A Management of Blunt Thoracic Trauma in an Emergency Department Observation Unit: Pre-Post Observational Study

BACKGROUND: The best management of patients with isolated blunt thoracic trauma at high risk of pulmonary complications (HRPC-BTT: 3 isolated rib fractures, sternal fracture, single or few pulmonary contusions or minimal pneumothorax) is still unclear. We compared efficacy and cost-effectiveness of a new clinical pathway involving an Emergency Department Observation Unit (EDOU) with routine care. METHODS: Design: Retrospective before-after study. Setting: Level II Trauma Center within a Regional Teaching Hospital. Participants: A consecutive series of patients with HRPC-BTT. Interventions: a new clinical pathway involving EDOU was implemented. Main outcomes: Death rate, tube thoracostomy, and re-admission of discharged patients. Hospital admission rate, length of hospital occupancy, overall costs, and cost-effectiveness were also compared in pre- and post-EDOU period. RESULTS: Two hundred forty patients were eligible for the study: 110 patients in the pre-EDOU period and 130 in the post-EDOU period. Thirteen (12%) of the treated patients were re-admitted to the ED in the pre-EDOU period compared with only five (4%) when the EDOU was available (p 0.03). The rate of tube thoracostomy performed in admitted patients significantly increased after EDOU implementation: 1 of 54 (1.9%) versus 4 of 32 (12.5%; p 0.05). The rate of hospitalization decreased from 49% in the pre-EDOU period to 24% in the post-EDOU period (p 0,005) and the length of stay in hospital in the pre-EDOU period was longer than in the EDOU period: mean 94.7 79.6 versus 65.7 60.6, respectively (p 0.02). Cost analysis revealed no relevant change in cost-effectiveness per patient (median; interquartile range): €487; €103 to 1959 versus €616; €124 to 1455, respectively, in the pre- and post-EDOU period. CONCLUSIONS: In managing patients affected by HRPC-BTT, a clinical pathway involving the EDOU seems to be more effective than routine care with little impact on cost. (J Trauma. 2012;72: 222–228. Copyright © 2012 by Lippincott Williams & Wilkins) KEY WORDS: Blunt thoracic trauma; emergency department observation unit; before-after study; prevention.