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Quantifying access block in a South African major trauma centre: a retrospective exploratory study
Nicholas George Chapman1, Ryoko Kinukawa1, Elchanan Reuven Nudelman1
1Trauma Directorate, Department of Surgery, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof Zone 6, Soweto, Johannesburg, 1862, South Africa.
Insights
Access block, a delay in emergency department (ED) patient bed access, affected 61.3% of patients. Key factors included CT imaging, ICU admission, and mechanical ventilation, highlighting the need for system-wide solutions.
Area of Science:
- Emergency Medicine
- Health Services Research
- Trauma Surgery
Background:
- Access block, defined as delays in emergency department (ED) patients accessing inpatient beds, significantly contributes to ED overcrowding and adverse patient outcomes.
- This phenomenon is a critical issue in healthcare systems globally, impacting patient flow and resource allocation.
Purpose of the Study:
- To quantify the prevalence of access block within the Trauma Emergency Unit (TEU) at Chris Hani Baragwanath Academic Hospital.
- To identify demographic and clinical factors associated with access block in trauma patients.
Main Methods:
- A retrospective review of consecutive patients presenting to the TEU resuscitation room between January 1 and December 31, 2022.
- Exclusion criteria included patients under 14 years (or under 10 for burns) and those managed by other services.
- Access block was defined as a delay exceeding 8 hours; univariable analyses identified associated factors.
Main Results:
- Access block affected 61.3% of the 2091 patients with recorded length-of-stay.
- Factors significantly associated with access block included CT imaging (OR 4.17), intensive care unit (ICU) admission (OR 3.69), and mechanical ventilation (OR 2.10).
- Conversely, penetrating trauma and burns were associated with lower odds of access block (OR 0.61 and 0.50, respectively).
Conclusions:
- The high prevalence of access block underscores a significant system-wide challenge within the TEU.
- CT imaging, ICU admission, mechanical ventilation, and nighttime presentation are key factors contributing to access block.
- Addressing access block requires comprehensive, whole-of-system solutions, aligning with international consensus.
Introduction:
Access block is defined as a delay in access to inpatient beds for patients from the Emergency Department (ED). It is a key contributor to ED overcrowding and is associated with worse patient outcomes. This study aimed to quantify access block within Chris Hani Baragwanath Academic Hospital's Trauma Emergency Unit (TEU) and identify associated factors.
Methods:
A retrospective review was conducted of all consecutive patients presenting to the TEU resuscitation room from January 1 to December 31, 2022. Patients aged <14 years (<10 for burns) and those managed by other services were excluded. Data on demographics, clinical characteristics, resuscitation length-of-stay, interventions, and disposition were analysed. Access block was defined as a >8 h delay for the purposes of this study. Univariable analyses were performed to identify associations with access block.
Results:
During the study period, 2270 patients were admitted from the resuscitation room to the ward without first requiring the operating theatre, of whom 2091 had a recorded length-of-stay. Access block affected 61.3%. In unadjusted analysis, factors significantly associated with access block included a requirement for CT imaging (OR 4.17), intensive care unit (ICU) admission (OR 3.69), mechanical ventilation (OR 2.10), blunt mechanisms of injury (OR 2.19), presenting at night (OR 1.85), and an arrival shock index ≥1 (OR 1.32). Conversely, presenting with penetrating trauma (OR 0.61), burns (OR 0.50), and undergoing intercostal catheter insertion (OR 0.53) were associated with significantly lower odds of access block. Time-to-CT was significantly longer in patients with access block (366 vs 165 min; P < 0.01). Patients requiring mechanical ventilation had significantly longer length-of-stay (834 vs 631 min; P < 0.01), even once time-to-CT was accounted for.
Conclusion:
Most admitted patients were affected by access block. Associated factors included CT imaging, ICU admission, mechanical ventilation, and presentation at night. This corroborates the international consensus that whole-of-system solutions are necessary to remedy it.