Category Archives: Hospital

Why Do Trauma Patients Get Readmitted?

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.

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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!

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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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.

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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Benefits Of A Dedicated Ortho Operating Room For Trauma

Level I and II trauma centers that are verified by the American College of Surgeons are required to have a method for ensuring that urgent orthopedic cases have good access to an operating room (OR). Some hospitals (that have room availability) have achieved this by dedicating an OR for this purpose. In a few hospitals, the room is available 24/7, but most provide daily block time that has a reasonable release time (typically about 6am). This allows procedures to reliably get done the next morning.

Previous papers have documented many of the benefits of this practice: decreased length of stay, fewer surgical revisions, decreased cost, and of course, fewer after-hours operations. But by definition, this adds a delay of several hours to the case. If the patient comes in at 7pm, the case may not start for 12 hours or more.

Could this increase the risk of infection or other complications? The orthopedic group at Stormont Vail in Topeka KS (Level I) looked at their retrospective experience over a 6 year period. They specifically examined cases in which a time delay could increase the infection rate: open tib/fib fractures. They recorded the usual demographics, time to procedure, and broke the data down by Gustilo grade of the fracture.

Here are the factoids:

  • The authors treated 297 patients with a total of 347 open fractures
  • About half were treated before a dedicated ortho OR was implemented, and half after
  • Average time to debridement in the dedicated OR was 13 hours, vs 5 hours in the on-call system
  • Overall, the number debrided within 24 hours was the same in both groups
  • Primary fracture union was significantly higher in the dedicated room group (73% vs 57%)
  • Patients treated initially in the dedicated room were significantly less likely to need an unplanned procedure later (for malunion or infection)
  • There was no difference in infection, non-union, or amputation rates

Bottom line: Let your orthopedic surgeon sleep if you have a dedicated OR so the work can get done first thing the next day! It saves wear and tear on the hospital infrastructure that occurs when cases are done in the middle of the night, as well as the surgeon. Besides saving time and money, final outcomes are better, too!

Reference: Use of the Dedicated Orthopaedic Trauma Room for Open Tibia and Femur Fractures: Does It Make a Difference? J Ortho Trauma 32(8):377-380, 2018.

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The Electronic Trauma Flow Sheet – Final Answer

After more than 10 years of experience, moving to an electronic trauma flow sheet is still not ready for prime time. I’ve seen many, many hospitals struggling to make it work. And all but a very few have failed.

There are two major problems. First, existing computer input technology is underdeveloped. Trying to rapidly put information into small windows on a computer, and having to switch between mouse and keyboard and back is just too slow. And second, output reports are terrible. Humans cannot scan 26 pages of chronological data and reconstruct a trauma activation in their head. There is so much extra data in the typical computer-generated reports, the signal (potential PI issues) gets lost in the noise.

The technology exists to remedy both of the problems. However, the EHR vendors keep tight control over data exchange in and out of their products. Sure, there is CareAnywhere and it’s ilk, but the user is still forced to use the vendor’s flawed input and output systems.

Bottom line: You can’t make a complex system (trauma care) easier or safer by adding complexity (the EHR). Yet.

The electronic trauma flow sheet will never work as well as it could until all the vendors settle on a strong data interchange standard to put data into and get reports out of the EHR. Once that happens, scores of startup companies will start to design easy input systems and report outputs or displays that are actually meaningful. There’s not enough interest in this niche market to make it worthwhile for a company the size of Epic or McKesson, but there is definitely enough for a lot of young companies just chomping at the bit in Silicon Valley.

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