Objective
The objective of this study was to assess the 1‐year outcomes of emergency department (ED) patients with complicated gallstone disease, including surgery rates, initial admission rates, ED revisits, repeat hospitalizations, and cost.
Methods
Using 3 linked statewide databases from the Maryland Healthcare Cost and Utilization Project, we identified patients with a primary diagnosis of complicated gallstone disease treated in an ED between 2016 and 2018. We measured the healthcare use and direct costs in the ambulatory surgery, inpatient, and ED settings for 1 year after the initial ED visit. Finally, we performed a multivariate logistic regression analysis comparing initially admitted versus discharged patients.
Results
Of the 8751 patients analyzed, 86.8% were admitted to the hospital and 13.2% were discharged on their initial ED visit. Of the admitted patients, 78.7% received a cholecystectomy during the initial hospitalization plus 6.1% at a later date; of the discharged patients, 41.5% received a cholecystectomy. Admitted patients demonstrated lower recurrent gallbladder complications compared with those discharged (7.5% vs 44.5%), fewer ED revisits (4% vs 20.3%), and fewer repeat hospitalizations (4.5% vs 16.7%). Despite this, the 1‐year cost in the admitted patients was higher ($9448 vs $2933). Obesity, age, and mood disorders but not race, ethnicity, or zip code were associated with admission at initial ED visit.
Conclusions
In our single‐state analysis of ED patients with complications of gallstone disease, most patients are admitted on the initial visit and receive a cholecystectomy during that hospitalization. The discharged group had higher rates of 1‐year complications, ED revisits, and repeat hospitalizations but lower cost.
Study Objective: ED patients with traumatic injuries who do not meet ACS criteria for trauma activation may have unrecognized critical injuries. These patients would benefit from early evaluation and treatment. We implemented a Rapid Trauma Evaluation (RTE) process at our high volume, Level 1 Trauma Center ED in July 2020. Our research hypothesis was that early screening of a focused number of ED trauma patients would identify occult injuries and shorten ED LOS.Methods: This was a prospective cohort study of ED patients who might require trauma upgrades. We reviewed all 2019 trauma upgrades at our facility and concluded that the majority (32%) of these were either falls above 65 years of age, or motorcycle accidents. Based on these findings the following criteria for RTE were established: any patient 1) age > 65 with ground level fall within 24 hours or 2) non-enclosed motorized device accidents (ie, motorcycles) would be evaluated as a part of the RTE process. These patients were evaluated immediately upon arrival in the ED trauma bay by an RN/EMT. This assessment involved focused history, repeat vital signs, undressing of patients, and nursing triage assessment. If the patient was deemed unstable based on abnormal vitals, had additional injuries or deteriorated, a physician was called for rapid assessment. We measured ED LOS during the study period and identified occult injures. The protocol was approved by the INOVA IRB. Sample size calculation (beta ¼ 0.8) for a 10% decrease in LOS was 306 subjects. Descriptive statistics were calculated and parametric outcomes were analyzed using Student's t-test (alpha ¼ 0.05).Results: The ED conducted 341 RTEs between July and December 2020. Of these, 5% required immediate trauma upgrades with diagnoses including intracranial hemorrhage, odontoid fractures, pulseless extremity, and pneumothorax. 25% of upgrades were admitted to Trauma Surgery service and 55% to the Medicine service with diagnoses including syncope, sepsis, and ACS. 37 subjects were analyzed for ED LOS. Mean LOS (in minutes) for RTE patients (218, SD 90) was not significantly lower than that for 2019 control upgrade patients (248, SD 78), p¼0.4. The study was terminated early due to positive results.Conclusions: The data suggest that assessment on arrival of patients either older than 65 years of age with falls or any victims of motorcycle collisions identifies occult injuries and may shorten ED LOS.
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