This is a question that comes up frequently in trauma performance improvement (PI) programs. Several of the PI audit filters typically used at trauma centers include a time parameter. Some of these include:

• Craniotomy > 4 hrs
• Laparotomy > 4 hrs
• OR for open fracture > 8 hrs (although this is now outdated)
• OR for compartment syndrome > 2 hrs

The question that needs to be asked is: 2 or 4 or 8 hours after what?

Let’s consider the following scenario:

A young male is involved in a motor vehicle crash and strikes his head. He enters your trauma center at exactly midnight as a trauma activation. Head CT shows a 12mm epidural hematoma with 8mm midline shift and ventricular effacement. GCS was 14 on arrival, but has declined to 12 by the time you leave the CT scanner. He is taken to the OR for craniotomy by neurosurgery at 4:15.

And this one:

A young male is involved in a motor vehicle crash and strikes his head. He enters your trauma center at exactly midnight as a trauma activation. Head CT shows a 7mm epidural hematoma with no shift and no effacement. GCS is 15, and the neurologic exam is completely normal. He is admitted to the SICU for neuro monitoring and is scheduled to have a repeat CT scan at 06:00. The scan shows significant expansion of the hematoma, with midline shift and ventricular effacement. He is taken to the OR for craniotomy by neurosurgery at 6:55.

My questions for you:

• When does the PI clock start ticking in each case?
• What information do you need to review to make this decision?
• Do you send a PI “love note” to the neurosurgeons in either case?

Share your thoughts on Twitter or by commenting below. I give you my answers in the next post.