Early discharge in Mild Acute Pancreatitis. Is it possible? Observational prospective study in a tertiary-level hospital

doi:10.1016/j.pan.2017.07.193

Pancreatology

Volume 17, Issue 5, September–October 2017, Pages 669-674

https://doi.org/10.1016/j.pan.2017.07.193 Get rights and content

Abstract

Background and aims

In acute pancreatitis (AP), first 24 h are crucial as this is the period in which the greatest amount of patients presents an organ failure. This suggests patients with Mild AP (MAP) could be early identified and discharged. This is an observational prospective trial with the aim to demonstrate the safety of early discharge in Mild Acute Pancreatitis (MAP).

Methods

Observational prospective study in a third level single centre. Consecutive patients with AP from March 2012 to March 2014 were collected. Inclusion criteria: MAP, tolerance to oral intake, control of pain, C Reactive Protein <150 mg/dL and blood ureic nitrogen < 5 mg/dL in two samples. Exclusion criteria: pregnant, lack of family support, active comorbidities, temperature and serum bilirubin elevation. Patients with MAP, who met the inclusion criteria, were discharged within the first 48 h. Readmissions within first week and first 30 days were recorded. Adverse effects related to readmissions were also collected.

Results

Three hundred and seventeen episodes were collected of whom 250 patients were diagnosed with MAP. From these, 105 were early discharged. Early discharged patients presented a 30-day readmission rate of 15.2% (16 patients out of 105) corresponding to the readmission rates in Acute Pancreatitis published to date. Any patient presented adverse effects related to readmissions.

Conclusion

Early discharge in accurately selected patients with MAP is feasible, safe and efficient and leads to a decrease in median stay with the ensuing savings per process and with no increase in readmissions or inmorbi-mortality.

Section snippets

Background and aims

Acute pancreatitis (AP) is a broad-ranging entity, which can go from a mild self-limiting disease that requires merely symptomatic treatment to a severe life-threatening illness that may require intensive care admission and aggressive treatment [1].

Our main objective in cases of AP is early detection of patients with severe condition or who are likely to worsen [2].

The first 24–48 h are crucial, as this is the period in which the highest proportion of patients present organ failure [3], [4].

Methods

This is a single-centre prospective observational study at a tertiary-level hospital. All consecutive adult patients (over 18 years old) diagnosed with AP and admitted to our centre from March 2012 to March 2014 were included. Diagnosis was based on characteristic abdominal pain, combined with elevated serum levels of pancreatic enzymes, as recommended in guidelines [1].

Data on demographic, clinical and laboratory parameters were recorded during the patient's admission to the emergency

Results

A total of 317 episodes were recorded between March 2012 and March 2014. Patients' mean age was 62 years (range: 18 to 96).

The flow chart in Fig. 2 presents the patients' distribution. One patient was excluded due to an error in the severity classification, and 66 patients who presented a moderate, severe or critical AP according to the DBC [5] were also excluded. From the 250 patients diagnosed with MAP within this period, 145 required admission for the reasons outlined in Table 1. Finally,

Discussion

This single-centre prospective observational study at a tertiary-level hospital was designed to assess the feasibility, safety and efficiency of a protocol for early discharge in selected patients diagnosed with MAP.

Patients without organ failure were classified as MAP by the Determinant Based Classification (DBC) [5] and by the Atlanta Modified Classification [6], which both have high potency for detecting more severe acute pancreatitis. In both classifications, the absence of organ failure

Disclosure

The authors have nothing to disclose.

Author's contributions

Neus Garcia Monforte involvement in the study was taking part in the design of the study.

Francisco Javier García Borobia involvement in the study was taking part in the design of the study.

Pere Rebasa Cladera involvement in the study was taking part in the design of the study and in the statistical analysis.

Juan Carlos García Pacheco involvement in the study was taking part in the acquisition of data.

Andreu Romaguera Monzonís involvement in the study was taking part in the acquisition of data.

References (26)

B.U. Wu et al.
Early changes in blood urea nitrogen predict mortality in acute pancreatitis
Gastroenterology
(2009 Jul)
E. Brullet et al.
A randomized study of the safety of outpatient care for patients with bleeding peptic ulcer treated by endoscopic injection
Gastrointest Endosc
(2004)
R.L. Hoffman et al.
Early discharge and readmission after colorectal resection
J Surg Res Elsevier
(2014 Aug 1)
T.L. Whitlock et al.
A scoring system to predict readmission of patients with acute pancreatitis to the hospital within thirty days of discharge
Clin Gastroenterol Hepatol [Internet]
(2011 Feb)
A.T. Ince et al.
A randomized controlled trial of home monitoring versus hospitalization for mild non-alcoholic acute interstitial pancreatitis: a pilot study
Pancreatology
(2014)
P. Rebasa et al.
Efectos adversos en cirugía general. Aná lisis prospectivo de 13.950 pacientes consecutivos
Cir Esp
(2011)
D.C. Whitcomb
Acute pancreatitis
N Engl J Med
(2006 Mar 2)
R. Mounzer et al.
Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis
Gastroenterology
(2012 Jun)
B.U. Wu et al.
Update in acute pancreatitis
Curr Gastroenterol Rep
(2010 Apr)
E.P. Dellinger et al.
Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation
Ann Surg
(2012 Dec)

P.A. Banks et al.

Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by.pdf

Gut

(2013)

WHO | WHO’s cancer pain ladder for adults. World Health Organization; Available from:...

D. Dindo et al.

Classification of surgical complications

Ann Surg

(2004)

Cited by (8)

Prospective evaluation of an emergency department protocol to prevent hospitalization in mild acute pancreatitis: Outcomes and predictors of discharge
2023, Pancreatology
While acute pancreatitis (AP) contributes significantly to hospitalizations and costs, most cases are mild with minimal complications. In 2016, we piloted an observation pathway in the emergency department (ED) for mild AP and showed reduced admissions and length of stay (LOS) without increased readmissions or mortality. After 5 years of implementation, we evaluated outcomes of the ED pathway and identified predictors of successful discharge.
We reviewed a prospectively enrolled cohort of patients with mild AP presenting to a tertiary care center ED between 10/2016 and 9/2021, evaluating LOS, charges, imaging, and 30-day readmission, and assessed predictors of successful ED discharge. Patients were divided into two main groups: successfully discharged via the ED pathway (“ED cohort”) and admitted to the hospital (“admission cohort”), with subgroups to compare outcomes, and multivariate analysis to determine predictors of discharge.
Of 619 AP patients, 419 had mild AP (109 ED cohort, 310 admission cohort). The ED cohort was younger (age 49.3 vs 56.3,p < 0.001), had lower Charlson Comorbidity Index (CCI) (1.30 vs 2.43, p < 0.001), shorter LOS (12.3 h vs 116 h, p < 0.001), lower charges (mean $6768 vs $19886, p < 0.001) and less imaging, without differences in 30-day readmissions. Increasing age (OR: 0.97; p < 0.001), increasing CCI (OR: 0.75; p < 0.001) and biliary AP (OR: 0.10; p < 0.001) were associated with decreased ED discharge, while idiopathic AP had increased ED discharge (OR: 7.8; p < 0.001).
After appropriate triage, patients with mild AP (age <50, CCI <2, idiopathic AP) can safely discharge from the ED with improved outcomes and cost savings.
Readmission in acute pancreatitis: Etiology, risk factors, and opportunities for improvement
2022, Surgery Open Science
Citation Excerpt :
Organ failure was defined according to the modified Marshall scoring system for organ dysfunction as a score of two or greater. Readmission rates in studies that included all patients treated for AP ranged from 7 to 34% and varied depending on etiology, disease severity, and medical comorbidities [8–30], Fig. 1. The median length of stay in four studies reporting readmission duration was 4–9 days [9,10,13,15].
Acute pancreatitis is associated with a readmission rate ranging from 7 to 34%. Readmission rates are highest among biliary (4–37%) and alcohol-induced (2–60%) acute pancreatitis. Severe acute pancreatitis and necrotizing pancreatitis have readmission rates ranging from 20 to 75%. The most common causes of readmission include recurrent acute pancreatitis (17–45% of readmissions) and smoldering symptoms/local complications (17–38%). A number of risk scores reliably estimate risk of readmission in acute pancreatitis. Decreased rates of readmission were reported in patients that underwent same-admission cholecystectomy in biliary pancreatitis and alcohol cessation interventions in alcohol-induced pancreatitis. This review article discusses readmission in acute pancreatitis, including etiology, risk factors, and opportunities for improved patient care.
The ratio of red blood cell distribution width to serum calcium predicts severity of patients with acute pancreatitis
2022, American Journal of Emergency Medicine
Citation Excerpt :
The Revised Atlanta Classification in 2012 proposed new classification criteria for AP, including mild acute pancreatitis (MAP) without organ failure (OF), moderately severe acute pancreatitis (MSAP) with OF lasting≤48 h, and severe acute pancreatitis (SAP) with persistent OF (POF) lasting>48 h [3]. Previous studies have shown that early discharge of accurately selected patients with MAP is feasible, safe and efficient and brings about a decrease in median stay with the ensuing savings per process and with no increase in re-admissions or in-hospital mortality [4]. But moderately severe or severe AP associated with local and/or systemic complications develops in approximately 20–30% of patients [5].
Illness severity of patients with acute pancreatitis (AP) at early stage is crucial because the identified moderate and severe cases need early intensive care to reduce the risk of serious complications such as multi-organ failure. Although red blood cell distribution width(RDW)and serum calcium(Ca)alone can be used as predictors of the severity of AP, they have low sensitivity and specificity. Thus, this study is aimed at evaluating the value of the ratio of RDW to serum calcium, which can all be acquired on admission, in predicting the severity of AP.
This study was based on a retrospective cohort study on patients with AP at the emergency department (ED) of West China Hospital Hospital from January 2016 to June 2016. We divided the patients with AP into two groups, mild acute pancreatitis (MAP) and moderate severe acute pancreatitis (MSAP) + severe acute pancreatitis (SAP). A receiver-operating characteristic (ROC) curve analysis was used to valuate the predictive value of the ratio of RDW to serum calcium for the severity of AP patients and the cut-off value for the ratio of RDW to serum calcium was calculated with sensitivity and specificity. P < 0.05 was considered statistically significant.
A total of 666 AP patients were enrolled in this study. These patients were divided into MAP (n = 518) and MSAP+SAP (n = 148) groups. The AUC of RDW/ Ca was 0.912 (95% CI 0.887 to 0.937, P < 0.001), larger than the AUCs of RDW (AUC = 0.768, 95% CI 0.723 to 0.812, P < 0.001) and Ca (AUC = 0.875, 95% CI 0.844 to 0.906, P < 0.001). The optimal cut-off value for RDW/ Ca to predict MSAP and SAP was 7.04 (sensitivity = 0.885, specificity = 0.834).
The RDW/Ca might be a valuable predictor of the severity of patients with AP.
Discharge protocol in acute pancreatitis: an international survey and cohort analysis
2023, Scientific Reports
Home care/outpatient versus hospital admission in mild acute pancreatitis: Protocol of a multicentre, randomised controlled trial (PADI_2 trial)
2023, BMJ Open
Home monitoring vs hospitalization for mild acute pancreatitis. A pilot randomized controlled clinical trials
2023, Medicine (United States)

View all citing articles on Scopus

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Early discharge in Mild Acute Pancreatitis. Is it possible? Observational prospective study in a tertiary-level hospital

Abstract

Background and aims

Methods

Results

Conclusion

Section snippets

Background and aims

Methods

Results

Discussion

Disclosure

Author's contributions

Gastroenterology

Gastrointest Endosc

J Surg Res Elsevier

Clin Gastroenterol Hepatol [Internet]

Pancreatology

Cir Esp

Acute pancreatitis

N Engl J Med

Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis

Gastroenterology

Update in acute pancreatitis

Curr Gastroenterol Rep

Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation

Ann Surg

Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by.pdf

Gut

Classification of surgical complications

Ann Surg