Epidemiology and Outcomes of Patients Presenting to United States Emergency Departments with Vaginal Bleeding

INTRODUCTION: There are significant gaps in knowledge regarding the epidemiology, management, and outcomes of patients presenting to the emergency department (ED) with vaginal bleeding. METHODS: This was a retrospective, successional cross-sectional study using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) examining all adult patients presenting to EDs with vaginal bleeding from 2011-2019. Patients were stratified by age, race/ethnicity, and pregnancy status. Main outcomes were ultimate outcome severity, presenting vital signs, and diagnostic tests performed. We defined high-severity outcome as any patient who was dead on arrival, died in the ED, or during that hospitalization; any patient admitted to the intensive care or stepdown units or to the cardiac catheterization lab or the operating room; or patients transferred to a non-psychiatric hospital. Moderate severity was defined as any patient admitted to floor-level care, held in observation, or transferred to a psychiatric hospital. We defined low-severity outcome as any patient discharged home. RESULTS: Patients presenting with a chief complaint of vaginal bleeding comprised 1.3% (95% CI, 1.2-1.4%,) of all ED visits, representing 14,620,933 total encounters. Of these patients, 53.0% (95% CI, 49.4-56.7%) were identified as pregnant. There was a lower prevalence of White patients presenting with this complaint compared to White patients presenting with any chief complaint (45.6% [95% CI, 41.9-49.4] vs 60.3% [95% CI, 57.7-62.8%]), with a reciprocal higher prevalence of Hispanic patients (21.1% [95% CI,17.7-24.5%] vs 13.2% [95% CI, 11.7-14.8%]). The majority of patients (88.1%, 95% CI, 86.1-90%) were classified as having a low-severity outcome, 10.3% (95% CI, 8.5-12.1%) were classified as moderate-severity, and 1.6% (95% CI,1.0-2.2%) as high-severity. Patients who were ultimately classified with high-severity outcomes had significantly higher shock indices at presentation and shorter wait times than patients with low-severity outcomes (0.75 [95% CI, 0.72-0.78] vs 0.68 [95% CI, 0.67-0.69], and 23.4 minutes [95% CI, 17.1-29.8] vs 41.7 minutes [95% CI, 37.1-46.4], respectively), despite no difference in median Emergency Severity Index triage score (2.5 [IQR 2.1-2.8] v 2.6 [IQR 2.2-2.9]). A quarter of patients (24.3% [95% CI, 20.8-27.7%]) received a pelvic exam: there were no significant differences in pelvic exam rate by age, pregnancy status, race/ethnicity, or ultimate outcome severity. CONCLUSION: Although most patients presenting to EDs with vaginal bleeding are discharged home, current triage models do not appear to appropriately risk-stratify higher risk patients. Disparities in presentation exist.