Emergency Department Disposition and Point-of-Care Ultrasound in Biliary Disease: Propensity-Weighted Cohort Study.

introductionBiliary tract disease is a frequent cause of abdominal pain among emergency department (ED) patients and accounts for a significant portion of hospital admissions and return visits. Our objective was to compare ED outcomes for patients ultimately diagnosed with biliary tract disease based on the use of point-of-care ultrasound (POCUS) during their initial visit. We specifically analyzed patients admitted after an unscheduled return visit within 72 hours vs those admitted directly from the ED.

methodsIn this retrospective cohort study we used propensity score weighting and included 1,228 adults admitted for biliary tract disease, either during their initial ED visit (n = 1,120, 91.2%) or following an unscheduled return visit within 72 hours (n = 108, 8.8%) at a tertiary center in Taiwan between 2021-2023. Outcomes included ED length of stay (LOS), costs, hospital LOS, intensive care unit (ICU) admission, and in-hospital mortality. We used multivariable regression models with inverse probability of treatment weighting adjustment to account for baseline differences.

resultsInitial discharge followed by admission after an unscheduled return visit was not associated with worse clinical outcomes compared to direct admission. There were no significant differences in in-hospital mortality (0.93% vs 1.16%; odds ratio [OR] 0.59, P = .56) or ICU admission (0.93% vs 0.71%; OR 1.78, P = .61). While the initial ED LOS was shorter (mean: 4 hours vs 15.6 hours; regression-adjusted difference -6.66 hours, P < .001) and the initial ED costs were lower (mean: NT5477 vs NT$16,269, a 66% savings; regression-adjusted difference: -NT$6,548, P < .001), this reflects an expected early discharge. Among patients ultimately requiring admission after an unscheduled return visit, those who received POCUS at their index visit had a significantly shorter initial ED LOS (mean: 2.97 hours vs 4.78 hours; regression-adjusted difference -1.42 hours, P = .006) and lower initial ED costs (mean: NT$3,248 vs NT$7,149; a 55% saving; regression-adjusted difference -NT$3,271, P < .001) compared to those who did not. This initial POCUS use did not increase adverse events; only one of the 108 patients in the unscheduled return visit group required ICU admission (0.9%, 95% CI, 0.02-5.1%), and no deaths occurred (0%, 95% CI, 0-2.78%).

conclusionInitial discharge following ED assessment appears safe for many low-risk patients ultimately diagnosed with biliary tract disease on repeat visit within 72 hours. Incorporating POCUS during the initial evaluation may shorten ED LOS and reduce costs for patients who later require admission, without apparent measurable negative effects on mortality, hospital, or ICU length of stay.