Which factors influence the ED length-of-stay after anterior shoulder dislocations: a retrospective chart review in 716 cases

Abstract

Background: Anterior shoulder dislocations (ASD) are commonly seen in Emergency Departments (ED). ED overcrowding is increasingly burdening many healthcare systems. Little is known about factors influencing ED length-of-stay (LOS) for ASD. This study defines the factors influencing ED LOS for ASD patients. Methods: Retrospective chart reviews were performed on all patients ≥12 years admitted with an anterior shoulder dislocation at two regional hospitals in the Netherlands between 2010 and 2016. The electronic patient records were reviewed for baseline patient characteristics, trauma mechanism, reduction methods, medication used, complications and the LOS at the ED. The main objective was determining factors influencing the LOS in patients with an anterior shoulder dislocation at the ED. Results: During the study period, 716 ASD occurred in 574 patients, 374 (65.2%) in males. There were 389 (54.3%) primary ASD; the remainder (327, 45.7%) were recurrent. Median LOS was 92 min (IQR 66 min), with a significantly shorter LOS in those with recurrent dislocations (p < 0.001), younger age group (p < 0.03) and in patients who received no medications in the ED (p < 0.001). Traction-countertraction and leverage techniques were associated with a significant more use of ED medication compared to other techniques. Although the use of more medication might suggest the LOS would be longer for these techniques, we did not find a significant difference between different reduction techniques and LOS. Conclusion: To our knowledge this study is the largest of its kind, demonstrating ED LOS in ASD patients is influenced by age, the need for medication and dislocation history, primary versus recurrent. Notably, we found that biomechanical reduction techniques, which are not primarily traction-countertraction or leverage techniques, e.g. scapular manipulation and Cunningham, were associated with less ED medication use. Further research is needed to define how reduction methods influence ED medication use, patient satisfaction and ED throughput times.

Austere Diagnosis and Reduction of Anterior Shoulder Dislocations: 10-Year Review of a Ski Patrol-Based Program with Emergency Medical Technicians

“…3,19,21,22,28,29 By considering biomechanical reduction attempts prior to pursuing procedural sedation, especially in cases of early presentation, hospital-based providers may avoid the potential complications, increased staffing and resource requirements, and lengthened time of care that have been associated with sedation related to glenohumeral reduction procedures. 3,28,[43][44][45][46] As a pertinent aside, the 46% EMT assessment sensitivity of humerus fractures was lower than that of other shoulder injury etiologies. Additionally, humerus fractures were uniquely noted to have a higher mean age than other shoulder injury categories and a statistically significant female predominance.…”

“…Many adverse medication events have occurred during sedation related to glenohumeral reduction procedures. 3,28,[43][44][45][46] Studies have noted concerning events, including apnea and bradycardia, in 8% of patients receiving ASD-related procedural sedation 45 and remarked on the "obvious danger" of sedating nonfasting patients. 19 In this respect, our findings may translate to a hospital setting because they support the conclusion that biomechanical reduction techniques and prompt relocation may eliminate the need for routine premedication, as has been proposed in other studies.…”

“…3,19,21,22,28,29 By considering biomechanical reduction attempts prior to pursuing procedural sedation, especially in cases of early presentation, hospital-based providers may avoid the potential complications, increased staffing and resource requirements, and lengthened time of care that have been associated with sedation related to glenohumeral reduction procedures. 3,28,43 -46…”

Assessment and management of shoulder dislocation

“…These techniques were less painful (1.47 and 1.59 on a visual analogue scale of 1 to 10) compared with traction and/or leverage techniques (visual analogue scale >4) 2021222324. Small sample sizes and possible bias in studies mean, however, that high quality evidence assessing the most successful and least painful technique is lacking 16202125…”

Success rate of anterior shoulder dislocation reduction by emergency physicians: a retrospective cohort study

“…Moreover, there is no consensus on the optimal use of sedatives or analgesics. Approximately 30% patients with shoulder dislocation, most commonly Hill–Sachs lesions and Bankart lesions, have associated fractures [ 3 ]. However, there is no consensus on the target population, location, and method for shoulder dislocation reduction associated with fracture [ 4 , 5 ].…”