Time-Management Study of Trauma Resuscitation Daniel Lowe, MD, Richard Pope, ANP, Jerris Hedges, MD, New Haven, Connecticut

A prospective time-management analysis of trauma resuscitation (TR) of 431 patients arriving at a university trauma center documents timing and or- ganization. Severity of injury, patient age, and po- tential airway injury were significant factors in- creasing the duration of TR up to a certain time (36 minutes). Moderately injured patients required less time (under 25 minutes). Patients needing emergent operations spent a minimal amount of time (20 minutes) in TR. Potential injuries involv- ing the airway or cervical spine, or shock, added minutes. A review of the timing and organization of TR suggests the need for improvement in airway as- sessment and management. Patients with certain mechanisms of injury and elderly patients with blunt injuries required additional time in TR. With surgery faculty supervision and senior resident at- tendance, the month of resident experience had no effect on TR times. A timely and organized TR is critical to trauma care. TR times should be docu- mented for quality assurance and ongoing review.

D eath after trauma occurs in a trimodal distribution. There is an immediate peak secondary to over-

whelming injury, a second peak minutes to hours from shock, and a third peak, involving sepsis and multiple organ failure, after several weeks [1]. The second peak is when surgical intervention can save the most lives. Delays during this period have been shown to result in prevent- able deaths [2,3]. This so-called golden hour is when timely and organized trauma resuscitation (TR) is essen- tial for optimal patient outcome. The standard of care for TR is presented in the Advanced Trauma Life Support Course (ATLS) sponsored by the Committee on Trauma of the American College of Surgeons (ACS) [4]. Al- though the timing and organization of TR are critical to patient outcome, standards of performance for this activi- ty are not available. For the purposes of this study, TR is defined as assessment and stabilization of vital functions and prioritization of therapeutic and diagnostic interven-

From the Departments of Surgery and Emergency Medicine, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Road, Port- land, Oregon 97201-3098.

Requests for reprints should be addressed to Daniel Lowe, MD, Department of Surgery, Yale .University School of Medicine, 333 Ce- dar Street, New Haven, Connecticut 06510.

Presented at the 76th Annual Meeting of the North Pacific Surgi- cal Association, Victoria, British Columbia, Canada, November 10-11, 1989.

tions for the severely injured patient arriving in the emer- gency department.

According to ACS standards for trauma centers, a board-certified, general surgeon is essential at TR. For university trauma programs, a footnote to this criterion states that a surgical resident is acceptable with promptly available faculty attendance [5]. Many university trauma centers have residents at various levels of training in charge of TR. Such a graded response, where a junior resident performs TR with a senior resident and faculty immediately available, is common for hospitals with training programs. Hoyt et al [6] have shown a beneficial effect of resident training on TR performance with a graded response.

The purpose of this study was to evaluate timing and organization of the TR, examine the effect of resident training on TR performance with a standardized (non- graded) response, and evaluate whether quality assur- ance standards for TR can be established.

MATERIAL AND METHODS Trauma patients arriving at the hospital for TR were

entered into the study. These patients were admitted to a designated TR room in the emergency department of a designated Level I trauma center. All patients meeting triage criteria (similar to ACS Committee on Trauma triage criteria) and transported to the trauma center dur- ing observer availability were entered into the study. Pa- tients transferred from other hospitals were not entered into the study. The TR response include the following personnel: faculty and residents in surgery, anesthesiolo- gy, and emergency medicine, three trauma nurses, radiol- ogy technician, and various support people. The leader of this team is a chief resident in surgery. Residents on the trauma service rotation rotate every 3 months beginning in July. All faculty and residents in attendance have com- pleted the ATLS course.

Trained observers (medical students, registered nurses from the Office of Quality Assurance, or authors RP or PF) were called to the emergency department upon notification of a pending trauma patient arrival. Ele- ments of the TR, as described by the ATLS manual and defined by the authors, were timed in minutes and sec- onds from time of patient arrival in the TR room. Each of the observers was supervised for a period of time for quality control of the data. Patients were not included if the observer was not present before patient arrival.

The observers, utilizing a hand-held stopwatch, timed TR elements from an area adjacent to the head of the bed within the TR room. A data evaluation form was kept for each patient entered. Additional data about injury sever- ity, length of stay, and demographics for each patient were obtained from the trauma registry.

Potential injury severity scores (none, moderate, se- vere) for airway, cervical spine, and shock were recorded by the observers upon the patient's arrival. These classifi-

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TABLE I Trauma Resusc i ta t i on De f in i t i ons

Potential InlurY scoring (none, moderate, severe) Airway: None, the patient Is talking; moderate, injury suspected, (GCS < 12 or maxillofaclal injury); severe, respiratory rate > 30/rain or <

10/rain, Cervical spine: None, alert, oriented, non-tender, no deficits; moderate, injury mechanism or equivocal examination; severe, paralysis or

cervical pain or tenderness, GCS < 10. Shock: None, HR 60-100, SBP > 90; moderate, HR ~> 100, SBP > 90; severe, HR > 100, SBP <: 90.

Events for timing 1. Contact t ime-- the time when patient arrives in resuscitation room (24-hour clock). 2. Airway aasassment--t lme of completion of the iniUai airway assessment; includes airway movement, ventilation, ability to protect

airway. 3. Administer oxygen---time to placement of oxygen in emergency department by any means, 4. Intubntlon~time to begin the process of intubetion; almost always announced by anesthesiologist or trauma surgeon at the head of the

table. Endla the time when the tube is in place and the patient Is being ventilated. If the tube is not confirmed as being In the airway and requires replacement, then the eddlUonal time Is added for the reinsertlon of the tube for the total time of intubatlon.

5. Immobilization check-- the physician checks to certify that the spine is in alignment and stabilized appropriately (collar Is in place or sand bags and/or tape have been placed).

6. Neck examlnntlon--the time for completion of a physical examination of the neck with the collar removed. 7. Intravenous I lnes~t lme of completion and administration of fluid. Each site noted for number, gauge, and attempts as well as being

present upon arrival. 8. Act iv i ty-- the time for COmpletion of various elements of the examination; absent means that it was not observed during the ED

resuscitation. 9. Dfilposltlon--the time when the patient leaves the ED trauma resuscitation room or a major operative procedure is begun (thoracotomy);

the total time of trauma resuscitation.

ED : emergency department; GCS : Glascow Coma Scale; HR : heart rate; SBP : systolic blood pressure.

TABLE II Pat ien t C h a r a ~ e r l s t l c s

Age* Male Female Total

Pediatrics (_< 16 y) 54 23 77 17 to 30 135 48 183 31 to 55 93 37 130 55 plus 26 15 41

Total 308 123 431

* Mean age (SEM) = 30.7 (4-0.82) years.

TABLE I l l M e c h a n i s m o f In jury In 431 Pa t ien ts and P rehosp l ta l

T ranspo r l in 298 Pa t ien ts

n %

Mechanism* Automobile 201 47 Pedestrian 50 12 Fall 47 11 Stab 32 7 Motorcycle 20 5 Gunshot 17 4 Other 64 15

Prehospltal transport Ground 187 63 Air 111 37

* Blunt trauma in 89%, penetrating trauma in 11%.

cation levels were predefined so that the observers could objectively assign levels based upon the clinical presenta- tion at arrival (Table I).

All data were entered into a personal computer data- base program. Statistical analysis utilized multiple analy- sis of variance, paired sample t tests when appropriate,

and means and standard error of the means for descrip- tive data presentations. Results were considered signifi- cant with a p value less than 0.05.

RESULTS Four hundred thirty-one patients undergoing TR

were prospectively analyzed between October 1988 and October 1989. Annually, the trauma center admits 1,800 patients. This sample of 431 patients represents 24% of the trauma service patients. Patient distribution accord- ing to time of day and day of week of the study group compared with the distribution of all 1,800 trauma pa- tients revealed the study sample was representative for these factors. Similarly, the study group did not differ by age, sex, or mechanism and severity of injury from the entire population for the year under study. Complete trauma registry data, including injury severity score, were available for 298 of the study patients.

The age and sex demographics and mechanism of injury of the patient population are shown in Tables II and III. The majority of patients experienced blunt trau- matic injury (382, 89%), and 11% were victims of pene- trating trauma. Prehospital intravenous lines had been placed in 401 patients (93%), and in 116 patients (27%), two intravenous lines were plaeed. Intubation was per- formed before hospitalization in 17 patients (4%). Infor- mation from the trauma registry about means of trans- portation was available for only 298 patients. One hundred eighty-seven patients (63%) were transported by ambulance, and 111 patients (37%) were transported by hdicopter.

Potential injury scores were "none" in 148 patients (34%), "moderate" in 200 patients (46%), and "severe" in 83 patients (19%) (Table IV). Potential injury scores directly correlated with injury severity scores (p <0.001 for airway and shock and p ffi 0.0262 for cervical spine).

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TABLE IV Potential Injury Score (PlS) and TR Time (mean mln 4-

SEM)

System PIS Number TR Time p Value*

Airway None 352 21.9 (4-0.6) - - Moderate 42 31.3 (4-2.2) <0.001 Severe 35 30.5 (4-3.0) <0.001

Shock None 260 22.0 (4-0.7) w Moderate 142 25.3 (4-1.2) 0.017 Severe 27 28.5 (4-3.2) <0.001

Cervical spine None 211 21.4 (4-0.8) Moderate 158 25.9 (4-1.0) <0.001 Severe 60 24.3 (4-1.5) 0.160

Total group None 148 20.1 (4-1.1) Any moderate 193 25.5 (4-0.9) <0.001 Any severe 90 26.7 (4-1.5) <0.001

�9 Versus no injury.

TABLE V TR Disposi t ion (431 PaUenta)*

Disposition n %

Radiology 207 48 CT scan 91 21 OR (emergent) 28 6 Home 39 9 Ward 16 4 Death 7 2 SICU 2 - - Other 41 10

�9 Mean length of stay, 5.83 4- 0.47 days (mean 4- SEM); mean length of stay In SICU, 1.04 4. 0.20 days.

CT = computed tomography; OR = operating room; SICU ffi surgical intensive care unit.

TABLE VI In jury Severity Score (ISS) and TR Times (376 Patients)

ISS n TR Time (Mean 4- SEM)

Disposition immediately after TR was primarily to radiology (48%) and CT scan (21%). The length of hospi- tal stay for the entire group averaged 5.83 days, with 1.04 days in the intensive care unit (Table V).

Injury severity scores were available for 377 patients. Analysis of variance for these patients showed a signifi- cant positive correlation of injury severity scores with TR time (r ffi 0.409, p <0.001). Comparing the TR times for 297 patients with injury severity scores below 15 (21.5 4- 0.62 minutes) and above 15 (34.0 4- 1.86 minutes) showed a significant increase in TR time for the more severely injured group (p <0.001). A tabulation of injury severity score groups with TR times showed an increase in TR time with increasing severity of injury (Table VI). Multifactorial analysis of variance showed injury sever- ity, age, and potential airway injury score to have a signif- icant effect on TR time (p <0.05). The other potential injury scores had no significant effect upon TR time.

A summary of the times for TR activities is shown in Table VII. These activities of the TR can be divided into three components, according to organization and timing: primary survey, secondary survey, and procedures and disposition. The primary survey, composed of initial as- sessments of airway, breathing, and circulation, was com- pleted in about 3 minutes after the patient's arrival. The secondary survey, a physical examination of the entire patient, was completed within 10 minutes. Procedures and disposition, completion of resuscitation measures, and planning disposition of the patient occupied the re- mainder of the time. The entire TR was completed on average in less than 24 minutes.

Not all activities were documented for each patient. For example, assess airway was documented for only 385 patients (89%), and nasogastric tubes were placed in 65 patients (15%). Lack of documentation means the activi- ty was not noted by the observer during the TR. The activity could have been done but not observed, or not done at all. The activities, number documented, percent- age of entire group, and average times (minutes 4- stan- dard error of the mean) are shown in Table VII.

The experience of the resident did not have an effect

Total minor to moderate Total severe

1-5 181 19.98 4- 0.74 6-10 80 23.08 4- 1.35

11-15 36 25.10 4- 1.66 16-20 29 31.23 4- 2.74 21-25 23 32.61 4- 3.07 26-30 13 43.22 4- 5.16 >30 14 34.96 4- 5.17

<15 297 21.5 4- 0.62 >15 79 34.0 4- 1.86

T A B L E V l l Summary of Ac t i v i t i es Dur ing TR (431 Pat ien ts )

Activity n % Mean (mln) SEM

Primary Survey

Assess airway 385 89 0.71 0.11 Oxygen administered 198 46 1.07 0.13 Neck Immobilized 283 66 1.50 0.23 1st IV 381 88 1.51 0.17 EKG monitor 364 84 3.11 0.27

Secondary Survey

Pupils 374 87 3.27 0.19 Pulses 299 69 3.50 0.18 Pelvic rock 277 64 3.84 0.22 2nd IV 312 72 4.80 0.23 Neck examination 312 72 5.45 0.30 Rectal 262 61 9.49 0.40 Back examination 161 37 9.95 0.71

Procedures and Disposition

Chest radiograph 263 61 11.07 0.35 Chest tube 23 5 11.17 1.62 Intubatlon 40 9 12.56 2.13 Neck radiograph 192 45 13.42 0.49 Foley catheter 138 32 17,06 0.71 NG tube 65 15 20.96 1.55 Disposition 431 100 23.59 0.61

EKG = electrocardiographic; IV = intravenous line; NG = nssogastrlc.

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TABLE VIII TR Time (mean In rain 4- SEM) and Level of

Resident Experience

No. of Month of Training Patients TR Time*

1 163 23.2 (1.0) 2 138 23.5 (1.1) 3 130 24.3 (1.1)

* Difference not significant.

TABLE IX TR Time (mean In rain 4. SEM) , ISS, and Level of

Resident Experience

TR Time" ISS Month 1 Month 3 All Months

<20 21.6 (1.04) 22.1 (1.33) 22.4 (0.71) (n = 130) (n = 66) (n = 258)

>--20 36.2 (3.53) 35.4 (4.42) 36.4 (2.65) (n = 16) (n = 14) (n : 42)

* N.S. by two-sample analysis for Month 1 versus Month 3; p <0.001 for ISS <20 versus ISS >--20.

TABLE X Timing of Procedures In Minutes (mean 4- SEM)

NO. of Procedure Patients Start Time Duration

Intubation 40 12.6 (4-2.1) 2.8 (4-0.4) Saphenous cutdown 20 Arrival 8.2 (4-0.9) Chest tube 23 11.2 (4-1.6) 9.8 (4-1.3) Diagnostic lavage 7* 21,5 (4-3,7) 24.6 (4-6.7)

* Diagnostic lavage is done infrequently; abdominal CT scan is preferred.

on the duration of the resuscitation. The month of the resident on the trauma service was not seen to affect the duration of TR for all patients or for patients with more severe injuries (injury severity score >20) even though the TR times were longer than in patients with less severe injuries (Tables VIII and IX).

Procedures done during the resuscitation were timed. The procedure, number, time at beginning of the proce- dure, and duration of the procedure are listed for intuba- tion, saphenous cutdown, chest tube placement, and diag- nostic lavage (Table X).

COMMENTS This prospective analysis provides insights into the

timing and organization of TR. These results can be utilized as performance standards for this critical activity to ensure ongoing quality assurance and education. It should be emphasized that these results are for a regional

trauma system and university trauma hospital as de- scribed. The triage criteria, team response, and endpoints of TR may differ in other regions. The critical timing and organization of TR require ongoing quality assurance review.

The endpoint of TR was defined as the time of leaving the TR room. The chief resident, with faculty supervision, determined the TR endpoint for the patients in this study. The effect of TR on outcome needs to be analyzed based on mortality or TRISS methodology [7]. Outcome analy- sis unrelated to this study was performed by a weekly multidisciplinary trauma conference. No preventable deaths or unexpected complications were noted in this patient group.

Analysis of the TR shows the activities are easily categorized according to timing and organization into three phases: primary survey, secondary survey, and pro- cedures and disposition. This is consistent with ATLS training and supports the organization provided by this educational course. All of the residents and faculty par- ticipants were ATLS-trained. No control group without ATLS training was available.

This study contrasts with previous reports citing the lack of benefit of ATLS [8]. The adequacy of resuscita- tion or accuracy of diagnosis was not directly evaluated here, although review by trauma registry and multidisci- plinary trauma conference showed minimal problems with missed or delayed diagnosis. A closer analysis of reports demonstrating the lack of benefit of ATLS may reflect management differences and experience with de- finitive care rather than the TR itself. These results sup- port ATLS as an educational course for the timely and organized approach to TR. Senior resident and faculty supervision during this critical time period is strongly believed to be necessary for optimal TR and probably for best quality of patient care.

In this series, the completion of TR was positively related to the severity of injury. Analysis of gunshot wounds showed no correlation with severity of injury. Patients with gunshot wounds were resuscitated and tak- en expeditiously to the operating room for emergency surgery. The high positive correlation of severity of injury and resuscitation time for patients with stab wounds sug- gests that this subgroup was unnecessarily delayed during TR.

In contrast to previously published reports, the level of training of the resident on the trauma service did not correlate with time of TR. Hoyt et al [6] reported a significant improvement in TR times during a 3-month trauma service rotation. Their reported times are 250% higher on the average for all patients (61 minutes versus 24 minutes) and over 300% greater for the less severely injured (75 minutes versus 23 minutes). The previously reported TR times for patients with severe injuries (injury severity score >20) averaged 59 minutes at the start of the resident rotation and decreased to 33 minutes after 3 months. These TR times for severely injured patients are not significantly different from ours (33 minutes versus 36 minutes). The senior resident and faculty participation

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in TR in the present study may account for these differ- encP~.

Airway assessment during TR was inaccurate in 20% of the patients. In the first 172 patients studied, 13 pa- tients underwent intubation during TR. An additional 34 patients underwent intubation within 4 hours after com- pletion of the TR. Intubation with suction, lighting, and proper equipment is necessary to minimize iatrogenic aspiration pneumonia or respiratory deterioration. Fur- ther study of this problem is warranted.

Intravenous lines were present on admission in 93% of the patients; two lines were present in 27%. The amount of fluid administered during this time period was not examined. The time to start an intravenous line in the emergency department (>2 minutes), the larger gauge available, the adjunctive pressure infusion devices, and the ability to do cutdowns in a short time (8 minutes) should obviate the need for almost all prehospital intrave- nous lines. The amount of fluid that can be administered and the time taken to start these lines do not justify prehospital placement under these circumstances. Lewis [9], in a model of fluid resuscitation for trauma, supports this contention. Animal studies of hemorrhage did not demonstrate any benefit from early fluid administration [10] and the experience in a major trauma system with analysis of 6,855 patients also failed to show any benefit from prehospital fluid administration [11].

Observer effect on the TR was not possible to mea- sure. However, after the first 172 patients were analyzed, a summary of some of the results were presented at a

trauma conference. The next 259 patients were compared with the first 172, and no significant differences were noted in the sequences of events or times. This suggests a minimal effect of the observer on TR.

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