Alexandra Wilson Pecci
Hospitals have a broader responsibility to elderly trauma patients than just the time spent within their walls, and should consider updating their strategies to ensure the best outcomes for these patients, research suggests.
Elderly trauma patients are increasingly likely to be discharged to skilled nursing facilities, rather than inpatient rehabilitation facilities (IRF), finds a study in The Journal of Trauma and Acute Care Surgery published in the April issue.
Discharge to skilled nursing facilities for trauma patients has, however, been associated with higher mortality compared with discharge to inpatient rehabilitation facilities or home.
Researchers wanted to "better characterize trends in trauma discharges and compare them with a population that is equally dependent on post-discharge rehabilitation." They not only examined trauma discharges, but also discharges of stroke patients, who have been taking up more inpatient rehabilitation facility beds.
Using data from 2003–2009 data from the National Trauma Data Bank and National Inpatient Sample, the retrospective cohort study found that elderly trauma patients were 34% more likely to be discharged to a skilled nursing facility and 36% less likely to be discharged to an inpatient rehabilitation facility. By comparison, stroke patients were 78% more likely to be discharged to an inpatient rehabilitation facility.
This is despite the findings of a 2011 JAMA study of patients in Washington State showing that "Discharge to a skilled nursing facility at any age following trauma admission was associated with a higher risk of subsequent mortality."
The Journal of Trauma and Acute Care Surgery study notes that "elderly trauma patients are the fastest-growing trauma population," which leads to the question: Where should hospitals be investing their money and time to ensure the best outcomes for these patients?
"I think hospitals should be investing in post-acute care discharge planning," says Patricia Ayoung-Chee, MD, MPH, Assistant Professor, Surgery, NYU School of Medicine, and lead author of the study. "What's the best post-acute care facility for patients? And it may end up needing to be individualized."
She says reimbursement and insurance factors have "played more of a role than anybody sort of thought about" in discharges, rather than what is always necessarily best for patients.
For example, to be classified for payment under Medicare's IRF prospective payment system, at least 60% of all cases at inpatient rehab facilities must have at least one of 13 conditions that CMS has determined typically require intensive rehabilitation therapy, such as stroke and hip fracture.
"I think the unintended consequence is that we may be discharging patients to the best post-acute care setting, but we also may not be," Ayoung-Chee said by email, and that question "is only now being looked at in-depth."
She says hospitals should think about truly appropriate discharge planning upfront.
For instance, at admission, hospitals can find out who the patient lives with, or what their social support system is like. If they have a broken dominant hand after a fall, will they be able to get help with their groceries? Do they live alone? Will they be able to use the bathroom?
Caring for patients also doesn't end when patients leave the hospital, she adds. Hence the study's title: "Beyond the Hospital Doors: Improving Long-term Outcomes for Elderly Trauma Patients."
Ayoung-Chee says the next step in her research is to look at a more longitudinal picture, following individual patients to see what factors play into their function or lack of function.
But hospitals can do some of that work on a smaller scale, with internal audits to determine which facilities have the best post-acute care outcomes. For instance, they could spend time examining which facilities had fewer readmissions compared to others, as well as how long it took patients to get home and their how satisfied they were with their care.
Other research is also trying to determine which facilities are best for elderly trauma patients. For instance, a second study, also published in The Journal of Trauma and Acute Care Surgery, shows that geriatric trauma patients have improved outcomes when they are treated at centers that manage a higher proportion of older patients.
One of the overarching takeaways from Ayoung-Chee's research is the idea that hospitals have a broader responsibility to patients than just the time spent within their walls.
"What we do doesn't just end upon patient discharge. If we truly want to get the biggest bang from our buck, we're going to have to think about the entire continuum," she says.
That could range from working to prevent falls that can cause elderly trauma, to seeing patients through all of the appropriate care needed to expect a good functional outcome. Good healthcare for elderly trauma patients should extend beyond the parameters of morbidity and mortality, and toward returning patients to their original functional status and, ultimately, independence, says Ayoung-Chee.
"Our long-lasting effect as healthcare providers isn't just what we do in the hospital," she says. "And we have to start thinking outside."