Background:Traumatic Brain Injury (TBI) is one of the leading causes of morbidity and mortality worldwide. Understanding the impact of trauma centers' hospital and nursing factors on patients with TBI outcomes is essential to decrease hospital-acquired conditions connected with nursing-sensitive indicators and connecting to discharge disposition. Patients with TBI have a greater chance of experiencing hospital-acquired conditions (HACs) than other trauma patients. Nurses have a significant impact on preventing HACs sensitive to nursing care. Understanding a patient’s specific functional capabilities and clinical conditions to predict discharge disposition is essential to a patient’s functional recovery.
Methods:
This study was a cross-sectional design utilizing secondary data analysis with data from the National Trauma Data Bank (NTDB) for 2017 and 2018. The NTDB collects data for all trauma admissions, including patients with TBI, from pre-hospital to discharge in trauma centers verified by the American College of Surgeons (ACS) in North America. Survival analysis utilized log-rank test and Cox regression when examining patient hospital and nursing factors of length of stay (LOS) data. Multinomial logistic regression was used to study inpatient mortality and discharge disposition.
Results:
Discharge Disposition: Community (HR 1.19; 95% CI, 1.06-1.33; P= 0.003) and nonteaching hospitals (HR 1.49; 95% CI, 1.22- 1.74; P= 0.000) had a significantly shorter LOS compared to the reference group of a teaching hospital. Patients aged 61 and older have a significantly increased (61-75 years, p= 0.003, 75 years and older, p= 0.00) likelihood of being discharged to short-term inpatient or acute inpatient rehabilitation. Comparing the primary payor effect on discharge disposition, self-pay (p= 0.00) and other government (p=0.001) insurance were significantly less likely to be discharged to a skilled nursing facility (SNF) or long-term acute care hospitals (LTACH). Patients aged 61 and older had a significantly increased (61-75 years, p= 0.004, 75 years and older, p= 0.00) likelihood of being discharged to short-term inpatient or acute inpatient rehabilitation. Patients with Medicare or Medicaid insurance had a significantly decreased (p= 0.003, 0.014) likelihood of going to an acute rehabilitation/short-term inpatient hospital versus those privately insured.
Inpatient mortality: Patients 75 years and older were five times as likely to experience inpatient mortality as those 18-30 years old (OR= 5.71, 95% CI [4.2,7.78]). Hispanic/ Latino had a statistically significant decrease in inpatient mortality of half the odds of experiencing inpatient mortality compared to white (OR=0.57, 95% CI [0.45,0.72]). Patients with self-pay were found to have a significant probability of inpatient mortality with two times the odds of experiencing in-hospital mortality (OR= 2.13, 95% CI [1.7, 2.66]) compared to privately insured.
Nursing Sensitive Indicators: There was a significant association between patients that developed NSI and ICU (p< .00) and hospital LOS (p<.001). There was a significant relationship between VAP and severe sepsis, X2(1, 4377) = 43.84, p= 0.00; DVT and PE occurrence, X2(1, 4371) =128.84, p<0.001; CLABSI and severe sepsis, X2(1, 4377) =19.10, p<0.001, thus linking HACs that are nursing sensitive to HACs that have not been linked.
Discussion:
This study has highlighted the relationship between patient, trauma center, nursing characteristics, and the impact on patients with moderate and severe TBI LOS, NSI, and discharge disposition. Identifying which components are most impactful to clinical outcomes can serve as areas of concertation to meet worldwide aims to support fully integrated trauma care systems for optional patient impacts.