Trauma Care Beyond the Hospital Doors: Lessons from Stroke Center Certification

Abstract

CONTEXT: Discharge to skilled nursing facilities (SNF) has been associated with increased long-term mortality. Currently, discharge disposition is not evaluated in trauma center verification but is a performance measure in primary stroke center (PSC) certification. OBJECTIVES: To determine trends in trauma and stroke patient discharges and examine the effect of PSC certification requirements on discharge disposition. Design, Setting, and Patients: Retrospective cohort study of adult trauma and stroke patients discharged from January 2003 to December 2009. The National Trauma Data Bank and Healthcare Cost and Utilization Project Nationwide Inpatient Sample were used to study trauma and stroke patients respectively. The Joint Commission PSC program was implemented December 2003. MAIN OUTCOME MEASURE: Relative risk of discharge to SNFs and inpatient rehabilitation facilities (IRF), over time. RESULTS: Over the period of the study, the proportion of trauma patients age ≥65 years increased from 23% (95% confidence interval [CI], 20.2%-25.8%) to 30% (CI, 25.6%-34.6%). In-hospital mortality decreased from 4.5% [CI, 2.0%-6.9%] in 2003, to 3.2% [CI, 2.8%-3.5%] in 2009. The majority of patients who survived hospitalization were discharged home (64.6% [CI, 61.3%-67.9%]). On average, stroke patients were 71.9 (SD, 0.01) years old and 72.6% (CI, 72.5%-72.6%) were age ≥65 years. In-hospital mortality was 6.1% (CI, 6.0%-6.1%). Less than half (45.7% [CI, 45.7%-45.8%]) of patients who survived hospitalization were discharged home. In 2009, trauma patients were 34% (adjusted RR 1.34 [CI, 1.15-1.57]) more likely to be discharged to SNF, compared to 2003, but 36% (adjusted RR 0.64 [CI, 0.48-0.85]) less likely to be discharged to IRF. However, stroke patients were 78% (adjusted RR 1.78 [CI, 1.74-1.82]) more likely to be discharged to IRF. The largest absolute increase (2.1% [CI, 2.1%-2.1%]) in stroke patient discharges to IRF occurred in the year following PSC implementation. CONCLUSIONS: After adjusting for confounding factors, there was a significant increase in trauma center discharges to SNF and a decrease in discharges to IRF. However, during the same period and especially after implementation of the PSC program, stroke patients were more likely to be discharged to IRF. Trauma centers should evaluate discharge disposition as a part of the verification process.