Category Archives: Hospital

Trauma And The Electronic Health Record

I’m going to dedicate this week to discussing the impact of the electronic health record (EHR) on trauma care.

First, I’ll talk a little about the history of the EHR, how it came about and why it was “encouraged” of all hospitals. I’ll also look at who the big players are. Next, I’ll review two studies of the impact of the EHR on ED productivity and patient stay.

And finally, I’ll really dig into using an electronic trauma flow sheet that interfaces with the EHR. My thinking has slowly been changing, but not by much. I’ll review my reasons, and talk about the (few) success stories that are out there.

Stay tuned!

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Hard Time Discharging Your Trauma Patient?

Trauma services tend to have fairly rapid patient turnover. Many of the patients that are seen have injuries that are easily managed, leading to discharge within one to two days. On the flip side, some have such severe injuries that they may be in the hospital for weeks or even months. But regardless of injury, there are always a few who we just can’t seem to discharge at all. Why does this happen?

The trauma program at the Massachusetts General Hospital looked at 5 years worth of admission data on adult patients. They looked at the usual hospital demographics, billing information, hospital financial information, and discharge disposition. The ultimate goal was to identify patients who had an excessively prolonged hospitalization (defined as 2 standard deviations above the average length of stay for the associated Diagnosis Related Group) and why.

Here are the factoids:

  • 155 of 3237 admitted patients (5%) had an extended stay. The total number of admits seems weird, since this would average out to only 650 admissions per year to this busy hospital.
  • The usual injury severity demographics were similar.
  • Extended stay patients tended to be older, sustained blunt trauma, were Medicare or no-pay patients, and were discharged to facilities other than home.
  • Length of stay was 3 times longer than the usual patients
  • Hospital cost was 3 times higher, and the hospital lost a lot of money on them.
  • In-hospital mortality was lower for these patients (?!).
  • The biggest factors delaying discharge were transfer to a rehab or other post-acute care facility, and self-pay or Medicare pay status.

Bottom line: Extended stay in the hospital when not medically indicated is a bad thing, and it’s a system problem. The chance of complications is always present, including deep venous thrombosis, exposure to resistant organisms, UTI, pneumonia, and medication error, just to name a few. And it’s generally bad for the hospital’s financial health, as well. If you are experiencing this at your center, carefully analyze the reasons why it typically occurs. Then work proactively to address them.

  • Identify potential problem discharge patients on their first day in the hospital
  • Develop special arrangements with post-discharge facilities.
  • Hire skilled (and aggressive) social workers
  • Don’t give up!

Related post:

Reference: Excessively long hospital stays after trauma are not related to the severity of illness. JAMA Surg 148(10):956-961, 2013.

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Impact Of A Geriatric Trauma Service

I previously wrote about the impact of adding a hospitalist to the trauma service to improve care of geriatric trauma patients. Method Dallas Medical Center created a specific geriatric trauma service, which they called the G-60 service, in 2009. They published their data after one year of experience in 2012.

All patients 60 years of age and older with injuries <48 hours old were admitted to a specific hospital unit. All admitted patients were seen immediately by the trauma surgeon and a hospitalist. Other involved services included rehab, palliative care, PT and OT, pharmacy, nutrition, respiratory therapy, and social work, as needed. The hospitalist was also tasked with expedited clearance for surgical procedures.

Time-to-care goals included G-60 service activation and ED evaluation within 30 minutes, admission to the G-60 unit within 4 hours, operative procedures (if needed) within 36 hours, and discharge within 5 days if appropriate. Multidisciplinary rounds with the full complement of personnel were held twice weekly.

A total of 393 patients were admitted to the G-60 service over a period of one year. A control group of 280 patients from the year before implementation were used for comparison.

Here are the factoids:

  • Mechanism of injury was blunt 98% of the time, as expected. Most were falls, and the frequency increased from 68% to 75% after implementation of G-60.
  • ICU admission rate remained steady at about 20%
  • Significant time-to-care decreases were seen in all 4 categories. ED length of stay decreased by 2 hours, and time to OR decreased by more than half a day.
  • Hospital length to stay decreased from 7 to 5 days, and ICU LOS decreased from 5 to 3 days. Both were statistically and financially significant.
  • There were significant decreases in the incidence of complications, including UTI, renal failure, CHF, ventilator associated pneumonia, and respiratory failure.
  • There was no change in DVT or PE rates.

Bottom line: Implementation of a multidisciplinary trauma service that addresses the special problems of injured elderly patients improves outcomes, and would appear to save a lot of money. I have observed a very obvious age shift in the trauma population at my own trauma center, and I know quite a few other trauma medical directors who are seeing the same thing. We are all going to need to develop the equivalent of a G-60 service to improve outcomes and reduce the financial challenges of taking care of these patients. However, using age 60 as the threshold will miss a number of elders who might benefit. Frailty measures and common sense will need to be taken into account to make sure all appropriate patients can benefit from this type of service.

Reference: Geriatric trauma service: A one-year experience. J Trauma 72(1):119-122, 2012.

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Adding A Hospitalist To The Trauma Service

Hospitals are increasingly relying on a hospitalist model to deliver care to inpatients on medical services. These medical generalists are usually trained in general internal medicine, family medicine, or pediatrics and provide general hospital-based care. Specialists, both medical and surgical, may be consulted when needed.

In most higher level trauma centers in the US (I and II), major trauma patients are admitted to a surgical service (Trauma), and other nonsurgical specialists are consulted based on the needs of the patients and the competencies of the surgeons managing the patients. As our population ages, more and more elderly patients are admitted for traumatic injury, with more and more complex medical comorbidities.

Is there a benefit to adding medical expertise to the trauma service? A few studies have now looked at this, and I will review them over the next few days. The Level I trauma center at Christiana Care in Wilmington, Delaware embedded a trauma hospitalist (THOSP) in the trauma service. They participated in the care of trauma patients with coronary artery disease, CHF, arrhythmias, chronic diseases of the lung or kidneys, stroke, diabetes, or those taking anticoagulants.

The THOSP was consulted on appropriate patients upon admission, or during admission if one of the conditions was discovered later. They attended morning and afternoon sign-outs, and weekly multidisciplinary rounds. A total of 566 patients with hospitalist involvement were matched to controls, and ultimately 469 patients were studied.

Here are the factoids:

  • Addition of the THOSP resulted in a 1 day increase in hospital length of stay
  • Trauma readmissions decreased significantly from 2.4% to 0.6%
  • The number of upgrades to ICU status doubled, but ICU LOS remained the same
  • Mortality decreased significantly from 2.9% to 0.4%
  • The incidence of renal failure decreased significantly
  • Non-significant decreases in cardiovascular events, DVT/PE and sepsis were also noted
  • There was no difference in the number of medical specialty consults placed (cardiology, endocrinology, neurology, nephrology)

Bottom line: This paper shows some positive impact, along with some puzzling mixed results. The decrease in mortality and many complications is very positive. Was the increase in ICU transfers due to a different care philosophy in medical vs surgical personnel? And the failure to decrease the number of specialty consults was very disappointing to me. I would expect that having additional medical expertise on the team should make a difference there.

Was the THOSP really “embedded” if they were not involved in the regular daily rounds? In this case, they were present only for handoffs and for weekly multidisciplinary rounds. I believe that having them on the rounding team daily would be of huge benefit, allowing the surgeons and hospitalists to learn from each other. Plus, there should be a benefit to the residents in a Level I center, helping them broaden their ability to care for these complicated patients.

Tomorrow: The G-60 Geriatric Trauma Service 

Reference: Embedding a trauma hospitalist in the trauma service reduces mortality and 30-day trauma-related readmissions. J Trauma 81(1):178-183, 2016.

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