Using trauma video review to search for the Goldilocks pre-activation time

Abstract

Objectives: We sought to determine the optimal time to pre-activation for trauma team activation that resulted in maximum team efficiency, measured by the time to complete critical actions (TCCAs) during resuscitation. We hypothesized that there exists a time window for trauma team pre-activation that minimizes TCCA.

Methods: This is an exploratory retrospective analysis of video-reviewed traumas at a level 1 trauma center from January 1, 2018 to 28 February, 2022 that received the highest trauma team activation and had a pre-arrival notification. A total of 11 TCCA categories were calculated using video timestamps. To compare TCCAs from different categories, normalized TCCAs (nTCCAs) were calculated by dividing each TCCA by the median time of its category. Pre-activation times were categorized into three groups: long pre-activation (≥8 min), mid pre-activation (≥4 and ≤7 min), and short pre-activation (≥0 and ≤4).

Results: There were 466 video-recorded level 1 trauma activations, which resulted in 2334 TCCAs. Of the 466 activations, 152 occured on the patient's arrival (0 min pre-activation). The majority (425) of patients had a pre-activation time of <7 min. Pre-activation of 4-6 min resulted in all but blood transfusion TCCAs being <15 min. Furthermore, mid pre-activation category corresponded to the most efficient trauma teams, with nTCCAs significantly shorter (median=0.75 (IQR 0.3-1.3)) than long (median=1 (IQR 0.6-2)) or short activation groups (median=1 (IQR 0.6-1.6)). A greater proportion of nTCCAs were shorter than their category median in the mid pre-activation category compared with long and short categories (59.1% vs 48.3% and 40%, respectively; p<0.01).

Conclusions: In this exploratory study, a pre-activation time of 4-7 min is associated with the best team efficiency as measured by TCCAs during trauma team activations. This timeframe may be an optimal window for trauma team activations but needs prospective and external validation.

Level of evidence: Level 4 retrospective exploratory study.

Keywords: emergency medical services; emergency treatment; video.

Figure 1. Definitions for pre-activation time and time to completion of critical action.

Figure 2. Distribution of pre-activation times.

Figure 3. Median and IQRs of time to complete critical action (TCCA) by category. TCCAs were deemed ‘assessed’ or completed when the evaluation in accordance with ATLS algorithms were performed, and necessary interventions were completed. eFAST, extended focused assessment with sonography in trauma; ETT, endotracheal tube; RSI, rapid sequence intubation.

Figure 4. Time to complete critical events versus pre-activation times. Different types of events are shown in different colors. A slight jitter has been applied to show density. Shaded region indicates apparent concentration of shorter time to complete critical events. eFAST, extended focused assessment with sonography in trauma; ETT, endotracheal tube; RSI, rapid sequence intubation; TCCA, time to complete critical action.

Figure 5. Average normalized time to complete critical actions (nTCCAs) versus pre-activation time. Values under 1 indicate above-average performance. Black vertical lines are SEM. P value brackets indicate individual comparisons between elements in either group.