title: A management of blunt thoracic trauma in an emergency department observation unit: pre-post observational study.
abstract: 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
  
  
  
  METHODS
  Retrospective before-after study.
  
  
  METHODS
  Level II Trauma Center within a Regional Teaching Hospital.
  
  
  METHODS
  A consecutive series of patients with HRPC-BTT.
  
  
  METHODS
  a new clinical pathway involving EDOU was implemented.
  
  
  RESULTS
  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.
authors.affiliation: Department of Emergency Medicine, Medicina e Chirurgia d'Accettazione e d'Urgenza Ospedali Riuniti di Ancona, Ancona, Italy. v.menditto@univpm.it
authors.forename: Vincenzo Giannicola
authors.initials: VG
authors.lastname: Menditto
authors.forename: Barbara
authors.initials: B
authors.lastname: Gabrielli
authors.forename: Matteo
authors.initials: M
authors.lastname: Marcosignori
authors.forename: Fabiana
authors.initials: F
authors.lastname: Screpante
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Pupita
authors.forename: Stefano
authors.initials: S
authors.lastname: Polonara
authors.forename: Aldo
authors.initials: A
authors.lastname: Salvi
authors.forename: Gian Mario
authors.initials: GM
authors.lastname: Raggetti
authors.forename: Giovanni
authors.initials: G
authors.lastname: Pomponio
mesh_terms: D003362:Cost-Benefit Analysis; D019091:Critical Pathways / Q000191:economics; D005260:Female; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D012189:Retrospective Studies; D013898:Thoracic Injuries / Q000191:economics / Q000401:mortality / Q000628:therapy*; D013907:Thoracostomy; D014193:Trauma Centers / Q000191:economics; D014949:Wounds, Nonpenetrating / Q000191:economics / Q000401:mortality / Q000628:therapy*