“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.

Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review

“…Decreasing overcrowding by combining OR methods were also found in González et al [172], Acuna, et al [132], and He et al [109]. Apart from these works, some authors proposed the use of lean six-sigma [194,195] and regression analysis [26,197,200].…”

“…Based on the review, 66.66% (n = 72 papers) of the papers evidenced the use of a single approach whilst 33.34% (n = 36 papers) tackled the extended LOS using a combination of two or more techniques. In particular, 63.88% (n = 23 papers) out of the hybrid-approached papers employed two methods, 30.55% (n = 11 papers) integrated three techniques, and 5.55% (n = 2 papers) mixed four methods as evidenced in Easter et al [25] and Fuentes et al [26]. Different process improvement methods have been combined for better assisting ED managers in addressing the prolonged stays in EDs.…”

“…Some of them are a mix of OR approaches as noted in He et al [109] and Sir et al [122]. Other papers combine different statistical techniques as evidenced in Fuentes et al [26], Huang et al [110], Techar et al [123], and Ross et al [118]. Another category includes the mix of lean manufacturing and other techniques as exposed in Blick [100], Chadha et al [101], and Furterer [106].…”

The Positive Impact on Emergency Department Length of Stay of a Clinical Practice Guideline-Directed Process for Direct Admission from the Emergency Department Computed Tomography Scan Suite to the Intensive Care Unit of Highest Level Trauma Activation Patients

“…[8][9][10][11][12][13][14][15][16] With documentation of increased morbidity and mortality from increased ED LOS, efforts to reduce ED LOS have ensued, and several specific approaches have been published (Table 1). [17][18][19][20][21] Regarding the critically ill trauma patient, the need for safe, expeditious transfer of patients out of the ED, into the ICU applies as well. Yet appropriate time spent in the ED involves stabilization of airway, breathing and circulation (ABC) with initial resuscitation, completing advanced trauma life support (ATLS) delineated primary and secondary surveys, as well as triage-directed diagnostic imaging.…”

“…In advancing this need to decrease ED LOS for critically ill patients, several institutions have published reports on novel interventions whereby ED patients were expedited in transfer from the ED to a respective ICU (both medical and surgical ICU patient admissions). [17][18][19][20][21] With these reported varied efforts, significant improvements in average ED LOS were shown. 9,[16][17][18][19][20][21] Importantly, an expedited transfer of patients from the ED to the ICU involves several resources and logistical issues including a readily and continually available ICU bed; a readily and continually available hospital "bed coordinator" to facilitate admission; as well as a readily and continually available ICU nurse to receive a "handoff" report.…”