title: "One-way-street" streamlined admission of critically ill trauma patients reduces emergency department length of stay.
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.affiliation: Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA. efuentes1@partners.org.
authors.forename: Eva
authors.initials: E
authors.lastname: Fuentes
authors.affiliation: Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
authors.forename: Jean-Francois
authors.initials: JF
authors.lastname: Shields
authors.affiliation: Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
authors.forename: Nandan
authors.initials: N
authors.lastname: Chirumamilla
authors.affiliation: Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
authors.forename: Myriam
authors.initials: M
authors.lastname: Martinez
authors.affiliation: Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
authors.forename: Haytham
authors.initials: H
authors.lastname: Kaafarani
authors.affiliation: Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
authors.forename: Daniel Dante
authors.initials: DD
authors.lastname: Yeh
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
authors.forename: Benjamin
authors.initials: B
authors.lastname: White
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Filbin
authors.affiliation: Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: DePesa
authors.affiliation: Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
authors.forename: George
authors.initials: G
authors.lastname: Velmahos
authors.affiliation: Departments of Emergency Medicine and Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
authors.forename: Jarone
authors.initials: J
authors.lastname: Lee
mesh_terms: D018806:APACHE; D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D016638:Critical Illness / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000592:standards*; D010360:Patient Transfer / Q000379:methods / Q000592:standards; D012189:Retrospective Studies; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000379:methods
keywords: Emergency Department Length of stay; Expedited admission; Intensive Care Unit