The impact of emergency department length of stay on the outcomes of trauma patients requiring hospitalization: a retrospective observational study

doi:10.5847/wjem.j.1920-8642.2023.016

Abstract

Abstract:

BACKGROUND: We aimed to explore the impact of the emergency department length of stay (EDLOS) on the outcome of trauma patients.

METHODS: A retrospective study was conducted on all trauma patients requiring hospitalization between 2015 and 2019. Patients were categorized into 4 groups based on the EDLOS (<4 h, 4-12 h,12-24 h, and >24 h). Data were analyzed using Chi-square test (categorical variables), Student’s t-test (continuous variables), correlation coefficient, analysis of variance and multivariate logistic regression analysis for identifying predictors of short EDLOS and hospital mortality.

RESULTS: The study involved 7,026 patients with a mean age of 32.1±15.6 years. One-fifth of patients had a short EDLOS (<4 h) and had higher level trauma team T1 activation (TTA-1), higher Injury Severity Score (ISS), higher shock index (SI), and more head injuries than the other groups (P=0.001). Patients with an EDLOS >24 h were older (P=0.001) and had more comorbidities (P=0.001) and fewer deaths (P=0.001). Multivariate regression analysis showed that the predictors of short EDLOS were female gender, GCS, SI, hemoglobin level, ISS, and blood transfusion. The predictors of mortality were TTA-1 (odds ratio [OR]=4.081, 95%CI: 2.364-7.045), head injury (OR=3.920, 95%CI: 2.413-6.368), blood transfusion (OR=2.773, 95%CI: 1.668-4.609), SI (OR=2.132, 95%CI: 1.364-3.332), ISS (OR=1.077, 95%CI: 1.057-1.096), and age (OR=1.040, 95%CI: 1.026-1.054).

CONCLUSIONS Patients with shorter EDLOS had different baseline characteristics and hospital outcomes compared with patients with longer EDLOS. Patients with prolonged EDLOS had better outcomes; however, the burden of prolonged boarding in the ED needs further elaboration.

Key words: Emergency department, Length of stay, Trauma, Management, Outcomes, Trauma activation criteria

Ahmed Faidh Ramzee, Ayman El-Menyar, Mohammad Asim, Ahad Kanbar, Khalid Ahmed, Bahaa Daoud, Saji Mathradikkal, Ahmad Kloub, Hassan Al-Thani, Sandro Rizoli. The impact of emergency department length of stay on the outcomes of trauma patients requiring hospitalization: a retrospective observational study[J]. World Journal of Emergency Medicine, 2023, 14(2): 96-105.

Figures/Tables 8

Figure 1.

Figure 2.

Table 1.

Patients demographics, clinical characteristics and injury severity based on emergency department length of stay (n=7,026)

Variables	<4 h (n=1,628)	4-12 h (n=3,561)	12-24 h (n=1,205)	>24 h (n=632)	P-value
Age, years	29.4±16.2	31.9±15.4	34.5±15.2	35.9±15.2	0.001
Males	1,467 (90.1%)	3,246 (91.2%)	1,068 (88.6%)	561 (88.8%)	0.030
EMS time, min	66 (50-81)	69 (54-88)	72 (55-91)	69 (54-86)	0.001
Mode of transportation
Ground ambulance	1,393 (85.6%)	2,972 (83.5%)	1,032 (85.9%)	525 (83.2%)	0.001
Helicopter	171 (10.5%)	339 (9.5%)	76 (6.3%)	55 (8.7%)
Private vehicle	64 (3.9%)	248 (7.0%)	94 (7.8%)	51 (8.1%)
Trauma activation code
TTA-1	767 (50.0%)	399 (12.1%)	104 (10.2%)	78 (14.4%)	0.001
TTA-2	762 (49.7%)	2,883 (87.4%)	901 (88.2%)	462 (85.1%)
TTA-3	5 (0.3%)	18 (0.5%)	17 (1.7%)	3 (0.6%)
EDLOS, h	2.4 (0.03-3.98)	6.9 (4.0-12.0)	16.2 (12.5-23.9)	33.8 (24.0-724.8)	0.001
Emergency department disposition
Operating room	594 (36.5%)	474 (13.3%)	171 (14.2%)	64 (10.1%)	0.001
Intensive care unit	526 (32.3%)	694 (19.5%)	181 (15.0%)	125 (19.8%)
Surgical ward	478 (29.4%)	2,342 (65.8%)	801 (66.5%)	416 (65.8%)
Transferred to other facility	4 (0.2%)	7 (0.2%)	3 (0.2%)	1 (0.2%)
Home	23 (1.4%)	44 (1.2%)	49 (4.1%)	26 (4.1%)
Comorbidities and injury severity
Hypertension	91 (5.6%)	236 (6.6%)	95 (7.9%)	68 (10.8%)	0.001
Diabetes mellitus	116 (7.1%)	256 (7.2%)	87 (7.2%)	56 (8.9%)	0.490
Alcohol consumption	140 (8.6%)	258 (7.2%)	78 (6.5%)	50 (7.9%)	0.160
Ethanol level, mmol/L	39.1±20.2	37.9±20.6	38.4±19.3	32.4±18.4	0.230
Injury Severity Score	14 (8-26)	10 (5-16)	10 (5-14)	10 (6-17)	0.001
Trauma Injury Severity Score	0.89±0.20	0.97±0.10	0.98±0.08	0.97±0.07	0.001
Revised Trauma Score	6.67±1.71	7.61±0.86	7.64±0.77	7.57±0.85	0.001
Head AIS	4 (3-5)	3 (3-4)	3.2±0.9	3.3±0.8	0.001
Chest AIS	3 (2-3)	3 (2-3)	2.6±0.7	2.7±0.7	0.001
Abdomen AIS	3 (2-4)	2 (2-3)	2.3±0.8	2.4±0.9	0.001
Pelvic AIS	2 (2-2)	2 (2-2)	2.1±0.4	2.2±0.5	0.020
Associated injuries
Head	679 (41.7%)	911 (25.6%)	315 (26.1%)	222 (35.1%)	0.001
Chest	631 (38.8%)	1245 (35.0%)	446 (37.0%)	200 (31.6%)	0.005
Abdomen	476 (29.2%)	565 (15.9%)	190 (15.8%)	114 (18.0%)	0.001
Spine	334 (20.5%)	912 (25.6%)	357 (29.6%)	222 (35.1%)	0.001
Upper extremities	389 (23.9%)	874 (24.5%)	268 (22.2%)	152 (24.1%)	0.450
Lower extremities	334 (20.5%)	880 (24.7%)	265 (22.0%)	109 (17.2%)	0.001

Table 1.

Table 2.

Prehospital and on-admission vital signs and laboratory findings based on emergency department length of stay

Variables	<4 h (n=1,628)	4-12 h (n=3,561)	12-24 h (n=1,205)	>24 h (n=632)	P-value
Heart rate at scene, beats per minute	95.7±25.0	93.1±20.5	91.8±18.6	89.7±17.8	0.001
Systolic blood pressure at scene, mmHg	129.4±26.7	129.8±21.8	131.1±23.2	133.2±23.4	0.009
Diastolic blood pressure at scene, mmHg	81.9±21.5	81.5±18.3	82.2±19.3	83.1±18.2	0.340
Respiratory rate at scene, breath per minute	19.2±6.1	18.9±4.5	18.6±3.7	18.2±3.1	0.001
GCS at scene	15 (10-15)	15 (15-15)	15 (15-15)	15 (15-15)	0.001
Heart rate at ED, beats per minute	98.5±24.8	90.6±18.9	88.6±17.5	87.8±16.6	0.001
Systolic blood pressure at ED, mmHg	121.2±24.2	125.2±18.4	127.6±18.9	128.5±19.9	0.001
Diastolic blood pressure at ED, mmHg	75.2±16.4	76.9±13.8	77.9±13.5	77.5±14.0	0.001
Respiratory rate at ED, breath per minute	20.2±4.7	19.4±3.7	19.3±3.7	19.1±2.5	0.001
GCS at ED	15 (4-15)	15 (15-15)	15 (15-15)	15 (15-15)	0.001
Shock index at ED	0.86±0.36	0.74±0.22	0.71±0.19	0.70±0.21	0.001
Laboratory findings (n=3,633)	(n= 967)	(n=1,941)	(n=536)	(n=189)	0.001
Lactate initial value, mmol/L (n=3,086)	3.2±2.9	2.5±1.5	2.3±1.5	2.4±1.5	0.001
Lactate consecutive reading, mmol/L (n=1,198)	2.9±2.3	2.3±1.7	2.0±1.3	2.0±1.5	0.001
Base deficit initial reading, mmol/L (n=2,751)	-4.6±5.0	-2.1±3.5	-1.3±2.9	-1.7±2.9	0.001
Base deficit consecutive reading, mmol/L (n=805)	-5.9±5.6	-3.2±3.7	-2.2±3.1	-3.1±3.9	0.001
Hemoglobin initial value, g/mL (n=3,508)	12.7±2.3	13.6±1.9	13.8±1.8	13.5±2.0	0.001
Hemoglobin consecutive reading, g/mL (n=1,885)	11.8±2.4	12.5±2.2	12.8±2.1	12.3±2.0	0.001
Myoglobin initial value, ng/mL (n=1,931)	374 (15-9,372)	306 (3-6,749)	281 (13-5,163)	246 (22-4,456)	0.001
Troponin initial value, ng/L (n=2,011)	10 (5.3-34.4)	10 (5.0-11.3)	10 (5.0-11.0)	10 (4.2-10.0)	0.001
Troponin consecutive reading, ng/L (n=724)	19 (7.7-93.1)	10.6 (5.9-37.9)	9.4 (6.1-28.3)	10 (4.6-18.3)	0.001

Table 2.

Table 3.

Figure 3.

Table 4.

Table 5.

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Variables	<4 h (n=1,628)	4-12 h (n=3,561)	12-24 h (n=1,205)	>24 h (n=632)	P-value
Initial CT scan	1,291 (79.3%)	3,221 (90.5%)	1,102 (91.5%)	588 (93.0%)	0.001
Number of CT scans in ED	5 (1-9)	5 (1-8)	5 (1-7)	5 (1-8)	0.001
Plain X-ray	1,386 (85.1%)	3,155 (88.6%)	1,053 (87.4%)	571 (90.3%)	0.001
FAST scan	1,502 (92.3%)	3,345 (93.9%)	1,123 (93.2%)	590 (93.4%)	0.160
Blood transfusion	602 (37.0%)	523 (14.7%)	125 (10.4%)	83 (13.1%)	0.001
Units of transfused blood	5 (1-49)	3 (1-73)	3 (1-37)	2 (1-25)	0.001
Complications
Pneumonia	113 (6.9%)	74 (2.1%)	28 (2.3%)	17 (2.7%)	0.001
Sepsis	41 (2.5%)	34 (1.0%)	7 (0.6%)	6 (0.9%)	0.001
Organ failure	7 (0.4%)	5 (0.1%)	2 (0.2%)	0 (0.0%)	0.090
ARDS	34 (2.1%)	22 (0.6%)	6 (0.5%)	3 (0.5%)	0.001
ICU LOS, d	5 (1-153)	3 (1-90)	3.5 (1-58)	4 (1-123)	0.001
Hospital LOS, d	7 (1-214)	4 (1-505)	4 (1-158)	6 (1-123)	0.001
Ventilatory days	4 (1-180)	6 (1-100)	6 (1-47)	4 (1-62)	0.040
In-hospital mortality	159 (9.8%)	63 (1.8%)	19 (1.6%)	7 (1.1%)	0.001
Place of death
ICU	145 (91.2%)	62 (98.4%)	17 (89.5%)	6 (85.7%)	0.010
Operating room	13 (8.2%)	0 (0.0%)	1 (5.3%)	0 (0.0%)	0.010
Surgical wards	1 (0.6%)	1 (1.6%)	1 (5.3%)	1 (14.3%)	0.010

Predictors	Odds ratio	95% confidence interval	P-value
Initial serum lactate value	1.033	0.976-1.093	0.262
Initial base deficit value	0.974	0.944-1.005	0.099
Initial blood hemoglobin level	0.922	0.874-0.973	0.003
Age in years	0.993	0.986-1.000	0.064
Gender (female)	1.670	1.135-2.463	0.009
Injury Severity Score	1.018	1.006-1.030	0.003
Glasgow Coma Score at the ED	0.853	0.831-0.876	0.001
Shock index at the ED	1.546	1.004-2.379	0.048
Blood transfusion	1.477	1.118-1.952	0.006