Tag Archives: nonsurgical service

Trauma Center

Nonsurgical Admissions And The Nelson Score

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All trauma centers admit some of their patients to nonsurgical services. This usually occurs when patients have medical comorbidities that overshadow their injuries. Unfortunately, the decision-making that goes into balancing the medical versus trauma issues is not always straightforward. The fear is that if trauma patients are inappropriately placed on a nonsurgical service, mortality and morbidity may be higher because their injuries may not receive adequate attention.

To take some of the variability out of the decision-making process for admitting service, two surgical groups on Long Island created a scoring system that incorporated several parameters described in the ACS Optimal Resource Document (Orange book). Some additional parameters were also included that the authors believed were relevant to the choice of admitting service. Here’s the final list:

The paper’s first author was a nurse, Laura Nelson, and hence this has come to be known as the Nelson Score. Patients with a score of 6 or 7 were considered definitely appropriate for nonsurgical admission. Scores of 4 or 5 were subject to more in-depth review, and those with a score of 3 or less were considered definitely appropriate for trauma service admission. There is no mention of what to do with a score of 6 in the original paper, but I presume it should be almost a slam dunk for considering nonsurgical admission.

The authors evaluated this system’s utility over a two year period. They found that using it placed more patients on the trauma service (nonsurgical admissions decreased from a peak of 28% to somewhere around 10%). They also examined morbidity and mortality statistics between the two types of admissions and found no significant differences.

The concept was further tested by the trauma group at UCHealth in Colorado Springs. They performed a retrospective review of four years of data that included over 2,000 patients. Patients were older (mean 79 years) and nearly all had blunt mechanism. Mean ISS was 9 and the nonsurgical admission rate was 19%. Patients with a Nelson score of 6 or 7 were even older and had more comorbidities.

Regression analysis did not identify admitting service as a predictor of mortality. The authors concluded that using this score is a safe way to objectively identify patients who would benefit from nonsurgical admission.

Bottom line: I have visited a number of hospitals that successfully use the Nelson score to assist with admission service decision-making while the patient is still in the emergency department. The only gray zone is the score of 4 or 5. Each program will need to determine their own cut point so they can make the service decision more objectively.

Trauma programs can also use this tool to expedite PI review of patients who have already been admitted to a nonsurgical service to check appropriateness. If the score is less than 6 further scrutiny is needed to determine if a consult from or transfer to trauma should be recommended.

References:

  1. Nonsurgical Admissions With Traumatic Injury: Medical Patients Are Trauma Patients Too. Journal of Trauma Nursing, 25 (3), 192-195, 2018.
  2. Evaluation of the Nelson criteria as an indicator for nonsurgical admission in trauma patients. Am Surg, 88(7), 1537-1540, 2022.
Nursing, Trauma Center

Impact Of A Trauma Nurse Practitioner Model On Nonsurgical Admissions

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Nonsurgical admissions are a concern for most verified/designated trauma centers. Under the current 2014 Resources for Optimal Care of the Injured Patient, all trauma patient admissions to a nonsurgical service must be concurrently reviewed by the trauma program. This process guards against trauma patients sneaking into the hospital on medicine services where the quality of the care for their injuries may not be monitored.

Typically, this requirement is met by having the trauma program manager (TPM), trauma PI coordinator (TPIC), or registrar run a daily admission report and mark patients with a potential trauma diagnosis for further review. Some clinician then reviews the patient in person or via a chart check. No further attention is needed if the patient has low acuity injuries or has been seen by the trauma or other surgical service. If not, additional scrutiny is recommended to identify patients who might be better off with a trauma service consult or even a transfer of service.

The trauma group at the Charleston Area Medical Center in West Virginia postulated that adopting a trauma nurse practitioner (TNP) model to provide care for patients otherwise admitted to a hospitalist service would improve care and decrease nonsurgical admissions. The nurses were supervised directly by the trauma attending surgeons.

They analyzed retrospective registry data during a 22-month period and compared nonsurgical admission rates with the same data for the preceding three years. Several performance metrics were evaluated, including length of stay and those statistics hospitals love to watch, discharge orders placed by noon, discharge location, and time to operating room.

Here are the factoids:

  • A total of 749 patients were admitted to the TNP service and 651 to hospitalist services
  • Patients in the TNP group were significantly younger (59 vs. 76) and more likely to be male
  • ISS was the same, but the TNP service patients had slightly more injuries (1.6 vs. 1.2) overall, and their patients were more likely to require an operation
  • The number of comorbidities was higher on the hospitalist service (2 vs. 1.6)
  • Hospital length of stay was one day shorter in the TNP group, which  was significant
  • TNP service patients were more likely to discharge home rather than to a skilled nursing facility
  • Time to OR for the TNP patients was significantly shorter by 11 hours
  • 30-day readmission rates were the same
  • The percentage of patients admitted to a nonsurgical service decreased from 20% to 14% after implementation

The authors concluded that the nonsurgical admission rate declined significantly, and several performance metrics also improved. In addition, the decreased length of stay was projected to result in a decrease of over $876,000 in hospital charges throughout the study.

Bottom line: This study illustrates some potential differences that surface when patients are admitted and managed by a trauma service rather than a hospitalist service. I say potential because there are a lot of confounders here.

The patients on the two services were very different. Although the TNP service patients had slightly more injuries (1.6 vs. 1.2), their ISS was identical. They also had fewer comorbidities. There appears to be some selection process in play here, but it was not explicitly stated in the paper. It also appears that older and more complicated patients, in terms of their comorbidities, were admitted to the hospitalists. Those with injuries more likely to require surgery were admitted to the TNP service.

Nonsurgical admission rates definitely decreased, but without knowing the selection criteria, this could have been due to just the presence of the TNP service and the desire to admit patients to it. The decreased hospital LOS and higher discharge rate to home are impressive, but could this also be due to these patients’ younger age?

The final issue is that the rules have changed! Starting later this year with the implementation of the 2022 Resource Document, the 10% nonsurgical admission rate threshold will disappear. Now, all nonsurgical trauma admissions must undergo primary review via the PI process. If any issues are identified, the ISS is greater than 9, or there was no trauma or surgical consultation, they must be escalated to a timely secondary review by the trauma medical director. Gone are the days of retrospective reviews of these cases!

What to do? It’s a balancing act in terms of trauma service capacity and staffing. Ideally, most injured patients are best served on the trauma or surgical specialty service. Several papers have outlined improved outcome metrics with this arrangement. Utilizing TNPs or physician assistants to capture and manage appropriate patients can definitely be helpful. 

An alternative is to integrate a hospitalist, preferably with geriatric expertise, into the trauma service so injured patients with more complex medical issues can be comfortably managed on the trauma service.

Reference: Rate of Nonsurgical Admissions at a Level 1 Trauma Center: Impact of a Trauma Nurse Practitioner Model. J Trauma Nurs 27(3):163-169, 2020.

 

Trauma Center

Nonsurgical Admissions And The Nelson Score

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All trauma centers admit some of their patients to nonsurgical services. This usually occurs when patients have medical comorbidities that overshadow their injuries. Unfortunately, the decision-making that goes into balancing the medical versus trauma issues is not always straightforward. The fear is that if trauma patients are inappropriately placed on a nonsurgical service, mortality and morbidity may be higher because their injuries may not receive adequate attention.

To take some of the variability out of the decision-making process for admitting service, two surgical groups on Long Island created a scoring system that incorporated several parameters described in the ACS Optimal Resource Document (Orange book). Some additional parameters were also included that the authors believed were relevant to the choice of admitting service. Here’s the final list:

The first author on the paper was a nurse, Laura Nelson, and hence this has come to be known as the Nelson Score. Patients with a score score of 7 were considered definitely appropriate for nonsurgical admission. Scores of 4 or 5 were subject to more in-depth review, and those with a score of 3 or less were considered definitely appropriate for trauma service admission. There is no mention of what to do with a score of 6 in the original paper, but I presume it should be almost a slam dunk for considering nonsurgical admission.

The authors evaluated this system’s utility over a two year period. They found that using it placed more patients on the trauma service (nonsurgical admissions decreased from a peak of 28% to somewhere around 10%). They also examined morbidity and mortality statistics between the two types of admissions, and found no significant differences.

The concept was further tested by the trauma group at UCHealth in Colorado Springs. They performed a retrospective review of four years of data that included over 2,000 patients. Patients were older (mean 79 years) and nearly all had blunt mechanism. Mean ISS was 9 and the nonsurgical admission rate was 19%. Patients with a Nelson score of 6 or 7 were even older and had more comorbidities.

Regression analysis did not identify admitting service as a predictor of mortality. The authors concluded that using this score is a safe way to objectively identify patients who would benefit from nonsurgical admission.

Bottom line: I have visited a number of hospitals that successfully use the Nelson score to assist with admission service decision-making while the patient is still in the emergency department. The only gray zone is the score of 4 or 5. Each program will need to determine their own cut point so they can make the service decision more objectively.

Trauma programs can also use this tool to expedite PI review of patients who have already been admitted to a nonsurgical service to check appropriateness. If the score is less than 6 further scrutiny is needed to determine if a consult from or transfer to trauma should be recommended.

References:

  1. Nonsurgical Admissions With Traumatic Injury: Medical Patients Are Trauma Patients Too. Journal of Trauma Nursing, 25 (3), 192-195, 2018.
  2. Evaluation of the Nelson criteria as an indicator for nonsurgical admission in trauma patients. Am Surg, 88(7), 1537-1540, 2022.
How to

Appropriateness Of Nonsurgical Admissions

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U.S. Trauma Centers that are verified by the American College of Surgeons must track the rate of trauma admissions to nonsurgical services. This is particularly important if the percentage of nonsurgical admissions exceeds 10% of their total admissions. The center’s performance improvement processes can then determine if the admission was appropriate and whether or not the trauma service should request a consult or transfer.

But how should we judge the appropriateness of nonsurgical admissions? There is tremendous variability in presenting mechanism and patient comorbidities. And the number of patients with some need for nonsurgical attention continues to grow with the rapidly increasing number of elderly falls.

The group at Southside Hospital in Bay Shore NY initially tracked all nonsurgical admissions and evaluated each individually at their community Level II trauma center. They then created and implemented a scoring system in order to develop a set of objective criteria that would predict patients better served with trauma consultation or admission.

The scoring tool was based on some of the information in the Optimal Resource Document, but was still somewhat arbitrary. The authors added criteria that reflected their own institutional philosophy of care. They explain their rationale clearly in the manuscript. Here is the final tool:

Criteria Points
Age > 65 years 1
3 or more comorbidities 1
ISS < 10 1
Ground level fall 1
No ICU admission 1
No need for surgical intervention 1
No blood products given 1

The maximum number of points possible is 7, with higher scores suggesting appropriateness for nonsurgical admission. The authors chose scores of 3 and 4 as the “grey zone” where further investigation was necessary to determine if a medical admission was proper. Lower numbers required trauma service admission, and higher ones did not.

The authors then examined changes in the percent of nonsurgical admissions after implementation, as well as mortality, morbidity, and hospital length of stay.

Here are the factoids:

  • Nonsurgical admission rates had historically been greater than 10% and had peaked at 28% at the time of scoring system implementation
  • After implementation, the nonsurgical admission rate dropped to under 10 %, where it remained for most of the time. There were a few spikes into the 14-17% range.
  • Mortality was insignificantly higher on the trauma service (2.1% vs 1.2%) as were complications (6.1% vs 5.5%)
  • Length of stay was statistically significantly longer on nonsurgical services (6.2 VS 5.1 days)

Bottom line: Centers that admit a large number of elderly falls patients may benefit from adopting this quick screening tool to determine the appropriate service. Ideally, all trauma patients would be admitted to the trauma service, but this is not feasible from a personnel and resource standpoint. If the number of potential nonsurgical admissions is high, applying a scoring system like this can help streamline the decision regarding admitting service.

Patients with very low scores (1-2) are obviously only appropriate for a trauma service admission. Likewise, those with very high scores (5-7) could easily and appropriately be managed on a hospital medicine service. The in-betweeners need more scrutiny by trauma program PI personnel to determine which service to admit to. 

Most importantly, don’t feel compelled to use this exact scoring system or threshold. Every hospital has different resources and a unique patient population. Add or remove criteria that you believe are appropriate. Adjust the threshold for added scrutiny as you see fit. Doing so will help keep your trauma PI workflow manageable.

Reference: Nonsurgical admissions with traumatic injury: medical patients are trauma patients, too. J Trauma Nursing 25(3):192-195, 2018.