Acute obstructive jaundice management in emergency: Management, clinical and patient’s safety considerations regarding the use of the short observation unit

Andrea Piccioni¹, Carmine Petruziello¹, Vincenzo Perri², Guido Costamagna², Francesco Franceschi¹, Matteo Bolcato³, Marco Trabucco Aurilio⁴,Veronica Ojetti¹

¹Emergency Department, Fondazione Policlinico Universitario A. Gemelli-IRCSS, Catholic University, Rome, Italy - ²Digestive Endoscopicy Unit, Scientific Institute for Research, Hospitalization and Health Care, Fondazione Policlinico Universitario A. Gemelli, IRCSS, Catholic University, Rome Italy - ³Legal Medicine, Department of Molecular Medicine, University of Padua, Padua, Italy - ⁴Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy

Introduction: Obstructive jaundice is a frequent cause of access to the Emergency Department (ED) and requires rapid hospitalization in order to perform an endoscopic retrograde cholangiopancreatography (ERCP). To reduce overcrowding, Brief Observation Units (BOU) were set up in EDs throughout Italy where patients receive treatment for 48-72 hours, significantly decreasing hospitalizations. The objective of this study is to evaluate the cost-effectiveness of a new model for managing obstructive acute jaundice in BOUs and provide indications regarding the possibility of systematic implementation thereof within EDs.

Materials and methods: From 1 January 2019 to 31 December 2019, we evaluated 213 patients (100 M/113F, mean age 65±16.8 years) who presented at the ED with acute obstructive jaundice and were subsequently admitted to the BOU. Each patient underwent blood tests, an ECG, and an ultrasound or CT scan to confirm the diagnosis. In addition, each patient presented with ERCP indications. We analyzed the introduction of the BOU from a clinical, economic and discharge time perspective and made some recommendations regarding the organizational opportunities.

Results: Clinical management in BOUs has produced excellent results, but it is not cost-effective. It does, however, produce excellent performance in terms of discharge times.

Conclusion: This study shows both good clinical performance in the procedures carried out in the BOU and the opportunity to avoid patient hospitalization, thus optimizing the use of available hospital beds. From an economic perspective, BOUs prove more costly and receive lower reimbursements from the Diagnosis Related Groups (DRG) system. However, despite its inefficacy in terms of costs, it may be used with certain objective advantages, especially in view of the need to liberate as many hospital beds as possible and avoid unnecessary hospitalizations during the current pandemic. Furthermore, BOUs may also improve clinical results and patient safety. Management of obstructive jaundice in BOUs may be seen as an alternative care setting to the traditional methods of admission, although with economic limitations.