Improving trauma care in exsanguinating patients with CHOP (critical haemorrhage to operating-room patient) resuscitation protocol-A cumulative summation (CUSUM) analysis.
INTRODUCTION
The standard protocol for exsanguinating trauma patients involves initial evaluation and resuscitation in the emergency department which then sets the stage for subsequent definitive care and disposition. This involves major coordination and mobilisation of resources which may cause a delay in intervention especially when most of these cases present after office hours. Our centre has employed a second-tier activation system (CHOP protocol) that immediately mobilises all respective trauma specialists including interventional radiologists and allows rapid access to the operating room.


OBJECTIVE
We hypothesised that exsanguinating patients managed by CHOP protocol have better overall outcome and survival.


METHODS
We identified trauma patients that fulfilled CHOP criteria from 2016 to 2019 and divided them into two groups: preCHOP (standard protocol) and CHOP. Data was extracted from a prospectively maintained trauma registry. Demographics, injury pattern and in-hospital data were analysed. The key outcome studied was the impact of CHOP protocol on the mortality rate. Success and failure of the two groups were analysed using CUSUM methodology.


RESULTS
Thirty-seven patients were managed by CHOP protocol since its introduction in March 2018 compared to 36 patients who underwent standard protocol. Majority of the cases were blunt trauma (89% CHOP vs 92% preCHOP). The mean Injury Severity Score was 37 for CHOP group and 39 for preCHOP group. We observed a significant improvement in time to intervention in CHOP patients (78 min vs 113 min), both during and after office hours. CHOP patients had lower mortality compared to preCHOP group (11% vs 31%) and the effectiveness of the protocol was seen in achieving significantly lower mortality compared to the predicted model. CHOP protocol was able to produce a consistent trend of desired outcomes leading to the CUSUM curve exhibiting a sustained downward slope.


CONCLUSION
The CHOP protocol, a relatively novel system in the local context, was able to achieve sustained improved outcomes compared to standard protocol. The CUSUM analysis concurred that implementation of CHOP protocol has helped to achieve consistent desired outcomes. It also suggested that the uptake and use of this protocol has integrated well into the existing workflow.
['Lee|Daniel Jin Keat|DJK|', 'Kang|Min Li|ML|', 'Christie|Lyndsay Mei Janet|LMJ|', 'Lim|Woan Wui|WW|', 'Tay|Dorithy Xiu-Hui|DX|', 'Patel|Sanjay|S|', 'Goo|Jerry Tiong Thye|JTT|']
D004636:Emergency Service, Hospital D058734:Exsanguination D006470:Hemorrhage D006801:Humans D015601:Injury Severity Score D009873:Operating Rooms D012151:Resuscitation D012189:Retrospective Studies D014193:Trauma Centers D014947:Wounds and Injuries
Critical haemorrhage Exsanguinating trauma Trauma resuscitation