Tag Archives: nonsurgical service

Nonsurgical Admissions And The Nelson Score

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.

Appropriateness Of Nonsurgical Admissions

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.