Abstract
OBJECTIVE: To clarify and improve the admission pathway for patients with brain metastases (Bmets) who present to the emergency department (ED) at initial diagnosis. BACKGROUND: ED length of stay (LOS) is a barrier to access for patients in need of emergency services. ED care and admission pathways are not standardized for patients with Bmets at our institution. METHODS: Single institution retrospective quality review of patients diagnosed with Bmets in the ED between 2017 and 2019. RESULTS: Among the 54 patients included in the study, 98% (53 patients) were admitted: 62.3% (33 patients) to Medicine, 28.3% (15 patients) to Neurosurgery, 7.55% (4 patients) to Neurology, and 1.89% (1 patient) to the MICU. Average LOS in the ED was 11.51 hours (SD 6.81, range 0.57-29.45 hours), with number of imaging studies and number of consults correlating with increased LOS. Predictive factors for the admitting service included: radiographic herniation or hydrocephalus correlated with neurosurgery admission (p=.011, p=0.074, respectively) and synchronous primary cancer diagnosis correlated with admission to medicine (p=.029). Neurosurgery generally admitted patients with fewer Bmets (average 1.3, p=.0017), compared to 5 Bmets for medicine, 5.5 for neurology, and 2 for MICU. There was no difference in 30-day readmission, death within 30 days, or overall survival. We developed an admissions pathway for Bmets patients based on the above. Patients are to be admitted to neurology for status epilepticus, to neurosurgery for hydrocephalus/fourth ventricular mass effect, mass>3cm, and to medicine when they have known active cancer or multiple masses most consistent with metastatic disease. If lesions are of unknown etiology, patients are admitted to neurology. CONCLUSIONS: Patients presenting to our ED with new Bmets experience long ED LOS despite high rates of admission. We evaluated which presentation characteristics can be appropriately and expeditiously designated to an admitting service and have formally implemented a pathway using these characteristics.