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Predicting Discharge Disposition in Trauma Patients: Development, Validation, and Generalization of a Model Using the National Trauma Data Bank
Background
Limited work has been done in predicting discharge disposition in trauma patients; most studies use single institutional data and have limited generalizability. This study develops and validates a model to predict, at admission, trauma patients’ discharge disposition using NTDB, transforms the model into an easy-to-use score, and subsequently evaluates its generalizability on institutional data.
Methods
NTDB data were used to build and validate a binary logistic regression model using derivation-validation (ie, train-test) approach to predict patient disposition location (home vs non-home) upon admission. The model was then converted into a trauma disposition score (TDS) using an optimization-based approach. The generalizability of TDS was evaluated on institutional data from a single Level I trauma center in the U.S.
Results
A total of 614 625 patients in the NTDB were included in the study; 212 684 (34.6%) went to a non-home location. Patients with a non-home disposition compared to home had significantly higher age (69 ± 19.7 vs 48.3 ± 20.3) and ISS (11.2 ± 8.2 vs 8.2 ± 6.3); P < .001. Older age, female sex, higher ISS, comorbidities (cancer, cardiovascular, coagulopathy, diabetes, hepatic, neurological, psychiatric, renal, substance abuse), and Medicare insurance were independent predictors of non-home discharge. The logistic regression model’s AUC was 0.8; TDS achieved a correlation of 0.99 and performed similarly well on institutional data (n = 3161); AUC = 0.8.
Conclusion
We developed a score based on a large national trauma database that has acceptable performance on local institutions to predict patient discharge disposition at the time of admission. TDS can aid in early discharge preparation for likely-to-be non-home patients and may improve hospital efficiency.
Journal Article
Researching quality in care transitions : international perspectives
\"This book is concerned with the complexities of achieving quality in care transitions. The organization and accomplishment of high quality care transitions relies upon the coordination of multiple professionals, working within and across multiple care processes, settings and organizations, each with their own distinct ways of working, profile of resources, and modes of organizing. In short, care transitions might easily be regarded as complex activities that take place within complex systems, which can make accomplishing high quality care challenging. As a subject of enquiry, care transitions are approached from many research, improvement and policy perspectives: from group psychology and human factors to social and political theory; from applied process re-engineering projects to exploratory ethnographic studies; from large-scale policy innovations to local improvements initiatives. This collection will provide a unique cross-disciplinary and multi-level analysis, where each chapter presents a particular depth of insight and analysis, and together offer a holistic and detail understand of care transitions.\"-- Provided by publisher.
Book
Interventions to improve discharge from acute adult mental health inpatient care to the community: systematic review and narrative synthesis
The transition from acute mental health inpatient to community care is often a vulnerable period in the pathway, where people can experience additional risks and anxiety. Researchers globally have developed and tested a number of interventions that aim to improve continuity of care and safety in these transitions. However, there has been little attempt to compare and contrast the interventions and specify the variety of safety threats they attempt to resolve.
The study aimed to identify the evidence base for interventions to support continuity of care and safety in the transition from acute mental health inpatient to community services at the point of discharge. Electronic Databases including PsycINFO, MEDLINE, Embase, HMIC, CINAHL, IBSS, Cochrane Library Trials, ASSIA, Web of Science and Scopus, were searched between 2000 and May 2018. Peer reviewed papers were eligible for inclusion if they addressed adults admitted to an acute inpatient mental health ward and reported on health interventions relating to discharge from the acute ward to the community. The results were analysed using a narrative synthesis technique.
The total number of papers from which data were extracted was 45. The review found various interventions implemented across continents, addressing problems related to different aspects of discharge. Some interventions followed a distinct named approach (i.e. Critical Time Intervention, Transitional Discharge Model), others were grouped based on key components (i.e. peer support, pharmacist involvement). The primary problems interventions looked to address were reducing readmission, improving wellbeing, reducing homelessness, improving treatment adherence, accelerating discharge, reducing suicide. The 69 outcomes reported across studies were heterogeneous, meaning it was difficult to conduct comparative quantitative meta-analysis or synthesis.
The interventions reviewed are spread across a spectrum ranging from addressing a single problem within a single agency with a single solution, to multiple solutions addressing multi-agency problems. We recommend that future research attempts to improve homogeneity in outcome reporting.
Journal Article
Study and evaluation of the characteristics of saline wastewater (brine) produced by desalination and industrial plants
Desalination and industrial plants all around the world generate large amounts of saline wastewater (brine). The discharge of brine from facilities poses a severe environmental threat, while at the same time, the opportunity to recover resources is being lost as discharged brine is rich in valuable metals that could be recovered as salts/minerals. To this aim, this study presents and analyzes for the first time the characteristics of different brine effluents (from industries such as desalination, oil and gas production, petrochemical, aquaculture, pharmaceutical, textile) to prevent environmental pollution and to recover valuable resources (i.e., salts, minerals, metals, chemicals) enabling the concept of waste-to-resource (circular water economy model). The results revealed that the common salinity values in brine effluents range from 0.5 to 150 g/L, while the only exception is the produced water from the oil and gas industry (up to 400 g/L). Brine effluents from all sectors contain sodium, chloride, calcium, and potassium ions in high concentrations, while the production of common salts such as NaCl, CaCl
2
, and MgCl
2
from brine can be economically profitable. Besides common ions, precious metals such as lithium, rubidium, and cesium are present in low concentrations (<25 mg/L); however, their extraction from brine effluents can be significantly profitable due to their very high sale price. The treatment and valorization of brine can be implemented by the hybridization of membrane-based, chemical, biological, and thermal-based technologies/processes in minimal and zero liquid discharge (MLD/ZLD) systems.
Graphical abstract
Journal Article
Environmental flow limits to global groundwater pumping
Groundwater is the world's largest freshwater resource and is critically important for irrigation, and hence for global food security
. Already, unsustainable groundwater pumping exceeds recharge from precipitation and rivers
, leading to substantial drops in the levels of groundwater and losses of groundwater from its storage, especially in intensively irrigated regions
. When groundwater levels drop, discharges from groundwater to streams decline, reverse in direction or even stop completely, thereby decreasing streamflow, with potentially devastating effects on aquatic ecosystems. Here we link declines in the levels of groundwater that result from groundwater pumping to decreases in streamflow globally, and estimate where and when environmentally critical streamflows-which are required to maintain healthy ecosystems-will no longer be sustained. We estimate that, by 2050, environmental flow limits will be reached for approximately 42 to 79 per cent of the watersheds in which there is groundwater pumping worldwide, and that this will generally occur before substantial losses in groundwater storage are experienced. Only a small decline in groundwater level is needed to affect streamflow, making our estimates uncertain for streams near a transition to reversed groundwater discharge. However, for many areas, groundwater pumping rates are high and environmental flow limits are known to be severely exceeded. Compared to surface-water use, the effects of groundwater pumping are markedly delayed. Our results thus reveal the current and future environmental legacy of groundwater use.
Journal Article
A review of use of barrier discharge for modification of surface of polymers
In the framework of this work, a review of the use of a barrier discharge for modifying the surfaces of various polymer products is given. There are various examples of reducing, increasing the wettability angle of modified samples, deforming, smoothing their surface and changing their surface energies.
Journal Article
Changing climate both increases and decreases European river floods
Climate change has led to concerns about increasing river floods resulting from the greater water-holding capacity of a warmer atmosphere
. These concerns are reinforced by evidence of increasing economic losses associated with flooding in many parts of the world, including Europe
. Any changes in river floods would have lasting implications for the design of flood protection measures and flood risk zoning. However, existing studies have been unable to identify a consistent continental-scale climatic-change signal in flood discharge observations in Europe
, because of the limited spatial coverage and number of hydrometric stations. Here we demonstrate clear regional patterns of both increases and decreases in observed river flood discharges in the past five decades in Europe, which are manifestations of a changing climate. Our results-arising from the most complete database of European flooding so far-suggest that: increasing autumn and winter rainfall has resulted in increasing floods in northwestern Europe; decreasing precipitation and increasing evaporation have led to decreasing floods in medium and large catchments in southern Europe; and decreasing snow cover and snowmelt, resulting from warmer temperatures, have led to decreasing floods in eastern Europe. Regional flood discharge trends in Europe range from an increase of about 11 per cent per decade to a decrease of 23 per cent. Notwithstanding the spatial and temporal heterogeneity of the observational record, the flood changes identified here are broadly consistent with climate model projections for the next century
, suggesting that climate-driven changes are already happening and supporting calls for the consideration of climate change in flood risk management.
Journal Article
Association between frailty and 30-day outcomes after discharge from hospital
Readmissions after hospital discharge are common and costly, but prediction models are poor at identifying patients at high risk of readmission. We evaluated the impact of frailty on readmission or death within 30 days after discharge from general internal medicine wards.
We prospectively enrolled patients discharged from 7 medical wards at 2 teaching hospitals in Edmonton. Frailty was defined by means of the previously validated Clinical Frailty Scale. The primary outcome was the composite of readmission or death within 30 days after discharge.
Of the 495 patients included in the study, 162 (33%) met the definition of frailty: 91 (18%) had mild, 60 (12%) had moderate, and 11 (2%) had severe frailty. Frail patients were older, had more comorbidities, lower quality of life, and higher LACE scores at discharge than those who were not frail. The composite of 30-day readmission or death was higher among frail than among nonfrail patients (39 [24.1%] v. 46 [13.8%]). Although frailty added additional prognostic information to predictive models that included age, sex and LACE score, only moderate to severe frailty (31.0% event rate) was an independent risk factor for readmission or death (adjusted odds ratio 2.19, 95% confidence interval 1.12-4.24).
Frailty was common and associated with a substantially increased risk of early readmission or death after discharge from medical wards. The Clinical Frailty Scale could be useful in identifying high-risk patients being discharged from general internal medicine wards.
Journal Article
Impact and experiences of delayed discharge: A mixed‐studies systematic review
Background
The impact of delayed discharge on patients, health‐care staff and hospital costs has been incompletely characterized.
Aim
To systematically review experiences of delay from the perspectives of patients, health professionals and hospitals, and its impact on patients’ outcomes and costs.
Methods
Four of the main biomedical databases were searched for the period 2000‐2016 (February). Quantitative, qualitative and health economic studies conducted in OECD countries were included.
Results
Thirty‐seven papers reporting data on 35 studies were identified: 10 quantitative, 8 qualitative and 19 exploring costs. Seven of ten quantitative studies were at moderate/low methodological quality; 6 qualitative studies were deemed reliable; and the 19 studies on costs were of moderate quality. Delayed discharge was associated with mortality, infections, depression, reductions in patients’ mobility and their daily activities. The qualitative studies highlighted the pressure to reduce discharge delays on staff stress and interprofessional relationships, with implications for patient care and well‐being. Extra bed‐days could account for up to 30.7% of total costs and cause cancellations of elective operations, treatment delay and repercussions for subsequent services, especially for elderly patients.
Conclusions
The poor quality of the majority of the research means that implications for practice should be cautiously made. However, the results suggest that the adverse effects of delayed discharge are both direct (through increased opportunities for patients to acquire avoidable ill health) and indirect, secondary to the pressures placed on staff. These findings provide impetus to take a more holistic perspective to addressing delayed discharge.
Journal Article