Appropriateness Of Nonsurgical Admissions

U.S. Trauma Centers that are verified by the American College of Surgeons must track the rate of trauma admissions to nonsurgical services. This is particularly important if the percentage of nonsurgical admissions exceeds 10% of their total admissions. The center’s performance improvement processes can then determine if the admission was appropriate and whether or not the trauma service should request a consult or transfer.

But how should we judge the appropriateness of nonsurgical admissions? There is tremendous variability in presenting mechanism and patient comorbidities. And the number of patients with some need for nonsurgical attention continues to grow with the rapidly increasing number of elderly falls.

The group at Southside Hospital in Bay Shore NY initially tracked all nonsurgical admissions and evaluated each individually at their community Level II trauma center. They then created and implemented a scoring system in order to develop a set of objective criteria that would predict patients better served with trauma consultation or admission.

The scoring tool was based on some of the information in the Optimal Resource Document, but was still somewhat arbitrary. The authors added criteria that reflected their own institutional philosophy of care. They explain their rationale clearly in the manuscript. Here is the final tool:

Criteria Points
Age > 65 years 1
3 or more comorbidities 1
ISS < 10 1
Ground level fall 1
No ICU admission 1
No need for surgical intervention 1
No blood products given 1

The maximum number of points possible is 7, with higher scores suggesting appropriateness for nonsurgical admission. The authors chose scores of 3 and 4 as the “grey zone” where further investigation was necessary to determine if a medical admission was proper. Lower numbers required trauma service admission, and higher ones did not.

The authors then examined changes in the percent of nonsurgical admissions after implementation, as well as mortality, morbidity, and hospital length of stay.

Here are the factoids:

  • Nonsurgical admission rates had historically been greater than 10% and had peaked at 28% at the time of scoring system implementation
  • After implementation, the nonsurgical admission rate dropped to under 10 %, where it remained for most of the time. There were a few spikes into the 14-17% range.
  • Mortality was insignificantly higher on the trauma service (2.1% vs 1.2%) as were complications (6.1% vs 5.5%)
  • Length of stay was statistically significantly longer on nonsurgical services (6.2 VS 5.1 days)

Bottom line: Centers that admit a large number of elderly falls patients may benefit from adopting this quick screening tool to determine the appropriate service. Ideally, all trauma patients would be admitted to the trauma service, but this is not feasible from a personnel and resource standpoint. If the number of potential nonsurgical admissions is high, applying a scoring system like this can help streamline the decision regarding admitting service.

Patients with very low scores (1-2) are obviously only appropriate for a trauma service admission. Likewise, those with very high scores (5-7) could easily and appropriately be managed on a hospital medicine service. The in-betweeners need more scrutiny by trauma program PI personnel to determine which service to admit to. 

Most importantly, don’t feel compelled to use this exact scoring system or threshold. Every hospital has different resources and a unique patient population. Add or remove criteria that you believe are appropriate. Adjust the threshold for added scrutiny as you see fit. Doing so will help keep your trauma PI workflow manageable.

Reference: Nonsurgical admissions with traumatic injury: medical patients are trauma patients, too. J Trauma Nursing 25(3):192-195, 2018.

Source: The Trauma Professionals’s Blog