Background
Trauma is the leading cause of death in patients under the age of 45. Over the last decade, there has been a progressive paradigm shift toward nonsurgical management of solid organ injuries in trauma patients. Endovascular therapy of solid abdominal organs and pelvic injuries has been associated with decreased need for blood transfusion and improved survival. This has placed interventional radiologists at the forefront of trauma care since IR can provide precise and timely control of bleeding with embolization.
The American College of Surgeons (ACS) Resources for Optimal Care of the Injured Patient stipulates the requirements for trauma center designation. Chapter 11, “Collaborative clinical services,” states, “In Level l and Level ll trauma centers, qualified radiologists must be available within 30 minutes to perform complex imaging studies or interventional procedures.”
In the past, the response time of the IR service at UT Health San Antonio, Texas, was limited by several factors. Critical time was lost while the trauma service contacted the IR fellow on call, the case was discussed, and the IR team then responded to the hospital prior to beginning the procedure. In most cases, the time between the initial phone call and the start time in the IR room was over 90 minutes. We faced serious challenges in the past, as the IR suite was not set up to perform emergent surgical interventions such as emergency thoracotomy, laparotomy, rapid transfusion protocols, etc. Furthermore, anesthesia was not readily available in the area.
As time passes, many patients may become more unstable and surgical interventions may become necessary. Many patients also had major injuries that require both surgical intervention and embolization, and transferring those patients between the IR suite and OR rooms presented a number of logistical problems.
Identifying a solution
In 2014, The University Hospital (San Antonio) implemented a rapid-response system called Code Angio, beginning with the inauguration of a hybrid OR/IR suite in the hospital’s new tower. Our Trauma Performance Improvement team set its goal for 30 minutes from activation to actual intervention (stick time) start time, in keeping with the ACS trauma center requirements.
Code Angio is activated by trauma surgery, emergency radiology or IR following direct communication between these services, based on specific indicators:
- Definite active extravasation is seen on a CT scan and the patient is not being operated by trauma surgery, regardless of being stable or unstable.
- The patient is hemodynamically unstable (SBP < 90 mmHg) with pelvic fractures, spleen or liver lacerations with/without imaging and the trauma surgical team, in consultation with IR, deems that image-guided intervention is necessary due to concern for extravasation.
Once the decision to activate Code Angio is finalized, the on-call IR faculty, IR fellow, IR technologist, OR transport, OR technician, OR nurses, anesthesia team and trauma surgery team are paged simultaneously by an automated system (everbridge.com) that pages the end user until they acknowledge receipt. All teams simultaneously converge on the hybrid OR/IR suite.
While the anesthesia team is working on resuscitation, the angiography table is set up by the OR tech, including a set of basic supplies open by the time the IR faculty arrives. Both groins are prepped and, depending on the type of injury, the abdomen and chest may also be prepped for other surgical interventions.
In patients who require open surgical interventions and may need adjunct embolization procedures, the IR team is in already in the room as a backup to perform angiograms and possible embolization after the initial bleeding is surgically controlled. Examples include 1) after packing in cases of liver injuries or 2) after the initial bleeding control is obtained in the intraperitoneal or preperitoneal area in cases of pelvic injuries.
In our institution, a Code Angio activation audit filter for November–December 2014 showed an average Code Angio time of 54 minutes, with the average of 49 minutes for the entire year of 2015. Over the subsequent years, our average annual times were 39.6 minutes (2016), 45 minutes (2017), 38.5 minutes (2018) and 38.5 minutes for 2019 as of the time of writing this article. Out data also highlight the months of September 2017 (with an average time of 28 minutes to intervention) and October 2018 (with an average time of 29 minutes to intervention).
Challenges
We have faced many challenges in the last 5 years. Sometimes the system was activated by mistake for stroke and vascular surgery interventions. Separate Code Neuro and Code Vascular systems were created to prevent this problem.
As Code Angio became considered the “default” system to get a rapid response by IR, the system was getting activated by nontrauma services such as the emergency department or the ICUs for massive GI bleeding needing a TIPS, septic patients with biliary or urinary obstructions, submassive PE, etc. These procedures are set up to be performed in the IR area and not in the OR. Erroneous activation by nontrauma services resulted in many problems as the initial line of communication was bypassed and the patients were rushed to the OR. We decided to limit the Code Angio activation process to radiology and trauma surgery only. Patients from the emergency department and the ICUs can still benefit from the Code Angio system but only after the system is activated and coordinated by the radiology resident in the ED.
Other challenges to reaching a 30-minute response time include the city’s traffic and living location of each person. In our practice, all IR faculty live within a 20-minute commute, but some of our techs live further out so that we sometimes have to start the case without the IR tech.
Conclusions
All Code Angio cases are discussed in a monthly interdisciplinary trauma meeting where any issues with response time, indications and patient outcomes are discussed.
In our experience, the rapid-response system has resulted in angiograms and embolization of more severe (higher AAST grade) splenic and liver injuries that in the past may have required operative intervention. We have seen a significant decrease in the transfusion requirement in splenic injuries but no decrease in the overall splenectomy rate.
Many questions remain unanswered. Many small areas of contrast extravasation can be self-limited and, because of our rapid response, we may be performing embolization of injuries that may have healed conservatively. Also some stable patients could have waited a few hours and not have had the procedure in the middle of the night. We also have realized that in most situations a start time of less than 30 minutes may not be a realistic goal given the complexity of the process.
In conclusion, our Code Angio rapid-response system has resulted in a significant improvement in the response times (from 117 to 43 minutes) in major trauma situations that can be treated with nonoperative interventions. There has been a significant trend towards treating higher degree of organ injuries with embolization that in the past may have been treated surgically. A true interdisciplinary approach between trauma surgery and IR is the cornerstone of the program with constant feedback and discussions to improve care. We still need to establish the impact of the Code Angio system on trauma patient outcomes.
Note: This article was based on a presentation by the authors at SIR 2019.
