Background/Purpose:
Given the complexity, chronicity and associated co-morbidities, management of SLE poses a challenge. Despite established care in private and fellow/resident clinics, our patients often go to ED, resulting in inappropriate and costly hospitalizations. Our aim is to reduce ED visits with appropriate outpatient rheumatology care, instate appropriate ED rheumatology consults, and reduce unnecessary hospitalizations.  

Methods:
We reviewed SLE patients seen by the Rheumatology Division at least once from 7/2013 to 6/2015, quantifying ED visits and subsequent hospitalization or discharge from 1/2010 to 6/2015. We compared age at SLE diagnosis, SLE duration when first seen by us, and insurance status of “ED users” (at least 1 ED visit) with “ED non-users” (no ED visits). Frequency of ED rheumatology consults among hospitalized vs. discharged patients was noted.  After introduction of education tools (Medical ground Rounds presentation of our data and implementation of required rheumatology rotation by our EM-IM residents), we re-assessed the relationship between ED visit frequency and clinic visits in ED user vs. non-users.

Results:
363 SLE patients had 1700 ED visits (range 1-72), leading to 774 hospitalizations over a 5.5-year period. 25 excluded due to lack of data. Among 338 patients, 95 were ED non-users and 243 were ED users, totaling 1608 ED visits with 727 hospitalizations. Among ED users, 61(25%) had no hospitalizations; 34 (14%) were followed privately vs. 201(83%) in clinic. 33(35%) private and 62(65%) clinic patients had no ED visits (Table 1). Only 112 (7%) of ED visits had a rheumatology consult in the ED; 68 (61%) were hospitalized and 44 (39%) were discharged.  Pre- and post-educational tools introduction data presented in Table 2.

Conclusion:
Our SLE cohort had frequent ED visits followed by high rate of hospitalization. The difference in mean age at SLE diagnosis, mean SLE duration and insurance status between ED users vs. non-users was small.  Only 14% of patients followed privately had any ED visits compared to 83% of clinic patients, yet the % of non-users was higher in clinic patients. Rheumatology consult was requested in only 7%, yet 39% resulted in discharge from the ED, potentially preventing unnecessary hospitalization. Pre- and post-educational tools showed reduction in ED visits and hospitalization among ED users, however, a decrease in clinic visits could be confounded by loss to follow-up. Consistent outpatient care in those not requiring hospitalization and case managers for high-risk patients should reduce inappropriate ED visits and subsequent hospitalizations.