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JOURNAL ARTICLE

Effective triage can ameliorate the deleterious effects of delayed transfer of trauma patients from the emergency department to the ICU

J David Richardson, Glen Franklin, Ariel Santos, Brian Harbrecht, Dan Danzl, Royce Coleman, Jason Smith, Frank Miller, Kelly McMasters
Journal of the American College of Surgeons 2009, 208 (5): 671-8; discussion 678-81
19476813

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.

STUDY DESIGN: 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.

CONCLUSION: 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.

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