Assessing the discharge disposition of orthopaedic trauma patients and its influence on patient outcomes

Trauma is a major cause of hospitalisation and mortality in working aged adults. In Victoria, a coordinated state trauma system was established in 1999 and resulted in a reduction in the risk of in-hospital mortality. This system was predominantly focused on the pre-hospital and hospital care of the injured patient, whereas the post discharge patient management was not specifically addressed in the design of the system. Rehabilitation is an accepted part of the continuum of care of the trauma patient and inpatient rehabilitation has been shown to benefit the spinal cord injured and the traumatic brain injured population. However, an equivalent level of evidence for the benefit of inpatient rehabilitation following orthopaedic trauma is lacking. Further, the decision-making regarding discharge destination following orthopaedic trauma is complex and strongly linked to socio-economic and financial factors. The aim of this thesis was to identify the predictors of discharge to inpatient rehabilitation, the role of inpatient rehabilitation following orthopaedic trauma in working aged adults, and its impact on patient outcomes. Data for this thesis were collected between 2007 and 2014. The Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) was used and the clinicians involved in the qualitative study worked in one of the four VOTOR hospitals or the rehabilitation centres that receive patients cared for acutely in these hospitals. The research findings show that it is possible to successfully predict those patients who are discharged to inpatient rehabilitation following isolated lower limb fracture using a simple bedside tool. This tool will assist the acute hospital clinicians plan early for discharge, with the aim of reducing confusion, limiting unnecessary inpatient rehabilitation referrals, and facilitating early and appropriate discharge. The importance of assisted discharge planning is underscored by the results of two qualitative studies, which showed marked variability between clinicians (both within the acute hospital and rehabilitation) in decision-making processes, and poor engagement of patients in their discharge planning. Patients also reported inadequate information about their injuries and their follow-up care. Outcomes for those discharged to inpatient rehabilitation were compared to home discharge. Using a propensity score analysis, patients discharged to inpatient rehabilitation were found to have worse return to work and functional outcomes at 12-months post-injury. However, the groups remain mismatched for some of the potential confounders and a randomised controlled trial is needed to definitively determine which discharge option results in superior long term outcomes. Based on the new knowledge presented in this thesis, a range of recommendations have been made to facilitate improved management of the orthopaedic trauma patient following their acute hospital stay. Involvement of the key stakeholders at all stages of the acute care, discharge planning and post-discharge stages of recovery, including patients, medical and allied health staff, administrators, funding bodies and policy makers will be vital to ensure best practice and care of the trauma patient throughout the continuum of care from time of injury to the ultimate aim of a return to community living.