate timing and frequency of follow up care in order to achieve maximum reduction in use of acute care services after discharge.