Clinical spectrum of discharges against medical advice in a developing country

Background  

Patients who leave the hospital before clinician certification of fitness are referred to as discharge against medical advice (DAMA). This phenomenon of discharges against medical advice is an undesirable but relatively common occurrence worldwide. Professional liability and harmful effect of this practice to individual health are of concern.     

Nine-year change of mortality and discharge against medical advice among major trauma patients in a Chinese Intensive Care Unit

Background

The mortality/morbidity of patients can be used to evaluate the quality of a trauma care, which can be influenced by incidence of discharge against medical advice (DAMA).

Objective

This study was to investigate annual changes of mortality/morbidity and DAMA of trauma patients in one Chinese Intensive Care Unit (ICU) in 9 years.

Methods

A retrospective analysis of data [age, Injury Severity Score (ISS), Acute Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma Scale (GCS), mortality rate, and DAMA] was performed with trauma patients admitted in the emergency ICU of the Second Affiliated Hospital of Zhejiang University from 2003 to 2011.

Results

The rate of total mortality (in-hospital death and dying at discharge) was 6.9 % and the rate of DAMA (deterioration at discharge and improvement at discharge) was 6.6 %. The mortality rate was significantly decreased from 11.1 to 4.6 %, and the rate of deterioration at discharge was increased from 2.8 to 6.4 %. Among the three periods (2003–2005, 2006–2008, and 2009–2011), the age and APACHE II score of patients in total death, deterioration at discharge, and death plus deterioration at discharge groups were highest in the period 2009–2011, whereas the GCS was statistically lower in all groups except in the deterioration at discharge group.

Conclusion

The medical quality of trauma care has been improved through gradual improvement of instruments and trained medical staffs. The rate of deterioration at discharge was increased, especially in elder patient group. The DAMA had a significant impact on the accurate assessment of trauma care, which should be paid more attention on its potential roles in the future.

     

Predictors of outcome in patients requiring surgery for liver trauma

INTRODUCTION: Severe bleeding from liver injury is one of the major causes of mortality in patients with abdominal trauma. The study was undertaken to assess factors that influence outcome following liver trauma. PATIENTS AND METHODS: This is a prospective study of patients with liver injury treated in one surgical ward at King Edward VIII Hospital over a 7-year period (from 1998 to 2004). Data collected included demographics, intra-operative findings, operative management and outcome. RESULTS: Of a total of 478 patients with abdominal trauma, 105 (22%) were found to have liver injuries, of whom only 7 were female. Their mean age was 27.81+/-10.33 years. Injuries were due to firearms (70), stabs (26) and blunt trauma (9). Nineteen patients presented with shock (systolic BP6h in 47 patients. Forty patients required ICU management (38%) and the mean ICU stay was 6.55+/-5.65 days. Twenty patients (19%) needed a re-laparotomy for various reasons. The complication rate was 37% and the mortality rate was 20% (23% for firearms, 44% for blunt trauma and 4% for stabs). The mortality rate in patients with shock was 58% compared to 12% in those who were not shocked (p<0.0001). Mortality rate was 2, 23 and 63% for Injury Severity Score (ISS)20, respectively (group 1 versus group 2 p=0.015; group 1 versus group 3 p<0.0001 and group 2 versus group 3 p=0.001). Mortality rates for delay 6h were 28 and 9%, respectively (p=0.008). Associated injuries led to a higher mortality (3% versus 27%; p=0.006). Hospital stay was 11.27+/-12.09 days. CONCLUSIONS: Liver injuries occurred in 22% of abdominal injuries. Injury mechanism, delay before surgery, shock on admission, grade of injury, associated injury and ISS are significantly associated with outcome.     

Predictors of adverse discharge disposition in adult spinal deformity and associated costs

Background Context

With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators of adverse discharge disposition in ASD surgeries is paramount.

Improving early identification of the high-risk elderly trauma patient by emergency medical services

Study objectiveWe sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients.MethodsThis was a retrospective cohort study of injured adults ≥65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score ≥ 16 and specific anatomic patterns of serious injury using abbreviated injury scale score ≥3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns.Results33,298 injured elderly patients were transported by EMS, including 4.5% with ISS ≥ 16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7–20.7) for ISS ≥ 16 to 2.9% (95% CI 2.6–3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS ≤ 14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS ≥ 16: sensitivity (92.1% [95% CI 89.6–94.1%] vs. 75.9% [95% CI 72.3–79.2%]), specificity (41.5% [95% CI 40.6–42.4%] vs. 77.8% [95% CI 77.1–78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices.ConclusionsHigh-risk elderly trauma patients can be defined by ISS ≥ 16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity.     

Predictors of blunt abdominal aortic injury in trauma patients and mortality analysis

ObjectiveBlunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought to identify risk factors for BAAI and risk factors for mortality in patients with BAAI using a large national database. We hypothesized that an Injury Severity Score of 25 or greater, and thoracic trauma would both increase the risk of mortality in patients with BAAI.MethodsThe Trauma Quality Improvement Program (2010-2016) was queried for individuals with blunt trauma. Patients with and without BAAI were compared. Covariates were included in a multivariable logistic regression model to determine mechanisms of injury, examination findings, and concomitant injuries associated with increased risk for BAAI. An additional multivariable analysis was performed for mortality in patients with BAAI.ResultsFrom 1,056,633 blunt trauma admissions, 1012 (0.1%) had BAAI. The most common mechanism of injury was motor vehicle accident (MVA; 57.5%). More than one-half the patients had at least one rib fracture (54.0%), or a spine fracture (53.9%), whereas 20.8% had hypotension on admission and 7.8% had a trunk abrasion. The average length of stay was 13.4 days and 24.6% required laparotomy, with 6.6% receiving an endovascular repair and 2.9% an open repair. The risk of death in those treated with endovascular vs open repair was similar (P = .28). On multivariable analysis, MVA was the mechanism associated with the highest risk of BAAI (odds ratio [OR], 4.68; 95% confidence interval [CI], 3.87-5.65; P < .001) followed by pedestrian struck (OR, 4.54; 95% CI, 3.47-5.92; P < .001). Other factors associated with BAAI included hypotension on admission (OR, 3.87; 95% CI, 3.21-4.66; P < .001), hemopneumothorax (OR, 3.67; 95% CI, 1.16-11.58; P < .001), abrasion to the trunk (OR, 1.49; 95% CI, 1.15-1.94; P = .003), and rib fracture (OR, 1.46; 95% CI, 1.25-1.70; P < .001). The overall mortality rate was 28.0%. Of the variables examined, the strongest risk factor associated with mortality in patients with BAAI was hemopneumothorax (OR, 12.49; 95% CI, 1.25-124.84; P = .03) followed by inferior vena cava (IVC) injury (OR, 12.05; 95% CI, 2.80-51.80; P < .001).ConclusionsIn the largest nationwide series to date, BAAI continues to have a high mortality rate with hemopneumothorax and IVC injury associated with the highest risk for mortality. The mechanism most strongly associated with BAAI is MVA followed by pedestrian struck. Other risk factors for BAAI include rib fracture and trunk abrasion. Providers must maintain a high suspicion of injury for BAAI when these mechanisms of injury, physical examination or imaging findings are encountered.     

Characteristics of trauma patients that leave against medical advice: An eight-year survey analysis using the National Hospital Ambulatory Medical Care Survey, 2009–2016

BackgroundLeaving against medical advice (AMA) is associated with increased readmission rates, fragmented patient care, and healthcare litigation. Understanding the factors associated with trauma patients leaving AMA from acute care settings will help guide better communication with trauma patients and improve patient satisfaction. This study aims to assess the sociodemographic and in-hospital care characteristics of trauma patients that leave AMA from acute care centers across the U.S.MethodsWe pooled and analyzed eight years of data (2009–2016) from the National Hospital Ambulatory Medical Care Survey. The outcome variable was whether the patient left AMA or not. The main predictors were the triage class, weekend presentation, health insurance status, the presence of chronic diseases, and the receipt of therapeutic and diagnostic procedures. The sociodemographic characteristics -age, sex, and race/ethnicity, were measured as potential confounders in the developed model. We performed logistic regression and reported the unadjusted and adjusted odds of leaving AMA as well as the 95% confidence intervals.ResultsThe weighted percent of the trauma patient population that left AMA was 1.8%. The odds of leaving AMA decreased with advancing age, and increased among non-Hispanic Blacks, compared with non-Hispanic Whites. After adjusting for age, race, and gender, the odds of leaving AMA increased among patients that lacked health insurance (AOR: 1.86; 95% CI: 1.51–2.31), and had diagnostic procedures (AOR: 2.79; 95% CI: 2.32–3.36). The odds of leaving AMA reduced among trauma patients who were classified as emergent (AOR: 0.70; 95% CI: 0.50–0.98) and had therapeutic procedures (AOR: 0.39; 95% CI: 0.32–0.47).ConclusionPredicting trauma patients with increased odds of leaving AMA will inform intentional communication that may reduce leaving AMA rates and improve care.     

Dementia as a predictor of mortality in adult trauma patients

Background

The specific contribution of dementia towards mortality in trauma patients is not well defined. The purpose of the study was to evaluate dementia as a predictor of mortality in trauma patients when compared to case-matched controls.

Trauma patient discharge and care transition experiences: Identifying opportunities for quality improvement in trauma centres

BackgroundChallenges delivering quality care are especially salient during hospital discharge and care transitions. Severely injured patients discharged from a trauma centre will go either home, to rehabilitation or another acute care hospital with complex management needs. This purpose of this study was to explore the experiences of trauma patients and families treated in a regional academic trauma centre to better understand and improve their discharge and care transition experiences.MethodsA qualitative study using inductive thematic analysis was conducted between March and October 2016. Telephone interviews were conducted with trauma patients and/or a family member after discharge from the trauma centre. Data collection and analysis were completed inductively and iteratively consistent with a qualitative approach.ResultsTwenty-four interviews included 19 patients and 7 family members. Participants’ experiences drew attention to discharge and transfer processes that either (1) Fostered quality discharge or (2) Impeded quality discharge. Fostering quality discharge was ward staff preparation efforts; establishing effective care continuity; and, adequate emotional support. Impeding discharge quality was perceived pressure to leave the hospital; imposed transfer decisions; and, sub-optimal communication and coordination around discharge. Patient-provider communication was viewed to be driven by system, rather than patient need. Inter-facility information gaps raised concern about receiving facilities’ ability to care for injured patients.ConclusionsThe quality of trauma patient discharge and transition experiences is undermined by system- and ward-level processes that compete, rather than align, in producing high quality patient-centred discharge. Local improvement solutions focused on modifiable factors within the trauma centre include patient-oriented discharge education and patient navigation; however, these approaches alone may be insufficient to enhance patient experiences. Trauma patients encounter complex barriers to quality discharge that likely require a comprehensive, multimodal intervention.     

Early predictors for massive transfusion in older adult severe trauma patients

BackgroundMany scoring systems for the early prediction of the need for massive transfusion (MT) have been reported; in most of these, vital signs are regarded as important. However, the validity of these scoring systems in older patients remains unclear because older trauma patients often present with normal vital signs. In this study, we investigated the effectiveness of previously described scoring systems, as well as risk factors that can provide early prediction of the need for MT in older severe trauma patients.MethodsWe prospectively collected data from a cohort of severe trauma patients (ISS ≥16 and age ≥16 years) admitted from January 2007 to March 2015. Trauma Associated Severe Hemorrhage (TASH), Assessment of Blood Consumption (ABC), and Prince of Wales Hospital (PWH) scores were compared between a younger and an older group. Furthermore, the predictors associated with MT in older severe trauma patients were assessed using multivariable logistic regression analyses.ResultsThe area under the curve (AUC) was significantly smaller for older group than for younger group for all three scoring systems (p < 0.05). The most important risk factors to predict the need for MT were related to anatomical factors including FAST results (odds ratio (OR): 5.58, 95% confidence interval (CI): 2.10–14.99), unstable pelvic fracture (OR: 21.56, 95% CI: 6.05–90.78), and long bone open fracture of the lower limbs (OR: 12.21, 95% CI: 4.04–39.09), along with pre-injury anticoagulant agent use (OR: 5.22, 95% CI: 1.30–19.61), antiplatelet agent use (OR: 3.81, 95% CI: 1.57–9.04), lactate levels (OR: 1.20, 95% CI: 1.04–1.39) and shock index (OR: 2.67, 95% CI: 1.05–6.84). Traditional vital signs were not early risk factors.ConclusionWe suggest that MT in older trauma patients should be considered on the basis of anatomical factors, pre-injury anticoagulant or antiplatelet agent use, lactate level and SI even if traditional vital signs are normal.     

Characteristics and outcomes of patients discharged home from the Emergency Department following trauma team activation

Objective

Past research on trauma teams has largely focused on the outcomes of severely injured patients. Few studies have looked at patients who have activated the trauma team but are discharged home directly from the Emergency Department. The aim of this study was to examine the characteristics and outcomes of these patients following discharge.

Methods

All adult Emergency Department discharged trauma patients who were contactable by telephone 7-14 days post-discharge and spoke English were eligible for the study. A 10-min questionnaire was conducted covering their perceptions of Emergency Department care, return to activities, discharge and follow-up care, missed injuries and pain management. Data were also collected on their age, sex, injuries and length of stay in the Emergency Department.

Results

Over the 169-day study period, 158 trauma patients were discharged from Liverpool hospital, which formed 30.1% of all patients treated by the trauma team. Of these, 106 patients were contactable and 100 completed the follow-up questionnaire. They suffered mainly minor injuries but stayed a median 341 min in the Department. Most patients (87%) reported that their health had impacted on their daily activities and about half of all full-time workers remained off work for 1 week or more. A small number of patients had missed fractures or other serious injuries. Two-third of patients visited a medical practitioner after discharge and 8 required further specialist and/or in-patient care.

Conclusion

Most trauma patients discharged from the Emergency Department continue to suffer significant morbidity after their departure from hospital and require further medical care. A small number of patients also had significant missed injuries. This suggests that more comprehensive discharge and follow-up care for these patients is warranted.     

Competitive advantage gained from the use of helicopter emergency medical services (HEMS) for trauma patients: Evaluation of 1724 patients

ObjectivesThe aim of the study was to analyze helicopter emergency medical service (HEMS) in comparison to EMS, in respect to patient’s mortality and morbidity.DesignFrom a cohort of traumatized patients (n = 1724) prospectively enrolled in the German trauma registry (DGU-R) at Frankfurt University Hospital from 2009 to 2013, 1646 could be analyzed for in-hospital mortality and short-term outcome (GOS) at discharge and compared between HEMS and EMS.Measurements and main results129 patients (7.8%) died in the hospital. Unadjusted mortality was significantly lower in the HEMS group compared to EMS (p = 0.001). In a multiple logistic regression analysis after adjustment of variables including reanimation and age as the strongest predictors, in-hospital mortality was significantly reduced in HEMS (p = 0.014, OR = 0.21). Further predictors in the multiple logistic regression analysis were GCS > = 8 (p = 0.001), RRsys (p < 0.001), ISS at Head/Neck > = 3 (p = 0.003), and total ISS > = 9 (p < 0.001). Total rescue time and on scene time were associated with mortality (p < 0.001) but not included in the multiple logistic regression model. Without adjustment, short-term outcome (GOS) was significantly improved (p = 0.014). In a linear model, after adjusting for multiple variables including age, ISS Head/Neck > = 3, ISS Extremities > = 3, GCS > = 8, and RRsys as the strongest predictors (p < 0.001), the association remained significant (p = 0.043). Further predictors in the multiple linear regression analysis were total ISS > = 9 (p = 0.002), ISS abdomen (p = 0.001), and ISS Chest (p = 0.011).ConclusionsA significant improvement for in-hospital survival for HEMS could be demonstrated. Especially in Germany, with a high number of secondary call outs (about 44%) after EMS has already reached the traumatized patient, HEMS must be the first choice for severely injured trauma patients. Dispatch criteria for immediate alarm of HEMS are recommended under practical considerations.     

Characterisation of orthopaedic trauma admitted to adult level 1 trauma centres

BACKGROUND: Despite the vast number of traumatic injuries that are orthopaedic in nature, comprehensive epidemiological data that characterise orthopaedic trauma are limited. The aim of this study was to investigate the nature of orthopaedic trauma admitted to adult Level 1 Trauma Centres. METHODS: Data were obtained from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which includes all patients with orthopaedic trauma admitted to the two adult Level 1 Trauma Centres in Victoria (Australia). Information was collected from the medical record and hospital databases on patients' demographics and injury event, diagnoses and management. RESULTS: Data were analysed on 784 patients recruited between August 2003 and March 2004. Patients were mainly young (<65 years) (70.7%), male (59.1%) and injured in a transport collision (51.3%). Fractures of the femur (23.7%) and spine (23.5%) were the most common injuries and were predominately managed with operative (87.6%) and conservative (78.8%) methods, respectively. Differences in most parameters were evident between younger (<65 years) and older (> or =65 years) patients. CONCLUSIONS: This study presents epidemiological data on patients with orthopaedic trauma who were admitted to adult Level 1 Trauma Centres. This information is critical for the future monitoring and evaluation of the outcomes of orthopaedic trauma.     

Prehospital education in triage for pediatric and pregnant patients in a regional trauma system without collocated pediatric and adult trauma centers

Purpose

Patient triage to the appropriate destination is critical to prehospital trauma care. Triage decisions are challenging in a region without collocated pediatric and adult trauma centers.

Predictors of transfer to rehabilitation for trauma patients admitted to a level 1 trauma centre—A model derivation and internal validation study

Objective

Determine the predictors of transfer to rehabilitation in a cohort of trauma patients and derive a risk score based clinical prediction tool to identify such patients during the acute phase of injury management.

Methods

Trauma registry data at a single level one trauma centre were obtained for all patients aged between 15 and 65 years admitted due to injury between 2007 and 2011. Multivariable logistic regression with stepwise selection was performed to derive a prediction model for transfer to rehabilitation. The model was tested on a validation dataset using receiver operator characteristic analyses and bootstrap cross validation on the entire dataset. A clinical prediction risk score was developed based on the final model.

Results

There were 4900 patients included in the study. Variables found to be the strongest predictors of rehabilitation after logistic regression with stepwise selection were pelvic injuries (OR 12.6 95% CI 6.2, 25.2 p < 0.001), need for intensive care unit admission (OR 7.2 95% CI 4.2, 12.3 p < 0.001) and neurosurgical operation (OR 10.5 95% CI 4.7, 23.1 p < 0.001). After bootstrap cross validation the mean AUC was 0.86 (95% CI 0.84, 0.89). The model had a sensitivity of 89% and specificity of 64%.

Conclusion

Intensive unit admission, neurosurgical operation, pelvic injuries and other lower limb injuries were the most important predictors of the need for rehabilitation after trauma. The prediction model has good overall sensitivity, discrimination and could be further validated for use in clinical practice.     

Diagnostic performance of serial haematocrit measurements in identifying major injury in adult trauma patients

Determination of occult haemorrhage is an essential part of trauma assessment. We evaluated the diagnostic utility of decreasing haematocrit (DeltaHct) in detecting major injury. Additionally, we tested the correlation between the volume of infused intravenous fluid (IVF) and DeltaHct. METHODS: Prospective observational study at a level one trauma centre. Inclusion criteria: Patients with suspected major injury. exclusion criteria: Patients who received blood transfusion in the first 4 h, and those who deceased or were transferred to other units before the completion of the observation period (4 h). We measured IVF and DeltaHct at 4 h after triage. We classified patients as having minor or major injury on the basis of injury severity score > or =15. Receiver Operating Characteristic (ROC) curve was used to test the diagnostic performance of DeltaHct in identifying major injury. We tested the operating characteristics of DeltaHct cut-off values of 5 and 10 in detecting major injury. We also measured the correlation of IVF and DeltaHct in a subgroup of patients with low potential for blood loss (ISS<3) to account for possibility of haemodilution. RESULTS: Four hundred and ninety-four patients (convenience sample) were enrolled (age 36+/-17 years, 82% male, 57% blunt trauma). Sixty-three patients (13%) had major injury. The area under the ROC curve for DeltaHct was not significantly different from the unity line (p=0.20). DeltaHct-4 h>5 points had a sensitivity of 40% (95% CI, 29-52%), specificity of 94% (95% CI, 92-96%), likelihood ratio for a positive test (LR+) of 7.1 (95% CI, 4.4-11.7), and likelihood ratio for a negative test (-LR) of 0.64 (95% CI, 0.52-0.78) in identifying major trauma. DeltaHct-4 h>10 points had sensitivity of 16% (95% CI, 9-27%), specificity of 95% (95% CI, 92-0.96%), +LR of 3.0 (95% CI, 1.5-5.9), and -LR of 0.89 (95% CI, 0.80-0.99). In our subgroup analysis, we detected no significant correlation (p=0.09) between the IVF and DeltaHct-4 h. CONCLUSIONS: DeltaHct-4 h>5 or 10 points is suggestive of major injury (high specificity and +LR). However, the failure to drop the Hct cannot be used to rule out major injury (low sensitivity and -LR).     

Identification of thoracic injuries by emergency medical services providers among trauma patients

IntroductionSevere thoracic injuries are time sensitive and adequate triage to a facility with a high-level of trauma care is crucial. The emergency medical services (EMS) providers are required to identify patients with a severe thoracic injury to transport the patient to the right hospital. However, identifying these patients on-scene is difficult. The accuracy of prehospital assessment of potential thoracic injury by EMS providers of the ground ambulances is unknown. Therefore, the aim of this study is to evaluate the diagnostic accuracy of the assessment of the EMS provider in the identification of a thoracic injury and determine predictors of a severe thoracic injury.MethodsIn this multicentre cohort study, all trauma patients aged 16 and over, transported with a ground erence standard. Prehospital variables were analysed using logistic regression to explore prehospital ambulance to a trauma centre, were evaluated. The diagnostic value of EMS provider judgment was determined using the Abbreviated Injury Scale (AIS) of ≥ 1 in the thoracic region as ref predictors of a severe thoracic injury (AIS ≥ 3).ResultsIn total 2766 patients were included, of whom 465 (16.8%) sustained a thoracic injury and 210 (7.6%) a severe thoracic injury. The EMS providers’ judgment had a sensitivity of 54.8% and a specificity of 92.6% for the identification of a thoracic injury. Significant independent prehospital predictors were: age, oxygen saturation, Glasgow Coma Scale, fall > 2 m, and suspicion of inhalation trauma or a thoracic injury by the EMS provider.ConclusionEMS providers could identify little over half of the patients with a thoracic injury. A supplementary triage protocol to identify patients with a thoracic injury could improve prehospital triage of these patients. In this supplementary protocol, age, vital signs, and mechanism criteria could be included.     

Clinician tasking in ambulance control improves the identification of major trauma patients and pre-hospital critical care team tasking

IntroductionTrauma remains the fourth leading cause of death in western countries and is the leading cause of death in the first four decades of life. NICE guidance in 2016 advocated the attendance of pre-hospital critical care trauma team (PHCCT) in the pre-hospital stage of the care of patients with major trauma. Previous publications support dispatch by clinicians who are also actively involved in the delivery of the PHCCT service; however there is a lack of objective outcome measures across the current reviewed evidence base. In this study, we aimed to assess the accuracy of PHCCT clinician led dispatch, when measured by Injury Severity Score (ISS).MethodsA retrospective cohort study over a 2 year period pre and post implementation of a PHCCT clinician led dispatch of PHCCT for potential major trauma patients, using national ambulance data combined with national trauma registry data.ResultsA total of 99,702 trauma related calls were made to SAS including 495 major trauma patients with an ISS >15, and a total of 454 dispatches of a PHCCT. Following the introduction of a PHCCT clinician staffed trauma desk, the sensitivity for major trauma was increased from 11.3% to 25.9%. The difference in sensitivity between the pre and post trauma desk group was significant at 14.6% (95% CI 7.4%–21.4%, p < .001).DiscussionThe results from the study support the results from other studies recommending that a PHCCT clinician should be located in ambulance control to identify major trauma patients as early as possible and co-ordinate the response.     

The presence of the adult respiratory distress syndrome does not worsen mortality or discharge disability in blunt trauma patients with severe traumatic brain injury

PURPOSE: To evaluate the prevalence of the acute respiratory distress syndrome (ARDS) among blunt trauma patients with severe traumatic brain injury (TBI) and to determine if ARDS is associated with higher mortality, morbidity and worse discharge outcome. METHODS: Blunt trauma patients with TBI (head abbreviated injury score (AIS)> or =4) who developed predefined ARDS criteria between January 2000 and December 2004 were prospectively collected as part of an ongoing ARDS database. Each patient in the TBI+ARDS group was matched with two control TBI patients based on age, injury severity score (ISS) and head AIS. Outcomes including complications, mortality and discharge disability were compared between the two groups. RESULTS: Among 362 TBI patients, 28 (7.7%) developed ARDS. There were no differences between the two groups with respect to age, sex, ISS, Glasgow coma score (GCS), head, abdomen and extremity AIS. The TBI+ARDS group had significantly more patients with chest AIS> or =3 (57.1% versus 32.1%, p=0.03). There was no difference with respect to overall mortality between the TBI+ARDS group (50.0%) and the TBI group (51.8%) (OR 0.79: 95% CI 0.31-2.03, p=0.63). There was no significant difference with respect to discharge functional capacity between the two groups. There were significantly more overall complications in the TBI+ARDS group (42.9%) compared to the TBI group (16.1%) (OR 3.66: 95% CI 1.19-11.24, p=0.02). The TBI+ARDS group had an overall mean intensive care unit (ICU) length of stay of 15.6 days, versus 8.4 days in the TBI group (p<0.01). The TBI+ARDS group had significantly higher hospital charges than the TBI group ($210,097 versus $115,342, p<0.01). CONCLUSION: The presence of ARDS was not associated with higher mortality or worse discharge disability. It was, however, associated with higher hospital morbidity, longer ICU and hospital length of stay.     

Predictors of change in ‘discharge destination’ following treatment for fracture neck of femur

Objectives

The purpose of our study was to analyse the incidence and factors predicting the ‘change in discharge destination’ in patients with fractured neck of femur who were treated surgically.

Materials and methods

Fifteen hundred and seventy-three consecutive patients admitted with a fractured neck of femur, residing in their own home prior to admission were studied. Patients who did not have an operation (n = 70) for their hip fracture were excluded from the study.Residential location in the UK is broadly categorised as:

(1)

living in their own home;

(2)

residential home;

(3)

nursing home;

(4)

hospitalised.

Results

A downward drift in “discharge destination” of 20% was noted after analysis. Univariate analysis revealed that age, gender, AMT score, place of fall, type of fracture, walking ability outdoor and indoor, ASA grade, medical co-morbidity requiring physician review and delay beyond 36 h to surgery had a significant effect.Multiple logistic regression analysis revealed that increasing age, male gender (OR = 1.67), accompaniment for outdoor mobilisation (OR = 1.96), increasing ASA grade, AMT score <6 (OR = 4.86), pre-operative medical condition requiring physician review (OR = 2.27), delay greater than 36 h for medical reasons (OR = 4.38) were predictors of the change in discharge destination.

Conclusion

The most important predictors of the change in the discharge destination were the medical condition, cognitive and physical function of the patient at admission. Male gender and increasing age were contributory. The only clinician dependent factor that seemed to affect this change of residential status was delay to surgery secondary to medical problems. Awareness of key predictors that affect the “discharge destination” can be useful for the multidisciplinary team and patients’ families to evaluate and plan for an early, satisfactory and appropriate referral to either community services or institutional care, which in turn could have a significant socioeconomic impact.