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
Ehyal Shweiki, Kathleen D Martin, Anne Judge, Megan Asher
ED-LOS, ED overcrowding, Direct from ED to ICU, ICU, Trauma
Citation Information :
Shweiki E, Martin KD, Judge A, Asher M. 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. Panam J Trauma Crit Care Emerg Surg 2018; 7 (2):89-96.
Introduction: Patients presenting to the emergency department (ED) as the highest level trauma activation (T1) are characteristically severely injured, having met physiologic or anatomic derangement criteria as defined by the American College of Surgeons’ (ACS) committee on trauma (COT) guidelines for field triage. ED overcapacity is a significant issue for the vast majority of hospitals in the United States. Multiple published reports show that ED overcapacity leads to delays in patient care and increased morbidity and mortality. Such negative impacts include those on trauma patients’ specifically. Based on literature-reported improved outcomes for decreased ED length of stay (LOS) in critically ill patients, we aimed for the expeditious transport from the ED computed tomography (CT) scanner suite to the intensive care unit (ICU), of T1 patients who were ultimately deemed to need ICU level of care. More, we hypothesized that a well-delineated, well-integrated multidisciplinary “direct to ICU” clinical practice guideline (CPG) would enable our stated aim to be achieved in a consistent manner.
Methods: This was a retrospective evaluation of patients admitted to a Level II trauma center over a 12 month period. The cohorts were patients who were highest level (T1) and whose immediate post-ED destination was the ICU. ED LOS of stay (LOS) was assessed for both pre-CPG (January–April, 2016) and post-CPG (May to December 2016) groups. Patients going directly to the operating room (OR), interventional radiology (IR), ED deaths or medical-surgical unit (MedSurg), i.e., ward/ floor admissions were excluded.
Results: The average ED LOS preimplementation of the CPG was 159 minutes (SD ± 8.8). The post-CPG implementation ED LOS average was 49 minutes (SD ± 8.87). Thus the ED LOS was 110 minutes less, post-CPG implementation. As a noteworthy comparative benchmark, the 2016 “one-way-street” article from the Massachusetts General Hospital reported an 82 minute median ED LOS for trauma patients admitted directly from the ED CT to the ICU.
Conclusion: Implementation of a multidisciplinary “direct to ICU” CPG enabled the very expeditious, reproducible and process-oriented transport of critically ill trauma patients from the ED CT suite to the ICU. In support of contemporary, evidence-based efforts to enhance trauma patient outcomes while also addressing ED overcapacity concerns, We propose this “direct to ICU” CPG model for use by other trauma centers.
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