Trauma Intensive Care Unit ‘Bouncebacks': Identifying Risk Factors for Unexpected Return Admission to the Intensive Care Unit

Abstract

Return transfer (RT) to the intensive care unit (ICU) negatively impacts patient outcomes, length of stay (LOS), and hospital costs. This study assesses the most common events necessitating RT in trauma patients. We performed a retrospective chart review of ICU RT from 2004 to 2008. Patient demographics, injuries and injury severity, reason for transfer, LOS, interventions, and outcomes data were collected. Overall, 158 patients required readmission to the ICU. Respiratory insufficiency/ failure (48%) was the most common reason for RT followed by cardiac (16%) and neurological (13%) events. The most commonly associated injuries were traumatic brain injuries (TBIs) (32%), rib fractures (30%), and pulmonary contusions (20%). Initial ICU LOS was 6.6 ± 8 days (range, 1 to 44 days) with 4.4 ± 7.8 ventilator days. Mean floor time before ICU RT was 5.7 ± 6.3 days (range, 0 to 33 days). Forty-nine patients (31%) required intubation and mechanical ventilation on RT. ICU RT incurred an additional ICU LOS of 8 ± 8.5 days (range, 1 to 40 days) and 5.2 ± 7.5 ventilator days. Mortality after a single RT was 10 per cent (n = 16). RT to the ICU most often occurs as a result of respiratory compromise, and patients with TBI are particularly vulnerable. Trauma pulmonary hygiene practices should be evaluated to determine strategies that could decrease RT.

Older Adults With Isolated Rib Fractures Do Not Require Routine Intensive Care Unit Admission

“…Respiratory failure is the leading cause of bouncebacks among trauma patients, and rib fractures are one of the most commonly associated injuries. 20 This finding suggests that, while clinicians at our center were conservative in their initial decision of where to admit patients, they may have transferred some patients out of the ICU before they were truly ready. Optimal criteria for transfer from an ICU are another important topic in understanding how best to treat these patients.…”

A Comprehensive Review of the Outcome for Patients Readmitted to the ICU Following Trauma and Strategies to Decrease Readmission Rates

“…Intensive care unit readmissions, regardless of the underlying causes, have historically been associated with increased mortality, length of stay, and hospital costs. [4][5][6][7][8] A systematic review conducted by Rosenberg and Watts spanning 8 primary studies of ICU readmission and 8 multi-institutional ICU outcome studies determined the average ICU readmission rate to be 7% with a range of 4% to 10%. 10 Reported mortality rates can vary from 20% to 40% compared to 4% to 8% for nonreadmitted ICU patients.…”

“…29 Decline in respiratory functioning has been singled out in multiple studies as a predictor of ICU readmission. 5,6,[8][9][10][11][12][13]17,18,[21][22][23][24]41,42 Implementation of appropriate respiratory care orders upon transfer to floor along with prompt respiratory therapy has been postulated to decrease ICU readmission secondary to pulmonary complications. 43 Along with respiratory illness, readmission to the ICU most commonly occurs as a result of cardiac, 24,43 neurological issues, 4 and sepsis.…”

“…21,25 Other factors commonly associated include hemorrhage, traumatic brain injury, rib fractures, and pulmonary contusions. [4][5][6]43 In addition, Jo et al discovered that history of diabetes mellitus, application of continuous renal replacement therapy during ICU stay, white blood cell count the day of extubation, and heart rate just before first ICU discharge were specific risk factors that can lead to ICU readmission. An ICU readmission study done in Taiwan 24 found that factors of readmission were ischemic heart disease, lung disorders, pneumonia, cardiovascular disease, diabetes mellitus, and chronic obstructive pulmonary disease.…”

Is fever control or improved survival the ‘risk factor’ for ventilator-associated pneumonia?

“…Firstly, independent risk factors for VAP, namely disease severity and lung contusion [ 2 , 3 ], are unevenly distributed between groups. In addition, other risk factors, such as chronic obstructive pulmonary disease (COPD) and ICU readmission [ 2 , 4 ], were not taken into account, suggesting any effect of fever control is likely subject to confounding.…”