Direct admission to improve timely access to care for patients requiring transfer to a level 1 trauma center

Abstract

Background: Emergency departments (EDs) at level 1 trauma centers are often overcrowded and deny ED-to-ED transfers from lower-tiered centers. Lack of access to timely level 1 care is associated with increased mortality. We evaluated the feasibility of a direct admission (DA) protocol as a method to increase timely access to a level 1 trauma center during periods of ED overcrowding.

Methods: During periods of ED overcrowding between 1 May and 31 December 2019, we admitted patients from referring EDs directly to the intensive care unit (ICU) or inpatient ward using the DA protocol. In a prospective comparative study design, we compared their outcomes to patients during the same period who were admitted through the ED when the ED was not overcrowded.

Results: During periods of ED overcrowding, transfer was requested and clinically accepted for 28 patients, of which 23 (82.1%, age 63±20.3 years, men 52.2% men) were successfully admitted via the DA protocol. Five (17.9%) were not successfully transferred due to lack of available inpatient beds. During periods when the ED was not overcrowded, 106 patients (age 62.8±23.1 years, men 52.8%) were admitted via the ED. There were no morbidity or mortality events attributed to the DA process. Time to patient arrival was 2.7 hours (95% CI 2.3 to 3.1) in the DA cohort and 1.9 hours (95% CI 1.5 to 2.4) in the ED-to-ED cohort (p=0.104). Up-triage to the ICU within 24 hours was performed in only one patient (4.3%). In-hospital mortality did not differ (3 (13%) vs. 8 (7.6%), p=0.392).

Discussion: The DA pathway is a feasible method to safely transfer patients from a referring ED to a higher-care trauma center when its ED is overcrowded.

Level of evidence: Level III, care management.

Keywords: access; and evaluation; emergency treatment; healthcare quality; multiple trauma.

Figure 1

Direct admission pathway for trauma patients. Each step of the pathway is indicated in a box, and steps in which a decision must be made are indicated in the diamonds. *The inpatient access line is a multiway call system staffed 24 hours/day, 7 days/week, by a bed manager. A bed manger is a non-clinician whose scope of practice is assigning inpatient bed locations for new admissions. +The direct admit team is a team of three individuals composed of nursing and physician leadership with knowledge of bed capacity and demand in all inpatient locations and the ED. The team works with the bed manager to discuss options for where a direct admit patient can be admitted. They have the authority to hold existing patients in their current location (eg, PACU) or request transfer of existing patients to a different inpatient location to facilitate a direct. ED, emergency department; ICU, intensive care unit; OR, operating room.

Figure 2

Emergency department locations of lower-level trauma centers for direct admission attempts which were transferred versus not transferred. Patients who were successfully transferred are indicated in green. Patients who were not transferred are indicated in red.