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

Introduction

Access to care at high-level trauma centers for severely injured patients is critical to achieving optimal outcomes.1 2 In an effective trauma system, severely injured patients who are taken to a lower-level or non-trauma center are first stabilized and then promptly transferred to higher-level care.3

The transfer process, however, is under threat from increasingly congested emergency departments (EDs). ED overcrowding can lead to delays in transfer and worse patient outcomes.4–6 Policy makers have taken notice of the challenges presented by congested EDs.7 8 The Commonwealth of Massachusetts became the first state to mandate hospital policies that address ED overcrowding.9 10 Massachusetts now requires all acute care hospitals to implement a ‘Code Help’ policy when their EDs are unable to accept new patients into licensed treatment spaces. These policies include deferring transfers from referring EDs to prevent suboptimal care in overcrowded areas with inadequate personnel coverage.11 Though these policies may reduce ED congestion, they risk exacerbating delays in access to high-level emergency care.

A frequent paradox is that, despite ED congestion, appropriate inpatient beds may be readily available. For example, the ED may be overcrowded with general medicine patients, whereas inpatient trauma or surgical specialized beds are open and available. Therefore, an opportunity exists for trauma patients to bypass the ED and to be admitted directly to the appropriate inpatient location. Direct admission (DA) is an alternative admission pathway in which a patient from a referring ED gains direct access to an inpatient location—either general care, intensive care unit (ICU) or OR—at the receiving hospital and bypasses its ED entirely. DA may be a useful mechanism to ensure timely transfer of severely injured patients from a referring ED to a higher level of care within the trauma system while avoiding further ED congestion.

Little is known about the design of an effective DA protocol or its feasibility. A multidisciplinary approach to DA includes coordination and correct routing of transfer calls, appropriate triage and admission determinations, accurate assignment to levels of care and locations, efficient mobilization and turnover of inpatient beds to accommodate urgent patients, and clear processes for rapid evaluation on arrival by the receiving clinical team.

We report the design and components of an institutional standard protocol for DA at a level 1 trauma center. Our objective was to evaluate the timely transfer of patients and potential adverse events related to the DA process. Our hypothesis was that DA could be effective and safe in enabling transfers.

Methods

DA protocol

The DA protocol was developed by a multidisciplinary team that included physician, nurse and administrative leaders from emergency medicine, trauma emergency operation, surgical critical care, radiology and inpatient bed management. The team was also tasked with developing processes to ensure that the pathway was implemented safely. The final policy and safety processes were implemented on May 1, 2019.

Figure 1 illustrates the DA protocol for trauma patients. If a bed could not be identified within 10 minutes of the request, the transfer was declined so as to give the referring hospital a timely decision so that they could seek transfer to another trauma center. Table 1 lists safety measures implemented in the protocol to ensure the safe transfer of patients.

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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.

Table 1

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Safety measures for direct admission pathway

Results

There were 23 patients admitted via DA during the study period, and 106 patients were admitted via the standard ED-to-ED pathway. Table 2 demonstrates patient characteristics and trauma presentation of the two cohorts. Patients were not different in terms of age, race, ethnicity, ICU LOS or hospital LOS. Overall, trauma mechanism, ISS score, GCS score and most AIS score were not significantly different. A high chest AIS score (3 to 6) and a low external AIS score (1 to 2) were more frequent in the DA cohort.

The incidence of successful transfer from the referring hospital was 82.1%. Five patients could not be transferred despite activation of the DA protocol. In all cases, the reason that the patient could not be successfully transferred was that a bed could not be identified within 10 minutes, which was the a priori defined turnaround time to decision. Figure 2 shows the location and success of transfers from referring EDs of a lower-level trauma center.

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There were no morbidity and mortality events attributed to the DA transfer process. Table 3 illustrates the comparison between the DA and ED-to-ED cohorts. The DA cohort had a lower rate of transfer compared with the ED-to-ED cohort (23, 82.1% vs. 106, 100%; p value<0.001). Time from request to arrival, up-triage to an ICU within 24 hours of arrival and rapid response/cardiopulmonary arrest within 24 hours of arrival, overall hospital mortality, and time to CT scan for those ordered within 6 hours of arrival were not different among the two cohorts. Among the three mortality events in patients in the DA cohort, all were attributable to patient and/or family wishes to focus on end-of-life care in the setting of severe injuries and were not related to the DA process.

There were 6 (26.1%) patients in the DA cohort who received an operating room procedure after transfer. These included replacement of the ascending aorta, rib Fx fixation, hemicraniectomy, cervical spine fusion and open reduction of a femur Fx, and stenting of the subclavian artery.

Discussion

To address challenges with ED crowding in our level 1 trauma center that result in delays or denials of transfers, we designed and implemented a protocol to increase timely access to care. In a prospective cohort study, we found that DA was effective more than 80% of the time in enabling access to high-level trauma care at our institution. Previous to implementation of the DA protocol, these patients would have been denied access. In addition, DA appears to be safe. There were no morbidity or mortality events attributed to the DA process after quality review by a group of evaluators composed of trauma surgeons and nurses. In addition, adverse events such as up-triage to an ICU, rapid response and cardiopulmonary arrest within 24 hours of transfer using DA were no different from transfers via the ED during the same period. Overall hospital mortality was also not different between the two cohorts.

Our findings offer evidence in support of DA as a viable strategy for level 1 or 2 trauma centers with highly congested EDs that threaten the timely transfer of trauma patients. Though we found a trend toward transfers in the DA cohort taking longer to arrive at our hospital by approximately 45 min, this difference was not statistically significant. We found that all transfers in the DA cohort who were successfully transferred had a time from initial call to decision communicated to the referring ED within the a priori defined target of 10 minutes. It is unclear whether there may be other aspects of the DA process that may cause a delay.

Though we cannot conclude that without the DA process patients would have received inadequate trauma care, we expect that the DA process is likely efficacious in ensuring more timely care for the patient, given that the selection of which level 1 trauma center to transfer a patient is typically (though not always) based on geographical proximity to the referring hospital. Thus, the DA process increases the likelihood that the patient gets access to the geographically more proximate hospital without needing to call additional hospitals for transfer that are less likely to be geographically as close by.

To our knowledge, our study is the first to report on the design and feasibility of DA for trauma patients. Previous literature regarding the development of strategies to ensure timely transfer to high-level care has focused on the geographical distribution of facilities and their proximity to patients.12–14 Several studies have demonstrated that delays in transfer to a higher-level trauma center result in worse outcomes.1–3 The American College of Surgeons recently published a study concluding that ‘access delayed is accessed denied’.15 In their study, Hashmi et al demonstrated that among more than 1.9 million trauma patients, states with better access to trauma care had lower age-adjusted mortality. DA represents one strategy to help ensure the optimization of patient safety in trauma system care and potentially to improve outcomes. Future studies should explore this relationship.

Several aspects of the DA protocol were essential to ensure appropriate care for these patients, and hospitals designing DA protocols should be attentive to these. First, the presence of the trauma team on arrival of the patient in the general care ward or ICU was critical. In many trauma bays at high-level centers, trauma team members maintain a continuous presence within the ED and are therefore present to ensure rapid assessment of the patient on arrival. In DA, patients are transferred directly to the inpatient location, which may not have trauma team members located there continuously. Within our DA protocol, when the trauma surgeon accepted the patient for transfer, trauma team members were informed about the expected arrival time of the patient, and a member of the trauma team, the bedside nurse and the nurse manager were designated to be present on the arrival of the patient. Primary surveys were performed for all patients at the time of arrival by the trauma team at the bedside, which included an attending and resident physician, as well as two or more nurses (bedside nurse and resource nurse).

In addition, the trauma team at the bedside that received the patient analyzed whether any further imaging was needed. For any imaging studies that were emergently indicated, the trauma team followed a protocol using an order system that indicated urgency and a hotline to connect with the radiologist. Radiologists at our hospital were educated about DA and were prepared to prioritize the patient for rapid imaging when indicated by the operation team. Ensuring ready access to imaging may be a challenge for hospitals. Hospitals implementing DA protocols should consider tracking metrics such as time to CT scan. In our study, this metric was similar for DA and ED-to-ED cohorts.

Given the impact of ED crowding on patient safety, an important future direction of DA would be to analyze whether such a pathway could be implemented to prevent ED overcrowding rather than purely in reaction to it, as our pathway was designed. By routinely performing DA in trauma patients, the ED may be less crowded with acutely injured patients and may be better able to care for those entering the ED from the street.

This study has several limitations. First, it was designed and implemented in a single center. The feasibility and effectiveness of the DA protocol at our institution may not be generalizable to other centers. In addition, we compared the cohort of patients exposed to the DA protocol with a contemporaneous control cohort that was not exposed to the DA protocol. Although we found no differences in the primary and secondary outcomes, the relatively lower number of patients in the DA cohort raises the possibility of type II error. Importantly, though the mortality rate was slightly higher in the DA cohort, the cause of mortality in each case was not attributable to any aspect of the DA process. In addition, though there were patients in the DA cohort who underwent operating room procedures, we did not observe any direct-to-operating room transfers. Thus, this aspect of the DA pathway needs to be further assessed for feasibility and safety. Finally, the major difference between the DA and non-DA populations was that the patients in the DA protocol were transferred to our institution during Code Help, a period of severe ED congestion, whereas those in the ED-to-ED pathway were transferred during a less congested period. Though the DA protocol specifically bypasses the ED, it is possible that significant ED congestion affects care on the general care wards, ICUs and operating rooms where these patients received care. As such, this may have impacted our results in a manner that we could not predict.

Conclusion

DA is a feasible method to transfer patients to a high-level trauma center when the ED is overcrowded. Adoption of DA may facilitate patient transfer to level 1 or 2 trauma centers and assist in providing timely care for critically injured patients.