title: Intensive care unit bounce back in trauma patients: an analysis of unplanned returns to the intensive care unit.
abstract: BACKGROUND
  Discharging patients from the intensive care unit (ICU) often requires complex decision making to balance patient needs with available resources. Unplanned return to the ICU ("bounce back" [BB]) has been associated with increased resource use and worse outcomes, but few data on trauma patients are available. The goal of this study was to review ICU BB and define ICU discharge variables that may be predictive of BB.
  
  
  METHODS
  Adults admitted to ICU and discharged alive to a ward from November 04, 2012, to September 9, 2012 (interval with no changes in coverage), were selected from our trauma registry. Patients with unplanned return to ICU (BB cases) were matched 1:2 with controls on age, Injury Severity Score (ISS), and duration of post-ICU stay. Data were collected by chart review then analyzed with univariate and conditional multivariate techniques.
  
  
  RESULTS
  Of 8,835 hospital admissions, 1,971 (22.3%) were discharged alive from ICU to a ward. Eighty-eight patients (4.5%) met our criteria for BB (male, 75%; mean [SD] age, 52.9 [21.9] years; mean [SD] ISS, 23.1 [10.2]). Most (71.6%) occurred within 72 hours. Mortality for BB cases was high (19.3%). Regression analysis showed that male sex (odds ratio, 2.9; p = 0.01), Glasgow Coma Scale [GCS] score of less than 9 (odds ratio, 22.3; p < 0.01), discharge during day shift (odds ratio, 6.9; p < 0.0001), and presence of one (odds ratio, 3.5; p = 0.03), two (odds ratio, 3.8; p = 0.03), or three or more comorbidities (odds ratio, 8.4; p < 0.001) were predictive of BB.
  
  
  CONCLUSIONS
  In this study, BB rate was 4.8%, and associated mortality was 19.3%. At the time of ICU discharge, male sex, a GCS score of less than 9, higher FIO2, discharge on day shift, and presence of one or more comorbidities were the strongest predictors of BB. A multi-institutional study is needed to validate and extend these results.
  
  
  METHODS
  Epidemiologic/prognostic study, level IV.
authors.affiliation: Department of Surgery, Medical University of South Carolina, Charleston, South Carolina 29245, USA. fakhry@musc.edu
authors.forename: Samir M
authors.initials: SM
authors.lastname: Fakhry
authors.forename: Stuart
authors.initials: S
authors.lastname: Leon
authors.forename: Chris
authors.initials: C
authors.lastname: Derderian
authors.forename: Hasan
authors.initials: H
authors.lastname: Al-Harakeh
authors.forename: Pamela L
authors.initials: PL
authors.lastname: Ferguson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data; D012307:Risk Factors; D012737:Sex Factors; D013997:Time Factors; D014947:Wounds and Injuries / Q000453:epidemiology / Q000628:therapy*; D055815:Young Adult