ER to OR Pathway for Patients with Acute Appendicitis and Acute Cholecystitis: Outpatient Emergency General Surgery

Author(s):
Husayn Ladhani; Morgan Pinkston; Barry Platnick; Eric Campion; Ernest Moore; Daniel VanDerPloeg; Renaldo Williams; Fredric Pieracci; D. Yeh, MD

Background:

The current healthcare workforce crisis has caused unique bed capacity issues. An Emergency Department to Operating Room (EDOR) pathway was implemented at our institution to eliminate inpatient admission for patients presenting with these two low acuity emergency general surgical conditions.

Hypothesis:

EDOR pathway can avoid inpatient admission without excessive readmissions.

Methods:

Over a 2-month period, patients presenting to our ED with acute appendicitis (AA) or acute cholecystitis (AC) with planned operative intervention were managed via the EDOR pathway: they were taken from the ER to OR if an OR was immediately available, or to the ED Clinical Decision Unit (CDU) while awaiting OR. Prior to this, patients for whom an OR was not immediately available were admitted to the ward and returned to their inpatient bed postoperatively prior to discharge. Following an uncomplicated operative course, EDOR pathway patients were discharged from the PACU.

Results:

A total of 56 patients were entered in the EDOR pathway: 30 (54%) with AA and 26 (46%) with AC (Table 1). Median [IQR] ED LOS was 8.6 [5.1-13.2] h. Thirty (54%) patients were transferred to CDU prior to OR; four were admitted postop and the remaining 26 were considered averted preop admissions. Of the 26 patients who bypassed the CDU (ED straight to OR), 6 were admitted postop and the remaining 20 were considered averted postop admissions. Therefore, a total of 46 (82%) out of 56 pathway patients were able to avoid admission. ED length of stay (LOS) was greater for patients with AC vs AA (12.7 h vs 5.4 h, p<.001), and more patients with AC were transferred to CDU prior to OR (85% vs 27%, p<.001). Postop, 46 (82%) were successfully discharged from PACU. The most common reason for admission postop was clinical judgment (more difficult than expected operative course, or high suspicion for complication). For the 23 patients with 30-day postoperative data, 6 (26%) presented to ED within 30 days for a suspected complication, of which only 2 (9%) were readmitted.

Conclusions:

An EDOR pathway was successful in avoiding hospital admission for >80% of acute appendicitis and acute cholecystitis patients with a 9% readmission rate.