RESUMO
BACKGROUND: Most patients who sustain a traumatic injury require outpatient follow-up. A common barrier to outpatient postadmission care is patient failure to follow-up. One of the most significant factors resulting in failure to follow-up is age more than 35 years. Recent work has shown that follow-up telephone calls reduce readmission rates. Our aim was to decrease no-show appointments by 10% in 12 months. STUDY DESIGN: The electronic medical records at our level I and II trauma centers were queried for all outpatient appointments for trauma between July 1, 2020, and June 9, 2021, and whether the patient attended their follow-up appointment. Patients with visits scheduled after August 1, 2021, received 24- and 48-hour previsit reminder calls. Patients with visits scheduled between July 1, 2020, and August 1, 2021, did not receive previsit calls. Both groups were compared using multivariable direct logistic regression models. RESULTS: A total of 1,822 follow-up opportunities were included in the study. During the pre-implementation phase, there was a no-show rate of 30.9% (329 of 1,064 visits). Postintervention, a 12.2% reduction in overall no-show rate occurred. A statistically significant 11.2% decrease (p < 0.001) was seen in elderly patients. Multivariate analysis showed standardized calls resulted in significantly decreased odds of failing to keep an appointment (adjusted odds ratio = 0.610, p < 0.001). CONCLUSIONS: Reminder calls led to a 12.2% reduction in no-show rate and were an independent predictor of a patient's likelihood of attending their appointment. Other predictors of attendance included insurance status and abdominal injury.
Assuntos
Traumatismos Abdominais , Pacientes não Comparecentes , Humanos , Idoso , Adulto , Cooperação do Paciente , Pacientes Ambulatoriais , Agendamento de ConsultasRESUMO
BACKGROUND: Nationally, the volume of geriatric falls with intracranial hemorrhage is increasing. Our institution began observing patients with intracranial hemorrhage, Glasgow Coma Scale of 14 or greater, and no midline shift or intraventricular hemorrhage with hourly neurologic examinations outside of the ICU in a high observation trauma (HOT) protocol. We first excluded patients on anticoagulants or antiplatelets (HOT I), then included antiplatelets and warfarin (HOT II), and finally, included direct oral anticoagulants (HOT III). Our hypothesis is that HOT protocol safely reduces ICU use and creates cost savings in this patient population. STUDY DESIGN: Our institutional trauma registry was retrospectively queried for all patients on HOT protocol. Patients were stratified based on date of admission (HOT I [2008-2014], HOT II [2015-2018], and HOT III [2019-2021]), and were compared for demographics, anticoagulant use, injury characteristics, lengths of stay, incidence of neurointervention, and mortality. RESULTS: During the study period, 2,343 patients were admitted: 939 stratified to HOT I, 794 to HOT II, and 610 to HOT III. Of these patients, 331 (35%), 554 (70%), and 495 (81%) were admitted to the floor under HOT protocol, respectively. HOT protocol patients required neurointervention in 3.0%, 0.5%, and 0.4% of cases in HOT I, II, and III, respectively. Mortality among HOT protocol patients was found to be 0.6% in HOT I, 0.9% in HOT II, and 0.2% in the HOT III cohort (p = 0.33). CONCLUSIONS: Throughout the study period ICU use decreased without an increase in neurosurgical intervention or mortality, indicating the efficacy of the HOT selection criteria in identifying appropriate candidates for stepdown admission and HOT protocol.
Assuntos
Anticoagulantes , Lesões Encefálicas Traumáticas , Humanos , Idoso , Estudos Retrospectivos , Anticoagulantes/uso terapêutico , Varfarina , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/terapia , Hemorragias Intracranianas , Escala de Coma de GlasgowRESUMO
BACKGROUND: Decreases in the rates of traditional autopsy (TA) negatively impact traumatology, especially in the areas of quality improvement and medical education. To help enhance the understanding of trauma-related mortality, a number of initiatives in imaging autopsy (IA) were conceived, including the postmortem computed tomography ("CATopsy") project at our institution. Though IA is a promising concept, few studies directly correlate TA and IA findings quantitatively. Here, we set out to increase our understanding of the similarities and differences between key findings on TA and IA in a prospective fashion with blinding of pathologist and radiologist evaluations. METHODS: A prospective study of TA versus IA was conducted at an Academic Level I Trauma Center (June 2001-May 2010). All decedents underwent a postmortem, whole-body, noncontrast computed tomography that was interpreted by an independent, blinded, board-certified radiologist. A blinded, board-certified pathologist then performed a TA. Autopsy results were grouped into predefined categories of pathologic findings. Categorized findings from TA and IA were compared by determining the degree of agreement (kappa). The χ(2) test was used to detect quantitative differences in "potentially fatal" findings (eg, aortic trauma, splenic injury, intracranial bleeding, etc) between TA and IA. RESULTS: Twenty-five trauma victims (19 blunt; 9 female; median age 33 years) had a total of 435 unique findings on either IA or TA grouped into 34 categories. The agreement between IA and TA was worse than what chance would predict (kappa = -0.58). The greatest agreement was seen in injuries involving axial skeleton and intracranial/cranio-facial trauma. Most discrepancies were seen in soft tissue, ectopic air, and "incidental" categories. Findings determined to be "potentially fatal" were seen on both TA/IA in 48/435 (11%) instances with 79 (18%) on TA only and 53 (12%) on IA only. TA identified more "potentially fatal" solid organ and heart/great vessel injuries, while IA revealed more spine injuries, "potentially fatal" procedure-related findings, and the presence of ectopic air/fluid. CONCLUSION: This limited study does not support substitution of noncontrast, computed tomography-based IA for TA. Our quantitative analyses suggest that TA and IA evaluations may be complementary and synergistic when performed concurrently. There are potential benefits to using IA in trauma process/quality improvement and in educational settings. Further research should focus on the value (and limitations) of the information provided by IA in the absence of TA.