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:

• Discharged to soon?

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

Medicine is full of conditions with eponyms. Trauma is no exception. There’s the Mattox maneuver and the Cushing response, to name two. Many times, the name is just a kind of vanity plate for the discoverer of the condition. But in the case of the LisFranc injury (or fracture), it makes some sense. This injury is tough to describe in a sentence or two, let alone a few words. 

Jacques LisFranc de St. Martin was a French surgeon and gynecologist (!) who described this condition in about 1815. It entails the fracture of the heads of the metatarsal bones and possible dislocation from the tarsals (the cuboid, navicular, and three cuneiform bones). This area is known as the LisFranc joint complex.

The injury can involve any or all of the metatarsals. The typical mechanism applies high energy across the midfoot, which can often be seen in head-on motor vehicle crashes. Crush injury to the proximal foot can also do this, such as running the foot over with a car. Occasionally, this injury pattern is produced with lower energy during sports play. In this case, the top of the foot is typically contacting the ground, plantar flexing it. At the same time, another player steps on the heel, grinding the foot into the ground (ouch). Interestingly, LisFranc did not describe the injury pattern or mechanism. His name is associated with the joint complex, and it is an injury to his joint complex.

Most of the time, the injury is obvious. There is usually notable pain and swelling of the foot. X-ray findings are generally not subtle. However, lower energy mechanisms may not cause much displacement, and initial imaging may not show the injury. If your patient starts to complain of pain in the midfoot when they begin to ambulate, think of LisFranc.

Treatment depends on the degree of displacement and the amount of disruption of the tarso-metatarsal joints. If minimal, a trial of nonoperative, non-weight bearing may be sufficient. But frequently, surgical reconstruction is required. 

For those of you with poor internet connections, I’ve created a downloadable version of today’s Mechanism of Injury For Prehospital Providers talk. 

Click here to download