Facility-Level Factors and Outcomes After Skilled Nursing Facility Admission for Trauma and Surgical Patients.

OBJECTIVE: Patients discharged to skilled nursing facilities (SNFs) have worse outcomes than those discharged to home, but whether this is due to differences in facility-level factors in addition to patient characteristics is not known. We aimed to determine whether SNF-level factors including nurse staffing and patient density are associated with outcomes after acute hospitalization for trauma or surgery. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Retrospective study of patients discharged to Medicare-certified SNFs after trauma or major surgery from 2007 to 2009. We measured the ratio of beds per nurse and the proportion of trauma and surgery patients at each facility (density). Outcomes were 1-year mortality, hospital readmission, and failure to discharge home at first discharge disposition. RESULTS: For 389,133 patients (mean age 78 years, 63% female) admitted to 3707 SNFs, mortality was 26%, hospital readmission 26%, and failure to discharge home 44%. After adjusting for patient-level factors, SNFs with fewer beds per nurse had lower odds of mortality [odds ratio (OR): trauma 0.84; (95% confidence interval: 0.77-0.91), surgery 0.80 (0.75-0.86)], readmission [OR: trauma 0.81 (0.74-0.88), surgery 0.71 (0.65-0.76)], and failure to discharge home [OR: trauma 0.82 [0.74-0.91], surgery 0.66 [0.60-0.72]). SNFs with greater density of specialty patients (>4.3% surgery, >14.1% trauma) had lower odds of readmission [OR: trauma 0.59 (0.53-0.66), surgery 0.62 (0.58-0.67)] and failure to discharge home [OR: trauma 0.48 (0.43-0.55), surgery 0.45 (0.42-0.49)]. CONCLUSIONS: There are modifiable SNF-level factors that influence long-term outcomes and may be targets for intervention. Staffing standardization and SNF specialization may reduce variation of quality in post-acute care.

Temporal trends in surgical intervention for severe traumatic brain injury caused by extra-axial hemorrhage, 1995 to 2012.

BACKGROUND: Surgical intervention for severe traumatic brain injury (TBI) caused by extra-axial hemorrhage has declined in recent decades. The effect of this change on patient outcomes is unknown. OBJECTIVE: To determine the change over time in surgical intervention in this population and to assess changes in patient outcomes. METHODS: In this retrospective cohort study, the Washington State Trauma Registry was queried from 1995 to 2012 for patients with extra-axial hemorrhage and head Abbreviated Injury Scale score of 3 to 5. Data were linked to the state-wide death registry to analyze long-term mortality. The primary outcome was inpatient mortality. Secondary outcomes included 6- and 12-month mortality and modified Functional Independence Measure at discharge. Multivariable analyses were completed for all outcomes. RESULTS: A total of 22974 patients met inclusion criteria. Over the study period, surgical intervention for severe TBI declined from 36% to 7%. There was a decline in case fatality from 22% to 12%. In 2012, the relative risk of inpatient mortality was 23% lower compared with 1995 (adjusted mortality risk ratio, 0.77; 95% confidence interval, 0.63-0.94). Changes in 6- and 12-month adjusted mortality and modified Functional Independence Measure were not statistically significant. CONCLUSION: The decline in surgical intervention for severe TBI caused by extra-axial hemorrhage in Washington State was ubiquitous across regional, demographic, and injury characteristic strata. There was concurrently a reduction in inpatient mortality in this population. Functional status and long-term mortality, however, have remained the same. Future studies are needed to better identify modifiable risk factors for improvement in functional status and long-term mortality in this population.

Risk factors for unplanned readmissions in older adult trauma patients in Washington State: a competing risk analysis.

BACKGROUND: Hospital readmission is a significant contributor to increasing health care use related to caring for older trauma patients. This study was undertaken with the following aims: determine the proportion of older adult trauma patients who experience unplanned readmission, as well as risk factors for these readmissions and identify the most common readmission diagnoses among these patients. STUDY DESIGN: We conducted a retrospective cohort study of trauma patients age 55 years and older who survived their hospitalization at a statewide trauma center between 2009 and 2010. Linking 3 statewide databases, nonelective readmission rates were calculated for 30 days, 6 months, and 1 year after index discharge. Competing risk regression was used to determine risk factors for readmission and account for the competing risk of dying without first being readmitted. Subhazard ratios (SHR) are reported, indicating the relative risk of readmission by 30 days, 6 months, and 1 year. RESULTS: The cumulative readmission rates for the 14,536 participants were 7.9%, 18.9%, and 25.2% at 30 days, 6 months, and 1 year, respectively. In multivariable models, the strongest risk factors for readmission at 1 year (based on magnitude of SHR) were severe head injury (adjusted SHR = 1.47; 95% CI, 1.24-1.73) and disposition to a skilled nursing facility (SHR = 1.54; 95% CI, 1.39-1.71). The diagnoses most commonly associated with readmission were atrial fibrillation, anemia, and congestive heart failure. CONCLUSIONS: In this statewide study, unplanned readmissions after older adult trauma occurred frequently up to 1 year after discharge, particularly for patients who sustained severe head trauma and who could not be discharged home independently. Examining common readmission diagnoses might inform the development of interventions to prevent unplanned readmissions.

Pre-hospital aspiration is associated with increased pulmonary complications.

BACKGROUND: Rates of ventilator-associated pneumonia (VAP) are highest among patients intubated on an emergency basis following trauma. We reported previously a retrospective analysis demonstrating an association between subjective aspiration and VAP after pre-hospital intubation. We hypothesize that by directing paramedics to note features of aspiration at intubation, we will confirm prospectively the association between pre-hospital aspiration and subsequent pneumonia in trauma patients. METHODS: Paramedics collected data regarding aspiration at the time of intubation. All intubated patients admitted to a level 1 trauma center intensive care unit (ICU) were included. Data comprised a clinical impression of pre-hospital aspiration, as well as the presence and timing of blood and emesis in the airway. Injury severity, co-morbidities, and outcomes were collected from the trauma registry. Healthcare-associated pneumonia (HAP) was identified by medical record review of both bronchoalveolar lavage culture results and discharge diagnosis. Descriptive statistics and univariate analysis of outcomes by aspiration status, as well as covariable adjustment using propensity scores, were performed. RESULTS: Of the 228 patients, 89 (39%) were determined by paramedics to have aspirated. The majority of those who aspirated (84 [94%]) did so prior to intubation. Patients who aspirated had higher Injury Severity Scores than those who did not aspirate (25.0 ± 1.7 vs. 21.9 ± 1.5 points; p=0.04) and lower preintubation Glasgow Coma Scale scores (8.2 ± 0.50 vs. 9.6 ± 0.40; p=0.02). Of the 89 patients who aspirated around the time of intubation, 14 (16%) developed HAP vs. five (3.6%) of those who did not aspirate (p<0.01). We observed non-significant increases in mortality rate, ICU length of stay (LOS) and duration of mechanical ventilation after aspiration (deaths: 21 [23.6%] vs. 23 [16.6%]; p=0.19; ICU LOS: 5.3 ± 0.9 vs. 4.1 ± 0.5 days; p=0.13; duration of mechanical ventilation: 5.3 ± 1.2 vs. 3.2 ± 0.5 days; p=0.10). CONCLUSIONS: Aspiration prior to intubation was reported commonly by paramedics and was associated with a higher risk of HAP.