Comparison of 1-Day Emergency Department Observation and Inpatient Ward for 1-Day Admissions in Syncope Patients

Innovative pathways allow safe discharge of mild acute pancreatitis from the emergency room

Acute pancreatitis (AP) is a leading cause of gastrointestinal-related hospitalizations in the United States, resulting in 300000 admissions per year with an estimated cost of over $2.6 billion annually. The severity of AP is determined by the presence of pancreatic complications and end-organ damage. While moderate/severe pancreatitis can be associated with significant morbidity and mortality, the majority of patients have a mild presentation with an uncomplicated course and mortality rate of less than 2%. Despite favorable outcomes, the majority of mild AP patients are admitted, contributing to healthcare cost and burden. In this Editorial we review the performance of an emergency department (ED) pathway for patients with mild AP at a tertiary care center with the goal of reducing hospitalizations, resource utilization, and costs after several years of implementation of the pathway. We discuss the clinical course and outcomes of mild AP patients enrolled in the pathway who were successfully discharged from the ED compared to those who were admitted to the hospital, and identify predictors of successful ED discharge to select patients who can potentially be triaged to the pathway. We conclude that by implementing innovative clinical pathways which are established and reproducible, selected AP patients can be safely discharged from the ED, reducing hospitalizations and healthcare costs, without compromising clinical outcomes. We also identify a subset of patients most likely to succeed in this pathway.

The Causal Effect of Community Hospitals on General Hospital Admissions. Evaluation of a Natural Experiment Using Register Data

Background

To reduce overall healthcare costs, several countries have attempted to shift services from specialist to primary care. This was also the main strategy of the Coordination Reform introduced in Norway in 2012. An important part of the reform was the introduction of Municipal Acute Wards (MAWs), a type of community hospital aimed at reducing admissions to general hospitals. The main objective of this paper is to investigate whether the implementation of MAWs had a causal effect on hospital admissions.

Methods

Monthly admission rates in total and by age groups for patients admitted with acute or elective conditions at internal medicine or surgical departments were analyzed using panel data regression techniques. We identified causal effects by exploiting the sequential roll out of the MAWs within fixed effect analyses. Our data covered all municipalities from start of 2010 until the end of 2017.

Results

The sequential implementation of the MAWs started during the summer of 2012. By the beginning of 2016 close to all municipalities had an operative MAW. The introduction of MAWs significantly reduced acute hospital admissions. The effect was strongest for patients ≥80 years admitted acutely to internal medicine departments. The effects were even stronger if the MAW had a physician on site 24/7 or was located close to a local emergency center.

Conclusion

Our findings suggest that this type of intermediate care unit is a viable option to alleviate the burden on hospitals by reducing acute secondary care admission volumes.

Using the Boston Syncope Observation Management Pathway to Reduce Hospital Admission and Adverse Outcomes

Introduction

In an age of increasing scrutiny of each hospital admission, emergency department (ED) observation has been identified as a low-cost alternative. Prior studies have shown admission rates for syncope in the United States to be as high as 70%. However, the safety and utility of substituting ED observation unit (EDOU) syncope management has not been well studied. The objective of this study was to evaluate the safety of EDOU for the management of patients presenting to the ED with syncope and its efficacy in reducing hospital admissions.

Methods

This was a prospective before-and-after cohort study of consecutive patients presenting with syncope who were seen in an urban ED and were either admitted to the hospital, discharged, or placed in the EDOU. We first performed an observation study of syncope management and then implemented an ED observation-based management pathway. We identified critical interventions and 30-day outcomes. We compared proportions of admissions and adverse events rates with a chi-squared or Fisher’s exact test.

Results

In the “before” phase, 570 patients were enrolled, with 334 (59%) admitted and 27 (5%) placed in the EDOU; 3% of patients discharged from the ED had critical interventions within 30 days and 10% returned. After the management pathway was introduced, 489 patients were enrolled; 34% (p<0.001) of pathway patients were admitted while 20% were placed in the EDOU; 3% (p=0.99) of discharged patients had critical interventions at 30 days and 3% returned (p=0.001).

Conclusion

A focused syncope management pathway effectively reduces hospital admissions and adverse events following discharge and returns to the ED.

Preventing Hospitalization in Mild Acute Pancreatitis Using a Clinical Pathway in the Emergency Department

GOALS

We created an observation pathway with close outpatient follow-up for patients with mild acute pancreatitis (AP) to determine its effect on admission rates, length of stay (LOS), and costs.

BACKGROUND

AP is a common reason for hospitalization costing $2.6 billion annually. Majority have mild disease and improve quickly but have unnecessarily long hospital stays.

STUDY

We performed a pilot prospective cohort study in patients with AP at a tertiary-care center. In total, 90 patients with AP were divided into 2 groups: observation cohort and admitted cohort. Exclusion criteria from observation included end-organ damage, pancreatic complications, and/or severe cardiac, liver, and renal disease. Patients in observation received protocolized hydration and periodic reassessment in the emergency department and were discharged with outpatient follow-up. Using similar exclusion criteria, we compared outcomes with a preintervention cohort composed of 184 patients admitted for mild AP in 2015. Our primary outcome was admission rate, and secondary outcomes were LOS, patient charges, and 30-day readmission.

RESULTS

Admitted and preintervention cohorts had longer LOS compared with the observation cohort (89.7 vs. 22.6 h, P<0.01 and 72.0 vs. 22.6 h, P<0.01). The observation cohort admission rate was 22.2% lower than the preintervention cohort (P<0.01) and had 43% lower patient charges ($5281 vs. $9279, P<0.01). Moreover there were significantly fewer imaging studies performed (25 vs. 49 images, P=0.03) in the observation cohort. There were no differences in readmission rates and mortality.

CONCLUSIONS

In this feasibility study, we demonstrate that a robust pathway can prevent hospitalization in those with AP and may reduce resource utilization without a detrimental impact on safety.

Role of emergency department observation units in the management of patients with unexplained syncope: a critical review and meta-analysis

This meta-analysis aimed to establish the role of standardized emergency department (ED) observation protocols in the management of syncopal patients as an alternative to ordinary admission. A systematic electronic literature search was performed to identify randomized controlled trials or observational studies evaluating syncopal patients managed in ED observation units. Data regarding mean length of stay, rate of etiological diagnosis, admission rate, and incidence of short-term serious outcomes were extracted. Six mostly single-center, small sized studies characterized by high heterogeneity, were included. A total of 458 patients were included with a balanced sex distribution (male 50.2%), a mean age of 60.1 years, and a considerable prevalence of heart disease (32.4%). Pooled analysis of the outcomes showed a mean stay of 28.2 hours, an etiological diagnosis rate of 67.3%, an admission rate of 18.5%, and a very low incidence of short-term serious outcomes (2.8%). Due to elevated diagnostic yield and low incidence of short-term adverse events, ED observation units-based management strategy seems ideal for patients with syncope. Nevertheless, further research is needed to identify criteria for selecting patients to be managed with this approach, define evaluation protocols, and confirm the safety of this strategy.

[Faintness in emergency departments is frequent, benign but expensive: An epidemiologic study of hospitalization's risk factors to reduce overcrowdings of emergency departments]

INTRODUCTION

We assessed (i) the frequency of consultations for faintness in the Emergency department (ED) of a University hospital centre (UHC), (ii) clinical epidemiology and (iii) cost of faintness, taking a particular interest into the determining risk factors for hospitalization.

METHODS

This epidemiological study has been conducted retrospectively, from data obtained for every patient having consulted for faintness in ED of Reims UHC (01/01/12-03/31/12). Every medical record was classified as syncope/lipothymia/brief consciousness loss on one hand and as syncope according to the definition of the French Health High Authority (FHHA).

RESULTS

Three hundred and forty-one patients out of 5953 (5.7%) were referred for faintness during the study period. Medical records were analysed for 296 patients. Sixty-two point eight percent were women, with a median age of 43years. Physical examination was normal for 57% of patients. For 48% of cases, there was no complete consciousness loss thus corresponding to lipothymia, which is not taken into account by the FHHA definition. Median length of stay in the ED was 4hours and 67 patients (22.6%) were hospitalized. Minimal estimated cost was 280,000 euros. Risk factors independently associated with hospitalization were age≥60 and complete consciousness loss unlike predisposing circumstances to vagal hypertonia.

CONCLUSION

Age≥60 and complete consciousness loss seemed to be associated with hospitalization.