The use of an emergency department observation unit in the management of abdominal trauma

The early management of gunshot wounds Part II: the abdomen, extremities and special situations

The management of gunshot wounds of the abdomen and extremities is evolving with centres who treat large volumes of such injuries tending to the application of a policy of selective non-operative management. This article discusses the management of gunshot wounds to the abdomen and extremities and reviews the evidence supporting these changing practices. Special situations such as wounding by shotguns or air rifles are also examined as are the special considerations needed when dealing with the gunshot injured pregnant women or in a child.

Beyond ureterolithiasis: gamut of abnormalities affecting the ureter

Nephrolithiasis is the most common condition involving the ureters. However, various other entities can affect the ureters, albeit less frequently. Imaging plays a crucial role in diagnosis, management, and follow-up of ureteral pathology. In the past decade, computed tomography urography has replaced traditional methods of ureteral imaging due to its high spatial resolution, multiplanar imaging, and rapid acquisition time. More recently, magnetic resonance urography has also been explored in evaluating ureteral abnormalities. In this review, we briefly discuss current imaging techniques used in assessment of the ureters and present a diverse group of diseases affecting the ureters. We begin with primary and secondary ureteral malignancies, followed by uncommon infectious/inflammatory diseases that can involve the ureters including tuberculosis, xanthogranulomatous pyelonephritis, and graft-versus-host disease. We then discuss the imaging characteristics of endometriosis and retroperitoneal fibrosis as two important examples of pelvic and retroperitoneal processes that occasionally obstruct the ureters and present with clinical symptoms similar to that of renal stones. We end with a brief discussion of miscellaneous conditions that affect the ureters, including ureteral hemorrhage, ureteral intussusception, ureteral pseudodiverticulosis, Malacoplakia, and ureteritis cystica. Knowledge of these entities and their characteristic imaging manifestations along with patient's clinical presentation allows accurate diagnosis and timely patient management.

Deriving a prediction rule for short stay admission in trauma patients admitted at a major trauma centre in Australia

INTRODUCTION

The aim of this study was to derive and internally validate a prediction rule for short stay admissions (SSAs) in trauma patients admitted to a major trauma centre.

METHODS

A retrospective study of all trauma activation patients requiring inpatient admission at a single inner city major trauma centre in Australia between 2007 and 2011 was conducted. Logistic regression was used to derive a multivariable model for the outcome of SSA (length of stay ≤2 days excluding deaths or intensive care unit admission). Model discrimination was tested using area under receiver operator characteristic curve analyses and calibration was tested using the Hosmer-Lemeshow test statistic. Validation was performed by splitting the dataset into derivation and validation datasets and further tested using bootstrap cross validation.

RESULTS

A total of 2593 patients were studied and 30% were classified as SSAs. Important independent predictors of SSA were injury severity score ≤8 (OR 7.8; 95% CI 5.0 to 11.9), Glasgow coma score 14-15 (OR 3.2; 95% CI 1.8 to 5.4), no need for operative intervention (OR 2.2; 95% CI 1.6 to 3.2) and age < 65 years. (OR 1.7; 95% CI 1.2 to 2.6). The overall model had an area under receiver operator characteristic curve of 0.84 (95% CI 0.82 to 0.87) for the derivation dataset. After bootstrap cross validation the area under the curve of the final model was 0.83 (95% CI 0.81 to 0.84).

CONCLUSIONS

We report a prediction rule that could be used to establish admission criteria for a trauma short stay unit. Further studies are required to prospectively validate the prediction rule.

State of the art: emergency department observation units

Hospitals and emergency departments face the challenges of escalating healthcare costs, mismatched resource utilization, concern over avoidable admissions, and hospital and emergency department overcrowding. One approach that has been used by hospitals to address these issues is the use of emergency department observation units. Research in this setting has increased in recent years, leading to a better understanding of the role of these units and their unique benefits. These benefits have been proven for health systems as a whole and for several acute conditions including chest pain, asthma, syncope, transient ischemic attack, atrial fibrillation, heart failure, abdominal pain, and more. Benefits include a decrease in diagnostic uncertainty, lower cost and resource utilization, improved patient satisfaction, and clinical outcomes that are comparable to admitted patients. As more hospitals begin to use observation units, there is a need for further education and research in how to optimize the use of emergency department observation units. The purpose of this article is to provide a general overview of observation units, including advancements and research in this field.

Serial hematocrit testing does not identify major injuries in trauma patients in an observation unit

BACKGROUND

Routine serial hematocrit measurements are a component of the trauma evaluation for patients without serious injury identified on initial evaluation. We sought to determine whether serial hematocrit testing was useful in detecting significant intra-abdominal injuries in trauma patients in our observation unit.

METHODS

We performed a retrospective chart review of all trauma patients placed in our observation unit over a 14-month period. Patients had received trauma surgery evaluation before placement in the observation unit and routinely received serial hematocrit testing (>or=2 hematocrit levels) while in the observation unit. We compared trauma patients with a hematocrit drop of 5 points or more to those without a significant hematocrit drop.

RESULTS

Three hundred sixty-five trauma patients were placed in the observation unit, and 310 patients (85%) had at least 2 hematocrits drawn during their stay. Of these patients, 20.6% had a hematocrit drop of 5 or more. Of patients with the hematocrit change, 18.8% were admitted to an inpatient unit from the observation unit compared to 9.3% of patients without a significant hematocrit change (P = .034). In one of these patients who had a computed tomography scan before observation admission, which demonstrated free fluid, the hematocrit drop assisted in diagnosing significant intra-abdominal injury.

CONCLUSION

Although serial hematocrit testing may be useful in specific situations, routine use of serial hematocrit testing in trauma patients at a level I trauma center's observation unit did not significantly aid in the detection of occult injury.

Beyond pulmonary edema: diagnostic, risk stratification, and treatment challenges of acute heart failure management in the emergency department

The majority of heart failure hospitalizations in the United States originate in the emergency department (ED). Current strategies for acute heart failure syndromes have largely been tailored after chronic heart failure guidelines and care. Prospective ED-based acute heart failure syndrome trials are lacking, and current guidelines for disposition are based on either little or no evidence. As a result, the majority of ED acute heart failure syndrome patients are admitted to the hospital. Recent registry data suggest there is a significant amount of heterogeneity in acute heart failure syndrome ED presentations, and diagnostics and therapeutics may need to be individualized to the urgency of the presentation, underlying pathophysiology, and acute hemodynamic characteristics. A paradigm shift is necessary in acute heart failure syndrome guidelines and research: prospective trials need to focus on diagnostic, therapeutic, and risk-stratification algorithms that rely on readily available ED data, focusing on outcomes more proximate to the ED visit (5 days). Intermediate outcomes (30 days) are more dependent on inpatient and outpatient care and patient behavior than ED management decisions. Without these changes, the burden of acute heart failure syndrome care is unlikely to change. This article proposes such a paradigm shift in acute heart failure syndrome care and discusses areas of further research that are necessary to promote this change in approach.

An evaluation of emergency physician selection of observation unit patients

OBJECTIVE

Appropriate patient selection is critical for maximal observation unit (OU) effectiveness. We hypothesized emergency physicians underuse the OU for admitted patients and overuse the OU for patients who would otherwise be discharged.

METHODS

Treating emergency physicians were asked about patient suitability for admission to an OU at a busy, urban, academic emergency department (ED) as part of a prospective cohort study of ED patients who were admitted or had an ED length of stay exceeding 4 hours. The OU was closed for renovation during the 2-month study, so physician opinion could be compared with patient course in the absence of observation services. Two blinded emergency physicians reviewed charts using structured forms and explicit definitions to determine actual patient course. Hospitalized patients were considered potential OU candidates according to a priori criteria: (1) hospital length of stay less than 48 hours, (2) no procedure or diagnosis requiring hospitalization, and (3) no death.

RESULTS

Of 1747 enrolled patients, 131 were excluded with incomplete data. Median age was 45 years. Patients were 40% white and 48% men. Emergency physicians identified 363 (23%) patients as observation candidates. Of these, 182 (50%) were actually discharged directly. The remaining 181 (50%) were hospitalized; 101 (56%) were observation candidates based on chart review. Of 799 admitted patients not selected for observation, 232 (29%) were suitable for observation by chart review.

CONCLUSIONS

Selection of patients for observation was suboptimal; emergency physicians routinely identified patients as OU candidates who were not ultimately admitted, and they missed many admitted patients who might have been appropriate OU candidates. Both over- and underuse should be addressed to maximize the effectiveness of OUs.

The pediatric hybrid observation unit: an analysis of 6477 consecutive patient encounters

OBJECTIVES

Pediatric observation units (OUs) are becoming more common in hospitals throughout the United States, providing physicians with a new disposition option for children who are judged to be too ill for home management. Some OUs function as "hybrid" units, serving both acutely ill and injured observation patients as well as scheduled elective procedure patients. How best to utilize this new resource is not yet defined. We studied the utilization of our pediatric hybrid OU during the first 2 years of operation to determine (1) the spectrum and frequency of diagnoses treated, (2) diagnoses and procedures most (and least) likely to attain discharge successfully within 24 hours, and (3) whether age was associated with inability to be discharged from the OU within 24 hours.

METHODS

The study setting was a 20-bed hybrid OU located in a pediatric tertiary care hospital in Salt Lake City, Utah. The records of all patients admitted during the first 2 years of OU operation, from August 1999 through July 2001, were examined retrospectively.

RESULTS

There were 6477 OU admissions: 4189 (65%) for acutely ill and injured observation patients and 2288 (35%) for scheduled elective procedure patients. For the observation patients, median age was 2.5 years and median length of stay was 15.5 hours. Common admission diagnoses in these patients included enteritis/dehydration (n = 722), orthopedic injuries (n = 362), asthma (n = 327), closed head injury (n = 289), urgent transfusion/infusion (n = 221), bronchiolitis (n = 212), croup (n = 207), abdominal pain (n = 199), cellulitis (n = 177), and nonfebrile seizure (n = 98). Overall, 15% of observation patients required subsequent inpatient admission for >24-hour stay. Observation diagnoses that were most likely to require inpatient admission were hematochezia (60%), viral pneumonia (46%), and bronchiolitis (43%). We demonstrated successful OU discharge rates (>85%) for several diagnoses not commonly reported: neonatal hyperbilirubinemia, aseptic meningitis, and diabetic ketoacidosis in the patient with known diabetes. Among the scheduled elective procedure patients, median age was 5.0 years and median length of stay was 3.0 hours. Only 1% of these patients required subsequent inpatient admission. In both populations, age < or =30 days was associated with increased need for inpatient admission, with a relative risk of 1.9 (95% confidence interval: 1.4-2.6) among the observation patients and 13.9 (95% confidence interval: 3.0-65.0) among scheduled procedure patients.

CONCLUSION

Our pediatric hybrid OU played an important role in the treatment of children who were admitted for observation as a result of acute illness or injury, as well as children who required scheduled procedures. For both patient types, we identified diagnoses that are most and least likely to attain successful discharge within 24 hours. The majority (85%) of observation patients were discharged successfully within 24 hours. Successful discharge rates for diagnoses that are not commonly managed in other pediatric OUs were reported. We identified certain age groups within selected diagnoses that may not have been appropriate for the OU.

Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury--a prospective study in 200 patients

PURPOSE

To assess the accuracy of computed tomography (CT) in demonstrating the presence or absence of peritoneal violation and type of intraperitoneal organ injury, if any, in hemodynamically stable patients with penetrating torso trauma but without definite peritoneal signs or radiographic evidence of free intraperitoneal air.

MATERIALS AND METHODS

During a 29-month period, helical CT with oral, rectal, and intravenous contrast material (triple-contrast) was performed in 200 hemodynamically stable patients, including 169 men (age range, 15-85 years; mean age, 31 years) and 31 women (age range, 17-45 years; mean age, 28 years) with penetrating torso trauma. The study group included 86 patients with gunshot wounds, 111 with stab wounds, and three impaled by sharp objects. CT scans were evaluated prospectively by three trauma radiologists for evidence of peritoneal violation to determine injury to intra- or retroperitoneal solid organs, bowel, mesentery, vascular structures, diaphragm, and urinary tract. Sensitivity, specificity, and accuracy of CT in the diagnosis of peritoneal violation were determined.

RESULTS

CT findings aided diagnosis of peritoneal violation in 34% of patients (68 of 200) and were negative for peritoneal violation in 66% of patients (132 of 200). Two patients with negative CT findings failed to improve with observation and underwent therapeutic laparotomy. CT had 97% sensitivity (66 of 68 findings), 98% specificity (130 of 132 findings), and 98% accuracy (196 of 200 findings) for peritoneal violation. CT aided diagnosis of 28 hepatic, 34 bowel or mesenteric, seven splenic, and six renal injuries. Laparotomy based on CT findings in 38 patients was considered therapeutic in 87% (33 of 38) and nontherapeutic in 8% (three of 38) and had negative results in 5% (two of 38).

CONCLUSION

Triple-contrast helical CT accurately demonstrates peritoneal violation and visceral injury in patients with penetrating torso wounds.

The use and effectiveness of an emergency department observation unit for elderly patients

STUDY OBJECTIVE

Emergency department observation units are cost-effective alternatives to hospital admission for selected patients. However, the use and effectiveness of these units in the elderly population is unclear. We sought to describe the use of an ED observation unit by elderly patients (>or=65 years), to determine whether the ED observation unit is effective for them in terms of ED observation unit length of stay and hospital admission rates, and to compare efficacy and return visit rates between younger and older patients.

METHODS

This is a retrospective observational cohort study of consecutive adult patients sent to an ED observation unit from 1996 to 2000 at a high-volume tertiary care suburban teaching hospital. ED observation unit length of stay of less than 18 hours and admittance rates of less than 30% were used as indicators of efficacy. Diagnosis, length of stay, hospital admission rates, and 30-day return visit rates were compared between younger and older patients.

RESULTS

Twenty-two thousand five hundred and thirty adult patients were observed, with 37.2% older than 65 years of age. The most common diagnoses in elderly patients were chest pain (24.0%), dehydration (11.7%), syncope (6.5%), back pain (4.6%), and chronic obstructive pulmonary disease (3.8%). Length of stay in the ED observation unit was longer for the elderly than younger patients but still averaged less than 18 hours (15.8 hours [95% confidence interval (CI) 15.7 to 16.0] versus 14.4 hours [95% CI 14.3 to 14.5], respectively). Elderly patients were more likely to be admitted from the ED observation unit than younger patients (26.1% versus 18.5%); however, their overall admission rate remained less than 30%. Compared with younger patients, the odds ratios for inpatient admission of elderly patients was highest for back pain (2.10; 95% CI 1.62 to 2.73), pyelonephritis (1.78; 95% CI 1.16 to 2.71), and chest pain (1.65; 95% CI 1.44 to 1.89). Thirty-day related return visit rates between age groups were similar (9.4% versus 7.6%).

CONCLUSION

Elderly ED observation unit patients had ED observation unit lengths of stay and hospital admission rates that were effective for an ED observation unit setting and ED return visits rates that were comparable with those of younger patients.

Use of emergency observation and assessment wards: a systematic literature review

INTRODUCTION

Observation and assessment wards allow patients to be observed on a short-term basis and permit patient monitoring and/or treatment for an initial 24-48 hour period. They should permit concentration of emergency activity and resources in one area, and so improve efficiency and minimise disruption to other hospital services. These types of ward go under a variety of names, including observation, assessment, and admission wards. This review aims to evaluate the current literature and discuss assessment/admission ward functionality in terms of organisation, admission criteria, special patient care, and cost effectiveness.

METHODS

Search of the literature using the Medline and BIDS databases, combined with searches of web based resources. Critical assessment of the literature and the data therein is presented.

RESULTS

The advantages and disadvantages of the use of assessment/admission wards were assessed from the current literature. Most articles suggest that these wards improve patient satisfaction, are safe, decrease the length of stay, provide earlier senior involvement, reduce unnecessary admissions, and may be particularly useful in certain diagnostic groups. A number of studies summarise their organisational structure and have shown that strong management, staffing, organisation, size, and location are important factors for efficient running. There is wide variation in the recommended size of these wards. Observation wards may produce cost savings largely relating to the length of stay in such a unit.

CONCLUSION

All types of assessment/admission wards seem to have advantages over traditional admission to a general hospital ward. A successful ward needs proactive management and organisation, senior staff involvement, and access to diagnostics and is dependent on a clear set of policies in terms of admission and care. Many diagnostic groups benefit from this type of unit, excluding those who will inevitably need longer admission. Vigorous financial studies have yet to be undertaken in the UK. Definitions of observation, assessment, and admission ward are suggested.

23-Hour observation solely for identification of missed injuries after trauma: is it justified?

BACKGROUND

The use of an observation period to identify missed injuries in trauma patients has gained favor in recent years. This study was undertaken in a population of patients with minimal or no identified injuries to determine the following: whether a period of in-patient observation identifies missed injuries; demographic factors associated with missed injuries; and morbidity of missed injuries.

METHODS

Over 4 years at a Level I trauma center, 4,738 patients were observed for 23 hours. Of these patients, 630 were converted to full admission and were reviewed. All medical records were reviewed for reason for observation, reason for conversion to full admission, and presence of missed injury.

RESULTS

In the 4,738 patients observed, 35 had a missed injury identified. No clinical factors studied were associated with identifying a missed injury. Of the 35 patients that had a missed injury, 21 did not have clinically relevant injuries, whereas the 14 remaining patients did. All of the 14 required prolonged hospital admissions and 9 underwent invasive procedures.

CONCLUSION

Of over 4,700 observed trauma patients, less than 0.5% remained hospitalized for significant missed injuries. No factors were identified that predicted missed injuries. Twenty-three-hour observation for the purpose of identifying missed injuries after thorough emergency department evaluation may not be justified.

Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy

OBJECTIVE

A prospective study was performed to determine the usefulness of triple-contrast helical CT in predicting peritoneal violation and the need for laparotomy in the treatment of penetrating torso trauma.

SUBJECTS AND METHODS

Triple-contrast helical CT scans were obtained in 104 hemodynamically stable patients with penetrating injuries to the torso (thoracoabdominal region including tangential wounds to the anterior abdomen, flank, back, and pelvis) over a 17-month period. The study group included 54 patients with gunshot wounds and 50 with stab wounds. No patient had a radiographic or clinical indication for immediate laparotomy. A positive finding on CT was defined as evidence of peritoneal violation or injury to the retroperitoneal colon, major vessel, or urinary tract. Patients with a positive CT, except patients with isolated liver injury or free fluid, underwent laparotomy. Patients with a negative finding on CT were initially observed.

RESULTS

CT studies were positive in 35 (34%) of 104 patients and negative in 69 (66%) of 104 of patients. Laparotomy was performed in 21 (60%) of 35 patients with positive CT; 19 (86%) of 22 were therapeutic, two (9%) were nontherapeutic, and one (5%) was negative (no injury was found). Nine patients with isolated hepatic injuries were successfully treated without laparotomy. Among patients with a negative CT, 67 (97%) of 69 were treated nonoperatively with success. CT had 100% (19/19) sensitivity, 96% (69/72) specificity, 100% (69/69) negative predictive value, and 97% (101/104) accuracy in predicting the need for laparotomy.

CONCLUSION

Triple-contrast helical CT can accurately predict the need for laparotomy and exclude peritoneal violation in penetrating torso trauma including tangential abdominal wounds.

Pediatric observation medicine

Observing pediatric patients in an OU (whether a pediatric or combined or hybrid unit) has many advantages: better patient care, a decrease in missed diagnoses and acuity, better risk management, decreased malpractice liability, cost effectiveness, increased patient and family satisfaction, and psychosocial benefits. Key principles of observation medicine (purpose, time frame, general patient inclusion and exclusion criteria, administration, CQI, and so forth) are equivalent for pediatric and adult observation patients, but there are important differences. Unique characteristics of pediatric observation patients include specific diagnosis, decreased length of stay, less need for cardiac monitoring, a highly variable admission rate, and a decreased percentage or admission rate to the OU from the ED. Whereas the adult OU is primarily a cardiac-monitoring unit, the pediatric OU is a respiratory and infectious disease unit with a frequent need for an i.v. therapy and hydration. Types of pediatric patients commonly treated in an OU include respiratory illnesses (asthma, croup, bronchiolitis, pneumonia), gastrointestinal disorders (gastroenteritis, abdominal pain), dehydration, infections (fever, cellulitis, lymphangitis, pyelonephritis or UTI), overdoses or poisonings, and seizures.

Management of traumatically injured patients in the emergency department observation unit

An EDOU may be an ideal setting for the short-term monitoring and treatment of certain acutely injured patients. The patients choosen for observation, and the diagnostic studies used, will be specific to a particular institution's availability and expertise. Pathways should be developed in conjunction with all services caring for these patients.

A short stay or 23-hour ward in a general and academic children's hospital: are they effective?

OBJECTIVE

We evaluated the usefulness of a short stay or 23-hour ward in a pediatric unit of a large teaching hospital, Westmead Hospital, and an academic Children's hospital, The New Children's Hospital, to determine if they are a useful addition to the emergency service.

METHODS

This is a descriptive comparison of prospectively collected data on all children admitted to the short stay ward at Westmead Hospital (WH) during 1994 and the short stay ward at the New Children's Hospital (NCH) during 1997-98. These hospitals service an identical demographic area with the latter (NCH) a tertiary referral center. The following outcome measures were used: length of stay, appropriateness of stay, rate of admission to an in-hospital bed, and rate of unscheduled visits within 72 hours of discharge. Adverse events were reported and patient follow-up was attempted at 48 hours after discharge in all cases.

RESULTS

The short stay ward accounted for 10.3% (Westmead Hospital) and 14.7% (New Children's Hospital) of admissions, with 56% medical in nature, 30% surgical, and the remainder procedural or psychological. Admission patterns were similar, with asthma, gastroenteritis, convulsion, pneumonia, and simple surgical conditions accounting for most short stay ward admissions. The short stay ward increased hospital efficiency with an average length of stay of 17.5 hours (Westmead Hospital) compared to 20.5 hours (New Children's Hospital). The users of the short stay ward were children of young age less than 2 years, with stay greater than 23 hours reported in only 1% of all admissions to the short stay ward. The rate of patient admission to an in-hospital bed was low, (4% [Westmead Hospital] compared to 6% [New Children's Hospital]), with the number of unscheduled visits within 72 hours of short stay ward discharge less than 1%. There were no adverse events reported at either short stay ward, with parental satisfaction high. The short stay ward was developed through reallocation of resources from within the hospital to the short stay ward. This resulted in estimated savings of $1/2 million (Westmead Hospital) to $2.3 million (New Children's Hospital) to the hospital, due to more efficient bed usage.

CONCLUSION

This data demonstrates the robust nature of the short stay ward. At these two very different institutions we have shown improved bed efficient and patient care in a cost-effective way. We have also reported on greater parental satisfaction and early return of the child with their family to the community.

Role of the short stay observation ward in accident and emergency departments in the United Kingdom

OBJECTIVE

To define the role of the accident and emergency (A&E) short stay ward by a survey of departments in the United Kingdom and review of published reports.

METHODS

A postal questionnaire with telephone follow up to all major A&E departments with short stay beds.

RESULTS

95 departments were found to have short stay beds. These units received between 19000 and 121000 new patients per year (mean 51000, median 50500) and had access to between two and 20 beds (mean 7.5, median 6). The level of provision varied from one bed per 2440 new attendances to one bed per 27250 new attendances (mean 8380, median 6625). Where data on admission rates were available the departments admitted between 0.1% and 13.3% of their new attendances (mean 2.62%, median 1.9%). Cover was typically provided by an A&E senior house officer with frequent senior ward rounds. While the casemix usually included minor head injuries and alcohol intoxicated patients, there was considerable variation in the cases admitted.

CONCLUSIONS

Short stay provision is highly variable in the United Kingdom. While there are many reports of well run short stay units, consistent evidence of clinical value and cost-effectiveness compared to other methods of care is lacking. Further comparative studies are required to define the role of the A&E short stay ward.

Stab wounds to the back and flank in the hemodynamically stable patient: a decision algorithm based on contrast-enhanced computed tomography with colonic opacification

PURPOSE

The authors wanted to determine whether contrast-enhanced computed tomography (CE-CT) with colonic opacification is an accurate tool to triage hemodynamically stable victims of stab wounds to the flank and back.

PATIENTS AND METHODS

One hundred forty-five consecutive patients were categorized as low-risk ( penetration superficial to the deep fascia) or high-risk (penetration beyond the deep fascia) based on CE-CT findings.

RESULTS

There were no significant differences in admission vital signs, Glasgow Coma Scale, or complete blood counts between low- and high-risk groups. None of the 92 low-risk patients required surgery or had sequelae. Six of the 53 high-risk patients underwent surgery, 2 based on initial CE-CT, 4 due to evolving clinical signs. The CE-CT correctly predicted surgical findings in all cases.

CONCLUSIONS

Hemodynamically stable patients with stab wounds to the back and/or flank can be successfully triaged based on CE-CT findings. Low-risk patients may be discharged immediately. High-risk patients may have a discharge decision implemented at 24 hours.

Occult pseudoaneurysm of the abdominal aorta following gunshot wound: the importance of plain film findings

A traumatic pseudoaneurysm of the abdominal aorta eluded detection at initial laparotomy, but was later detected serendipitously. Early abdominal x-ray film and appreciation of paraspinal bullet fragments could have led to its earlier detection. A portable abdominal x-ray film should be a routine part of the preoperative resuscitation of abdominal gunshot wounds.

Ten year review of thoracic and abdominal penetrating trauma management

A ten year review of penetrating thoracic and abdominal trauma examined pattern of injury, patient management and outcome. Ninety-six patients were included in the study, 55 with injury to the abdomen, 31 the thorax and 10 with injury to both areas. Fifty-eight cases were managed non-operatively; 5 combined abdominal and thoracic injuries, 26 thoracic and 27 abdominal. Two cases went on to require operative management for intra-abdominal injury. Thirty-eight cases were managed operatively; 5 combined cavity injuries, 5 thoracic and 28 abdominal. Injuries were found in all of the combined cavity and thoracic cavity cases. Of the 28 abdominal cases, nine were found on laparotomy to have no significant visceral or vessel injury, one, however, was performed for omentum protruding through the wound. While a negative laparotomy was a relatively safe procedure, non-operative management had the advantages of a shorter hospital stay without wound-related morbidity. Selective non-operative management was found to be a relatively safe approach in this series.

Can short hospital admissions be avoided? A review of admissions of less than 24 hours' duration in a paediatric teaching hospital

OBJECTIVE

To review the records of children admitted to hospital for less than 24 hours to assess the appropriateness of the admission and subsequent discharge, and the suitability of these patients for admission to a short stay area rather than the hospital wards.

DESIGN

Retrospective study consisting of a one in three sample of all children admitted to the hospital's general medical units over one year. All admissions were listed sequentially, and every third patient was included in the study.

SETTING

Royal Children's Hospital, Melbourne; a tertiary paediatric hospital with a major primary care role.

PARTICIPANTS

There were a total of 660 patients eligible for inclusion in the study; 220 were selected, and all records were reviewed.

RESULTS

It was found that although 87.7% of admissions could be justified on medical grounds alone, the children quickly recovered with at least 65% being fit for discharge within 12 hours of admission. In spite of this the mean duration of admission was 17.0 hours. The majority of patients were suffering from easily diagnosed and treated disorders, with 78.9% falling into four diagnostic groups (asthma, ingestions, infections, and convulsions). Criteria for admission to a short stay observation area were satisfied in 65% of patients (at the time of the study no such area existed in the hospital). No patients were discharged inappropriately early.

CONCLUSIONS

A significant number of children require brief hospitalisation for relatively minor illness, but unnecessary delays caused by administrative aspects of hospital admission and relatively infrequent inpatient review by medical staff often lengthen the period of admission. Significant cost savings are possible with the use of a short stay facility, and a large number of patients are suitable for this form of care.

Probability of appendicitis before and after observation

STUDY OBJECTIVE

To examine patients with abdominal pain for changes in probability of appendicitis during observation.

STUDY DESIGN

Retrospective cohort study.

SETTING

University-affiliated community hospital.

METHODS

252 patients with abdominal pain who were examined underwent short-term (10.4 hours) observation (95% confidence interval [CI], 8.7, 12.1) before the decision to operate during a one-year period. Alvarado's scoring system and a probability-of-diagnosis nomogram were used to assign scores and estimate probability of appendicitis.

MEASUREMENTS AND RESULTS

In the study group, mean score of patients with appendicitis increased after observation from 6.8 (95% CI, 6.2, 7.4) to 7.8 (95% CI, 7.3, 8.3), corresponding to a change in probability of appendicitis from 50% to 65%. Mean score of patients without appendicitis decreased from 3.8 (95% CI, 3.5, 4.1) to 1.6 (95% CI, 1.58, 1.62), corresponding to a change in probability from 35% to 22%. The difference between mean scores for patients with and without appendicitis increased from 2.6 (95% CI, 2.0, 3.2) to 6.2 (95% CI, 6.15, 6.25) during observation. The study group initially had intermediate probability of appendicitis (score, 4.35; 95% CI, 4.04, 4.66) compared with high probability for patients who went directly to surgery after their initial evaluation (63 patients; score, 7.59; 95% CI, 7.05, 8.73) and low probability for patients with abdominal pain who were sent home after their initial evaluation without observation or surgery (2,097 patients; score, 1.87; 95% CI, 1.48, 2.26).

CONCLUSION

In this group of patients with intermediate initial probability of appendicitis, observation improved the ability to distinguish patients with from those without appendicitis.