D.J. Wilson1, A. Tatakis1, J. Gellings1, C. Caswell1, W. Butak1, A. Farah1, D. Milia1, D. Holena1 1Medical College Of Wisconsin, Milwaukee, WI, USA
Introduction:
For traumatically injured patients requiring surgical control of hemorrhage, decreased time to operation is associated with decreased mortality. This relationship has been demonstrated with prehospital time and time spent in the resuscitation bay, but little is known about the time between patient arrival in the operating room (OR) and the start of the operation, or door-to-incision (DTI) time. Equipment preparation and pre-operative procedures may lead to delays that have yet to be characterized. Leveraging audiovisual recordings from our intraoperative trauma video review (IOTVR) program, we sought to characterize the magnitude and variability of DTI times and secondarily hypothesized that DTI time is associated with patient physiology and required interventions.
Methods:
One emergency trauma OR at our level-1 trauma center is equipped to record video, sound, and patient vitals. During an 8-week period from June to July 2024, data was abstracted to measure the timing and occurrence of activities during DTI time. Information captured included timing of OR preparation, patient arrival, line placement (central, arterial, or peripheral), intubation, other procedures (e.g., urinary catheter placement), skin preparation, draping, and incision. Location of injury, emergency room (ER) procedures or activation of massive transfusion protocol (MTP), and hypotension (systolic blood pressure <90 mmHg) were also noted.
Results:
Twenty-seven cases were reviewed, with 85% resulting from a penetrating mechanism. MTP had been activated before OR arrival in 33% of cases (9/27), 12% (3/26) were hypotensive on arrival, and 38% (10/26) had pre-incision hypotension. The median DTI time was 15 minutes (IQR 8.8- 16.4) with a nearly four-fold variation between the shortest (5.6 minutes) and longest (21.3 minutes) times. Arterial lines were placed in 24 patients in the OR requiring a median of 4.9 mins (IQR 3.9-7.5). Eleven peripheral IVs were placed with a median of 3.5 minutes (IQR 1.4-5.6), and four central lines were placed with a median of 7 minutes (IQR 3.5-10.3) (Figure). Other procedures included endotracheal intubation (23/27) and urinary catheter placement (22/27), including preoperative placement in all patients undergoing MTP. Neither DTI times nor preoperative procedure times were found to be associated with patient hypotension.
Conclusion:
Procedures during DTI time and DTI itself are subject to variability in patients undergoing emergent trauma operations. Understanding the timeline from patient injury to definitive hemorrhage control offers essential insights that may be used to reduce DTI and improve hemorrhage control. IOTVR is a critical tool for quality improvement that can be used to elucidate processes of care that are difficult to study in its absence.