No Correlation Found Between Length of ER Stay and Mortality Rates

How much does ER and ED overcrowding affect trauma patient care?

authors Christopher Cussat

A recent study conducted at St. Louis University (SLU) found that the amount of time a trauma patient stays in the emergency department (ED) makes no real difference in that patient's mortality rate.

Published this year in the Journal of Hospital Administration under the title, "Does emergency medicine length of stay predict trauma outcomes at a Level I Trauma Center?"—research for this retrospective database review studied Level I and Level II activated adult trauma patients at SLU Hospital during a one year period between 2010 and 2011.

According to one of the authors, Kamal (Komo) Gursahani, MD, of SLU's School of Medicine, this study supports the idea the systems and processes that SLU Hospital's Level I Trauma Center have established are perfected for the care of the critically injured. In fact, it’s effective even at times when patients requiring treatment in the ED outweigh the resources available in the ED. "Therefore, the community can be confident that the process of triaging injured patients based on specific criteria is an effective system that properly differentiates patients in need of immediate interventions from those who are stable enough to wait without affecting overall mortality," she added. After the study's authors assessed the relationship between trauma patients' emergency department length of stay (EDLOS) on their subsequent hospital length of stay and mortality, it was determined the length of stay in emergency rooms (ERs) doesn’t seem to affect the rate of trauma patient mortality.

The data also determined that while high ER volume did increase a trauma patient's length of stay in the ED, there was no association between staying in the ED (more than four hours) and subsequently increased mortality in trauma patients. This issue of high ER volume and its correlation to overcrowding and treatment were also considered in the analysis. "ED overcrowding is an issue that has surfaced as a priority for hospitals to address and manage over the last decade and currently presents a difficult problem for hospitals across the country, as well as right here in St. Louis," noted Gursahani.

Although primary study author, associate professor and SLU Care Physician Group ED doctor, Preeti Dalawari, MD, MSPH, said the study showed the ED's systems were able to accommodate a fluctuating volume of patients without posing a significant risk to trauma patients. She also noted the system is at an all-time high for patients passing through the ER and ED. Overcrowding is a pressing issue because critically ill patients boarding in emergency departments use substantial resources, especially the time of emergency physicians and nurses. "ERs and EDs are extremely busy, and now with the Affordable Care Act, they've only gotten busier—as a result, the demands on resources and manpower may eventually add to the length of stay or morbidity of other patients," she said.

Like Dalawari, Gursahani agreed the issue of overcrowding still doesn’t seem to directly affect trauma patient mortality rates. "ED overcrowding, which leads to increased lengths of stay in the ED for emergency room patients, is a concern of the day with its own inherent patient safety considerations. However, even when the ED is crowded, the 'protocolized' way in which we handle major trauma victims is the key to effective treatment and saving lives."

She further explained that Level I designated trauma centers are accredited based on the availability of specific resources and specialty services for the care of the traumatically injured patient. "These assessment and treatment protocols have been created to harness these services. This study supports they are effective and life-saving, even when the ED and hospital are crowded."

In other words, although the length of time a trauma patient spends in the ED is associated with hospital crowding, this ‘time’ doesn’t affect their overall mortality, concurred co-author Eric Armbrecht of the Center for Outcomes Research at SLU. "Overcrowding may impact overall patient satisfaction and hospital staff stress, but the primary outcome for trauma care (survival) remained favorable at about 95.5 percent."

Due to the consensus of these results, this study does not help to guide doctors and care providers as far as the management of insurance restrictions on trauma patient care. According to Gursahani, the Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals to diagnose and stabilize any and every potential emergency medical condition that walks or rides through the doors of a U.S. emergency department, regardless of their payor, or lack thereof. 

"In my experience, providers aren’t even aware of insurance status while treating these patients. As tertiary care facilities, in general, trauma centers accept any patient that requires a higher level of trauma care as long as they have the capacity to provide the standard of trauma care," she noted.

Perhaps the most important question regarding this study is whether its results should change the way EDs operate and function, regarding evaluation protocols, admission, and discharge. Gursahani's answer is cautious, "On one hand, this study directly disputes a previously published study finding that mortality in trauma victims actually goes up as patients are in the ER longer." She also noted that other studies specifically investigating the outcomes of non-trauma patients in EDs who have prolonged lengths of stay have also shown an increase in mortality rates. But in the end (based on the data derived and described above), Gursahani concluded this study, like most others previously published, still supports the current practice patterns established by designated trauma centers.


Saint Louis University School of Medicine:

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