191 Comparing Cost, Risk Factors, and Rates of Return in Immediate versus Delayed Cholecystectomy for Emergency Department Patients with Biliary Colic Using Statewide Linked Datasets

Abstract

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.