Provider Perception of Time During Trauma Resuscitation: A Prospective Quantitative Trauma Video Review Analysis

The effect of a clock's presence on trauma resuscitation times in a Dutch level-1 trauma center: a pre-post cohort analysis

PURPOSE

Interventions performed within the first hour after trauma increase survival rates. Literature showed that measuring times can optimize the trauma resuscitation process as time awareness potentially reduces acute care time. This study examined the effect of a digital clock placement on trauma resuscitation times in an academic level-1 trauma center.

METHODS

A prospective observational pre-post cohort analysis was conducted for six months before and after implementing a visible clock in the trauma resuscitation room, indicating the time passed since starting the in-hospital resuscitation process. Trauma patients (age ≥ 16) presented during weekdays between 9.00 AM and 9.00 PM were included. Time until diagnostics (X-Ray, FAST, or CT scan), time until therapeutic intervention, and total resuscitation time were measured manually with a stopwatch by a researcher in the trauma resuscitation room. Patient characteristics and information regarding trauma- and injury type were collected. Times before and after clock implementation were compared.

RESULTS

In total, 100 patients were included, 50 patients in each cohort. The median total resuscitation time (including CT scan) was 40.3 min (IQR 23.3) in the cohort without a clock compared to 44.3 (IQR 26.1) minutes in the cohort with a clock. The mean time until the first diagnostic and until the CT scan was 8.3 min (SD 3.1) and 25.5 min (SD 7.1) without a clock compared to 8.6 min (SD 6.5) and 26.6 min (SD 11.5) with a clock. Severely injured patients (Injury Severity Score (ISS) ≥ 16) showed a median resuscitation time in the cohort without a clock (n = 9) of 54.6 min (IQR 50.5) compared to 46.0 min (IQR 21.6) in the cohort with a clock (n = 8).

CONCLUSION

This study found no significant reduction in trauma resuscitation time after clock placement. Nonetheless, the data represent a heterogeneous population, not excluding specific patient categories for whom literature has shown that a short time is essential, such as severely injured patients, might benefit from the presence of a trauma clock. Future research is recommended into resuscitation times of specific patient categories and practices to investigate time awareness.

Evaluating emergency department tube thoracostomy: A single-center use of trauma video review to assess efficiency and technique

BACKGROUND

Emergency department tube thoracostomy is a common procedure; however, assessing procedural skills is difficult. We sought to describe procedural variability and technical complications of emergency department tube thoracostomy using trauma video review. We hypothesized that factors such as hemodynamic abnormality lead to increased technical difficulty and malpositioning.

METHODS

Using trauma video review, we reviewed all emergency department tube thoracostomy from 2020 to 2022. Patients were stratified into hemodynamically abnormal (systolic blood pressure <90 or heart rate >120) and hemodynamically normal (systolic blood pressure ≥90 or heart rate ≤120). Emergency department tube thoracostomies outside of video-capable rooms, with incomplete visualization, or in patients undergoing cardiopulmonary resuscitation or resuscitative thoracotomy were excluded. The primary outcome was a procedure score modified from the validated tool ranging from 0 to 11 (higher score indicating better performance). Also measured were procedural times to (1) decision to place, (2) pleural entry, and (3) procedure completion. Postprocedure x-ray and chart review were used to determine accuracy.

RESULTS

In total, 51 videos met the inclusion criteria. The median age was 34 [interquartile range 24-40] years, body mass index 25.8 [interquartile range 21.8-30.7], predominately male (75%), blunt injury (57%), with Injury Severity Score of 22 [14.5-41]. The median procedure score was 9 [7-10]. Emergency department tube thoracostomies in patients with abnormal hemodynamics had significantly lower procedure scores (8 vs 10, P < .05). Hemodynamically abnormal patients had significantly shorter times from decision to proceed to pleural entry (4.05 vs 8.25 minutes, P < .001), and to completion (6.31 vs 14.23 minutes, P < .001). The most common complication was malpositioning (35.1%), with no significant difference noted when comparing hemodynamically normal and abnormal patients (P = .41).

CONCLUSION

Using trauma video review we identified significant procedural variability in emergency department tube thoracostomy, mainly that hemodynamic abnormality led to lower proficiency scores and increased malpositioning. Efforts are needed to define procedural benchmarks and evaluation in the context of patient outcomes. Using this technology and methodology can help establish procedural norms.

Factors Affecting Peripheral Intravenous Catheter Placement During Pediatric Trauma Resuscitation

INTRODUCTION

Intravenous access is required for resuscitation of injured patients but may be delayed in children because of challenges associated with peripheral intravenous (PIV) catheter placement. Early identification of factors predisposing patients to difficult PIV placement can assist in deciding strategies for timely intravenous access.

METHODS

We conducted a retrospective, video-based review of injured children and adolescents treated between April 2018 and May 2019. Patient demographic, physiological, injury, and resuscitation characteristics were obtained from the patient record, including age, race, weight, injury type, Injury Severity Score, initial systolic blood pressure, initial Glasgow Coma Score, intubation status, activation level, and presence of prearrival notification. Video review was used to determine the time to PIV placement, the number of attempts required, the purpose for additional access, and the reason for abandonment of PIV placement. Multivariable regressions were used to determine factors associated with successful placement.

RESULTS

During the study period, 154 consented patients underwent attempts at PIV placement in the trauma bay. Placement was successful in 139 (90.3%) patients. Older patients (OR [odds ratio]: 0.9, 95% confidence interval [CI]: 0.9, 0.9) and patients who required the highest level activation response (OR: 0.0, 95% CI: 0.0, 0.3) were less likely to have an attempt at PIV placement abandoned. Children with nonblunt injuries (OR: 11.6, 95% CI: 1.3, 119.2) and pre-existing access (OR: 39.6, 95% CI: 7.0, 350.6) were more likely to have an attempt at PIV placement abandoned. Among patients with successful PIV placement, the time required for establishing PIV access was faster as age increased (-0.5 s, 95% CI: -1.1, -0.0).

CONCLUSIONS

Younger age was associated with abandonment of PIV attempts and, when successful, increased time to placement. Strategies to improve successful PIV placement and alternate routes of access should be considered early to prevent treatment delays in younger children.

Time is tissue: Barriers to timely transfusion after pediatric injury

ABSTRACT

Strategies to improve outcomes among children and adolescents in hemorrhagic shock have primarily focused on component resuscitation, pharmaceutical coagulation adjuncts, and hemorrhage control techniques. Many of these strategies have been associated with better outcomes in children, but the barriers to their use and the impact of timely use on morbidity and mortality have received little attention. Because transfusion is uncommon in injured children, few studies have identified and described barriers to the processes of using these interventions in bleeding patients, processes that move from the decision to transfuse, to obtaining the necessary blood products and adjuncts, and to delivering them to the patient. In this review, we identify and describe the steps needed to ensure timely blood transfusion and propose practices to minimize barriers in this process. Given the potential impact of time on hemorrhage associated outcomes, ensuring timely intervention may have a similar or greater impact than the interventions themselves.