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.
We’ve all taken care of them. The nasty patient. Sure, trauma can ruin one’s day. And a person can’t be expected to be on their best behavior after, say, a major car crash. But after the dust settles and the patient is recovering, we sometimes get a glimpse of their real personality. And sometimes, it turns out, they are just not really that nice.
Most patients don’t realize that being nasty to their caregivers creates problems for themselves. Yes, we are trauma professionals, and we should be able to take care of anybody, anytime, under any circumstances. But human nature is what it is. We unconsciously try to minimize discomfort. And this may mean unconsciously reducing cares and interpersonal communication with the offensive individual.
The most important thing we can do is to make sure that the patient is aware that their behavior is not acceptable, and to set strict limits. A tight feedback loop is important. Equally as important, every provider needs to have the same limits, so the patient can’t play them against each other, trying to manipulate the system. Often times, the mere fact that the patient knows that the entire team has a uniform set of limits and expectations can help shape their behavior. This lets them recover as quickly as possible, and get out of the hospital at the earliest opportunity.
How can we accomplish this? Our hospital has developed a sort of “behavioral contract” that is provided to potential problem patients (and their visitors/families) to shape behavior before it has a chance to deteriorate. Nurses and/or doctors review the contract with the patient, explaining each point. They are them asked to sign, but even if they refuse, they are told they are still bound by it. Every trauma professional involved knows the limits so there is no room for manipulation. Here’s a copy of ours:
Have a look at our behavioral contract, and let me know your thoughts, or share the tools and tips you use to deal with this issue.
Download the behavioral contract here
The April newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Prehospital.
In this issue you’ll find articles on:
- EMS Handoff
- Safe aeromedical transport
- Evaluated but not transported by EMS?
- And more!
Subscribers received the newsletter first on Friday. If you want to subscribe (and download back issues), click here.
Download the newsletter here!
Hematuria ranges from microscopic to gross. Microscopic means blood that can only be seen with a microscope, and gross means visible to the naked eye. In trauma, we only care about gross hematuria, which ranges from the faintest of pink to the deepest red.
In trauma, gross hematuria is a result of an injury to kidney, ureter or bladder. Blunt injury to the ureter is so rare it’s reportable, so you can pretty much forget that one unless the mechanism is extreme. So you really just need to focus on kidney and bladder.
Any victim of blunt trauma that presents with visible hematuria needs to be evaluated by CT of the abdomen and pelvis with an added CT cystogram. Standard CT technique is done without a urinary catheter, or with the catheter clamped. Only 50% of bladder injuries show up with this technique.
CT cystogram is an add-on to the standard CT, and consists of the administration of contrast into the bladder which is then kept under pressure while the scan is done. Delayed slices through the pelvis after the bladder is depressurized and emptied is routine. Nearly 100% of bladder injuries are detected using this technique.
If the CT shows a renal laceration or hematoma, the patient should be admitted and managed according to your solid organ injury protocol. Kidney injuries fare better that livers and spleens, and only rarely require surgery. If no kidney or bladder injury is seen, the default diagnosis of a renal contusion is the culprit. No treatment is needed, and the patient can be discharged if no other injuries are present. The blood will clear over a few days, but may disappear and reappear a few times in the process. The patient can followup with their primary care physician in a week or two.
There was a well-publicized and tragic case of mistaken identity after a motor vehicle crash in Indiana about 8 years ago. A van carrying several college students and staff crashed, resulting in multiple fatalities at the scene. Survivors were transported to a Michigan trauma center, and it wasn’t until five weeks later that the identity mixup was discovered.
One of the fatally injured students and one of the survivors were both female, blonde, and about the same height and size. Their identities were not confirmed because the next of kin of the deceased was advised not to look at the body. And the face of the surviving woman was significantly contused and she had sustained multiple facial fractures. She remained comatose and intubated for over month after the other was buried (by the wrong family, it turns out). After extubation, she began correcting people who called her by the deceased woman’s name, and the correct identification was finally made.
How can this happen?! It’s not as difficult as it might seem, for a number of reasons:
- Faces and identifying marks may be mutilated
- Position in the vehicle may be mistaken
- Bystander descriptions are notoriously inaccurate in these situations
It is neither practical nor safe to delay transport from the scene in the interest of obtaining positive identification. And hospitals have even less information than prehospital providers, whom they rely on almost exclusively for accurate data.
What can be done to avoid a case of mistaken identity? EMS and hospitals must develop protocols to follow in any case where multiple patients are treated at once. The baseline assumption must be that the identities are unclear or unknown until definitively made, and preferably from multiple sources. What are these definitive items?
- An official ID that is still on the victim’s person (not cut off in the clothes)
- Self identification
- Visual identification from someone who personally knows the victim and views or talks to them
- Written description, where the patients have very different identifying characteristics
However, remember that every one of these can be made in error. This is why multiple sources are so important. If in doubt, the patients should remain a “Doe” and not be given a real name.
If you have specific protocols or policies, please share them with me by email so I can post them!