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Emergency Department Length of Stay Is an Independent Predictor of Hospital Mortality in Trauma Activation Patients

Mowery, Nathan T. MD; Dougherty, Stacy D. MD; Hildreth, Amy N. MD; Holmes, James H. IV MD; Chang, Michael C. MD; Martin, R. Shayn MD; Hoth, J. Jason MD; Meredith, J. Wayne MD; Miller, Preston R. MD

Journal of Trauma and Acute Care Surgery: June 2011 - Volume 70 - Issue 6 - p 1317-1325
doi: 10.1097/TA.0b013e3182175199
Original Article

Background: The early resuscitation occurs in the emergency department (ED) where intensive care unit protocols do not always extend and monitoring capabilities vary. Our hypothesis is that increased ED length of stay (LOS) leads to increased hospital mortality in patients not undergoing immediate surgical intervention.

Methods: We examined all trauma activation admissions from January 2002 to July 2009 admitted to the Trauma Service (n = 3,973). Exclusion criteria were as follows: patients taken to the operating room within the first 2 hours of ED arrival, nonsurvivable brain injury, and ED deaths. Patients spending >5 hours in the ED were not included in the analysis because of significantly lower acuity and mortality.

Results: Patients spent a mean of 3.2 hours ± 1 hour in the ED during their initial evaluation. Hospital mortality increases for each additional hour a patient spends in the ED, with 8.3% of the patients staying in the ED between 4 hours and 5 hours ultimately dying (p = 0.028). ED LOS measured in minutes is an independent predictor of mortality (odds ratio, 1.003; 95% confidence interval, 1.010–1.006; p = 0.014) when accounting for Injury Severity Score, Revised Trauma Score, and age. Linear regression showed that a longer ED LOS was associated with anatomic injury pattern rather than physiologic derangement.

Conclusion: In this patient population, a longer ED LOS is associated with an increased hospital mortality even when controlling for physiologic, demographic, and anatomic factors. This highlights the importance of rapid progression of patients through the initial evaluation process to facilitate placement in a location that allows implementation of early goal directed trauma resuscitation.

From the Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.

Submitted for publication September 27, 2010.

Accepted for publication February 24, 2011.

Supported by Institution Departmental Funds.

Presented at the 69th Annual Meeting of the American Association for the Surgery of Trauma, September 22–25, 2010, Boston, Massachusetts.

Address for reprints: Nathan T. Mowery, MD, Department of Surgery, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157; email:

© 2011 Lippincott Williams & Wilkins, Inc.