Stone ME Jr, Marsh J, Cucuzzo J, et al.. Factors associated with trauma clinic follow-up compliance after discharge: experience at an urban Level I trauma center
The journal of trauma and acute care surgery
01/2014; 76(1):185-90. DOI: 10.1097/TA.0b013e3182aafcd5
Disparities in access to postdischarge services for trauma patients exist, and clinic follow-up remains an important avenue to ensure initial and continued access to postdischarge services. In addition, follow-up is vital to rigorous long-term trauma outcomes research. However, there is a relative paucity of literature specifically addressing clinic follow-up. The purposes of this study were to elucidate factors associated with clinic follow-up compliance and noncompliance after discharge from an urban Level I trauma center and to confirm the prevailing notion that follow-up in trauma clinic is poor.
Our trauma registry was queried for all trauma service discharges of patients 18 years and older for a 2-year period. Patients with incomplete information were excluded. Demographic data such as race/ethnicity and insurance status were collected on all patients. Primary outcome was defined as trauma clinic follow-up within 4 weeks after discharge. Patients compliant with follow-up were compared with noncompliant patients.
After exclusion criteria were applied, there were 1,818 discharges included in the analysis, with 564 (31%) complying with follow-up (p < 0.001). Factors significantly associated with follow-up noncompliance included patients older than 35 years, white race, Medicaid/Medicare payers, blunt mechanism, extended hospital length of stay, and discharge to rehabilitation facilities. No insurance, penetrating mechanism, short hospital stay, discharge to home, and weekend discharge were all significantly associated with follow-up compliance. Discharge on weekends and to home were independent predictors of compliance, whereas, Medicaid/Medicare insurance status and operative intervention were independent predictors of noncompliance.
This study indentifies factors associated with trauma clinic follow-up compliance and confirms the notion that trauma clinic follow-up compliance at an urban Level I trauma center is alarmingly low. These findings may serve as targets to improve follow-up, thereby improving trauma outcomes research and long-term outcomes. Consequently, clinic follow-up compliance warrants further study and consideration as an essential trauma registry datum.
Prognostic study, level III.
Available from: Luke P H Leenen
- "Prospective data collection might even have increased the percentage of delayed diagnosed injuries and therefore our data are most likely an underestimation.Enderson et al.previously described this phenomenon. The outpatient department follow-up rate in this study was 78%, which is considered fairly high in a trauma population232425. We believe this follow-up rate adds to the validity and improves the accuracy of type 3 delayed diagnosed injuries.In polytrauma patients most delayed diagnosed injuries were found after formal tertiary survey but during hospital admission. "
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Due to prioritisation in the initial trauma care, non-life threatening injuries can be overlooked or temporally neglected. Polytrauma patients in particular might be at risk for delayed diagnosed injuries (DDI). Studies that solely focus on DDI in polytrauma patients are not available. Therefore the aim of this study was to analyze DDI and determine risk factors associated with DDI in polytrauma patients.
In this single centre retrospective cohort study, patients were considered polytrauma when the Injury Severity Score was ≥16 as a result of injury in at least 2 body regions. Adult polytrauma patients admitted from 2007 until 2012 were identified. Hospital charts were reviewed to identify DDI.
1416 polytrauma patients were analyzed of which 12% had DDI. Most DDI were found during initial hospital admission after tertiary survey (63%). Extremities were the most affected regions for all types of DDI (78%) with the highest intervention rate (35%). Most prevalent DDI were fractures of the hand (54%) and foot (38%). In 2% of all patients a DDI was found after discharge, consisting mainly of injuries other than a fracture. High energy trauma mechanism (OR 1.8, 95% CI 1.2-2.7), abdominal injury (OR 1.5, 95% CI 1.1-2.1) and extremity injuries found during initial assessment (OR 2.3, 95% CI 1.6-3.3) were independent risk factors for DDI.
In polytrauma patients, most DDI were found during hospital admission but after tertiary survey. This demonstrates that the tertiary survey should be an ongoing process and thus repeated daily in polytrauma patients. Most frequent DDI were extremity injuries, especially injuries of the hand and foot.
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ABSTRACT: 1. To determine whether negative pressure dressings (NPD) are superior to conventional compressive dressings (CD) for split-thickness skin grafts (STSG) placed on healthy, low-risk wounds. 2. To determine cost difference of NPD versus CD.
Retrospective SETTING:: Level I Trauma Center PATIENTS/PARTICIPANTS:: 195 traumatic wounds treated with STSG.
Patients were assigned outcomes based on postoperative documentation: completely healed, incompletely healed (small areas of graft necrosis), failed, or lost to follow-up. The costs associated with the each dressing type were documented.
35 of 195 STSG were lost to follow-up, leaving N=120 STSG-NPD, N=40 STSG-CD. Of the remaining 120 STSG treated with NPD, 91 completely healed, 23 incompletely healed, and 6 failed. Of the 40 STSG treated with a compressive dressing, 37 completely healed, 1 incompletely healed, and 2 failed. Patients treated with compressive dressings had higher likelihood of healing relative to the NPD (p = 0.018). Analyzing the outcomes as failed versus "not failed" revealed no significant difference between the groups (p = 1.00). There were more smokers in the compression dressing group (p=0.022). In this series, the mean cost associated with NPD compared to compressive dressing was $2,370 more per patient.
There is a high rate of successful healing of split-thickness skin grafts for traumatic extremity wounds regardless of dressing used. The increased cost of NPD is not justified in wounds that are at low risk for STSG failure.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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