Benchmarking emergency department thoracotomy: Using trauma video review to generate procedural norms

Emergency department thoracotomy (EDT) must be rapid and well-executed. Currently there are no defined benchmarks for EDT procedural milestones. We hypothesized that trauma video review (TVR) can be used to define the 'normative EDT' and generate procedural benchmarks. As a secondary aim, we hypothesized that data collected by TVR would have less missingness and bias than data collected by review of the Electronic Medical Record (EMR).

We used continuously recording video to review all EDTs performed at our centre during the study period. Using skin incision as start time, we defined four procedural milestones for EDT: 1. Decompression of the right chest (tube thoracostomy, finger thoracostomy, or clamshell thoracotomy with transverse sternotomy performed in conjunction with left anterolateral thoracotomy) 2. Retractor deployment 3. Pericardiotomy 4. Aortic Cross-clamp. EDTs with any milestone time ≥ 75^th percentile of time or during which a milestone was omitted were identified as outliers. We compared rates of missingness in data collected by TVR and EMR using McNemar's test.

44 EDTs were included from the study period. Patients had a median age of 30 [IQR 25-44] and were predominantly African-American (95%) males (93%) with penetrating trauma (95%). From skin incision, median times in minutes to milestones were as follows: right chest decompression: 2.11 [IQR 0.68-2.83], retractor deployment 1.35 [IQR 0.96-1.85], pericardiotomy 2.35 [IQR 1.85-3.75], aortic cross-clamp 3.71 [IQR 2.83-5.77]. In total, 28/44 (64%) of EDTs were either high outliers for one or more benchmarks or had milestones that were omitted. For all milestones, rates of missingness for TVR data were lower than EMR data (p < 0.001).

Video review can be used to define normative times for the procedural milestones of EDT. Steps exceeding the 75^th percentile of time were common, with over half of EDTs having at least one milestone as an outlier. Data quality is higher using TVR compared to EMR collection. Future work should seek to determine if minimizing procedural technical outliers improves patient outcomes.