(P73) Predictors of Prolonged Hospital Length of Stay After Traumatic Brain Injury

Objectives: The aim of this study was to identify factors associated with prolonged hospital length of stay (PLOS) following traumatic brain injury (TBI).

Background: For TBI survivors, recovery can be a long and arduous process with a significant number of days spent in the inpatient and rehabilitation settings.(1-6) Hospital length of stay (HLOS) after TBI is a crucial metric of injury severity, resource utilization and treatment related costs.(7-8) Risk factors for PLOS after TBI require further characterization as there is a dearth of literature on this important topic.(5-6) Identification of the risk factors associated with PLOS in TBI patients may help health systems develop standards of care and facilitate early mobilization of resources, promote timely discharge and reduce health care costs.

Methods: De-identified patient data for individuals with diagnosed TBI who were evaluated by the trauma surgery service at a single U.S. level 2 academic trauma and tertiary referral center between January 2017 and August 2022 were extracted from the hospital’s prospectively collected trauma registry. PLOS was defined as the 95th percentile of the in-hospital length of stay of the entire patient cohort. Patients with PLOS were compared with those without PLOS (normal HLOS). Clinical/injury factors, insurance status and discharge disposition were analyzed. In addition, a logistic regression model was developed that examined PLOS (outcome variable) using ICU stay, Glasgow coma scale (GCS) score on hospital arrival, injury severity score (ISS), hospital discharge disposition, use of a ventilator, in hospital cardiac arrest, alcohol withdrawal and unplanned intubation as predictor variables. Statistical analysis included descriptive statistics, chi square test, Wilcoxon rank sum test and multivariate logistic regression modeling (OR; 95% CI).

Results: The threshold for PLOS was >24 days. In the cohort of 1343 patients, 77 had PLOS. PLOS was significantly associated with male gender (80% vs 64%;P <.003), longer mean ICU stays (16.4 vs 1.5 days;P <.001) higher mean ISS (18.6 vs 13.8;P <.001), lower mean GCS score (11.3 vs 13.7;P <.001) and greater mean complication burden (0.7 vs 0.1;P <.001). PLOS patients were more likely to have moderate/severe TBI (44% vs 14%;P <.001), were more likely to die in hospital (19% vs 7%;P <.001), be discharged to a facility (55% vs 29%;P <.001) and use Medicaid (36% vs 22%;P <.005). In terms of complications, PLOS was associated with higher rates of cardiac arrest (5% vs 0.5%;P=0.002), unplanned intubations (13% vs 1%;P <.001), inpatient alcohol withdrawal (10% vs 2%;P <.001), ventilator associated pneumonia (5% vs 0.1%;P <.001) and acute respiratory distress syndrome (3% vs 0.2%;P <.02). Both groups had similar mean ages, racial distributions, Medicare/commercial insurance use and rates of orthopedic injuries, alcohol related injuries, unplanned extubations and operating room revisits. In the regression model, presence of an ICU stay (OR 2.5, CI 1.1-5.7) disposition to inpatient facility (OR 3.0 CI 1.6-5.9), ventilator use (OR 4.1, CI 2.0-8.4), unplanned intubation (OR 3.4, CI 1.1-10.5) and inpatient alcohol withdrawal (OR 3.5, CI 1.2-10.3) predicted PLOS.

Conclusions: TBI patients with PLOS were more likely to have severe injuries, in-hospital complications and Medicaid insurance use and less likely to be discharged to home. PLOS status was predicted by ICU stay, intubation, alcohol withdrawal and disposition to inpatient and post-acute care facilities. These findings have significant implications for quality improvement and resource utilization at acute care hospitals. Efforts to reduce in-hospital complications and expedite discharge to long term facilities may reduce length of stay and accompanying costs in TBI patients. Further validation of these results is needed from larger, multicenter studies with diverse patient populations.

References (Optional): 1. Carroll, Ellen L., et al. "Mild traumatic brain injury recovery: a growth curve modelling analysis over 2 years." Journal of neurology 267 (2020): 3223-3234.

2. Forslund, Marit V., et al. "Global outcome trajectories up to 10 years after moderate to severe traumatic brain injury." Frontiers in neurology 10 (2019): 219.

3. Dams-O’Connor, Kristen, et al. "Functional outcome trajectories following inpatient rehabilitation for TBI in the United States: a NIDILRR TBIMS and CDC interagency collaboration." The Journal of head trauma rehabilitation 35.2 (2020): 127.

4. Cullen, Nora. "Canadian healthcare perspective in traumatic brain injury rehabilitation." The Journal of head trauma rehabilitation 22.4 (2007): 214-220.

5. Yue, John K., et al. "Predictors of Extreme Hospital Length of Stay After Traumatic Brain Injury." World Neurosurgery 167 (2022): e998-e1005.

6. Abujaber, Ahmad, et al. "Predicting prolonged length of stay in patients with traumatic brain injury: a machine learning approach." Intelligence-Based Medicine 6 (2022): 100052.

7. Pavlov, Vladislav, et al. "Mild traumatic brain injury in the United States: demographics, brain imaging procedures, health-care utilization and costs." Brain injury 33.9 (2019): 1151-1157.

8. Tardif, Pier-Alexandre, et al. "Hospital length of stay following admission for traumatic brain injury in a Canadian integrated trauma system: a retrospective multicenter cohort study." Injury 48.1 (2017): 94-100.

Funding (Optional): N/A