A recently implemented ER-to-OR pathway has demonstrated reduced inpatient admissions without a significant increase in readmissions for patients with acute appendicitis and acute cholecystitis. The findings, presented during the 2023 annual meeting of the Surgical Infection Society, highlight the potential positive impact of this strategy on patients and hospitals during the COVID-19 pandemic.
“An ED [emergency department]-to-OR fast-track pathway utilizing the clinical decision unit for patients presenting with these two most common [emergency general surgery] conditions is safe, can avoid the majority of inpatient admissions and is associated with a very low rate of admission in 30 days,” said lead study author Husayn Ladhani, MD, a general surgery specialist at Denver Health Medical Center.
As Dr. Ladhani explained, the pandemic put extreme stress on the healthcare system, leading to critical staffing shortages and delays in treatment for emergency general surgery patients.
To mitigate these factors, Dr. Ladhani and colleagues implemented an ER-to-OR pathway for patients presenting with acute appendicitis or acute cholecystitis and planned for operative intervention. The objective was to reduce the number of inpatient admissions for these common conditions with a relatively short length of stay (LOS).
The study involved 166 consecutive patients over four months, with a median age of 38 years and majority being female. The median LOS in the ED was 9.4 hours, while 60% of patients were admitted to the clinical decision unit prior to OR with a median LOS of 5.9 hours. Only 19% of these patients were admitted postoperatively, and the overall readmission rate within 30 days was 3%.
Comparing patients who went directly to the OR versus those who went to the clinical decision unit prior to OR, researchers found no significant difference in rates of discharge from the PACU, 30-day visits or 30-day admissions between the two groups. Of note, 81% of patients in the pathway were able to avoid a hospital admission, Dr. Ladhani said.
Patients with cholecystitis had a longer stay in the ED and clinical decision unit compared with those with appendicitis. According to Dr. Ladhani, this was likely due to the practice of performing most cholecystectomies during daylight hours at the institution.
Among the patients discharged from the PACU, only two (1.5%) were admitted within 30 days, with one case unrelated to the index operation.
Dr. Ladhani noted several limitations of the study, including a short period, lack of historical cohort, variability in discharge rates among providers and exclusion of patient consultations.
“Despite these limitations, the ER-to-OR pathway presents a promising solution for reducing inpatient admissions for patients with acute appendicitis and acute cholecystitis, especially in times of healthcare system stress like the COVID-19 pandemic,” Dr. Ladhani said.
The researchers plan to compare these results with a historical cohort to measure the true impact of the pathway on LOS in the ED, admission rates, cost savings to patients and hospital capacity.
“The potential financial implications of this pathway include the possibility of accepting more inter-facility transfers, treating more patients and decreasing costs for patients by spending less time in the hospital system,” Dr. Ladhani added. “The only perceived disadvantage is the possibility of lower billing by the surgeon.”
Abstract discussant, Jeffrey A. Claridge, MD, the director of the Division of Trauma, Burns, Critical Care and Acute Care Surgery at MetroHealth Medical Center, in Cleveland, emphasized that this study is an early report and a proof of concept, and comparators are not yet available.
Dr. Claridge also noted that a clearer description of the study setting would be useful, as these findings may not be generalizable to other emergency general surgery care settings. In addition, said Dr. Claridge, there are potential implications of performing gallbladder surgeries in the middle of the night, given the staffing and resources available for such cases.
Dr. Claridge also had questions regarding the selection criteria for patients who are eligible for the ER-to-OR pathway, as many patients with appendicitis and cholecystitis require admission due to comorbidities, anticoagulant use or advanced disease processes.
Finally, Dr. Claridge emphasized the importance of considering patient satisfaction and outcomes in future research on the ER-to-OR pathway, as these factors are crucial in determining the overall success and effectiveness of the approach.
This article is from the September 2023 print issue.