ABSTRACT
BACKGROUND: Patients with unplanned readmissions to the intensive care unit (ICU) are at high risk of preventable adverse events. The Rothman Index represents an objective real-time grading system of a patient's clinical condition and a predictive tool of clinical deterioration over time. This study was designed to test the hypothesis that the Rothman Index represents a sensitive predictor of unanticipated ICU readmissions. METHODS: A retrospective propensity-matched cohort study was performed at a tertiary referral academic medical center in the United States from January 1, 2022, to December 31, 2022. Inclusion criteria were adult patients admitted to an ICU and readmitted within seven days of transfer to a lower level of care. The control group consisted of patients who were downgraded from ICU without a subsequent readmission. The primary outcome measure was in-hospital mortality or discharge to hospice for end-of-life care. Secondary outcome measures were overall hospital length of stay, ICU length of stay, and 30-day readmission rates. Propensity matching was used to control for differences between the study cohorts. Regression analyses were performed to determine independent risk factors of an unplanned readmission to ICU. RESULTS: A total of 5,261 ICU patients met the inclusion criteria, of which 212 patients (4%) had an unanticipated readmission to the ICU within 7 days. The study cohort and control group were stratified by propensity matching into equal group sizes of n = 181. Lower Rothman Index scores (reflecting higher physiologic acuity) at the time of downgrade from the ICU were significantly associated with an unplanned readmission to the ICU (p < 0.0001). Patients readmitted to ICU had a lower mean Rothman Index score (p < 0.0001) and significantly increased rates of mortality (19.3% vs. 2.2%, p < 0.0001) and discharge to hospice (14.4% vs. 6.1%, p = 0.0073) compared to the control group of patients without ICU readmission. The overall length of ICU stay (mean 8.0 vs. 2.2 days, p < 0.0001) and total length of hospital stay (mean 15.8 vs. 7.3 days, p < 0.0001) were significantly increased in patients readmitted to ICU, compared to the control group. CONCLUSION: The Rothman Index represents a sensitive predictor of unanticipated readmissions to ICU, associated with a significantly increased mortality and overall ICU and hospital length of stay. The Rothman Index should be considered as a real-time objective measure for prediction of a safe downgrade from ICU to a lower level of care.
ABSTRACT
BACKGROUND: Well-developed trauma programs take years of planning, dedication, and commitment to the trauma population to achieve the desired outcomes and, even more, resilience and persistence to maintain a high-quality standard of care. Despite widespread trauma care systems across the nation and their link to improved outcomes for the trauma patient, there is a paucity of literature outlining the foundational elements required to evolve and grow a successful trauma program. OBJECTIVE: The purpose of this article is to outline the key elements for developing and maintaining a successful trauma program that yields high-quality patient outcomes. METHODS: Developing a program requires intense focus and continued efforts. Multiple foundational building blocks can facilitate program success and foster program growth. RESULTS: Foundational elements include leadership structure and support, building the right team, clinical expertise, trauma registry, program data, research, outreach and education, injury prevention, and ensuring adequate survey readiness. Building on these foundational elements, engagement of stakeholders at all levels throughout the program and organization can help drive program growth. Using these strategies, a program has been able to grow from 7.6 full-time equivalents to 24.4 in just a few short years while achieving, exceeding, and sustaining top metrics across state and national benchmarks. CONCLUSION: A program can achieve sustainable, high-quality outcomes for the trauma patient by following a structured team approach to program development. Using the outlined building blocks for program development and sustainability, a successful trauma program can lead to improved patient and program outcomes.
