1414. Optimizing hospital admission rates in patients with traumatic subarachnoid hemorrhage

Authors: Risheng Xu, MD; Chau Vo, BS; Wuyang Yang; Jason Liew, BA; Ted Alban; James Feghali, MD; Justin Caplan, MD; Rafael Tamargo, MD; Judy Huang, MD (Baltimore, MD)

Introduction: Patients are often routinely admitted for observation due to isolated traumatic subarachnoid hemorrhage(tSAH). Here, we characterize factors associated with adverse outcomes or readmissions, and identify those predictive of patients who may not require hospitalization. Methods: All patients who presented with tSAH from 1/2017-3/2017 to our Emergency Department were identified. Factors associated with neurologic decline, neurosurgical intervention, hospital readmission, or death were identified via multivariate logistic regression. Based on these findings, we retroactively identified a patient subpopulation who may not require admission. We report their outcomes, summarize their admission rates, and compare their hospitalization costs. Results: An admission diagnosis of intracranial hemorrhage was identified in 215 consecutive patients over three months, of which 49(22.8%) had tSAHs. On multivariate analysis, patient characteristics associated with neurologic decline, neurosurgical intervention, hospital readmission, or death included orientation(OR:0.45,p=0.029) and warfarin use(OR:7.5,p=0.04). We retroactively looked for a subpopulation of patients who were oriented to self, place, and time, and did not have a history of warfarinuse. Of these 28 patients, 10 were discharged without admission, and their average emergency room costs were $2004, compared to 18 patients admitted to the hospital, whose average length of stay was 2.5 days and hospitalization costs were $8823(p<0.001). No patients in either cohort had adverse outcomes, and none were readmitted for tSAH-related reasons within an average follow-up time of 9.6 months. Extrapolated over one year, this represents a potential avoidance of >70 hospital admissions and >$550,000 in direct healthcare costs. Conclusion: Patients with tSAH who are fully oriented and not taking warfarin, and who have no conditions necessitating admission to another medical service, are less likely to have neurologic decline, require neurosurgical intervention, hospital readmission, or mortality. In carefully selected patients, ED observation and discharge without neurosurgical admission may be an effective strategy to facilitate improved healthcare resource utilization.