Emergency department (ED) crowding and delays in care represent a national problem; no large study has examined the impact of such delays in surgical patients. We sought to determine the impact of delayed transfer from the ED on outcomes in trauma/emergency general surgical patients in a center that has developed a policy to triage more critically ill/severely injured patients to earlier ICU admission. ⋯ Experienced clinicians can effectively triage more critically injured patients to earlier ICU admission and alter associations between ED length of stay and mortality. Hospitals with a large trauma/emergency general surgery caseload resulting in delays in ED throughput should institute policies and procedures for triage of more severely injured patients for early ICU admission and develop a monitoring system to ensure that delays do not adversely affect patient outcomes.
J David Richardson, Glen Franklin, Ariel Santos, Brian Harbrecht, Dan Danzl, Royce Coleman, Jason Smith, Frank Miller, and Kelly McMasters.
Department of Surgery, University of Louisville, Louisville, KY, USA. jdrich01@louisville.edu
J. Am. Coll. Surg. 2009 May 1;208(5):671-8; discussion 678-81.
BackgroundEmergency department (ED) crowding and delays in care represent a national problem; no large study has examined the impact of such delays in surgical patients. We sought to determine the impact of delayed transfer from the ED on outcomes in trauma/emergency general surgical patients in a center that has developed a policy to triage more critically ill/severely injured patients to earlier ICU admission.Study DesignAll trauma patients admitted from January 2005 to April 2007 in a Level I trauma center were divided into a nondelayed (6 hours) group. Factors associated with their injuries and outcomes were determined from a large prospective database and all deaths were examined by root-cause analysis. Sentinel events were examined in all deaths and among randomly selected survivors.ResultsAmong 3,918 patients, ED stay was often prolonged. The nondelayed group spent a mean of 3 hours in the ED compared with 14.6 hours in the delayed group. Patients admitted earlier were more seriously injured and had markedly worse outcomes, with overall mortality of 18% versus 2.3% in the nondelayed and delayed group, respectively. Mortality did not increase with time spent in the ED but, in fact, decreased after 4 hours. Case analysis disclosed two deaths that might have been altered by earlier ICU transfer.ConclusionExperienced clinicians can effectively triage more critically injured patients to earlier ICU admission and alter associations between ED length of stay and mortality. Hospitals with a large trauma/emergency general surgery caseload resulting in delays in ED throughput should institute policies and procedures for triage of more severely injured patients for early ICU admission and develop a monitoring system to ensure that delays do not adversely affect patient outcomes.