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Choosing Wisely: A Prospective Study of Direct to OR Trauma Resuscitation Including Real-Time Trauma Surgeon After-Action Review.

INTRODUCTION
Although several centers have "Direct to OR" (DOR) resuscitation programs, there are no published prospective studies on optimal patient selection, interventions, outcomes, or real-time surgeon assessments.


METHODS
DOR cases over 1 year were prospectively enrolled. Demographics, injury types/severity, triage criteria, interventions, and outcomes including Glasgow Outcome Score (GOS) were collected. Detailed time-to-event and sequence data on initial lifesaving interventions (LSI) or emergent surgeries (ES) were analyzed. A structured real-time attending surgeon assessment tool (SAT) for each case was collected. DOR activation criteria were grouped into categories: mechanism, physiology, injury pattern, or EMS suspicion.


RESULTS
There were 104 DOR cases; 84% male, 80% penetrating, and 39% severely injured (ISS>15). The majority (65%) required at least one LSI (median of 7 mins from arrival), and 41% underwent immediate emergent surgery (median 26 mins). Blunt patients were more severely injured, more likely to undergo LSI (86% vs 59%), but less likely to require ES (19% vs 47%, all p<0.05). Analysis of DOR criteria categories showed unique patterns in each group for interventions and outcomes (Figure), with EMS suspicion associated with the lowest need for DOR. SAT results found DOR was indicated in 84% and improved care in 63%, with a small subset identified (9%) where DOR had a negative impact.


CONCULSION
DOR resuscitation facilitated timely emergent interventions in penetrating truncal trauma and a select subset of critically ill blunt patients. Unique intervention/outcome profiles were identified by activation criteria groups, with little utility among activations for EMS suspicion. Real-time SAT identified high and low yield DOR groups.


LEVEL OF EVIDENCE
Level III, prospective observational study.