Update Course Rewind: ED Utilization 2022

Hi everyone, I'm Cecilia Heymann from Cincinnati's Children's Hospital. Hello, I'm Britney Levy, a research resident at Cincinnati Children's Hospital Medical Center. If you miss our update course 2022, don't worry, because we're making an upcoming series with the rewinds of every talk. This talk is about which patients we can discharge from the ED. The moderator for this talk is Dr. Mark Wulkan. He's the surgeon in chief for Akron Children's Hospital. Well now we're going to talk about what you can send home from the emergency room. And I have with me Justin Huntington and Elizabeth Speck. Dr. Elizabeth Speck is a pediatric surgeon from Matt Children's Hospital at University of Michigan, and Dr. Huntington is a pediatric surgeon from Akron Children's Hospital. Okay, let's start with the first presentation. So you have a patient that comes in, you see the X-ray, they've got a pneumothorax. The kid looks pretty good, can you send this patient home from the emergency room? I have found this to be a high bar because within a group of practice, they're going to be some who want immediately Vats chest tubes and some wanting to send home right away. So I have found it to be a hard protocol for everybody to adopt. That's Dr. Matt Carman, the surgeon in chief at Oshi Children's Hospital in Buffalo, New York. So what did the poll say, Ellen? About 70% are saying no. So 70% will not send this patient home. But let's see what data Dr. Speck has to share. Uh the NWPC looked at this and they they really supported changing the paradigm for management of spontaneous pneumothorax. So they did a really good study that demonstrated, you really can aspirate the chest. If they uh successfully, you know, pass your test of time, repeat the imaging, asymptomatic, send them home. And if not, cut bait and go to early vats. That was pretty clear. Of course, that begs the question here in the New England Journal of Medicine study in 2020. If your algorithm can start by sending them home after an aspiration, what if you just start by not doing anything? This study demonstrated with 85% of these patients never underwent an intervention of any sort. So they were able to just be observed, get a repeat chest X-ray four hours later if their symptoms were at least manageable and their x-ray wasn't worse, send them home. But some may have some concerns about this. As Dr. Michael Golfan, he's a pediatric surgeon from Tix. situation now, so maybe in the US that people had can reach in a hospital or in emergency room very quickly, that sounds okay. But if not, you need to be concerned about what's going on. If the patient go home three hours away, we don't know thetition during the night. I agree with Miguel, like you need to have some guidelines, right? If someone got transferred to your hospital from six hours away, that's probably not the person you want to send back out just like straight from the ER with no intervention, but I mean, it's against all surgical teaching, right? I think that's what makes people so uncomfortable is they're like, well, we were always taught you have to get the lung to come up and you have to do this, you have to do that. And this article pretty strongly says, maybe you don't. Agreeing with him was Dr. Beth Resky, a pediatric surgeon from Cincinnati's Children's Hospital. As we could all predict, Dr. Todd Ponsky had a follow-up question. Has anyone seen a patient in extremis from a spontaneous pneumothorax? I have. I'm talking about one is just movable. Right. The point is this is probably not as dangerous as we thought. Okay. So spontaneous pneumothorax with no or minimal symptoms that has a fast and secure way to come back to the hospital, can be discharged from the ED. Let's jump to next case. You have a 13-year-old, 5-day history of coughing, and worsening chest pain, and you see some pneumo mediastinum. What do you do? What's the uh poll look like? Okay, how many are saying to send the patient home? Um 14%. Okay, so let me rephrase this. Only 14% of the audience would send this patient home, meaning 86% will admit them. How about the people in the room? Raise your hand if you get an esophagram. CT scans? Admit them? Todd. Of course. I think I'm allowed to make baby steps. I used to get like a million studies and now I don't get any studies. But I'm still a bit nervous. So I watch them for 12 hours or 24 hours and send them home. To make sure I didn't miss something like an esophageal leak or something that. Okay. So let let's see what data has to say. Uh Dr. Sanchez all the University of Michigan looked at the all of the esophagrams done for spontaneous pumo mediastinum and the the the short version is they were all negative. I looked up all of our data since 2016, same thing. 30% of our patients um got an esophagram. 100% were negative. So I think the the the point there is don't get an esophagram. Uh you have a chest x-ray that shows pumo mediastinum, you're you're just CT is not going to show anything different. It's going to show pumo mediastinum. You don't need an esophagram, so just don't admit them, send them home. You could probably logically think from this then that if somebody really did have an esophageal leak, they would probably present with more than just pumo mediastinum. Then spontaneous pumo mediastinum caused by viral infection with mild cough can be discharged from the ED. Let's see what's next. So we have a healthy 12-year-old girl in the ER, 24-hour history of right lower quadrant pain, white counts 14, ultrasound is read as equivocal for appendicitis. What do you do, Todd? It's equivocal with no which those are good secondary signs. So no evidence of inflammation. Um I actually do, Mark, send them home. So as a reminder, it's important to talk to the parents and explain that even though it's unlikely, this can still turn into appendicitis. I think this one also depends on your institution because some places have MRIs that they can do all hours of the day and it also goes back to the practice pattern of like we have patients that don't use cars. You know, there's some art to this, but I think for the most part, you send them and give them instructions of when to come back. And that was Dr. Justin Huntington. And also he has a follow-up question. Some a New York physician calls you from another hospital and says ultrasound or CT shows appendicitis. Then they come and your radiologist looks at it and they say it's equivocal. What do you do with that patient? Yeah. I'll tell you my bias. I think you either treat them with a week of antibiotics or you operate. Or or you can send them home and tell them to come back if it's a problem. I've also had the scenario where you have a patient that has like minimal pain, has not had any antibiotics or anything. The ER doc decided to get a CT for the heck of it and they say it's appendicitis. But, you know, minimal appendicitis, they'll tell you that early appendicitis. What do you do with that patient? Trust the technology. As I trust myself. I trust the exam over the technology. I sent that patient home and tell him to come back. People people have follow-up like something called appendicitis of the tip of the appendix defined by ultrasound or even CT scan, and all those patients sent home, none of them had had surgery for appendicitis. We have some discussion here, but let's see what data says. Like I said, there wasn't really a lot about what do you do with an equivocal ultrasound, but this is just sort of validating what we already know that ultrasound is really effective in kids and then you can improve the accuracy a little bit by using like an Alvarado type score. Okay, so equivocal ultrasound for appendicitis, mild symptoms, and a fast and secure way to return to the hospital. Those children can be sent home. Perfect. Let's see another case. Okay, straddle injuries. So you have a six-year-old girl that fell on her bike and has a straddle injury, no active bleeding, you feel like you can get a reasonable awake exam in the ER. So do you send this patient home from the ER, Todd? Let me ask you this, what do you need to see in the ER to say it's adequate? Not sure. What do you need to see it to send them home from the ED? Yeah, I think it's, you know, no active bleeding, perineal body intact, they can urinate, this should be fine. Okay, and the data for this was explained by Dr. Ellen Cisco. So let's see what she had to say. So this paper was talking about, you know, the option of sending patients home from the ED after conscious sedation in the ED to get a better evaluation. We've actually been looking at Akron children's at our data of perennial injuries coming in. We have about 200 patients and almost half of them get sent home from the ED without even seeing a surgery consult. Yeah, I think I think it says two things. Number one, we think we're seeing all these, we're not. The ER's sending tons of these kids home that you never hear about. The other thing is, if you booked them for the OR, you're probably going to put a stitch in and whether that was necessary is debatable. So basically, straddle injury with no active bleeding or perineal compromise can be discharged from the emergency department. Ready for the next one. So you have an American football player in high school, gets hit in the head, loses consciousness for about 30 seconds. He wakes up, he's neurologically intact. We don't even ask this question, does he need a head CT? Mark, are you suggesting you don't need to get a cat scan? Not for a 30-second loss of consciousness. So anyhow, that's not that's not even this question. So we're just we're just probing it. That's not even so the question so he had a negative head CT. Now do can he go home with a loss of consciousness, negative head CT. Wait, go home. But he had unconsciousness. Let's see what the data has to say. That basically just showed what we talked about that if you have concussion, they included negative head CT, so it they talk about readmission. I think it's almost zero. Okay. So according to this, a head trauma with a 30 seconds or less unconsciousness that has a negative CT is allowed to go home from the ED. Great. Do we have another case? We have another case. Let's see. A kid that comes into the ED successful iliac colicception reduction. How long do people watch them that's in the from the year. I see four hours. Next day? Do you admit them? Admit? I admit. I send them home. Four hours. I send them home. All right. Seems like four hours is pretty consistent. Well, didn't see this one coming. So, a successful reduction of an intussusception can be sent home from the ED after two or four hours of watching it. That's amazing. Okay. Let's see that last case. So no loss of consciousness, a baby linear skull fracture, would you send this baby home? I may have been better to do an older kid because obviously you're thinking NAT also. NAT. Just to clarify for those that are not from here as me. NAT means non-accidental trauma. It's used for child abuse. And the chances of this being NAT in a kid who's over two years old is very unlikely. So I know our we're we're working through a protocol where I think we're going to use two as a cutoff. Skull fractures in patients older than two years that has no loss of consciousness and has no suspicion for NAT can be discharged from the ED. So I do want to say how important this is because as Dan's been pointing out to me across the country, there's access issues. And we are occupying beds and uh uh with patients that don't need to be there because of people like me and I I do think this is important. That's why I was very excited for this session. Wait, wait. We have a bonus track from Dr. Mira Cogel. So there's a bunch of evidence for the grade one and grade twos isolated solid organ injury that those patients could be discharged from the EDM. That's for grade one, grade two isolated. So they can't also have a femur fracture and a head injury, but if they need a transfusion or something like that, they tend to need it in the first four hours. Four hours, recheck a hematocrite or just what. So so I mean we do it based on how they're doing. Looking good after four hours, you send them home. Grade two. liver spleen and. Liver. Liver spleen kidney, grade one, grade two. Yeah. Awesome. So now we are going to summarize who we can send from the ED. Spontaneous pneumothorax with no or minimal symptoms, spontaneous pumo mediastinum with a viral cough and no other symptoms, equivocal ultrasound for appendicitis, mild symptoms, head trauma with less than 30 seconds of unconsciousness and negative CT, straddle injury with no active bleeding or perineal compromise, successful intersiception reduction, skull fractures older than two years, no NAT or loss of consciousness, and our bonus track, isolated solid organ injury grades one or two. That's why we do this course. I will change my practice now. This was awesome. So, there you have it, our update course 2022 rewind in which patients can you send home from the ED. I hope you really like it. If you want to see more, go to state current talks. But until then, I'm Cecilia Hekena from Cincinnati's Children's Hospital. And I'm Britney Levy. Thank you for watching.