Emergency Department Utilization after Lower Extremity Bypass for Critical Limb Ischemia

Abstract

Patients with critical limb ischemia (CLI) utilize hospital resources at high rates. One major driver for resource utilization is emergency department (ED) visits. Our goal was to assess perioperative ED visits after lower extremity bypass (LEB) for CLI. All patients undergoing LEB for CLI from 2008 to 2017 at our institution were analyzed. ED visits and details of the visit within 30 and 90days of discharge from index admission were recorded. Multivariable analysis was performed to identify risk factors for any ED presentation and ED presentation without hospital admission. There were 317 patients identified who underwent infrainguinal LEB for CLI. Average age was 66 years, and 60.6% of patients were male. Within 30 and 90days, 24.3% and 36.3% presented to the ED overall, and 16.7% and 26.5% of all postoperative patients had an ED presentation without hospital admission, respectively. Most common reasons for any ED visits and for ED visits without admission within 30days were wound complications (22.1% and 20.8%), cardiac complications (16.9% and 17%), and ipsilateral leg pain (10.4% and 11.3%), respectively. Cryopreserved vein bypass (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.02-8.84, P=0.046) and index length of stay (LOS) (OR 1.09, 95% CI 1.04-1.15, P<0.001) predicted any 30-day ED visit. Active leg infection at the time of bypass (OR 2.35, 95% CI 1.21-4.58, P=0.012) and index LOS (OR 1.05, 95% CI 1.004-1.09, P=0.033) predicted 30-day ED presentation without hospital admission. Most common reasons for any ED visit and for ED visits without admission within 90days were surgical wound complications (15.8% and 14.3%), cardiac complications (14.9% and 14.3%), and nonsurgical wounds (9.6% and 9.5%), respectively. Chronic renal insufficiency (CRI) (OR 2.73, 95% CI 1.52-4.93, P=0.001) and index LOS(OR 1.07, 95% CI 1.01-1.12, P=0.017) predicted any 90-day ED visit. CRI (OR3.34, 95% CI 1.81-6.17, P=0.001) predicted 90-day ED presentation without hospital admission. For multiple ED visits within 90days, there were 5 patients each with 5 ED visits, 12 each with 4 ED visits, 26 each with 3 ED visits, and 47 each with 2 ED visits. There is a high rate of ED utilization in CLI patients after LEB. Targeting these patients with closer follow-up and improved outpatient ambulatory access could assist in decreasing the frequency of postoperative ED visits. Particular areas of targeted improvement are those patients who presented to the ED and were not admitted.