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After Hospital Discharge, Trauma Patients Face Increased Death Risk

Nursing homes present biggest threat

More adults treated at hospitals for trauma — from car accidents to falls — are surviving those injuries than they did a decade ago, according to a study released today in the Journal of the American Medical Association. But results from the large study of trauma patients' records suggest that health researchers need to explore what accounts for a higher risk of dying after a patient leaves the hospital.

Researchers analyzed records from 1995 through 2008 of nearly 125,000 residents of Washington state age 18 and older who had been hospitalized for traumatic injuries, and then discharged home, to rehab or to a nursing home. The researchers found that within three years of leaving the hospital 16 percent of trauma patients died, a figure that is 10 percentage points higher than the death rate of the population. The risk was even higher for those sent to a nursing home, where one in three trauma patients died within three years. Researchers also found that falls caused more deaths than all other types of trauma, including car accidents.

"We get patients out of the hospital alive, now we have to go to the next step when they are discharged and see if we can make a difference," says Saman Arbabi, M.D., one of the authors of the study, who is a University of Washington associate professor of surgery in the Division of Trauma, Burns and Critical Care at Harborview Medical Center in Seattle.

More than half of the study population who were over the age of 65 went to nursing homes after their hospital stay. Patients of any age sent to nursing homes were at much greater risk of dying in the first year after injury than patients who were sent home or to rehab, a finding that was not surprising to Arbabi, who noted that patients sent to nursing homes are generally at a "lower functioning status" than those who are sent home or to rehab.

However, the study of adult trauma patients in Washington state revealed that over time there was a change in the proportion of people sent to rehab or nursing homes. "The number of patients going to skilled nursing facilities is steadily increasing, while the number of patients going to rehab is steady, it's not increasing. This suggests that we are using nursing homes more often than before," explains Arbabi. He adds that the greatest discrepancy in the risk of dying between those who go to rehab and those sent to nursing homes was among patients between the ages of 45 and 75. He added that increasing medical supervision or physical therapy in nursing homes might improve older people's chances of surviving traumatic injuries.

Researchers looked at how patients were injured, including physical injuries caused by falls, gunshots, knife wounds or blunt force from motor vehicle crashes. They found that the risk of dying within three years after a bad fall surpassed all other types of trauma for older adults, including motor vehicle accidents. Arbabi said that's true not only for Washington state but for the rest of the country as well.

Because the analysis is based on limited patient records, researchers noted that it wasn't possible to determine whether other disorders or disease may have contributed to the death rate of trauma victims.

Trauma experts say that the study should cause people to temper their expectations of the degree to which they can recover from a traumatic injury. "I think people can realistically expect us to fix traumatic injuries, but we can't always put you back to 100 percent of where you started right before your injury," says Elliott R. Haut, M.D., a trauma surgeon and researcher who is an associate professor of surgery and anesthesiology at the Johns Hopkins University School of Medicine.

Haut says that health educators could help prevent falls by deploying the same kind of media blitz used to tackle driver safety. "People know to wear seat belts and not to drink and drive. I think fall prevention in the elderly hasn't been pushed quite as hard as other messages," says Haut. He points to such things as using a walker if you need one, getting new glasses if needed, doing exercises that help increase strength and balance, or having an occupational therapist recommend changes at home to reduce risks of falls.

Overall, says Arbabi, the study shows the need for looking beyond the hospital to ensure that trauma care pays off. "Society spends all that money to keep people alive. But if we discharge patients and don't follow up, then maybe we're not getting our investment back."

Laurie Udesky is a writer in San Francisco.

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