• Factors Associated with Length of Stay and Discharge Disposition in Older Trauma Patients

      Brotemarkle, Rebecca Ann; Resnick, Barbara (2013)
      Factors Associated with Length of Stay and Discharge Disposition in Older Trauma Patients Abstract Background: Trauma patients over the age of 65 are living longer and staying active at older ages. Older trauma patients tend to have longer lengths of stay (LOS) and to be discharged more often to rehabilitation and skilled nursing facilities. Understanding the factors that influence LOS and discharge disposition is needed to guide interventions focused on decreasing LOS and assuring that patients are discharged to the least restrictive setting. Purpose: The purpose of this study was to explore the impact of patient and system related factors on LOS and discharge disposition for older adults hospitalized for traumatic injury. Methods: This was a secondary data analysis using descriptive data from rehabilitation notes during inpatient encounters. Data analysis was done using structural equation modeling and logistic regression. Results: 132 patients were randomly selected from 1387 patients admitted to a level 1 trauma center. The majority were Caucasian (83.9%, n = 111), 46.9% (n = 62) were males with an average age of 78.3 (S.D. = 9.7) years. On average participants had 2.29 (S.D. = 1.96) comorbidities and approximately two thirds (65.9%, n = 87) were rated as having severe injuries. The average length of stay was 4.3 (S.D. = 4.0) days with 57.6% (n = 76) of patients discharged to a facility. The model had a fair fit to the data and demonstrated that younger patients who had more comorbidities, were likely to have more pain. Older patients with more comorbidities, higher injury severity, more days from admission to evaluation, and lower pain were more likely to have a longer LOS which explained 37% of the variance in LOS. Based on logistic regression analysis, having longer LOS (O.R. = .049, 95% CI .008 - .301, p=.001) and more pain (O.R. = .531, 95% CI .310 - .908, p=.021) were associated with decreased likelihood of returning home versus being discharged to a facility. Conclusion: Increased focus on pain and pain management, consideration of comorbidities, and decreasing time from admission to initial evaluation by rehabilitation therapists among older trauma patients may help to decrease LOS and facilitate discharge to the least restrictive setting.
    • Post-operative epicardial pacing and hemodynamic support among Aortic Valve Patients

      Brady, Barbara Anne; Storr, Carla L. (2013)
      Background: Burdens of cardiac and extra-cardiac co-morbidity, coupled with complex surgical and anesthesia interventions, require intense intra- and post-operative monitoring and care to optimize outcomes. Despite a need for clinical guidance, a paucity of studies explores post-operative temporary epicardial pacing, vasopressor and inotropic medication use among aortic valve replacement (AVR) patients. Purpose: To better target post-operative interventions for AVR patients, associations between pre and intra-operative risk factors (e.g., chronic conditions, QRS duration and medication use), cardiovascular interventions (pacing and hemodynamic support), and post-operative outcomes (morbidity and resource utilization) were explored. Methods: Medical records of 195 patients having an AVR from 11/2007 to 10/2011 were reviewed from a single academic medical center. Cross-sectional analyses used multivariable analyses to identify factors associated with temporary epicardial pacing, acute kidney injury, and length of stay. Results: Patients were equally represented in gender, nearly all (88%) Caucasian, with a mean age of 67.7 years (SD=12.9). More than a third of patients (36%) were paced at time of bypass separation; 13% of the total continued to be paced after 7 a.m. of post-operative day-1. Females were more likely to be paced in the CSICU (OR = 3.08, 1.30-7.31), while pre-operative co-morbidities, ejection fraction, QRS duration, stain or ACE/ARB uses and CPB time did not have an independent effect. Post-operative pacing and level of hemodynamic support were not associated with day-2 renal function. Prolonged CSICU stays were associated with female gender, age>75 years, and if both epicardial and hemodynamic supports were used as compared to no cardiovascular support. Prolonged hospital stays were associated with prolonged CSICU stay > 4 days and age>75 years. Conclusions: Post-operative management of AVR patients has considerable variability. While it would be useful to pre-operatively identify patients requiring extended post-operative pacing and hemodynamic support, no co-morbidities were associated. Additional studies are needed to better risk stratify AVR patients so interventions can be targeted so the care team can better plan care and monitor progress.
    • Predictors of Length of Hospital Stay and Readmission in Hematologic Stem Cell Transplant Recipients

      SUNDARAMURTHI, THIRUPPAVAI; Friedmann, Erika; 0000-0001-9136-3840 (2015)
      Background: Hematopoietic stem cell transplantation (HSCT) is an established treatment for patients with various malignant and non-malignant diseases. The intense nature of the transplant experience mandates the presence of a consistent caregiver throughout the inpatient phase and after discharge. Increased length of hospital stay (LOS) and unplanned readmission increase health care costs. Identifying patients at risk for prolonged LOS and readmission and the caregiver factors that might contribute to these outcomes has the potential to reduce health care costs and patient's suffering. Caregiver characteristics are examined as predictors of these outcomes in cancer patients, but data are lacking on whether they predict LOS and readmission in HSCT recipients. Purpose: To examine caregiver characteristics as predictors of LOS and readmission risk for HSCT recipients. Methods: A secondary data analysis obtained in a study of the effectiveness of problem solving education in caregivers and patients during allogeneic HSCT at National Institutes of Health (Bevans et al., 2013) was conducted. Generalized linear mixed method models were used to examine predictors of LOS and generalized estimated equation models were used to examine predictors of 30-day readmission. Independent variables included: patient factors [age, disease condition, disease stage, comorbidity index, infection, psychological distress, and performance status] and caregiver factors [age, gender, relationship to patient, health problems, self-efficacy, burden and psychological distress]. Results: Reduced intensity conditioning allogeneic transplant recipients (N=60) and their caregivers (N=72) were included. Patients had a mean age of 46 years, were largely males (63%), and white (68%). Caregivers had a mean age of 52 years, were predominantly females (75%) and white (73.6%). Average LOS was 25 days and 35% of the patients were readmitted within thirty days after discharge. Patient factors that predicted LOS were disease stage (p=0.01), infection status (p=<.001) and comorbidity index (p=0.03). Infection status predicted readmission risk (p=<.001). Caregiver factors did not predict LOS or readmission. Caregiver psychological distress tended to predict LOS (p=0.09). Conclusions: Caregiver variables did not add meaningful information beyond traditional patient factors in predicting LOS and readmission in this population. More longitudinal, prospective studies are needed to understand the influence of caregiver factors on these outcomes.
    • Time to surgery and outcomes in patients with head injury

      Kim, Young-Ju; Johantgen, Mary E. (2006)
      Head injury is a time-sensitive trauma requiring rapid diagnosis, aggressive surgical evaluation, and prevention of secondary insults. However, studies examining the benefits of timely surgery in patients with head injury have yielded inconsistent conclusions. This study examined predictors of time to surgery and how time influenced three patient outcomes: hospital mortality, length of hospital stay (LOS), and discharge disposition to home rather than another facility. The Quality Health Outcomes Model was utilized as a conceptual framework for the study. Using a multivariate, cross-sectional design, the study took advantage of the National Trauma Data Bank (NTDB) version 4.0. This database was established by the American College of Surgeons Committee on Trauma (ACSCOT), and included data from more than 255 trauma centers throughout the U.S. that voluntarily submitted data. The final sample of head injured patients that met inclusion criteria was 493 patients from the 17 level I and II trauma centers. The factors influencing time to surgery included patient characteristics (e.g., age, Glasgow coma scale (GCS) score, injury severity score (ISS), emergency department (ED) arrival time), and trauma center characteristics (e.g., ownership, teaching status, designation type, center level). Two-level hierarchical models were used to analyze data at the patient level while incorporating a unique random effect for each trauma center. Patients with a GCS score of 3 to 8 in the first ED assessment had earlier time to surgery when compared to those with a GCS of 13 to 15 (Estimate = -.305, 95% CI = -.434 to -.177). Patients who arrived at the hospital during the daytime (8am-6pm) had a significantly quicker time to surgery than those who arrived during the nighttime (Estimate = -.147, 95% CI = -.258 to -.036). With regard to outcomes, patients who received surgery within 4 hours of arrival had half the likelihood of mortality when compared to those who received surgery greater than 4 hours after ED arrival (OR = .498, 95% CI = .246 to .999). When patients had a surgery within 4 hours of arrival, they had significantly shorter LOS than patients who had a surgery more than 4 hours (Estimate = -.103, 95% CI = -.194 to -.012). No significant relationship was found between time to surgery and discharge to home, a proxy for better functional status. Based upon the results of this study using a large sample from multiple centers, benefits of early clinical assessment and quick access to neurosurgical intervention are substantiated. However, more complete data representing pre-trauma center care (e.g., ambulance time and treatment) and discharge functional measure are desirable.