New England Surgical Society

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Direct admission to improve timely access to Level I trauma care: a cohort study
*Apostolos Gaitanidis, *Kerry Breen, *Alice Gervasini, *Ali Raja, *Peter Dunn, George Velmahos, *Kyan Safavi
Massachusetts General Hospital, Boston, MA

Objective: Emergency Departments (EDs) at Level I trauma centers are often over-crowded. This causes delays or denials for transfers from lower-tiered trauma centers, potentially placing critically-ill patients at risk. In this study, we prospectively evaluate a Direct Admission (DA) protocol during periods of ED over-crowding.
Design: Prospective cohort study
Setting: Level I trauma center, May-December 2019
Patients: Transferred patients were arranged for admission to the intensive care unit (ICU) or floor (Figure 1). Patient outcomes were compared to transfer patients being admitted via the ED.
Interventions: Direct hospital admission
Main Outcome Measures: Proportion of transfers rejected, rate of up-triage to ICU within 24 hours , time to arrival, in-hospital mortality.
Results: During ED over-crowding, transfer was requested for 28 patients, of which 23 (82.1%, age 63 ± 20.3, 52.2% males) were directly admitted and 5 (17.9%) were rejected. During the same period, 106 patients (age 62.8 ± 23.1, males 52.8%) were admitted via the ED. Time to patient arrival was longer in the DA cohort (2.7 [95% CI: 2.3-3.1] vs. 1.9 [95% CI: 1.5-2.4], p=0.104), although not statistically significant. Up-triage to the ICU within 24 hours was performed for only 1 patient (4.3%). In-hospital mortality did not differ between groups (3 [13%] vs. 8 [7.6%], p=0.392).
Conclusions: The DA pathway is a feasible way to transfer patients to the nearest Level I trauma center when the ED is over-crowded. Adoption may facilitate patient transfer to Level I trauma centers and assist in providing timely care for critically-ill patients.


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