4.2 Multiple Hospital Visits

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Description of Indicator

Relationship to Quality Medical care should be safe, effective and efficient
Type of Indicator Posthospital Outcome, System level
Proposed Data Source Administrative Data
Definition Number of patients with an injury* diagnosis AND non-elective injury* related hospital visit within 7 days of hospital discharge per 100 patients
Numerator All patients age 18 years and older diagnosed with a head injury, spine injury, intra-abdominal injury or long bone fracture* AND a non-elective injury related hospital visit within 7 days of hospital discharge (ward discharge or ED discharge)
Denominator All patients age 18 years and older diagnosed with a head injury, spine injury, intra-abdominal injury or long bone fracture* AND discharged from hospital (ward discharge or ED discharge)
Benchmark Not specified at present
Risk Adjustment Not specified at present

* Inclusion criteria for the indicator is limited to specific diagnoses that may be associated with increased risk of delayed presentation or adverse events: head, spine (cervical, thoracic, lumbar), intra-abdominal and long bone fractures.


This indicator is intended to monitor the rate that recently discharged patients re-present to hospital with a non-elective injury problem. It is an amalgamation of two indicators, Readmission and Multiple ED Visits.


Panel Review
Panelists noted this to be a particularly interesting indicator as it could be used to perform comparisons across different health domains (e.g. injury versus myocardial infarction) and institutions. Measurement challenges that were noted included identifying appropriate data sources and distinguishing elective from non-elective hospital visits. It was suggested that the indicator may be helpful to trigger a full medical record audit. Panelists discussed whether risk adjustment was important for this indicator.
While the proposed indicator suggests measuring hospital visits within 7 days of hospital discharge, some panel members suggested longer time frames up to 30 days post-discharge may be more appropriate.


Trauma Center Review
It was noted that some trauma centers and hospitals already collect this data for visits up to 30 days post discharge and it was suggested that this timeframe may be more appropriate. It was discussed that the reason for a subsequent visit must be identified, as this may be appropriate for this to occur in some cases (e.g. follow up with surgeon, suture removal). Trauma centers had concerns that current documentation procedures make it difficult to access information about care of patients at other facilities and implementation may require additional resources to ensure that information is consistently reported and is accessible to all trauma centers.


Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: One study showed no significant association between the quality indicator and hospital mortality15. Two studies demonstrated that implementation of a trauma quality improvement program that included the quality indicator was associated with a reduction in preventable death44,45.
Reliability: No studies identified.
Risk Adjustment: No studies identified.
Utilization: Measures of Multiple Hospital Visits are used by a moderate number of trauma centers: USA 19% (37/200), Canada 29% (10/35), Australasia 17% (2/12).


This indicator is an amalgamation of two indicators: Readmission and Multiple ED Visits proposed by the American College of Surgeons Committee on Trauma2 and Chadbunchachai et al.44,45.


2. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient 2006. Chicago: American College of Surgeons; 2006.
15. Copes WS, Staz CF, Konvolinka CW, Sacco WJ. American College of Surgeons audit filters: associations with patient outcome and resource utilization. J Trauma. 1995;38(3):432-438.
44. Chadbunchachai W, Saranrittichai S, Sriwiwat S, Chumsri J, Kulleab S, Jaikwang P. Study on performance following Key Performance Indicators for trauma care: Khon Kaen Hospital 2000. J Med Assoc Thai. 2003;86(1):1-7.
45. Chadbunchachai W, Sriwiwat S, Kulleab S, Saranrittichai S, Chumsri J, Jaikwang P. The comparative study for quality of trauma treatment before and after the revision of trauma audit filter, Khon Kaen hospital 1998. J Med Assoc Thai. 2001;84(6):782-790.