Timeliness in obtaining emergent percutaneous procedures in severely injured patients: How long is too long and should we create quality assurance guidelines?

Abstract

RESEARCH • RECHERCHETimeliness in obtaining emergent percutaneous procedures in severely injured patients: How long is too long and should we create quality assurance guidelines?Background: Modern trauma care relies heavily on nonoperative, emergent percutaneous procedures, particularly in patients with splenic, pelvic and hepatic injuries. Unfortunately, specific quality measures (e.g., arrival to angiography times) have not been widely discussed. Our objective was to evaluate the time interval from arrival to initiation of emergent percutaneous procedures in severely injured patients.Methods: All severely injured trauma patients (injury severity score [ISS] > 12) presenting to a level 1 trauma centre (2007)(2008)(2009)(2010) were analyzed with standard statistical methodology.Results: Among 60 severely injured patients (mean ISS 31, hypotension 18%, mortality 12%), the median time interval to the initiation of an angiographic procedure was 270 minutes. Of the procedures performed, 85% were therapeutic embolizations and 15% were diagnostic procedures. Splenic (median time 243 min, range 32-801 min) and pelvic (median time 278 min, range 153-466 min) embolizations accounted for 43% and 25% of procedures, respectively. The median embolization procedure duration for the spleen was 28 (range 15-153) minutes compared with 59 (range 34-171) minutes for the pelvis. Nearly 22% of patients required both an emergent percutaneous and subsequent operative procedure. Percutaneous therapy typically preceded open operative explorations. Conclusion:The time interval from arrival at the trauma centre to emergent percutaneous procedures varied widely. Improved processes emphasizing patient transition from the trauma bay to the angiography suite are essential. Discussion regarding the appropriate time to angiography is needed so this marker can be used as a quality outcome measure for all level 1 trauma centres. Contexte :De nos jours, en traumatologie, les soins reposent largement sur des interventions non chirurgicales percutanées d'extrême urgence, particulièrement chez les patients blessés à la rate, au bassin et au foie. Malheureusement, les indices de qualité spé-cifiques (p. ex., temps écoulé entre l'arrivée et l'angiographie) n'ont pas fait l'objet de discussions approfondies. Notre objectif était de mesurer le temps écoulé entre l'arrivée et l'instauration des interventions percutanées d'extrême urgence chez les grands blessés. Méthodes

The potential benefit of a hybrid operating environment among severely injured patients with persistent hemorrhage

“…5,6,8 A total of 7% of the patients displaying persistent hypotension required both approaches, with 97% of those sustaining either pelvic fractures or liver injuries as the dominant source of ongoing bleeding. While this subset of patients totals only 35 individuals, it is apparent that those who were directed to the angiography suite (25 patients) before an operative repair had a significantly lower mortality than those who went to the OR (10 patients) first followed by a subsequent percutaneous technique.…”

“…In summary, 92% of the patients who required both percutaneous and open modalities or 6% overall would have "clearly" benefited. 5,6,8 The concept of utility is further enhanced by a discussion of the patients who presented with injuries that could have "potentially" benefited from access to a RAPTOR suite. In total, 148 patients (30%) with vascular injuries who displayed persistent hypotension are available for debate regarding potential efficiencies in both patient care and flow inherent within a RAPTOR environment.…”

“…More specifically, intermittently hypotensive patients have been shown to possess a "door-to-needle" time of 49 minutes at our institution. 8 When compared with a prospective audit of the time from ED admission to arrival within the RAPTOR (22 minutes for all RAPTOR interventions vs. 37 minutes for percutaneous procedures within the RAPTOR ["door-to-needle" time]) among hypotensive patients, it seems that transfer to a hybrid suite may bypass some of the delay inherent in pursuing initial angiographic interventions within the purely radiologic suite. Further study of the root cause for this difference is required.…”

Damage control resuscitation: lessons learned

“…As timing of interventions is so critical, interventional radiology facilitates need to be rapidly available 24 h a day to be effective and, this requires organisational development and investment in major trauma centres [ 54 ]. It is important to balance decision making and remember that not all bleeding can be controlled non-operatively in a timely manner [ 55 ]. Multidisciplinary input is critical and the application of some of these techniques remains controversial [ 24 , 56 ].…”

Current opinion on catheter-based hemorrhage control in trauma patients

“…While angiographic embolization and aortic occlusion balloons have been routinely used for the last 20 years, in most current instances, they are slower at achieving hemorrhage control than standard operative interventions for the treatment of traumatic hemorrhage. 7,8 TREATMENT DELAYS IN HEMORRHAGING TRAUMA PATIENTS Treatment delays in hemorrhaging trauma patients are a serious problem because of the high risk of death caused by hemorrhage in the first initial hours after the injury. In patients with NCTH, treatment decisions are complicated by multiple factors, such as polytrauma, variable in-hospital locations for advanced diagnostic imaging, catheter-based and open surgical procedures necessitating intrahospital transport, 9 and varying availability of specialists depending on the day and time of injury.…”