Carrie Sims

The Surgical Revolving Door: Risk Factors for Hospital Readmission

BACKGROUNDnUnplanned hospital readmissions increase healthcare costs and patient morbidity. We sought to identify risk factors associated with early readmission in surgical patients.nnnMATERIALS AND METHODSnAll admissions from a mixed surgical unit during 2009 were retrospectively reviewed and unplanned readmissions within 30 d of discharge were identified. Demographic data, length of stay, pre-existing diagnoses, and complications during the index admission were evaluated. T-tests and Fisher exact tests were used to examine the relationship of independent variables with readmission. Univariate and multivariate regression analysis were performed.nnnRESULTSnA total of 1808 index admissions occurred during the study period. In all, 51 (3%) patients were readmitted within 30 d of discharge. The majority of readmissions (53%) were for infectious reasons. On univariate analyses, DVT (P = 0.004) and acute renal failure (P = 0.002) were associated with increased risk of readmission. Readmitted patients were also more likely to have public insurance (63% versus 37%, P = 0.03) and have a longer stay in the hospital (8 d, range 4-14 d versus 3 d, range 2-7 d, P = 0.001). Initial admission after trauma evaluation was associated with a decreased risk of readmission (OR 0.374, P = 0.004). Other demographic variables and pre-existing conditions were not associated with increased readmission. On multivariate logistic regression only DVT (P = 0.039) and LOS (P = 0.014) remained significant.nnnCONCLUSIONSnIncreased LOS and the development of a DVT are risk factors for early unplanned hospital readmission. Admission following trauma is associated with a decreased risk of readmission, possibly due to proactive multidisciplinary discharge planning and geographically-based nurse practitioner involvement.

Complications following thoracic trauma managed with tube thoracostomy

INTRODUCTIONnTube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mechanism of injury traditionally does not alter chest tube management, complication rates may vary depending on the severity of injury. The purpose of this study was to investigate the incidence of and risk factors associated with chest tube complications (CTCs) following thoracic trauma.nnnMETHODSnA retrospective chart review of all trauma patients (≥16 years old) admitted to an urban level 1 trauma centre (1/2007-12/2007) was conducted. Patients who required chest tube (CT) therapy for thoracic injuries within 24 h of admission and survived until CT removal were included. CTCs were defined as a recurrent pneumothorax or residual haemothorax requiring CT reinsertion within 24 h after initial tube removal or addition of new CT >24 h after initial placement. Variables including demographic data, mechanism, associated injuries, initial vital signs, chest abbreviated injury score (AIS), injury severity score (ISS), Glasgow coma score (GCS) and length of stay (LOS) and CT-specific variables (e.g. indication, timing of insertion, and duration of therapy) were compared using the chi square test, Mann-Whitney test, and multivariate analysis.nnnRESULTSn154 patients were included with 22.1% (n=34) developing a CTC. On univariate analysis, CTCs were associated with longer ICU and hospital LOS (p=0.02 and p<0.001), increased chest AIS (p=0.01), and the presence of an extrathoracic injury (p=0.047). Results of the multivariate analysis indicated that only increased chest AIS (OR 2.49; p=0.03) was a significantly independent predictor of CTCs.nnnCONCLUSIONSnCTCs following chest trauma are common and are associated with increased morbidity. The severity of the thoracic injury, as measured by chest AIS, should be incorporated into the development of CT management guidelines in order to decrease the incidence of CTCs.

Early hospital readmission in the trauma population: Are the risk factors different?

INTRODUCTIONnHospital readmission rates will soon impact Medicare reimbursements. While risk factors for readmission have been described for medical and elective surgical patients, little is known about their predictive value specifically in trauma patients.nnnPATIENTS AND METHODSnWe retrospectively identified all admissions after trauma resuscitation to our urban level 1 trauma centre from 1/1/2004 to 8/31/2010. All patients discharged alive were included. Data collected included demographics, Injury Severity Score (ISS), and length of stay (LOS). We analyzed these index admissions for the development of complications that have previously been shown to be associated with readmission. Readmissions that occurred within 30 days of index admission were identified. Univariable and multivariable analyses were performed. p<0.05 was considered significant.nnnRESULTSnWe identified 10,306 index admissions, with 447 (4.3%) early (within 30 days) readmissions. Mean ISS was 11.1 (SD 10.4). On multivariable analysis, African-American race (OR 1.3, p=0.009), pre-existing chronic obstructive pulmonary disease (COPD) (OR 1.5, p=0.02), and diabetes mellitus (OR 1.8, p<0.001) were associated with readmission, along with higher ISS (OR 1.01, p<0.001), ICU admission (OR 2.1, p<0.001), and increased LOS (OR 1.01, p<0.001). Among many in-hospital complications examined, only the development of surgical site infection (SSI) (OR 1.9, p=0.02) was associated with increased risk of readmission.nnnCONCLUSIONSnTrauma patients have a low risk of readmission. In contrast to elective surgical patients, the only modifiable risk factor for readmission in our trauma population was SSI. Other risk factors may present clinicians with opportunities for targeted interventions, such as proactive follow up or early phone contact. With future changes to health care policy, clinicians may have even greater motivation to prevent readmission.

Contemporary Comparison of Surgical and Interventional Arteriography Management of Blunt Renal Injury

PURPOSEnHigh-grade renal injuries have traditionally been treated operatively. Alternatively, embolotherapy is used to control hemorrhage, but there are few studies that validate this practice after renal injury. Embolotherapy may offer an effective and safe means to arrest hemorrhage after high-grade blunt renal injury.nnnMATERIALS AND METHODSnRetrospective analysis was performed of high-grade renal injury (grade III or higher). Patients who were initially treated with arteriography were compared with those who underwent surgery. Statistical analysis was performed with Wilcoxon rank-sum and χ(2) tests.nnnRESULTSnSixty-nine patients were identified, 28 of whom had contrast agent extravasation on computed tomography (CT). Of these 69 patients, 17 underwent operation and 20 underwent arteriography. The surgical cohort had a higher injury severity score (39.6 vs 24.2; P < .01), but there was no difference in renal injury grade (P = .9). The arteriography cohort received significantly more contrast medium (P < .001). Contrast agent extravasation was confirmed angiographically in six of 12 patients who had this finding on CT, and embolotherapy controlled bleeding in all six. No significant difference was noted in transfusion need, recurrent hemorrhage, creatinine level at discharge, glomerular filtration rate, or length of stay (P > .4 for each endpoint). There was a trend toward a longer stay in the intensive care unit in the surgical cohort and a higher likelihood of discharge to home in the arteriography group (P = .08 for each endpoint).nnnCONCLUSIONSnEmbolotherapy offers a safe means to diagnose and arrest hemorrhage after renal injury. The additional contrast agent needed for imaging does not increase the incidence of nephropathy irrespective of renal injury grade.

Detecting intimate partner violence: more than trauma team education is needed.

BACKGROUNDnIntimate partner violence (IPV) is an underappreciated cause of morbidity and mortality in female trauma patients. We investigated the impact of a domestic violence education program for trauma residents on the detection of IPV.nnnSTUDY DESIGNnIn January 2008, an educational IPV program was implemented for all trauma residents. A retrospective review of all female patients evaluated by the trauma service before and after institution of the IPV program was performed. Medical records were reviewed for demographic data, injury mechanism, social habits, and IPV documentation. Chi-square and Fishers exact tests were used to compare patients before and after institution of the educational IPV program.nnnRESULTSnThe records of 645 female trauma patients evaluated in 2007 and 2008 were reviewed. Patients were not routinely asked about IPV, despite implementation of the educational program; 39.9% were asked about IPV in 2007 versus 46.1% in 2008 (p = 0.11). The positive disclosure of IPV did not increase from 2007 to 2008 (20.1% versus 21.2%; p = 0.83). Documentation about social habits increased considerably. In 2008, patients were asked more regularly about alcohol (71.8% versus 80.8%; p = 0.01), drugs (64.1% versus 73.7%; p = 0.01), and tobacco use (67.0% versus 78.1%; p = 0.002). Importantly, patients with documented IPV (n = 57) frequently presented to the trauma team with nonviolent mechanisms of injury (n = 30, 52.6%).nnnCONCLUSIONSnIPV is a frequent finding in female trauma patients. Despite increased education, questions about IPV are not documented routinely. In addition, screening at-risk patients by mechanism will underestimate the prevalence of IPV. Universal screening should be mandated to increase IPV detection and enhance opportunities for intervention.

Colonic injuries and the damage control abdomen: does management strategy matter?

BACKGROUNDnThe optimal management of colon injury patients requiring damage control laparotomy (DCL) is controversial. The objective of this study was to assess the safety of colonic resection and anastomosis versus fecal diversion in trauma patients requiring DCL.nnnMETHODSnPatients with traumatic colon injuries undergoing DCL between 2000 and 2010 were identified by the database and chart review. Those who died within 48 h were excluded. Patients were divided into two groups: those undergoing one or more colonic anastomoses with or without distal colostomy (group 1) and those undergoing colostomy only or one or more colonic anastomoses with a protecting proximal ostomy (group 2). Variables were compared using Wilcoxon rank sum, χ2, or Fisher exact tests as appropriate.nnnRESULTSnSixty-one patients were included (group 1, n=28 and group 2, n=33). Fascial closure rates (group 1, 50% versus group 2, 61%; P=0.45), hospital length of stay (29 versus 23 d; P=0.89), and in-patient mortality (11% versus 12%; P=1.0) were similar between groups. There were a total of 11 anastomotic leaks, five of which were related to non-colonic enteric repairs. Colonic anastomosis leak rates were 16% overall (six of the 38 patients), 14% in group 1 (four of the 28 patients), and 20% in group 2 (two of the 10 patients). Compared with patients who did not leak, patients who leaked had a higher median age (37 versus 25 y; P=0.05), greater likelihood of not achieving facial closure before post-injury day 5 (18% versus 2%; P=0.003), and a longer hospital length of stay (46 versus 25 d; P=0.003).nnnCONCLUSIONSnOutcomes after colonic injury in the setting of DCL were similar regardless of the surgical management strategy. Based on these findings, a strategy of diversion over anastomosis cannot be strongly recommended.

Mineralocorticoid deficiency in hemorrhagic shock

BACKGROUNDnIn the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease severity, the development of acute renal insufficiency, and increased mortality. We hypothesized that severely injured trauma patients presenting with hemorrhagic shock would demonstrate a high degree of MD. We also hypothesized that MD in these patients would be associated with increased length of stay, hypotension, fluid requirements, and acute kidney injury (AKI).nnnMATERIALS AND METHODSnThirty-two trauma patients in hemorrhagic shock on admission to the trauma bay (SBP <90 mm Hg × 2) were enrolled. Blood samples were obtained on ICU admission and 8, 16, 24, and 48 hours later. Plasma aldosterone (PA) and renin (PR) were assayed by radioimmunoassay. MD was defined as a ratio of PA/PR ≤2. Demographic data, injury severity score, ICU and hospital length of stay, fluid requirements, mean arterial pressure, serum sodium, hypotension, and risk for AKI were compared for patients with and without MD.nnnRESULTSnAt ICU admission, 48% of patients met criteria for MD. Patients with MD were significantly more likely to experience hypotension (MAP ≤60 mm Hg) during the study period. MD patients required significantly more units of blood in 48 h than non-MD patients (13 [7-22] versus 5 [2-7], P = 0.015) and had increased crystalloid requirements (18L [14-23] versus 9L [6-10], P < 0.001). MD patients were at higher risk for AKI according to RIFLE and AKIN criteria.nnnCONCLUSIONSnMD is a common entity in trauma patients presenting in hemorrhagic shock. Patients with MD required a more aggressive resuscitative effort, were more likely to experience hypotension, and had a higher risk of AKI than non-MD patients. Future studies are needed to fully understand the impact of MD following trauma and the potential role for hormonal replacement therapy.