title: Emergency department crowding and the performance of damage control resuscitation in major trauma patients with hemorrhagic shock.
abstract: OBJECTIVE
  Uncontrolled hemorrhagic shock is the leading cause of potentially preventable death in major trauma patients. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, hemostatic resuscitation, and damage control surgery, has been highly recommended for trauma patients. This study investigated whether emergency department (ED) crowding was associated with poor performance of the DCR strategies in treating hemorrhagic shock trauma patients.
  
  
  METHODS
  This was a retrospective cohort study in an urban tertiary hospital conducted from January 2010 to December 2013. Major trauma patients who presented to the ED with hemorrhagic shock were included. ED crowding, measured by ED occupancy rate, was categorized into three groups (low, medium, and high). The performance of DCR and inpatient outcomes were analyzed using multivariate logistic analysis.
  
  
  RESULTS
  Of the 3,037 major trauma patients assessed, 852 met the inclusion criteria and were enrolled in the study. Patients in the high-crowding group had delayed initiation of transfusion (high vs. medium and low, 2.5 hours vs. 2.1 hours and 1.0 hours, respectively, p = 0.01), received less blood products in the ED (both comparisons p < 0.01), and experienced delays in procedures (4.5 hours vs. 3.3 hours and 2.4 hours, p < 0.01). However, the amount of crystalloid solution was similar among patients in all three groups (p = 0.17). In multivariate analysis, more patients from the high-crowding group developed traumatic coagulopathy in the intensive care unit (29.7% vs. 24.1% and 16.3%, p < 0.01), while no clear relationship was found between ED crowding and 30-day mortality or early lactate clearance rate (p > 0.05).
  
  
  CONCLUSIONS
  ED crowding was associated with poor performance of DCR for major trauma patients in the ED. New strategies should be implemented to ameliorate crowded conditions and potential adverse outcomes.
authors.affiliation: Departments of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, Hangzhou, China.
authors.forename: Dingqian
authors.initials: D
authors.lastname: Wu
authors.affiliation: Hangzhou XiXi Hospital, affiliated hospital of Zhejiang Chinese Medical University, Hangzhou, China.
authors.forename: Xiaoxia
authors.initials: X
authors.lastname: Zhou
authors.affiliation: Departments of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, Hangzhou, China.
authors.forename: Ligang
authors.initials: L
authors.lastname: Ye
authors.affiliation: Hangzhou XiXi Hospital, affiliated hospital of Zhejiang Chinese Medical University, Hangzhou, China.
authors.forename: Jianxin
authors.initials: J
authors.lastname: Gan
authors.affiliation: Departments of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, Hangzhou, China.
authors.forename: Mao
authors.initials: M
authors.lastname: Zhang
mesh_terms: D000328:Adult; D001803:Blood Transfusion; D003441:Crowding; D000077324:Crystalloid Solutions; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000592:standards; D005260:Female; D006786:Hospitals, Urban; D006801:Humans; D007022:Hypotension / Q000150:complications; D007552:Isotonic Solutions; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012151:Resuscitation / Q000379:methods* / Q000592:standards*; D012189:Retrospective Studies; D012771:Shock, Hemorrhagic / Q000628:therapy*; D062606:Tertiary Care Centers
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions