No Time Like the Present: An Emergent OR Protocol

General Information

Institution Name: Washington Regional Medical Center

Author Name and Title: Heather Beauford

Name of Case Study: No Time Like the Present: An Emergent OR Protocol

Identification of Local Problem

Washington Regional Medical Center is the only Level II, state-verified trauma center in the northwest region of Arkansas, and the highest level of trauma care within a 150-mile radius. Our trauma center has been participating in TQIP since 2018. Immediate access to the operating room for hemorrhage control was identified as a gap in optimal emergent care.

In smaller community trauma centers, operating rooms are often in short supply and high demand. We noted on the Spring 2023 TQIP report a rise in the median time to hemorrhage control compared to other hospitals. Our median time was 124 minutes compared to the benchmark of 55 minutes. On the subsequent reports, the time to hemorrhage control continued to rise, reaching as high as 160 minutes on the Spring 2024 report. There was obvious concern about this delay and the potential impacts that it could have on bleeding trauma patients. 

Context of the QI Activity

An extensive drill-down was performed on all emergent cases going to the OR for hemorrhage control to identify delays. The two main barriers to efficient OR utilization included a lack of clear, concise communication of the patient’s needs and OR room availability.

Interventions

To improve the gaps in communication, we instituted a standard terminology phrase for all patients requiring immediate access to the operating room, known as a T-10. This notification is sent out to all pre-designated team members involved in trauma care in the form of a paging alert. It is a one-call notification system with uniform message delivery, which was supported by education and mock drills to enforce understanding and a streamlined process. This alert communicates the patient’s current location, emergent status, and type of operative intervention needed. In addition, an overhead page is sent out hospital-wide for additional team communication. A T-10 can be implemented by any trauma surgeon, neurosurgeon, or orthopedic surgeon.

Once a T-10 is activated, each trauma team member has a designated role in expediting the patient to the operating room.  The OR and anesthesia team begin immediate room set-up, while the blood bank team prepares emergent release products with the understanding that the patient is in transit to the operating room. The ICU and PACU teams work to ensure adequate resources postoperatively, while the house supervisor and chaplain aid with family support. The emergency department staff and trauma nurse clinician continue patient care and transportation to the operating room with a bedside handoff in the OR suite. The overall goal is to provide timely lifesaving interventions through a streamline process of communication and teamwork.

Costs and Funding Sources 

There were no additional institutional costs associated with this process improvement.

Overall Results and Analysis 

After implementation of the T-10 process, all activations were monitored and measured. This change was not positively reflected in the TQIP report until the third cycle following implementation, at which time we saw a significant decline in the number of minutes to hemorrhage control. The median time dropped 91% from 160 minutes to 14 minutes on the following report.  This progress was sustained with a 51-minute median time on the following TQIP report, remaining below the ‘all hospital’ median time of 55 minutes. 

We monitored for T-10 activation compliance with each emergent OR procedure based upon select criteria (2 Systolic Blood Pressure readings below 90 on patients who were deemed to have emergent OR procedures by the surgeon within their note(s). This was monitored for Exploratory Laparotomy and Thoracotomy cases only. Feedback was provided to providers on a 1:1 basis for non-activated cases meeting criteria. The activation compliance significantly improved with education. Furthermore, there has been a significant decline in the time to OR for T-10 activations versus a non-activated emergent OR case in both trauma surgery and neurosurgical procedures, further validating the value of a T-10 activation.

Limitations

This activation is at the discretion of the on-call surgeon. A noted limitation of this process is when the actual T-10 page does not get sent out.  This occurs for a variety of reasons, but primarily because the OR team has responded and confirmed that an OR room is readily available. Unfortunately, this results in multiple additional phone calls and offline communications on the back end, including calls to the blood bank and bed control command center.

Lessons Learned 

We learned that communication is essential, and the more you can limit one-off calls, the more efficient the process becomes.  We included key terminology in our T-10 page, so one streamlined message would be delivered and understood by all receiving members.

We also found that feedback forms involving all trauma members and pre-hospital providers were a huge success.  These feedback forms created a strong team dynamic with continued improvement in hemorrhage control times and positive patient outcomes.

Lastly, we also learned that if a process is successfully implemented and understood, it can also be utilized for other related processes. After recognizing the improvements in patient care, we began encouraging our neurosurgery team to utilize this page for their patients in need of emergent craniotomies. Later, we even re-created the protocol for emergent Interventional Radiology cases with a similar structure, enforcing a one-call paging system and streamlining communication.