• Vincenzo Giannicola Menditto, Barbara Gabrielli, Matteo Marcosignori, Fabiana Screpante, Giuseppe Pupita, Stefano Polonara, Aldo Salvi, Gian Mario Raggetti, and Giovanni Pomponio.
• Department of Emergency Medicine, Medicina e Chirurgia d'Accettazione e d'Urgenza Ospedali Riuniti di Ancona, Ancona, Italy. v.menditto@univpm.it
• J Trauma Acute Care Surg. 2012 Jan 1;72(1):222-8.

BackgroundThe 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.MethodsDesignRetrospective before-after study.SettingLevel II Trauma Center within a Regional Teaching Hospital.ParticipantsA consecutive series of patients with HRPC-BTT.Interventionsa new clinical pathway involving EDOU was implemented.Main OutcomesDeath 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.ResultsTwo 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.ConclusionsIn 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.

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