Protocol for Urgent and Emergent Cases at a Large Academic Level 1 Trauma Center

Background Level 1 trauma centers are capable of caring for every aspect of injury and contain 24-hour in-house coverage by general surgeons, with prompt availability of nearly all other disciplines upon request. Despite the wide variety of trauma, currently reported protocols often focus on a single surgical service and studies describing their implementation are lacking. The aim of the current study was to characterize all urgent and emergent cases at a large academic Level 1 trauma center, characterize the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on timing of surgery. Methods For this retrospective review, all urgent and emergent cases treated at a single institution, during a 34-month period (January 1, 2015–October 31, 2017), were identified. All included cases were subject to the Institutional Guidelines for Operative Urgent/Emergent Cases. Demographic characteristics for non-elective surgical emergent cases were compiled by level of urgency and operating room (OR) waiting times were compared by year, department, and Level. Results A total of 11,206 urgent and emergent operative cases were included, among over 16 surgical departments. Level 2 cases represented the majority of urgent/emergent cases (33%–36%), followed by Level 3 (25%–26%), Level 1 (21%–22%), Level 4 (12%–16%), and Level 5 (2%–4%). Univariate analysis demonstrated that the proportion of urgent and emergent cases, by level of urgency, did not significantly differ between each year. Operating room waiting time decreased significantly over each year from 2015, 2016, and 2017: 193.40 ± 4.78, 177.20 ± 3.29, and 82.01 ± 2.98 minutes, respectively. Conclusions To the authors’ knowledge, this is the first study to characterize all urgent and emergent cases at a large academic Level 1 trauma center, outline the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on surgical waiting times over a 34-month period.


Methods
For this retrospective review, all urgent and emergent cases treated at a single institution, during a 34-month period (January 1, 2015-October 31, 2017), were identified. All included cases were subject to the Institutional Guidelines for Operative Urgent/Emergent Cases. Demographic characteristics for non-elective surgical emergent cases were compiled by level of urgency and operating room (OR) waiting times were compared by year, department, and Level.

Conclusions
To the authors' knowledge, this is the first study to characterize all urgent and emergent cases at a large academic Level 1 trauma center, outline the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on surgical waiting times over a 34-month period.

Introduction
The American Trauma Society and American College of Surgeons (ACS) designate a Level 1 trauma center as one capable of caring for every aspect of injury and containing 24-hour inhouse coverage by general surgeons, with prompt availability of orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial surgery, pediatric and critical care [1]. There is well-established literature, specific to various surgical specialties, describing the nature of cases classified as urgent/emergent, and the optimal timing for such cases [2][3][4][5][6]. Treatment delays for emergency surgery also significantly increase the economic impact of care, due largely to complications and length of hospital stay [7].
However, there is a lack of descriptive studies that outline all urgent and emergent cases seen at a Level 1 trauma center, identifying the most represented surgical departments and type of cases. Additionally, there is a lack of reported standardized triage protocols that take into consideration appropriate timing for such non-elective urgent cases. Current triage protocols that have been reported in the literature [8][9][10] underrepresent the variety of surgical specialties present in a Level 1 trauma center, and studies demonstrating their implementation and efficacy are limited. The aim of the current study was to summarize all urgent and emergent cases at a large academic Level 1 trauma center, characterize the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on timing of surgery.

Institutional guidelines for operative urgent/emergent cases
In an effort to improve waiting times for urgent/emergent surgical cases, and ensure appropriate care for all patients, the Institute for Healthcare Optimization (IHO) was consulted to assist in designing a set of institutional guidelines for the triage of surgical cases. This group has previously applied variable methodology (VM), a concept of appropriating limited resources accounting for variability in healthcare delivery and acuity, successfully in numerous hospitals and institutions [5,11]. An Executive Steering Committee, Advisory Committee, and Working Committee -each consisting of clinicians, hospital administrators, and consultants -were assembled. In combination with variable methodology, queuing theory is an accurate tool to determine the expected supply of a hospital resource and its allocation [12].
Urgent/emergent cases were defined by the institution as patients requiring access to the operating room (OR) within 24 hours of the decision to operate. Clinical need was further classified into five levels, based on the maximum clinically acceptable waiting time between a case being posted and OR access: patient needing surgical intervention within one hour (Level 1), within two hours (Level 2), within six hours (Level 3), within 12 hours (Level 4), and within 24 hours (Level 5). The OR guidelines for the management of urgent/emergent patient flow have been summarized for this institution (Figure 1). An urgent/emergent case is first posted by the treating surgeon, and the patient is prepared for surgery (i.e., NPO, consented, diagnostic workup, surgical site marked). Cases are assigned to an OR and started by level of urgency.
Cases within a level are accommodated in the order of posting. The posting surgeon may request a change in the queue within a level or change in the level only if the clinical status of the patient has changed. For urgent/emergent cases that cannot be placed in an OR within the maximal clinically acceptable waiting time, elective cases on the same surgical service are delayed to accommodate the urgent/emergent case. If there are no appropriate elective cases of the same service, then the first available OR of any surgical service is delayed to accommodate the urgent/emergent case. Monthly reports detailing performance regarding maximal clinically acceptable waiting time are distributed to chiefs of each surgical service and reviewed by the institution's Surgical Executive Committee.

Study design and recorded data
For this retrospective review, all urgent and emergent cases treated at a single institution, the Johns Hopkins Hospital, during a 34-month period (January 1, 2015-October 31, 2017), were identified. All included cases were subject to the Institutional Guidelines for Operative Urgent/Emergent Cases. Operative cases during the study period that were not urgent/emergent were excluded from this study.
Demographic characteristics for urgent cases were compiled by the OR nurse administrator including: the level of urgency (based on institutional guidelines and designated by the treating surgeon), time the case was posted, time the case entered the OR, time the case exited the OR, title of the case, current procedural terminology (CPT) code, surgical specialty, and duration of surgery. The in-room time was calculated as the difference between the time a case exited and entered the operating room. The difference between the time a case was posted and entered the operating room was defined as the waiting period. No protected health information or patient information was collected in this study and Institutional Review Board approval was not required since this was conducted as part of a quality improvement initiative.

Statistical analysis
Continuous demographic data are presented as means with standard deviations. Where applicable, frequencies were compared with Chi-squared tests. A Mann-Whitney U-test was used to compare continuous variables. All analyses were performed in GraphPad Prism 6 (GraphPad Software Inc., La Jolla, California).

Distribution of urgent/emergent cases
Over the 34-month study period (January 1, 2015-October 31, 2017), trauma surgery (24%) and neurosurgery (18%) comprised the most Level 1 cases ( Figure 2), with transplant (19%) and trauma surgery (17%) comprising the most Level 2 cases (Figure 3). General surgery and orthopaedic surgery represented the majority of Level 3-Level 5 cases (Figures 4-6   When assessed by level of urgency, exploratory laparotomy was the most common Level 1 procedure and second most common Level 2 procedure. ECMO cannulation and craniotomy for hematoma evacuation were the next most common Level 1 procedures. Kidney transplant, exploratory laparotomy, and abdominal wound revision/irrigation/exploration/debridement were the most common Level 2 procedures. Appendectomy, open reduction of the elbow, leg wound revision/irrigation/exploration/debridement, and esophagogastroduodenoscopy (EGD) were the most common Level 3 and Level 4 cases. The most common Level 5 cases were bone marrow biopsy, bronchoscopy, and Hickman catheter placement ( Table 4).    Table 5). Chi-square previously demonstrated no significant differences with regards to the proportion of each level represented, among all urgent/emergent cases for a given year. Given the consistent distribution of urgency over the three years, it is unlikely that differences in post-to-room time be attributed to greater proportions of Level 1 and Level 2 cases in later years.  The mean overall post-to-room time for Level 1 cases, 31.22 ± 3.42 minutes, was significantly below the threshold one hour acceptable waiting time (p < 0.05). When assessed by department, orthopaedic surgery was the only service where the mean post-to-room time exceeded the allowable one hour for Level 1 cases (105.2 ± 69.9 minutes), with a violation frequency present in 9% (7/80) of orthopaedic Level 1 cases. Among Level 2 cases, Chi-square demonstrated that the frequency of post-to-room time violations, exceeding the two-hour allowable period, was only significant for transplant surgery (mean 297.7 ± 35.9 minutes) and cardiothoracic surgery (mean 190 ± 21.5 minutes) (p < 0.05 for both; p > 0.05 for all other departments). All other departments had a mean post-to-room time within the two-hour allowable period, with a frequency of violation that was not significant on Chi-square analysis (p > 0.05 for all). The overall mean post-to-room time was within the allowable time for Level 3-5 cases, as were the mean post-to-room times with respect to department (p > 0.05 for all). The frequency of postto-room time violations, with respect to level and department, was not significant for any department among Level 3-5 cases (p < 0.05 for all) ( Table 5).

Discussion
Trauma system regionalization of patients with life-threatening emergent and urgent cases to Level 1 trauma centers has demonstrated significant reduction in hospital mortality [10].
Among Level 1 trauma centers, however, there is a lack of established triage protocols to optimize surgical timing. Triage protocols for urgent and emergent operative cases reported in the literature typically focus on general surgery alone-underrepresent the variety of surgical specialties present in a Level 1 trauma center [2,3,[7][8][9][10]. Additionally, there are few studies demonstrating the implementation and efficacy of such protocols at large-volume centers.
Following a Delphi method of international expert opinions and questionnaires, the World Society for Emergency Surgery (WSES) created a standard triage protocol known as the Timing of Acute Care Surgery classification (TACS) [9]. However, there are no reports describing the implementation or efficacy of this classification system. In a nationwide cohort study of 173,643 general surgery cases, by Mullen et al. [13], laparoscopic cholecystectomy and laparoscopic appendectomy were the most common urgent and emergent surgical cases. However, the study failed to compare the frequency of urgent and emergent cases from other surgical specialties, with respect to institution and study period. In addition, there was a heterogenous population of institutions represented, without stratification for Level 1 trauma centers. In the current study of 11,209 cases, exploratory laparotomy, ECMO cannulation, and craniotomy for epidural hematoma were the most common Level 1 cases, performed by the respective departments of trauma surgery, general surgery, and neurosurgery.
Some authors have suggested the use of dedicated ORs for emergency surgery. However, this is often not feasible or efficient in large volume centers, and has shown mixed results with respect to waiting time [14,15]. In a study implementing dedicated operating rooms for emergency surgery, from a large children's Level 1 trauma hospital, dedicated 'add-on' ORs resulted in decreased elective surgery cancellations but did not significantly impact waiting times for emergency cases designated Priority 1 (≤ 1 hr) or Priority 2 (≤ 4 hr) [15]. It is important to note here that the current institution has two ORs designated as trauma rooms, into which urgent/emergent cases frequently are placed. However, there is no precedent of always having an OR empty and waiting for an emergency as exists at some trauma centers.
Several authors have proposed mathematical algorithms to inform sequencing of urgent/emergent cases [16][17][18]. In one such model, Dexter et al. [18] summarize three objectives when scheduling emergent operative cases: 1) minimizing wait time, 2) adhering to the posting order, and 3) reflecting medical priority. The protocol implemented at Johns Hopkins Hospital exemplifies these three objectives. Additionally, the mean overall waiting period for an urgent/emergent case entering the OR decreased significantly each year (p < 0.05), resulting in a waiting time that was less than half from 2015 to 2017 (193 vs. 82 minutes). This was accomplished without any significant change in the distribution of urgency between each year. As such, these results suggest that acclimation and multi-departmental practice with an established protocol is necessary in order to match clinically acceptable waiting times for urgent/emergent cases.
Limitations of this study include those inherent to retrospective single-institution studies. The study is also limited in reporting clinical outcomes following implementation of the trauma protocol. We acknowledge that the distribution of urgent/emergent cases may vary from institution to institution, depending on the referral region, relative size of various departments, and other factors. However, to the authors' knowledge, this is the first study to characterize all urgent and emergent cases at a large academic Level 1 trauma center, outline the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on surgical waiting times. We hope this description of types of urgent/emergent cases and validation of our institution's protocol for reducing OR waiting time will be helpful to other large-volume Level 1 trauma centers. Level 1 trauma centers are capable of caring for every aspect of injury and have 24-hour inhouse coverage by general surgeons, with prompt availability of orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial surgery, pediatric and critical care. Despite the wide variety of trauma, protocols in the current literature often focus on a single surgical service. To the authors' knowledge, this is the first study to characterize all urgent and emergent cases at a large academic Level 1 trauma center across all surgical specialties, to outline the specialty and nature of emergent operative cases, and to assess the efficacy of the institutional trauma protocol on surgical waiting times over a 34-month period.