Audit of time to emergency trauma laparotomy K. I. M. Henderson, T. J. Coats*, T. B. Hassan² and K. Brohi AccidentandEmergencyDepartment,RoyalLondonHospitalsNHSTrustand*AcademicUnitofAccidentandEmergencyMedicine,QueenMary andWest®eldCollege,UniversityofLondon,Londonand ²AccidentandEmergencyDepartment,LeicesterRoyalIn®rmaryNHSTrust,Leicester, UK Correspondence to: DrK.I.M.Henderson,RoyalLondonHospitalsNHSTrust,WhitechapelRoad,LondonE11BB,UK Background: An analysis of the process of care may improve quality of care within a trauma system. Early operative control of haemorrhage is vital and any delay before surgery may adversely affect outcome. Methods: Times from activation of the aeromedical team to arrival in the emergency department and theoperatingroomforpatientswithliverorspleeninjurywereanalysedtoidentifyfactorsthatdelayed laparotomy.Theseresultswerecomparedwiththoseofanationaldatabase. Results: Themediantimefromemergencycalltooperationwas127min140minforbluntand86min for penetrating injuries). Time from arrival in the emergency department to the operating room was 54min56minforbluntand37minforpenetratinginjuries).Anaudit®lter,setattheupperquartileof the emergency call to operating room time, selected 21 patients whose records were examined; ®ve correctable delays were identi®ed. Compared with the national trauma database, these patients had longer on-scene times, but signi®cantly shorter times to operation from the emergency call 127 versus 161min)andarrivalattheemergencydepartment54 versus 115min),althoughthepatientsweremore severelyinjuredmedianInjurySeverityScore34 versus 24). Conclusion: The time to emergency trauma laparotomy may be used effectively as an audit of process fortheclinicalgovernanceofatraumasystem. PresentedtotheBritishTraumaSociety,Bath,October1997andtheFacultyofAccidentandEmergencyMedicine, Glasgow,December1997,andpublishedinabstractformas J Accid Emerg Med 1998; 15: 134 Paperaccepted17November1999 BritishJournalofSurgery2000, 87, 472±476 Introduction Quality assurance and improvement programmes that analyse the provision of trauma care to injured patients have tended to utilize mortality, and to a lesser extent morbidityanddisability,asmarkersofeffectiveness.While these outcome measures are important and powerful indicatorsofthecapabilityandef®cacyofatraumasystem, theyhavesigni®cantlimitations.Foratraumasystemthat managespatientsfromthemomentofinjurythroughto dischargefromrehabilitationservices,thesedistantend- pointsprovidelittleinformationabouttheprocessofcare thatisdelivered.Manyfactorsareinvolvedindetermining the ®nal outcome of a trauma patient. Management decisionsthathaveclinicallyimportantconsequencesmay becomehiddenamongthemyriadofotherinterventions thatoccurduringmultidisciplinarycare.Whileoutcome measuresmayidentifythepresenceofde®ciencieswithina particulartraumasystem,itmaybedif®culttoidentifythe pointsatwhichthesede®ciencieslie.Itthereforebecomes impossible to implement change and so neither quality assurancenorqualityimprovementisachieved. Traumaauditcanbemadeeasierandmoreeffectivebyan analysisoftheprocessofcare.Byfocusingtheauditinthis waythestudybecomesmoredirectedandde®cienciesinthe systemaremoreapparent.Improvingoneaspectofasystem mayleadtoimprovementsinotherareas.Asanexample,itis known that evacuation of an extradural haematoma is a time-dependent procedure 1 .Ifcarriedoutwithin4hof injurythereisasigni®cantimprovementinsurvivaland disability.Anauditof`timetoextraduralevacuation'might identifyandthencorrectaproblemwithaccesstocomputed tomographyCT).Asubsequentimprovementinthecareof otherpatientswithinjuriesrequiringCTmayalsobeseen. Anidealaudittoolisclinicallyrelevantandimportant, relatedtooutcome,easytomeasureandtoapply.Itshould beabletoidentifyde®cienciesinmanagementonalocal levelandallowcomparisonstobemadeagainstregionalor Original article 472 ã 2000BlackwellScienceLtd BritishJournalofSurgery2000, 87, 472±476