Identification of Local Problem
Internal performance dashboard identified prolonged time to OR for emergent class cases. Review of our TQIP benchmark report further validated and highlighted the specific delay for patients presenting in hemorrhagic shock. Median time to surgery was 100 minutes, nearly double the national median. Delays were identified in transport to OR and additional in-room delays before incision.
Context of the QI Activity
The project was conducted at an ACS Verified Level I Trauma center with real-time performance monitoring and an established PIPS infrastructure. Multidisciplinary engagement from ED, OR, trauma surgery, and trauma program supported rapid-cycle improvement and implementation of process changes.
What were the interventions?
- Transport Workflow Redesign: Shift from an OR-driven “pull” model to an ED-initiated “push” process to expedite movement of unstable patients to the OR.
- Instrument Readiness Optimization: Color-coded, pre-positioned trauma case carts placed outside the trauma OR to decrease in-room setup delays.
- Decision-Making Improvements: Development of a clinical practice guideline prioritizing early operative intervention over CT imaging for patients requiring ongoing resuscitation.
- PIPS Review: Creation of a “Blood to CT” audit filter and focused reviews of hemorrhagic cases exceeding 60 minutes from arrival to incision.
Costs and Funding Sources
This initiative required no additional funding. Process changes were implemented using existing staff and resources. Minor update of color coding OR carts was absorbed within routine operational budget.
Overall Results and Analysis
Following implementation, the Fall 2024 TQIP report demonstrated a significant reduction in median time to surgery for hemorrhagic shock patients from 100 minutes down to 46 minutes. Sustained change was demonstrated on real-time dashboard monitoring to remain below the 60-minute target. The Spring and Fall 2025 TQIP reports remained with times below the national average (51 and 48 minutes).
Limitations
- The initiative was conducted at a single high-volume Level I center, limiting generalizability.
- Some cases required individualized clinical decision-making.
Lessons Learned
- Collaborative, multidisciplinary engagement is essential for meaningful and sustained process improvement.
- Small workflow changes can have significant impact on hemorrhage control timelines.
- Integrating PI audit filters into routine review drives continual accountability and early identification of drift.
- Prioritizing early operative intervention over CT in unstable patients improves timeliness and aligns care with best-practice trauma principles.
