Factors influencing discharge location after hospitalization resulting from a traumatic fall among older persons

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.

Effects of Peer Mentoring for Caregivers of Patients With Acquired Brain Injury: A Preliminary Investigation of Efficacy

Objective

To evaluate effectiveness of a peer mentor intervention for caregivers of patients with acquired brain injury (ABI) in encouraging caregiver participation in support services to prepare them for the role of caregiving and in reducing caregiver stress and depression.

Design

Controlled trial with participants randomized to either usual care or 1-to-1 visits with a family caregiver peer mentor during the ABI inpatient rehabilitation stay.

Setting

Nonprofit rehabilitation hospital specializing in care of persons with brain and spinal cord injury.

Participants

Caregivers (N=36) of patients with ABI admitted for rehabilitation whose discharge location was home with care provided by family members (caregivers: 93% female; 58% White; mean age, 48±10.4y).

Interventions

One-to-one peer mentoring visits during the inpatient stay with a trained peer mentor who is also a family caregiver of a survivor of brain injury.

Main Outcome Measures

Frequency of participation in support services for family caregivers, reported caregiver stress, and reported caregiver depressive symptoms.

Results

There was no difference between groups in participation in support services for family caregivers. Participants in the peer mentor intervention group reported significantly greater improvement in caregiver stress at discharge and 30 days post discharge than participants in the usual care group. Reported depressive symptoms were also lower for the intervention group, but change scores did not achieve statistical significance at discharge or 30-day follow-up.

Conclusions

Peer mentoring appears to improve caregivers' ability to handle the stress of caregiving and reduces reported depressive symptoms. There was no between-group difference noted in participation in support services for families; however, participation was adversely affected by restrictions imposed during the coronavirus disease 2019 pandemic, which may have masked any effect.

Fall Risk, Supports and Services, and Falls Following a Nursing Home Discharge

Background and Objectives

Falls are a major source of morbidity and mortality among older adults; however, little is known regarding fall occurrence during a nursing home (NH) to community transition. This study sought to examine whether the presence of supports and services impacts the relationship between fall-related risk factors and fall occurrence post NH discharge.

Research Design and Methods

Participants in the Minnesota Return to Community Initiative who were assisted in achieving a community discharge (N = 1459) comprised the study sample. The main outcome was fall occurrence within 30 days of discharge. Factor analyses were used to estimate latent models from variables of interest. A structural equation model (SEM) was estimated to determine the relationship between the emerging latent variables and falls.

Results

Fifteen percent of participants fell within 30 days of NH discharge. Factor analysis of fall-related risk factors produced three latent variables: fall concerns/history; activities of daily living impairments; and use of high-risk medications. A supports/services latent variable also emerged that included caregiver support frequency, medication management assistance, durable medical equipment use, discharge location, and receipt of home health or skilled nursing services. In the SEM model, high-risk medications use and fall concerns/history had direct positive effects on falling. Receiving supports/services did not affect falling directly; however, it reduced the effect of high-risk medication use on falling (p < .05).

Discussion and Implications

Within the context of a state-implemented transition program, findings highlight the importance of supports/services in mitigating against medication-related risk of falling post NH discharge.

Payer Source Associated with Disparities in Procedural, but Not Surgical, Care in a Trauma Population

Trauma centers are legally bound by Emergency Medical Treatment and Active Labor Act to provide equal treatment to trauma patients, regardless of payer source. However, evidence has suggested that disparities in trauma care exist. This study investigated the relationships between payer source and procedures (total, diagnostic, and surgical) and the number of medical consults in an adult trauma population. This is a 10-year retrospective trauma registry study at a Level I trauma facility. Payer source of adult trauma patients was identified, demographics and variables associated with trauma outcomes were abstracted, and multivariate logistic regression tests were used to determine statistical differences in the number of procedures and medical consults. Of the 12,870 records analyzed, 69.1 per cent of patients were commercially insured, 21.2 per cent were uninsured, and 9.6 per cent had Medicaid. After controlling for patient- and injury-related variables, the commercially insured received more total procedures (4.30) than the uninsured (3.35) or those with Medicaid (3.34), and more diagnostic (2.59) procedures than the uninsured (2.03) or those with Medicaid (2.04). There was not a difference in the number of surgical procedures or medical consults among payer sources. This study noted that disparities (measured by the number of procedures received) compared by payer source existed in the care of trauma patients. However, for medical consults and definitive care (measured by surgical procedures), disparities were not observed. Future research should focus on secondary factors that influence levels of care such as patient-level factors (health literacy) and trauma program policies.

Clinical and non-clinical factors that predict discharge disposition after a fall

BACKGROUND

Falls can result in injuries that require rehabilitation and long-term care after hospital discharge. Identifying factors that contribute to prediction of discharge disposition is crucial for efficient resource utilization and reducing cost. Several factors may influence discharge location after hospitalization for a fall. The aim of this study was to examine clinical and non-clinical factors that may predict discharge disposition after a fall. We hypothesized that age, injury type, insurance type, and functional status would affect discharge location.

METHODS

This two-year retrospective study was performed at an urban, adult level-1 trauma center. Fall patients who were discharged home or to a facility after hospital admission were included in the study. Data was obtained from the trauma registry and electronic medical records. Logistic regression modeling was used to assess independent predictors.

RESULTS

A total of 1,121 fallers were included in the study. 621 (55.4%) were discharged home and 500 (44.6%) to inpatient rehabilitation (IRF)/skilled nursing facility (SNF). The median age was 64 years (IQR: 49-79) and 48.4% (543) were male. The median length of hospital stay was 5 days (IQR: 2.5-8). Increasing age (p < 0.001), length of stay in the ICU (p < 0.001), injury severity (p < 0.001), number of comorbidities (p = 0.038), having Medicare insurance (p = 0.025), having a fracture at any body region (p < 0.001), and ambulation status (p = 0.025) significantly increased the odds of being discharged to IRF/SNF compared to home. The removal of injury severity score and ICU length of stay from the "late/regular discharge" model, to create an "early discharge" model, decreased the accuracy of the prediction rate from 78.5% to 74.9% (p < 0.001).

CONCLUSION

A combination of demographic, clinical, social, economic, and functional factors can together predict discharge disposition after a fall. The majority of these factors can be assessed early in the hospital stay, which may facilitate a timely discharge plan and shorter stays in the hospital.

Multilevel Comparisons of Hospital Discharge among Older Adults with a Fall-Related Hospitalization

OBJECTIVE

We examined multilevel factors associated with hospital discharge status among older adults suffering a fall-related hospitalization.

DATA SOURCES

The 2011-2013 (n = 131,978) Texas Inpatient Hospital Discharge Public-Use File was used.

STUDY DESIGN/METHODS

Multilevel logistic regression analyses estimated the likelihood of being discharged to institutional settings versus home.

PRINCIPAL FINDINGS

Factors associated with a greater likelihood of being discharged to institutional settings versus home/self-care included being female, white, older, having greater risk of mortality, receiving care in a non-teaching hospital, having Medicare (versus Private) coverage, and being admitted from a non-health care facility (versus clinical referral).

CONCLUSIONS

Understanding risk factors for costly discharges to institutional settings enables targeted fall-prevention interventions with identification of at-risk groups and allows for identifying policy-related factors associated with discharge status.

Examining the relationship between preinjury health and injury-related factors to discharge location and risk for injury-associated complications in patients after blunt thoracic trauma: a pilot study

OBJECTIVE

To determine whether preinjury health and injury-related factors were associated with posthospitalization discharge location and injury-associated complications for patients with blunt thoracic trauma.

METHODS

A retrospective analysis using registry data from a level 1 trauma center was conducted. A random sample of 200 patients admitted between 2009 and 2012 was included. Relationships between variables were assessed through cross-tabulation with the chi-square analysis; a P value <.05 was considered statistically significant.

RESULTS

Alcohol/drug use was related to hospital discharge location. Most patients with alcohol involved injuries discharged to locations other than home or long-term care facilities. Of the 59 patients who required intensive care, their length of stay was less than 3 days, and 24 required mechanical ventilation for short periods. Most blunt thoracic trauma patients were hospitalized less than 7 days. A relationship was identified between discharge location and the presence of any of the National Trauma Databank comorbid conditions and the comorbid condition of bleeding. A relationship between rib fractures and injury-associated complications was not found. The complication of pneumonia was related to length of stay and primary payment method.

CONCLUSION

Comorbid medical conditions and injury-related factors were associated with injury-related complications and discharge location for select variables. Further exploration with is needed to elucidate the associations more fully.

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.

Low-impact pelvic fractures in the emergency department

Objective:

We examined the records of patients presenting to the emergency department (ED) with low-impact pelvic fractures. We describe frequency, demographics, management and patient outcomes in terms of ambulatory ability, living independence and mortality.

Methods:

Patients treated for a pelvic fracture over a 2-year period in Kingston, Ont., were identified. We performed a retrospective hospital record review to distinguish high- versus low-impact injury mechanisms, and to characterize the injury event, ED management and outcomes for patients with low-impact fractures.

Results:

Of 132 pelvic fractures identified, 77 were low-impact fractures. Patients were predominantly women (82%) with a mean age of 81 years; 96% had some pre-existing medical comorbidity. The pubic rami were most commonly involved (86%). The median length of stay in the ED was 9.4 hours. Twenty-five patients (32%) were admitted to hospital. Ten patients had surgical stabilization, mostly of the acetabulum. Five patients died in hospital, 4 from pneumonia and 1 from myocardial infarction. Eight additional patients died within 1 year of injury. At discharge, only 18% lived independently and 16% walked without aids versus 42% and 38%, respectively, before injury.

Conclusion:

Low-impact pelvic fractures affect predominantly elderly women with pre-existing comorbidities. A substantial amount of time and resources in the ED are used during the workup of these patients and while awaiting their disposition from the ED. These injuries are important because they affect independence and seem associated with an increased risk of death.

Mandatory health care insurance is associated with shorter hospital length of stay among critically injured trauma patients

BACKGROUND

The implementation of the Affordable Care Act stimulated interest in outcomes of patients in Massachusetts, a state mandating health insurance as of 2006. We sought to determine the impact of an insurance mandate on hospital use and outcomes among trauma intensive care unit (ICU) patients.

METHODS

This is a retrospective cohort study of trauma patients admitted to the ICU conducted at an academic, trauma center. Patients before (2004-2006) and after (2008-2012) the implementation of mandatory health insurance were compared using propensity matching to control for confounders. Outcomes were hospital length of stay (LOS), ICU LOS, in-hospital mortality, and discharge disposition.

RESULTS

Overall, 1,668 trauma patients were included, with 530 matched on the propensity score in each group. Hospital LOS decreased by a median of 2.0 days, from 9.0 days (interquartile range, 4-15 days; p < 0.01) before to 7.0 days (interquartile range, 4-14) after implementation of the legislation. There were no differences in ICU LOS (3.0 days to 3.0 days, p = 0.44) and mortality (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.83-1.63). Compared with discharges to home, the patients were more likely to be discharged home with home health services after the legislation (OR, 1.70; 95% CI, 1.08-2.68), but there was no significant change in the likelihoods of the patients being discharged to skilled nursing and rehabilitation facilities (OR, 0.97; 95% CI, 0.72-1.31).

CONCLUSION

Implementation of health care reform was associated with a decrease in hospital LOS, with an increase in use of home health services and no change in ICU LOS and mortality among trauma ICU patients at our institution.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Structure, process, and outcomes in skilled nursing facilities: understanding what happens to surgical patients when they cannot go home. A systematic review

BACKGROUND

The surgical population is aging, and greater numbers of surgical patients are being discharged to skilled nursing facilities. Post-acute care is a poorly understood but very important aspect of our healthcare system.

METHODS

This systematic review examines the current body of literature surrounding the structural, process of care, and outcomes measurements for patients in skilled nursing facilities. English language articles published between 1998 and 2011 that purposed to examine nursing facility structure, process of care, and/or outcomes were included.

RESULTS & CONCLUSIONS

Abstracts (2129) were screened and 102 articles were reviewed in full. Twenty-nine articles were included in the qualitative synthesis. The role of the care setting and care delivery in contributing to outcomes has not been well studied, and no strong conclusions can be made. This area of care currently represents a "black box" to practicing surgeons. An understanding of these factors maybe instrumental to determining future directions for research to maximize positive outcomes for these patients.

Effects of fall injury type and discharge placement on mortality, hospitalization, falls, and ADL changes among older people in Taiwan

A longitudinal study was conducted to investigate the effects of injury type and discharge placement on mortality, falls, hospital admissions, and changes in activities of daily living (ADLs) over a 12-month period among older fallers. Of 762 community-dwelling people aged 65 years or older who visited an emergency department (ED) of a general hospital in Taiwan due to a fall, 273 sustained a hip fracture, 157 had a vertebral fracture, 47 had a distal forearm fracture, 102 had a traumatic brain injury, and 183 had soft-tissue injuries. Results showed that, compared to patients with a soft-tissue injury, those with TBI had significantly higher risks of dying (rate ratio (RR)=3.59) and hospital admissions (RR=3.23) and better improvement in ADLs (1.93 points) at 6 months post-injury, and those who sustained a hip fracture (4.26 and 4.41 points), a vertebral fracture (3.81 and 3.83 points), or a distal-forearm fracture (2.80 and 2.80 points) had significantly better improvement in ADLs at 6 and 12 months post-injury. Patients discharged to a nursing home had a significantly increased risk of death (RR=2.08) and hospital admission (RR=2.05) than those returning to their usual residence during the first year post-injury. No significant differences in the occurrence of falls during the first post-injury year were found among patients with different injury types or between those with different discharge placements. In conclusion, among the five major fall injury types in older people, TBIs result in the highest risk of death and hospital admissions, while hip and vertebral fractures exhibited the largest improvement during the first year after injury. Additionally, nursing home care may be associated with increased risks of death and hospital admissions than home care. In addition to primary prevention of falls, further research to investigate mechanisms leading to TBIs during a fall is needed to facilitate effective secondary fall-prevention programs for older people.

Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact?

BACKGROUND

Risk-adjusted analyses are critical in evaluating trauma outcomes. The National Trauma Data Bank (NTDB) is a statistically robust registry that allows such analyses; however, analytical techniques are not yet standardized. In this study, we examined peer-reviewed manuscripts published using NTDB data, with particular attention to characteristics strongly associated with trauma outcomes. Our objective was to determine if there are substantial variations in the methodology and quality of risk-adjusted analyses and therefore, whether development of best practices for risk-adjusted analyses is warranted.

STUDY DESIGN

A database of all studies using NTDB data published through December 2010 was created by searching PubMed and Embase. Studies with multivariate risk-adjusted analyses were examined for their central question, main outcomes measures, analytical techniques, covariates in adjusted analyses, and handling of missing data.

RESULTS

Of 286 NTDB publications, 122 performed a multivariable adjusted analysis. These studies focused on clinical outcomes (51 studies), public health policy or injury prevention (30), quality (16), disparities (15), trauma center designation (6), or scoring systems (4). Mortality was the main outcome in 98 of these studies. There were considerable differences in the covariates used for case adjustment. The 3 covariates most frequently controlled for were age (95%), Injury Severity Score (85%), and sex (78%). Up to 43% of studies did not control for the 5 basic covariates necessary to conduct a risk-adjusted analysis of trauma mortality. Less than 10% of studies used clustering to adjust for facility differences or imputation to handle missing data.

CONCLUSIONS

There is significant variability in how risk-adjusted analyses using data from the NTDB are performed. Best practices are needed to further improve the quality of research from the NTDB.

A model to advance nursing science in trauma practice and injury outcomes research

AIMS

This discussion paper reports development of a model to advance nursing science and practice in trauma care based on an analysis of the literature and expert opinion.

BACKGROUND

The continuum of clinical care provided to trauma patients extends from the time of injury through to long-term recovery and final outcomes. Nurses bring a unique expertise to meet the complex physical and psychosocial needs of trauma patients and their families to influence outcomes across this entire continuum.

DATA SOURCES

Literature was obtained by searching CINAHL, PubMed and OvidMedline databases for 1990-2010. Search terms included trauma, nursing, scope of practice and role, with results restricted to those published in English. Manual searches of relevant journals and websites were undertaken.

DISCUSSION

Core concepts in this trauma outcomes model include environment, person/family, structured care settings, long-term outcomes and nursing interventions. The relationships between each of these concepts extend across all phases of care. Intermediate outcomes are achieved in each phase of care and influence and have congruence with long-term outcomes. Implications for policy and practice.  This model is intended to provide a framework to assist trauma nurses and researchers to consider the injured person in the context of the social, economic, cultural and physical environment from which they come and the long-term goals that each person has during recovery. The entire model requires testing in research and assessment of its practical contribution to practice.

CONCLUSION

Planning and integrating care across the trauma continuum and recognition of the role of the injured person's background, family and resources will lead to improved long-term outcomes.

Age differences in fall-related injury hospitalisations and trauma presentations

AIM

To examine fall-related hospitalised morbidity in New South Wales (NSW) and to describe the pattern of fall-related major trauma presentations at a Level 1 Trauma Centre in NSW for younger and older fallers.

METHODS

Fall-related injuries were identified in the NSW Admitted Patients Data Collection during 1 July 1999-30 June 2008 and the trauma registry of the NSW St George Public Hospital during 1 January 2006-6 December 2008.

RESULTS

There were 434 138 hospitalisations and 862 fall-related trauma presentations. Older fallers had a higher incidence of hospitalisation, being more likely to fall on the same level during general activities at home, injuring their hip or thigh. Older fallers were also more likely to have an Injury Severity Score > 9, undergo physiotherapy and stay in hospital for >1 day than younger fallers.

CONCLUSION

Falls, particularly for older individuals, are an important cause of serious injury, representing a considerable burden in terms of hospitalised morbidity.

Institutional variations in frequency of discharge of elderly intensive care survivors to postacute care facilities

OBJECTIVE

To examine variations in the frequency of discharge of elderly patients to postacute care facilities across multiple intensive care units and identify the influence of institutional and patient factors on the frequency of postacute care discharge.

DESIGN

Observational cohort study.

SETTING

Consecutive admissions from 65 intensive and coronary care units in 24 US hospitals during 2002-2008. Each hospital had a clinical information system in place.

PATIENTS

A total of 13,370 admissions in patients aged≥65 yrs who were alive at hospital discharge and met inclusion criteria.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic, clinical, diagnostic, and physiological variables were obtained on all patients. In addition, information for each hospital and intensive care unit was recorded. Among hospital survivors, 46.2% were discharged to postacute care facilities with a range of 8.8-77.8%. A multivariable logistic regression model was developed that predicted discharge to a postacute care facility. The major variables affecting postacute care discharge were diagnosis, day 5 physiology, and day 5 therapy; these variables accounted for 61% of the model's explanatory power. Patient age, hospital bed size, teaching status, and intensive care unit type also affected postacute care discharge. Physiology and therapy on day 1 had little impact on postacute care discharge. The model accounted for only 31% of the variation in rates across intensive care units, indicating that unmeasured factors play a part in dictating discharge location.

CONCLUSION

Discharge of elderly intensive care unit patients to postacute care facilities varies widely by institution. These variations are only partially explained by differences in patient and institutional characteristics and are affected more by diagnosis and physiology on day 5, respectively. Unmeasured factors such as admission from a postacute care facility, postacute care availability, patient preferences, and socioeconomic factors may account for unexplained variations in postacute care discharge.