Association of Psychosocial Factors and Hospital Complications with Risk for Readmission After Trauma

National analysis of health-related social needs among adult injury survivors

BACKGROUND

Despite advances in trauma care, the effects of social determinants of health continue to be a barrier to optimal health outcomes. Health-related social needs (HRSNs), now the basis of a Centers for Medicare and Medicaid Services national screening program, may contribute to poor health outcomes, inequities, and low-value care, but the impact of HRSNs among injured patients remains poorly understood at the national level.

METHODS

Using data from the nationally representative 2021 Medical Expenditure Panel Survey, injured patients were matched with uninjured controls via coarsened exact matching on age and sex. We then determined the prevalence of HRSNs based on core needs identified by Centers for Medicare and Medicaid Services: food, utilities, living situation, transportation, and personal safety. We used multivariable regression models to evaluate the association between HRSNs and health, delays in care, and emergency department visits.

RESULTS

Overall, 43% of injured patients reported one or more HRSNs. Compared with uninjured controls, injured patients were more likely to have unmet needs in all five HRSN domains (adjusted odds ratio, 1.44-2.00; p < 0.05 for all). In stratified analyses, HRSNs were highest among patients with lower income (65.1%), those who identified as Non-Hispanic Black patients (61.3%), and patients with Medicaid (66.1%). Increasing number of HRSNs was associated with worse physical and mental health (p < 0.05). Injured patients with three or more HRSNs were also more likely to delay care because of cost (adjusted odds ratio, 3.79; 95% confidence interval, 2.29-6.27) and had greater emergency department utilization (adjusted incidence rate ratio, 1.47; 95% confidence interval, 1.16-1.87).

CONCLUSION

In this nationally representative study, nearly half of injured patients had one or more HRSNs. Greater numbers of HRSNs were associated with worse health outcomes, delayed care, and low-value care. As national screening for HRSNs is implemented, strategies to address these factors are needed and may serve to optimize health and health care utilization among injury survivors.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Intensive Care Unit Readmissions in a Level I Trauma Center

INTRODUCTION

Intensive care unit (ICU) readmissions are associated with increased morbidity and mortality rates, longer hospitalization, and increased health-care expenditures. This study sought to present a large cohort of trauma patients readmitted to the ICU, characterizing risk factors and providing quality improvement strategies to limit ICU readmission.

METHODS

A retrospective cohort analysis was conducted on adult trauma patients admitted to the ICU at a single level I trauma center from 2014 to 2021. Patients were split into readmission and no readmission groups. Patients experiencing readmission were compared to a similar group that was not readmitted using descriptive statistics and logistic regression.

RESULTS

In this study, 3632 patients were included and 278 (7.7%) were readmitted to the ICU. Significant differences were found in age, Elixhauser Comorbidity score, number of days on a ventilator, and number of patients requiring ventilator support. Furthermore, logistic regression showed that increasing age and the Elixhauser Comorbidity Score were associated with an increased likelihood of ICU readmission. Over the study period, the ICU readmission rate increased while the ICU length decreased.

CONCLUSIONS

Age, Elixhauser Comorbidity score, and ventilator use were all significant risk factors for ICU readmission. During our study period, a concerning trend of increasing ICU readmissions and decreased ICU length of stay was found. By identifying this trend, our institution was able to employ mitigation strategies that have successfully reversed the trend in ICU readmissions, decreasing the rate below the national average.

Trauma Patient-Centered Discharge Plan Form: A Pilot Study

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.

Predictors of care discontinuity in geriatric trauma patients

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.

Predictors of hospital readmission after trauma: A retrospective cohort study in New Zealand

INTRODUCTION

Understanding predictors of hospital readmission following major trauma is important as readmissions are costly and some are potentially avoidable. This study describes the incidence of, and sociodemographic, injury-related and treatment-related factors predictive of, hospital readmission related to: a) all-causes, b) the index trauma injury, and c) subsequent injury events in the 30 days and 12 months following discharge for major trauma patients nationally in New Zealand.

METHODS

Data from the New Zealand Trauma Registry (NZTR) was linked with Ministry of Health hospital discharge data. Hospital readmissions were examined for all patients entered into the NZTR for an injury event between 1 January and 31 December 2018. Readmissions were examined for the 12-months following the discharge date for participant's index trauma injury.

RESULTS

Of 1986 people, 42% had ≥1 readmission in the 12 months following discharge; 15% within 30 days. Seven percent had ≥1 readmission related to the index trauma within 30 days of discharge; readmission was 3.43 (95% CI 1.87, 6.29) times as likely if the index trauma was self-inflicted compared to unintentional, and 1.64 (95% CI 1.15, 2.34) times as likely if the index trauma involved intensive care unit admission. Those admitted to hospital for longer for their index trauma were less likely to be readmitted due to their index trauma injury within 30 days compared to those admitted for 0-1 day. Seventeen percent were readmitted for a subsequent injury event within 12 months, with readmission more likely for older people (>65 years), those with comorbidities, Māori compared with non-Māori and those with higher trauma injury severity.

CONCLUSION

A substantial proportion of people are readmitted after discharge for major trauma. Factors identified in this study will be useful to consider when developing interventions to reduce preventable readmissions including those related to the index trauma injury, readmissions from other causes and subsequent injury-related readmissions. Further research specifically examining planned and unplanned readmissions is warranted.

Status and Risk Factors in Patients Requiring Unplanned Intensive Care Unit Readmission Within 48 Hours: A Retrospective Propensity-Matched Study in China

Aim

This study investigated the current status and related risk factors of 48-hour unplanned return to the intensive care unit (ICU) to reduce the return rate and improve the quality of critical care management.

Methods

Data were collected from 2365 patients discharged from the comprehensive ICU. Multivariate and 1:1 propensity score matching analyses were performed.

Results

Forty patients (1.69%) had unplanned readmission to the ICU within 48 hours after transfer. The primary reason for return was respiratory failure (16 patients, 40%). Furthermore, respiratory failure (odds ratio [OR] = 5.994, p = 0.02) and the number of organ failures (OR = 5.679, p = 0.006) were independent risk factors for unplanned ICU readmission. Receiver operating characteristic curves were drawn for the predictive value of the number of organ injuries during a patient's unplanned transfer to the ICU (area under the curve [AUC] = 0.744, sensitivity = 60%, specificity = 77.5%).

Conclusion

The reason for patient transfer and the number of organ injuries during the process were independent risk factors for patients who were critically ill. The number of organs damaged had a predictive value on whether the patient would return to the ICU within 48 hours.