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"One-way-street" streamlined admission of critically ill trauma patients reduces emergency department length of stay.
Intern Emerg Med. 2017 Oct; 12(7):1019-1024.IE

Abstract

Emergency department (ED) overcrowding remains a significant problem in many hospitals, and results in multiple negative effects on patient care outcomes and operational metrics. We sought to test whether implementing a quality improvement project could decrease ED LOS for trauma patients requiring an ICU admission from the ED, specifically by directly admitting critically ill trauma patients from the ED CT scanner to an ICU bed. This was a retrospective study comparing patients during the intervention period (2013-2014) to historical controls (2011-2013). Critically ill trauma patients requiring a CT scan, but not the operating room (OR) or Interventional Radiology (IR), were directly admitted from the CT scanner to the ICU, termed the "One-way street (OWS)". Controls from the 2011-2013 Trauma Registry were matched 1:1 based on the following criteria: Injury Severity Score; mechanism of injury; and age. Only patients who required emergent trauma consult were included. Our primary outcome was ED LOS, defined in minutes. Our secondary outcomes were ICU LOS, hospital LOS and mortality. Paired t test or Wilcoxon signed rank test were used for continuous univariate analysis and Chi square for categorical variables. Logistic regression and linear regressions were used for categorical and continuous multivariable analysis, respectively. 110 patients were enrolled in this study, with 55 in the OWS group and 55 matched controls. Matched controls had lower APACHE II score (12 vs. 15, p = 0.03) and a higher GCS (14 vs. 6, p = 0.04). ED LOS was 229 min shorter in the OWS group (82 vs. 311 min, p < 0.0001). The time between CT performed and ICU disposition decreased by 230 min in the OWS arm (30 vs. 300 min, p < 0.001). There was no difference in ED arrival to CT time between groups. Following multivariable analysis, mortality was primarily predicted by the APACHE II score (OR 1.29, p < 0.001), and not ISS, mechanism of injury, or age. After controlling for APACHE II score, there was no difference in mortality between the two cohorts (OR = 0.49, p = 0.28). Expedited admission of critically ill trauma patients immediately following CT imaging significantly reduced ED LOS by 3.82 h (229 min), without a change in ICU LOS, hospital LOS, or mortality. Further studies are needed to assess the impact of expedited admission on morbidity and mortality.

Authors+Show Affiliations

Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. efuentes1@partners.org.Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.Departments of Emergency Medicine and Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

27473424

Citation

Fuentes, Eva, et al. ""One-way-street" Streamlined Admission of Critically Ill Trauma Patients Reduces Emergency Department Length of Stay." Internal and Emergency Medicine, vol. 12, no. 7, 2017, pp. 1019-1024.
Fuentes E, Shields JF, Chirumamilla N, et al. "One-way-street" streamlined admission of critically ill trauma patients reduces emergency department length of stay. Intern Emerg Med. 2017;12(7):1019-1024.
Fuentes, E., Shields, J. F., Chirumamilla, N., Martinez, M., Kaafarani, H., Yeh, D. D., White, B., Filbin, M., DePesa, C., Velmahos, G., & Lee, J. (2017). "One-way-street" streamlined admission of critically ill trauma patients reduces emergency department length of stay. Internal and Emergency Medicine, 12(7), 1019-1024. https://doi.org/10.1007/s11739-016-1511-x
Fuentes E, et al. "One-way-street" Streamlined Admission of Critically Ill Trauma Patients Reduces Emergency Department Length of Stay. Intern Emerg Med. 2017;12(7):1019-1024. PubMed PMID: 27473424.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - "One-way-street" streamlined admission of critically ill trauma patients reduces emergency department length of stay. AU - Fuentes,Eva, AU - Shields,Jean-Francois, AU - Chirumamilla,Nandan, AU - Martinez,Myriam, AU - Kaafarani,Haytham, AU - Yeh,Daniel Dante, AU - White,Benjamin, AU - Filbin,Michael, AU - DePesa,Christopher, AU - Velmahos,George, AU - Lee,Jarone, Y1 - 2016/07/29/ PY - 2016/04/26/received PY - 2016/07/19/accepted PY - 2016/7/31/pubmed PY - 2018/9/11/medline PY - 2016/7/31/entrez KW - Emergency Department Length of stay KW - Expedited admission KW - Intensive Care Unit SP - 1019 EP - 1024 JF - Internal and emergency medicine JO - Intern Emerg Med VL - 12 IS - 7 N2 - Emergency department (ED) overcrowding remains a significant problem in many hospitals, and results in multiple negative effects on patient care outcomes and operational metrics. We sought to test whether implementing a quality improvement project could decrease ED LOS for trauma patients requiring an ICU admission from the ED, specifically by directly admitting critically ill trauma patients from the ED CT scanner to an ICU bed. This was a retrospective study comparing patients during the intervention period (2013-2014) to historical controls (2011-2013). Critically ill trauma patients requiring a CT scan, but not the operating room (OR) or Interventional Radiology (IR), were directly admitted from the CT scanner to the ICU, termed the "One-way street (OWS)". Controls from the 2011-2013 Trauma Registry were matched 1:1 based on the following criteria: Injury Severity Score; mechanism of injury; and age. Only patients who required emergent trauma consult were included. Our primary outcome was ED LOS, defined in minutes. Our secondary outcomes were ICU LOS, hospital LOS and mortality. Paired t test or Wilcoxon signed rank test were used for continuous univariate analysis and Chi square for categorical variables. Logistic regression and linear regressions were used for categorical and continuous multivariable analysis, respectively. 110 patients were enrolled in this study, with 55 in the OWS group and 55 matched controls. Matched controls had lower APACHE II score (12 vs. 15, p = 0.03) and a higher GCS (14 vs. 6, p = 0.04). ED LOS was 229 min shorter in the OWS group (82 vs. 311 min, p < 0.0001). The time between CT performed and ICU disposition decreased by 230 min in the OWS arm (30 vs. 300 min, p < 0.001). There was no difference in ED arrival to CT time between groups. Following multivariable analysis, mortality was primarily predicted by the APACHE II score (OR 1.29, p < 0.001), and not ISS, mechanism of injury, or age. After controlling for APACHE II score, there was no difference in mortality between the two cohorts (OR = 0.49, p = 0.28). Expedited admission of critically ill trauma patients immediately following CT imaging significantly reduced ED LOS by 3.82 h (229 min), without a change in ICU LOS, hospital LOS, or mortality. Further studies are needed to assess the impact of expedited admission on morbidity and mortality. SN - 1970-9366 UR - https://www.unboundmedicine.com/medline/citation/27473424/"One_way_street"_streamlined_admission_of_critically_ill_trauma_patients_reduces_emergency_department_length_of_stay_ L2 - https://dx.doi.org/10.1007/s11739-016-1511-x DB - PRIME DP - Unbound Medicine ER -