Why Do Trauma Patients Get Readmitted?

April 23, 2020 The Trauma Pro Leave a comment

Readmission of any patient to the hospital is considered a quality indicator. Was the patient discharged too soon for some reason? Were there any missed or undertreated injuries? Information from the Medicare system in the US (remember, this represents an older age group than the usual trauma patient) indicates that 18% of patients are readmitted and 13% of these are potentially preventable.

A non-academic Level II trauma center in Indiana retrospectively reviewed their admissions and readmissions over a 3 year period and excluded patients who were readmitted on a planned basis (surgery), with a new injury, and those who died. This left about 5,000 patients for review. Of those, 98 were identified as unexpected readmissions.

There were 6 major causes for readmission:

Wound (23) – cellulitis, abscess, thrombophlebitis. Two thirds required surgery, and 4 required amputation. All of these amputations were lower extremity procedures in obese or morbidly obese patients.
Abdominal (16) – ileus, missed injury, abscess. Five required a non-invasive procedure (mainly endoscopy). Only 2 required OR, and both were splenectomy for spleen infarction after angioembolization.
Pulmonary (7) – pneumonia, empyema, pneumothorax, effusion. Two patients required an invasive procedure (decortication, tube placement).
Thromboembolic (4) – DVT and PE. Two patients were admitted with DVT, 2 with PE, and 1 needed surgery for a bleed due to anticoagulation.
CNS (21) – mental status or peripheral neuro exam change. Eight had subdural hematomas that required drainage; 3 had spine fractures that failed nonoperative management.
Hematoma (5) – enlargement of a pre-existing hematoma. Two required surgical drainage.

About 14% of readmissions were considered to be non-preventable by a single senior surgeon. Wound complications had the highest preventability and CNS changes the lowest. Half occurred prior to the first followup visit, which was typically scheduled 2-3 weeks after discharge. This prompted the authors to change their routine followup to 7 days.

Bottom line: This retrospective study suffers from the usual weaknesses. However, it is an interesting glimpse into a practice with fewer than the usual number patients lost to followup. The readmission rate was 2%, which is pretty good. One in 7 were considered “preventable.” Wounds and pulmonary problems were the biggest contributors. I recommend that wound and pulmonary status be thoroughly assessed prior to discharge to bring this number down further. Personally, I would not change the routine followup date to 1 week, because most patients have far more complaints that are of little clinical importance than compared to 2 weeks after discharge.

Reference: Readmission of trauma patients in a nonacademic Level II trauma center. J Trauma 72(2):531-536, 2012.

Hospital

Hard Time Discharging Your Trauma Patient?

April 21, 2020 The Trauma Pro Leave a comment

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!

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

Philosophy

Yet Another One: The Eleventh Law Of Trauma

April 15, 2020 The Trauma Pro Leave a comment

If you have followed this blog for any period of time, you are aware of the skepticism I bring to bear when I am reading new material or learning of new ideas. Why is this? Because it is very difficult in this day and age to ascertain the veracity of anything we see, hear, or read.

This is not new compared to, say, a hundred years ago. The media were a bit different, but the underlying issues were the same. There have always been two major factors at play: information overload and the biases built into our human brain operating system.

There is a huge body of new information in every field that is being produced every year. Given the pressures that most researchers are under to publish or perish, a huge number of papers are sent to journals for review. Unfortunately, this leads to a huge number of publications that are of lower quality.

This also contributes to another recognized phenomenon, the half-life of facts. Think about all the things you learned during your training that are no longer believed to be true. Stress causes ulcers. Steroids are good in head injury. There is a definite decay curve for the old facts that occurs as new knowledge is acquired.

So we have a huge amount of potential junk to sort through to figure out what cellular mechanisms are correct or which medications work for a disease. And then we run into our own operating system problems.

All humans have our own innate beliefs that are shaped by experience and all the information we’ve consumed over the years. And we are genetically programmed to do this:
Learn something new —> believe it —> verify it

And many of us never get to the verify stage because another operating system issue, confirmation bias, takes over. If we learn something that confirms an existing belief, we are much more likely to believe and much less likely to verify. If we learn something that opposes our belief, we still want to believe what we already do and find every flaw in the new data that might refute it.

So here is my eleventh law of trauma:

“Don’t believe anything you learn, especially if it supports what you already believe”

And here is it’s corollary:

“Don’t believe everything you think!”

Bottom line: If you read or hear something new, first examine the source. Is it legitimate and reliable? Where did it get the info? Then check out that source. Critically evaluate it, even if it already supports what you believe. Always treat new information, especially if you think it’s right, as an opportunity to learn something new. Sometimes you will find real gems in the things you thought were wrong, and real crap in the things you believed to be right!

It’s time to flip the algorithm to:
Learn something new —> verify it —> believe it

Procedures

Can Chest Tube Insertion Result In Exposure To Coronavirus?

April 15, 2020 The Trauma Pro Leave a comment

Endotracheal intubation is considered an aerosol-producing procedure. In this new age of SARS-CoV-2 and COVID-19, most hospitals are stepping up the level of personal protective equipment (PPE) used when performing this procedure. This has also resulted in modifications in the location where intubation is performed and the choice of drugs used.

But what about needle and chest thoracostomy? These are different than intubation in that the respiratory tract is usually not directly accessed. However, there is the opportunity for exposure to pleural fluid. In the case of needle thoracostomy, it is possible that air under pressure in the chest can force tiny droplets or even an aerosol out and into the air. There is less likelihood of aerosolization during tube thoracostomy, where liquid and droplet exposure can be anticipated.

What do we know about pleural fluid and the novel coronavirus? Basically nothing. And there is very little literature out there regarding other respiratory viruses in pleural fluid either. The only paper I could find (reference below) was published five years ago by a Spanish group. They compared the presence of bacteria and viruses in the pleural fluid of patients with community acquired pneumonia against an uninfected control group. They found only one incidence of virus in the pleural fluid in one patient, a human metapneumovirus. Is this comforting? Probably not.

Trauma patients with chest trauma are likely very different. Those with a hemo- or pneumo-thorax, by definition, had some violation of the surface of the lung. to cause the leak This injury is very likely to breach alveoli which are laden with coronavirus, thus contaminating the pleural fluid. Once that occurs, it is possible that the entire thorax surrounding the lung is contaminated. Note: this is one of those “common sense” assumptions with absolutely no data currently to back it up.

Bottom Line: This is yet another of the many questions about SARS-CoV-2 that we just don’t have an objective answer to. However, since we are already limiting exposure during or forgoing laparoscopic procedures altogether to avoid vaporizing viral particles in smoke, it makes sense to protect ourselves during procedures that involve pleural fluid in trauma patients.

Until we have more data, needle and tube thoracostomy procedures should be considered at least a droplet-prone procedure, if not an aerosol-producing one. This means that trauma professionals should don appropriate personal protective equipment as dictated by their local policies and procedures before performing these procedures.

Reference: Detection of bacteria and viruses in the pleural effusion of children and adults with community-acquired pneumonia. Future Microbiology 10(6):909-916, 2015.

The Trauma Pro

Monthly Archives: April 2020

Why Do Trauma Patients Get Readmitted?

Hard Time Discharging Your Trauma Patient?

Yet Another One: The Eleventh Law Of Trauma

Can Chest Tube Insertion Result In Exposure To Coronavirus?

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