title: Effective triage can ameliorate the deleterious effects of delayed transfer of trauma patients from the emergency department to the ICU.
abstract: BACKGROUND
  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.
  
  
  METHODS
  All trauma patients admitted from January 2005 to April 2007 in a Level I trauma center were divided into a nondelayed (<or=6 hours) group or a delayed (>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.
  
  
  RESULTS
  Among 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, University of Louisville, Louisville, KY, USA. jdrich01@louisville.edu
authors.forename: J David
authors.initials: JD
authors.lastname: Richardson
authors.forename: Glen
authors.initials: G
authors.lastname: Franklin
authors.forename: Ariel
authors.initials: A
authors.lastname: Santos
authors.forename: Brian
authors.initials: B
authors.lastname: Harbrecht
authors.forename: Dan
authors.initials: D
authors.lastname: Danzl
authors.forename: Royce
authors.initials: R
authors.lastname: Coleman
authors.forename: Jason
authors.initials: J
authors.lastname: Smith
authors.forename: Frank
authors.initials: F
authors.lastname: Miller
authors.forename: Kelly
authors.initials: K
authors.lastname: McMasters
mesh_terms: D000328:Adult; D002423:Cause of Death; D006259:Craniocerebral Trauma / Q000401:mortality; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D010360:Patient Transfer / Q000458:organization & administration*; D013997:Time Factors; D014193:Trauma Centers / Q000458:organization & administration*; D014218:Triage / Q000458:organization & administration*; D014947:Wounds and Injuries / Q000401:mortality*