MONTREAL – A trauma checklist may help increase the proportion of trauma patients who are discharged home from an emergency department, according to a single-center study that tracked trauma admissions before and after institution of a trauma checklist.
Dr. Amani Jambhekar, a surgery resident at New York Methodist Hospital, Brooklyn, presented the study findings at the Central Surgical Association’s annual meeting. Discharges in July and August of 2015, after the checklist had been implemented, increased significantly, from a 6.5% rate in the first study month, before the checklist was implemented, to a 23.4% and 16.7% rate for the last two study months (P = .004).
However, the injury severity score decreased over the period of the study, from a mean of 7.27 in the first month of the study to 4.60 in the last month of the study (P = .019), and the injury severity level was generally low.
When a trauma patient is admitted who might fare well at home, not only does the admission represent a potentially avoidable cost, it also exposes patients, particularly elderly patients, to infection risk, increased immobility, and other negative effects of hospitalization.
“Why don’t we discharge patients from the emergency department more? Well, there’s a significant fear of ‘bounce-backs,’ ” Dr. Jambhekar said. The bounce-back phenomenon, where patients who are discharged and then present again and are admitted, had not been well studied among trauma patients discharged from the emergency department, he added.
Risk factors for readmission after a hospital discharge had been studied, and may include low socioeconomic status, no insurance or publicly provided insurance, long initial inpatient stay, and higher Injury Severity Score (ISS). “But none of this had been evaluated in patients who were initially discharged from the emergency department,” said Dr. Jambhekar.
New York Methodist, the study site, is a 651-bed urban community hospital. It sees approximately 100,000 emergency department (ED) visits per year, with 8,000 trauma patients coming through the door of the ED in the first 11 months of the hospital’s designation as a level II trauma center.
Dr. Jambhekar and her colleagues evaluated 376 trauma patients, divided into two groups. The first group of 198 patients was seen in the 3 months before the checklist was put in place. The second group of 178 patients was seen in the 60 days after the trauma checklist was mandated. Patients were included in the study if they had been evaluated by the trauma surgery service.
The trauma checklist contained basic demographic and history information, as well as information about the patients’ ED course – for example, what imaging studied were obtained, lab values, what consults they received. The ISS was calculated prior to patient disposition.
“We wanted to present a template to all of our providers to use, in order to correctly document patients’ injuries. If they knew the extent of every patient’s injuries, they could correctly identify patients who were safe to discharge from the emergency department.” One limitation of the study, said Dr. Jambhekar, is overtriage of patients to the trauma center. This is evidenced by the relatively low ISS scores. “As our trauma center became more popular in Brooklyn and in New York City, more patients were brought to our trauma center, even when they could have adequately been treated elsewhere.”
The study didn’t have long-term follow-up of patients to see if they were satisfied with their care, and if they had recovered from their injuries. The exact cost of outpatient follow-up is also uncertain, said Dr. Jambhekar.
Dr. Jambhekar and her colleagues plan to investigate safety and cost outcomes for discharge of trauma patients from the ED; they also will look at the bounce-back phenomenon, and long-term outcomes for outpatient care of trauma patients.
They reported no relevant financial disclosures.
On Twitter @karioakes