Chockalingam, Kumarappan
(2020)
Door to Skin Time in Patients Undergoing Emergency Trauma Craniotomy.
Masters thesis, Universiti Sains Malaysia.
Abstract
Background and Objective
Traumatic brain injury (TBI) is predicted to be the third leading cause of death and
disability worldwide in 20201. It places a significant burden on health care especially in
developing countries like Malaysia. For a subset of patients’ with TBI with significant
intracranial bleed, urgent surgical intervention remains the mainstay of treatment.
Although all efforts are taken to ensure that patients received surgical intervention in a
timely manner, often we find that there are inadvertent delays in management of these
patients. This study aims to evaluate the performance of neurosurgery referral centre in
Malaysia, review the possible pitfalls and propose ways to improve performance
Methods
This is a retrospective study conducted in HSAJB between 1st January 2019 and 31st
December 2019. All patient with traumatic brain injury admitted to HSAJB with
abnormal CT brain findings requiring urgent craniotomy was enrolled in this study. A list
of patients who underwent emergency craniotomy or craniectomy from our operating
theatre registry. The demographic data and required clinical data were extracted from the
clinical notes. The data obtained were entered into computer software Statistical Package
for Social Science (SPSS) version 22. Data distributions were described with
nonparametric statistics.
Results
A total of 154 patients who were subjected to emergency trauma craniotomy during the
duration of study was included in this study. Overall, the median Door to Skin times were
605 minutes, Door to CT time was 131 minutes, CT to Review time was 274 minutes,
Review to Booking time was 20minutes, Booking to OT time was 90 minutes and OT to Skin time was 62 minutes. Patients who were directly admitted to HSAJB had an overall
median Door to Skin time of 459 minutes. At discharge, there were a total of 102 patients
(66.23%) with poor outcome. On performing simple logistic regression, we found that
the polytrauma, hypotensive episode, ventilated patients, severe TBI and Door-Skin times
were all significantly associated with poor outcomes. The adjusted OR for Door to Skin
times was 1.005 with 95% CI (1.002-1.008). Hence, for every minute delay in Door to
Skin time, there was 1.005 time increase likelihood of having poor outcome during
discharge. During the 6 months follow up, the number of patients with poor outcome
reduced to 58 patients (37.66%). We found that regardless of patients’ clinical
characteristic, every minute delay in Door to Skin led to 1.008 (1.005 -1.011, CI 95%)
times increase in having poor outcome at 6 months.
Conclusion
Door to Skin time is directly proportional to poor outcomes in patients with TBI. Despite
being the regional neurosurgical and trauma referral centre, there are still significant
delays in patient management leading to delayed surgical intervention. Concerted efforts
from all parties involved in trauma care with established neurotrauma protocol are
essential in eliminating this delay.
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