Original Contributions
Factors Affecting ED Length-of-Stay in Surgical
Critical Care Patients
BARBARA DAVIS, RN, MSN,* SARA SULLIVAN, RN, CEN,*
AMY LEVINE, MD,t JOHN DALLARA, MD*
To determine what patient characteristics are associated with prolonged
emergency department (ED) length-of-stay (LOS) for surgical critical care
patients, the charts of 169 patients admitted from the ED directly to the
operating room (OR) or intensive care unit (ICU) during a 6-week period
in 1993 were reviewed. The ED record was reviewed for documentation of
factors that might be associated with prolonged ED LOS, such as use of
computed tomographic (CT), radiology special procedures, and the num-
ber of plain radiographs and consultants. ED LOS was considered to he
the time from triage until a decision was made to admit the patient. Using
a Cox proportional hazards model, use of CT and special procedures were
the strongest independent predictors of prolonged ED length-of-stay. The
number of plain radiographs and consultants had only a minimal effect.
Use of a protocol-driven trauma evaluation system was associated with a
shorter ED LOS. In addition to external factors that affect ED overcrowd-
ing, ED patient management decisions may also be associated with pro-
longed ED length-of-stay. Such ED-based factors may be more important
in surgical critical care patients, whose overall ED LOS is affected more
by the length of the ED work-up rather than the time spent waiting for a
ICU bed or operating suite. (Am J Emerg Med 1995;13:495-500. CopyrigM
© 1995 by W.B. Sounders Company)
Emergency department (ED) overcrowding continues to
be a major problem nationwide. Many factors have been
implicated to account for the increasing volume and acuity
experienced by EDs in recent years. These include the in-
creasing demand on emergency services caused by sub-
stance abuse and violence, the greater number of poor and
uninsured patients with limited access to other sources of
health care, increased emphasis on outpatient management
of sicker patients, and a shortage of experienced ED person-
nel. 1"6 In addition, there may be a tendency to assign ED
patients requiring admission a lower priority for inpatient
beds because they tend to be underinsured, to consume
more hospital resources, and to have longer hospital length-
of-stay. 7-9 A recent survey of ED directors nationwide re-
ported median ED holding times of 2.0 hours for a hospital
From the *Department of Emergency Medicine, Duke Univer-
sity Medical Center, Durham, NC, and the tDepartment of Epi-
demiology, The University of North Carolina at Chapel Hill.
Manuscript received September 7, 1994.
Address reprint requests to Dr Dallara, Department of Emer-
gency Medicine, Box 3096, Duke Medical Center, Durham, NC
27710.
Key Words: Emergency services, length-of-stay, overcrowd-
ing, criticalcare, decision-making, trauma system, Cox propor-
tional hazards.
Copyright © 1995 by W,B, Saunders Company
0735-6757/95/1305-0001 $5.00/0
bed (1.5 hours for an intensive care unit (ICU) bed). There
have been many reports of ED overcrowding and patient
diversions during periods of peak ED volume. ~
Several types of solutions have been proposed to address
the issue of ED overcrowding. These include hospital-based
initiatives designed to improve the availability of inpatient or
observation beds; greater and more flexible ED staffing, en-
couraging appropriate use of ED for medical care4"9't°; de-
velopment of triage protocols to screen patients with non-
urgent problems 11; and contingency plans for times of need
such as ambulance or aircraft diversion. 2"~°
Prolonged ED length-of-stay (LOS) may have other con-
tributing factors more intrinsic to the ED itself. Management
decisions in the ED, time of day of presentation, and other
patient characteristics can affect the length of the ED work-
u p . 12 This may be particularly true for ED critical care pa-
tients, who may have shorter holding times (ie, the time
waiting for an ICU bed or or suite) relative to the length of
their ED evaluation and their overall LOS. Identifying the
factors that most affect the length of work-up in the ED
(referred to here as " E D L O S " ) can allow a more focused
approach to improving the efficiency of ED-based patient
evaluation.
In this study, the authors examined characteristics hy-
pothesized to be associated with prolonged ED LOS, includ-
ing computed tomographic (CT) scanning, other special pro-
cedures (typically radiology diagnostic procedures), the
"number of plain radiographs performed, and the number of
consultants called. We also tested a secondary hypothesis
that use of our protocol-driven trauma evaluation system
("trauma system") resulted in decreased ED LOS.
METHODS
All ED charts of surgical critical care patients between August 20,
1993 and October l, 1993 were retrospectively reviewed. Critical
care patients were defined as those sent to the operating room (OR)
or ICU directly from the ED. 12 Patients were excluded if the ED
chart could not be located, In addition, because nursing documen-
tation was so important for our variables of interest, we excluded
charts in which the nursing flow sheet(s) were missing.
Duke University Medical Center is a Level I Trauma Center, with
a volume of 50,000 patients annually. Approximately two thirds of
our multisystem trauma cases are referred from a network of out-
lying rural and community hospitals by either ground or air ambu-
lance. Forty percent of our patient population has private health
insurance, 30% has either Medicare or Medicaid, and the remaining
30% has no insurance coverage.
495
496 AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 13, Number 5 • September 1995
In our ED, all patients with significant traumatic injuries (Table 1)
receive a standardized "trauma system" evaluation. Each patient is
assessed by a dedicated trauma team consisting of three nurses,
respiratory therapy, a second-year surgery resident, the ED attend-
ing physician, and a representative from the trauma service (typi-
cally a third-year or more senior resident). Initial resuscitation,
blood testing, and radiographs are protocol-driven using preprinted
order sheets. Using a separate critical care flow sheet developed by
the ED staff, the primary nurse is responsible for documenting the
patient's physical examination, fluids and medications adminis-
tered, consultants called, testing performed, and other significant
events (such as vomiting episodes and allergic reactions). Major
patient management decisions, such as hospital admission, specialty
consultation, and the need for ED-based testing (eg, CT scanning,
peritoneal lavage) are made jointly by the ED faculty and the senior
representative from the admitting service.
Although based on the specific criteria listed in Table 1, activation
of the trauma system varies by the attending and resident physicians
on duty, time of day, and the current ED census. In particular, some
providers activate the system more liberally than others for ex-
pected patients who appear to be clinically stable and have only
single-organ system involvement (eg, hip fracture, isolated facial
fracture requiring surgery, isolated eye injury).
Each study chart was evaluated by a single reviewer (B.D. or
S.S.). Information was extracted on demographics, illness severity
as defined by trauma score) 3 disposition, and admitting service.
Total LOS was defined as the time from triage until report was
called to the OR or ICU. The reviewer also determined the ED LOS,
defined as the time from triage until the ED work-up was completed
(ie, the patient was simply waiting for an OR suite or ICU bed).
Holding time was defined as the time from completion of the ED
work-up until report was called. For 58 charts, two reviewers inde-
pendently determined the ED LOS variable to examine its reliabil-
ity. For patients in whom two ED LOS values were available be-
cause of overlap in reviewing, the value from the principal reviewer
(B.D.) was used.
Information was extracted from each chart on use of CT scanning
(head, abdomen, or both), and other ED-based special procedures
(eg, radiology diagnostic tests, diagnostic or therapeutic maneuvers
performed in the ED). The number of plain radiographs and con-
sultants was recorded, and was divided into ordinal categories after
a preliminary review of the data. The number of plain radiographs
TABLE1. Guidelines for Activating Trauma System*
Trauma score <13
Glasgow coma score <11
Hypotension or unstable vital signs
Traumatic arrest
High energy dissipation or rapid deceleration injury
Falls of more than 10 feet
Near drowning, hypothermia, or hyperthermia
High-risk motor vehicle crash:
Extrication time more than 20 minutes
Passenger compartment invasion more than 1 foot
Ejected from vehicle
Death of other passenger
Any pedestrian struck by vehicle
Other multisystem or major injuries
Penetrating trauma to head, neck, torso, groin, or midthigh
Amputation above ankle or wrist
Burns (>20% 2nd or 3rd degree)
Paralysis or paresthesias
Assaults, abuse, or battering injuries
* Adapted from the Duke ED Patient Care Handbook, Joint Com-
mittee for Clinical Practice and Standards, July 1992.
ordered was divided into five groups: none, 1, 2 to 3 (typical trauma
series), 4 to 5, and 6 or more. The number of consultants was di-
vided into three groups: none, 1, and 2 or more. A consultant was
defined a priori as a specialist not normally performing initial patient
evaluations in the ED (such as an orthopedist or neurosurgeon).
Each ED chart was reviewed in the same manner to minimize any
observer bias, and the information was entered directly into a cus-
tomized computer database (Epi Info, version 5.01b~4). Each re-
viewer was given a brief training session in computerized data entry
using Epi Info written by one of us (J.D.), and regular meetings
between the investigators and reviewers were held to discuss prob-
lems that arose during data collection and entry.
Summary statistics for total LOS, ED LOS, and holding times
were calculated. Because of the authors' interest in those factors
that affected the ED-based work-up, the analysis focused on factors
associated with ED LOS (instead of total LOS, which included hold-
ing time).
Univariable comparisons of ED LOS were made for dichotomous
and ordinal values of all major variables. To assess the effect of
multiple simultaneous factors affecting ED LOS, a Cox proportional
hazards model of time-to-ED discharge was created (PHREG pro-
cedure,~5 Statistical Applications Software [SAS]). All variables met
Cox assumptions, ie, log( - log(S)) functions were linear and parallel
for all discrete variable levels. Starting with all variables in the
model, and controlling for demographics and admitting service, a
succinct model was created by successively eliminating factors that
did not reach at least borderline significance (P ~< .2). All factors in
the final model were retained at P < .05 level (except for the number
of radiographs, which was retained at a P = .08 level of signifi-
cance).
Survival curves were then generated to compared the independent
effect of each variable that was a significant predictor of ED LOS in
the final model. These curves showed the proportion of patients
with their ED work-up not yet completed with and without the vari-
able of interest (eg, CT versus no CT) over a given interval of ED
LOS, adjusting for the simultaneous effect of all other variables in
the model. The proportion of patients with their ED work-up not yet
complete at 2 and 4 hours after triage was estimated from this func-
tion for the typical patient with and without the characteristic of
interest (eg, CT versus no CT).
Hazard ratios were calculated for each factor in the final model.
They represent the relative likelihood that a patient with a given
characteristic would have completed their ED work-up during a
given thne interval, simultaneously adjusting for all other factors in
the model. A hazard ratio greater than one signifies a shorter ED
LOS, because the likelihood of the ED work-up being completed
over time is greater. Likewise, a hazard ratio of less than one sig-
nifies a longer ED LOS.
RESULTS
O n e h u n d r e d e i g h t y - f o u r p a t i e n t s w e r e a d m i t t e d to t h e O R
or I C U directly f r o m t h e E D d u r i n g t h e s t u d y period. O f
t h e s e , 15 p a t i e n t s (8%) w e r e e x c l u d e d b e c a u s e o f p o o r -
quality d o c u m e n t a t i o n or missing c h a r t i n f o r m a t i o n . T h e re-
m a i n i n g 169 p a t i e n t s w e r e i n c l u d e d in t h e study.
T h e overall E D L O S a n d h o l d i n g t i m e s are s h o w n in T a b l e
2. M o s t p a t i e n t s s t a y e d in the E D a b o u t 2 to 3 h o u r s a n d
w a i t e d 30 to 60 m i n u t e s for e i t h e r a n O R suite or I C U bed.
H o l d i n g t i m e s w e r e e x t r e m e l y s k e w e d ; 47% o f t h e p a t i e n t s
h a d h o l d i n g t i m e s o f less t h a n 30 m i n u t e s , w h e r e a s 6 %
w a i t e d m o r e t h a n 4 h o u r s . T h e m e d i a n v a l u e s a n d t h e inter-
quartile r a n g e (ie, 25th to 75th p e r c e n t i l e values) give a b e t t e r
picture o f the typical p a t i e n t .
S e l e c t e d p a t i e n t c h a r a c t e r i s t i c s are s h o w n in T a b l e 3. T h e
m e a n p a t i e n t age w a s 36 --- 22 y e a r s (range, 0 to 95 years),
DAVIS ET AL • FACTORS AFFECTING ED LENGTH-OF-STAY 497

TABLE 2. LOS and Holding Times* (Minutes) of Surgical Table 3 also shows the corresponding values of ED LOS
Critical Care Patients (N = 169) for each variable studied. In this univariable comparison,
four factors were strongly associated with an increased ED
Holding Time
ED LOS for OR/ICU Total LOS
LOS: use of CT scanning, special procedures, four or more
plain radiographs, and two or more consultants. Use of our
Mean ± SD 191 ± 141 69 ± 94t 260 ± 169 protocol-driven trauma evaluation system ( " t r a u m a sys-
Median 157 35 232 tem") was not associated with a shorter ED LOS in the
Range 5-855 0-480 10-930 crude data. However, a greater proportion of the trauma
Mode 120 0 270
system patients underwent CT scanning (65% versus 11%)
* Time waiting for an OR suite or ICU bed. and special procedures (26% versus 9%) than in the non-
1" Large departure from normal distribution. trauma system group, which would tend to conceal a bene-
ficial effect of the trauma system in the unadjusted ED LOS.
with a median age of 36 years. Most of the patients were This was unmasked by examining the effect of the trauma
men, and three quarters had normal trauma scores (ie, score system on ED LOS in each of these groups. F o r the group
of 16). The CT scanning was performed in one third of the with (N = 54) and without (N = 115) CT scanning, the
population. Special procedures consisted of 19 diagnostic trauma system decreased the mean ED LOS from 346 to 249
minutes (P = .02, Kruskal-Wallis test) and from 173 to 75
radiology procedures (including nine aortic arch arterio-
minutes (P < .001, Kruskal-Wallis test), respectively.
grams, four intravenous pyelograms, three ultrasound exam-
A Cox proportional hazards model of time to completion
inations, and one magnetic resonance imaging [MRI]), four
of the ED work-up (ie, ED LOS) was constructed to identify
neurosurgical procedures (two ventriculostomies and two
the independent predictors of prolonged ED LOS. This
Halo placements) and three complex fracture reductions.
method adjusts for the effect of multiple factors determining
Several additional patient characteristics are helpful in de-
ED LOS. The final model, shown in Table 4, corrected for
scribing the study population. One hundred and twenty-
demographics, admitting service, and illness severity (as
seven patients (75%) were sent to the operating room, and
measured by trauma score). Use of either CT scanning or
the remaining 42 (25%) were admitted to the ICU. Most of
special procedures was associated with longer ED LOS (haz-
the patients were admitted by the orthopedic surgery (36%),
ard ratios [HR] less than one), and use of the trauma system
trauma surgery (20%), or neurosurgery (18%) services. Only
was associated with shorter ED LOS (HR greater than one).
10 patients (6%) had immediate indications for surgery be-
This means, for example, that patients who received CT
cause of penetrating trauma to the abdomen (N = 8) or neck
scanning were 4.5 times less likely (ie, 1 divided by .22) to
(N = 2).
complete their ED work-up within a given time interval than
those who did not. By contrast, individuals who went
TABLE 3. Selected Variables and ED LOS through the trauma system were five times more likely to
ED LOS P Value complete their ED work-up within a given time interval than
Variable Number (Minutes) (pair)* those who did not. The number of plain radiographs and
consultants had a smaller, less significant effect. Admitting
Age NS service had only a small effect on ED LOS (data not shown).
/>65 27 (16%) 159 Figures 1 and 2 are survival (time-to-event) curves show-
<65 142 197 ing the effect of CT scanning and the trauma system on
Sex NS
Male 116 (69%) 178 completion of the ED work-up, after correcting for other
Female 53 219 factors that were observed to affect ED LOS. In contrast to
Trauma score NS most survival analysis curves, a lower lying curve is better
16 125 (74%) 186 for L O S ; this means that a greater proportion of patients
13-15 18 261 have had the event of interest (ie, completion of ED work-
~<12 26 168 up) over time. In our data, more than half (54%) of the pa-
CT scan <.001 tients who received CT scanning were still in the ED after 4
Yes 54 (32%) 271 hours, compared with only 7% of those who did not undergo
No 115 154 the test. Even more dramatically, only 1% of the patients
Special procedure .002
Yes 26 (15%) 290
No 143 173 TABLE 4. Selected factors affecting completion of ED
Plain radiographs <.001 Work-up
/>4 24 (14%) 302 Hazard 95% Confidence
1-3 145 172
Variable Ratio Interval
Consultants <,001
/>2 28 (17%) 304 Age > = 65 years 1.54 0.95-2.48
0-1 141 168 Sex = male 1.40 0.98-2.02
Trauma system NS Trauma score 13-15 (versus 16) 0.48 0.27-0.84
Yes 65 (38%) 187 Trauma score ~<12 (versus 16) 1.21 NS
No 104 193 CT scanning 0.22 0.13-0.41
Special procedures 0.32 0.20-0.54
* Comparison of ED LOS among pairs using Kruskal-Wallis test. Trauma system 5,1 2.9-9.0
Abbreviation: NS, not significant.
498 AMERICANJOURNALOF EMERGENCYMEDICINE• Volume13, Number5 • September1995

1
2 hrs: CT scan: 87% still in ED
0.9 No CT scan: 55% still in ED
¢z
= 0.8
"~ 4 hrs: CT scan: 54;~oS::::I inn ED
o ~ 0.7
FIGURE 1. Effect of CT
~. 0.6
UJE scanning on ED LOS. Surgical
o 0.s OR and ICU admissions ad-
justed for age, sex, admitting
= ~ 0.4 service, trauma score, special
.o "6 procedures, and trauma sys-
= 0.3 tem.
o.
2
n
0.2
0.1
0
60 120 180 240 300 360 420 480
Length of ED Stay (minutes)

who went through the trauma system were still in the ED
after 4 hours, compared with 42% of those who did not. (The
10 patients with immediate indications for surgery, all of
whom received the trauma system, were omitted from this
graph to improve comparability of the two groups.) The
graphical effect of special procedures on ED LOS is not
shown, and was similar to that of CT scanning.
We examined the reliability of the ED LOS variable in a
subset of the charts. Fifty-eight charts were reviewed by two
independent observers to determine ED LOS. There was
perfect agreement (to the minute) in 41% of the cases. The
remaining cases had disagreements of 1 to 60 minutes (28%),
1 to 2 hours (22%), and more than 2 hours (9%). In 69 % of
the cases, there was disagreement of less than one hour.
Cases with larger disagreement tended to be those with
longer total LOS, but the correlation was weak (r = . 14).
DISCUSSION
This study shows that ED-based management decisions,
particularly use of CT a n d other ED-'based special proce-
dures, have the largest independent effect on ED LOS in our
population of surgical critical care patients. These types of
ED-based decisions may be especially important for deter-
mining overall LOS in critical care patients, whose holding
times (ie, time waiting for a bed) tend to be short relative to
the length of their ED work-up. It is likely that testing deci-
sions and use of protocols are important determinants of ED
LOS for other groups of patients.
ED-based causes of prolonged ED LOS are only part of
the larger problem of ED overcrowding. Many other factors
external to the ED are precipitating ED overload nation-
wide, such as substantial numbers of poor and uninsured
patients, increasing substance abuse and violence, and
greater emphasis on outpatient management of sicker pa-
tients. ~-8 Suggestions to deal with the overcrowding problem
have focused on improved/flexible staffing, hospital policy
changes, and crisis management. 2'9 Increasing the speed and
efficiency of the ED work-up is an important adjunct to these
proposals so that EDs can better handle the continuing in-
crease in patient volume and acuity that most EDs expect in

1 2 hrs: No Trauma System: 82% still in ED

0.9 "~ ~ , ~ Trauma System: 39% still in ED
e~
,= 0.8 \ ~ 4 hrs: No Trauma System: 42% still in ED
o 0.7
FIGURE 2. Effect of trauma
~. 0.6 system on ED LOS (excluding
mE
8 0.5 10 patients with immediate in-
~. "X~ ---*- No Trauma System dications for surgery). Surgi-
c ~>, 0.4 cal OR and ICU admissions
adjusted for age, sex, admit-

"'<_2'
~ 0.3 ting service, trauma score,
special procedures, and CT
2 0.2
0. scanning.
0.1
0
60 120 180 240 300 360 420 480
Length of ED Stay (minutes)
DAVIS ET AL • FACTORS AFFECTING ED LENGTH-OF-STAY;
the near future. More importantly, emergency department
physicians and nurses may have more control over decisions
involving the ED workup, a luxury less often enjoyed when
pursuing policy and other administrative changes at the hos-
pital level.
Knowing what factors have the greatest effect on ED LOS
can focus our efforts for change in the ED itself. For this
group of surgical critical care patients, it was clear that CT
scanning and other time-consuming diagnostic procedures
performed outside the department, typically in radiology,
were a major problem (the common parlance is "lost in
x-ray"). Solutions may include use of ultrafast helical CT
scanning, performing CT scanning or special procedures in a
CT/fluoroscopy suite located in the ED, and postponing
elective special procedures such as Halo placement and
nonurgent fracture manipulation until the patient has been
triaged to an appropriate critical care unit. Less effort might
be spent trying to limit the number of plain radiographs and
consultants, because these theoretical causes of prolonged
ED LOS appeared to be less important.
The use of our ED-based "trauma system" was associated
with dramatically shorter ED LOS. However, the patients
who received the trauma system still might not be fairly
compared with the remaining population of surgical critical
care patients, even after correcting for other factors ob-
served to affect ED LOS (and omitting those patients with
immediate indications for surgery). Nevertheless, the large
difference in ED LOS between the two groups strongly sug-
gests that the trauma system was at least in part responsible
for the observed effect. What is less clear is how the system
exerted its beneficial effect. We believe that an automated,
systematic initial evaluation of the patient and a focused
effort by ED staff were both essential to its success. This
underscores the need for adequate (and if necessary, flexi-
ble) ED staffing. A protocol-based trauma system may in-
crease efficiency, but only if supported by enough ED per-
sonnel. It is important to note that our trauma system does
not encourage less diagnostic testing, nor does it give pa-
tients a higher priority than they would otherwise have by
virtue of their illness or injury.
There are several important limitations to our study. First,
we did not correct for admitting diagnosis or mechanism of
injury in examining the factors affecting ED LOS. Certain
types of injuries or illness might be given higher priority by
the ED staff and get through their ED work-up faster. How-
ever, correcting the survival curves for age, sex, illness se-
verity, and admitting service probably accounted for some of
this diagnostic mix effect. It might be that the beneficial
effect of our trauma system was partly caused by differences
in diagnosis or mechanism of injury; by omitting the patients
with immediate operative indications, we attempted to min-
imize this bias.
In addition to problems of diagnostic mix, we were unable
to correct for how busy the ED was on a particular day. The
number and acuity level of patients in the ED at any given
time would likely have a strong effect on the length and
efficiency of the ED work-up, and might introduce a bias.
For example, use of the trauma system might be less likely
on busy days, which would tend to overstate the system's
benefit in reducing ED LOS. However, it is likely that the
level of patient activity in the ED did not have much effect
499
on the decision to perform CT scanning and special proce-
dures that were clinically indicated. We did not attempt to
correct for the availability of ICU beds or OR suites because
these would principally affect the holding time, but not the
length of the ED-based work-up.
A final limitation was our definition of ED LOS. In order
to study factors affecting ED LOS, one would ideally like to
isolate the time required for the ED work-up from the hold-
ing time. However, what defines the point when the ED
work-up is complete, and how accurately can we determine
this time from a chart review? In our data, we had fair agree-
ment between two observers using a common-sense proto-
col, supporting the validity of the variable. However, there
were several cases of large disagreement in ED LOS, and
not always in cases where total LOS was excessively long.
Better definition of what constitutes ED LOS versus holding
time, as well as prospective data collection, may help im-
prove the validity of the ED LOS variable and the conclu-
sions drawn from its use.
CONCLUSION
In addition to administrative and societal factors that af-
fect ED overcrowding, ED-based patient management deci-
sions such as use of CT and ED-based special procedures
strongly affected ED LOS in a population of surgical critical
care patients. Such factors may have a larger effect on over-
all LOS in this group of patients, who tend to have shorter
ED holding times. Factors identified as independent predic-
tors of prolonged ED LOS are candidates for ED-based in-
terventions to reduce LOS. These interventions might in-
clude faster procedures (ultrafast CT scanning), performing
the tests in the ED proper, or delaying certain procedures
until after the patient is transferred to another critical care
suite. By contrast, factors associated with shorter ED LOS,
such as a protocol-driven trauma evaluation system, can be
implemented.
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