Discussion
In theory, quicker control of bleeding should be associated with improved outcomes, and this has been demonstrated in some, but not all studies examining timing of IR embolization, especially in pelvic trauma. Using TQIP 2013 and 2014 databases, Matsushima et al demonstrated an increased risk of in-hospital mortality with longer times to pelvic angioembolization with an odds ratio (OR) of 1.79 for each hour of delay.7 Huang et al demonstrated that, in their Level 1 trauma center’s experience, delaying angiography beyond 5 hours was associated with increased mortality (OR 3.8), even in normotensive patients.8 A 2021 study by O’Connell et al compared mortality of patients with pelvic fractures and hemorrhagic shock in their center to historically published mortality data. They showed that their center achieved lower in-hospital mortality using a protocolized approach with a median time to embolization of less than 90 min.9 Their comparison of historically published groups, however, did not contain data on time to angiography thus making conclusions about the relevance of timing imprecise.
Conversely, Rahal et al examined outcomes of patients with pelvic injuries requiring embolization and concluded that the time to angiography was not associated with a survival advantage after adjusting for confounders.10 A recent study using PUF 2018–2021 compared outcomes of patients undergoing angiography within 60 min of ED discharge versus longer and demonstrated that the risk-adjusted outcomes were similar between the two cohorts.11 They did note that approximately 9.8% of the variations in the proportion of the 60 min intervention were due to hospital-level factors.9
An implicit goal of the new ACS standard is to decrease the time to hemorrhage control analogous to the “door to ballon” time in myocardial infarction. Centers have explored various methods to improve communication between IR and trauma teams, the activation/mobilization of the IR team, transport methods, as well as other efforts to decrease the time to actual needle puncture. Our results, however, suggest that, despite the new requirement and process improvement efforts by trauma centers, there has to date been no significant impact on the time to angiography or patient outcomes.
To our knowledge, this is the first study to examine the effect of this new requirement using the most recent data that is available. These events are fairly rare within each individual center and therefore are best studied using a national database. This, however, also imposes the limitations of the TQP-PUF. The database does not capture the time of the decision for angiography, and we therefore cannot discern whether the 60-minute threshold was met. Yet, since the time from ED admission to angiography was unchanged before and after the implementation of this threshold, this data point may be less relevant. The PUF also only captures the initial vital signs and, therefore, cannot accurately characterize the patient’s hemodynamic status and the actual urgency for an intervention, which is partially dependent on the vital sign trends and response to fluid and blood transfusions. We selected only those patients who underwent angiography within 4 hours as we hypothesized that beyond this window the patients were more stable, and the standard would not apply to them. To validate this assumption, we also analyzed cohorts using selection criteria of angiography within 5 and 6 hours from admission and noted that the non-significant differences between the 3 years persisted (5 hours: 2.2 hours (2019), 2.1 hours (2021), 2.2 hours (2023), p=0.064); (6 hours: 2.4 hours (2019), 2.3 hours (2021), 2.3 hours (2023), p=0.095).
Furthermore, this data only examines the first full year after this requirement went into effect; it is possible that ongoing process improvement efforts within each center will decrease the times to IR intervention and possibly improve patient outcomes in the future. It will be therefore important to re-examine this data in the future to ensure that resources are not being spent in vain.
Conclusions
Our analysis of the 2019, 2021 and 2023 PUF databases demonstrates that the times to IR intervention and outcomes were unchanged despite the 2020 position article by the Society for Interventional Radiology5 and the introduction of the ACS 2022 Standards requiring a 60-minute deadline from request to needle puncture for IR hemorrhage control. Further review of future TQIP databases should be conducted to re-evaluate whether the 60-minute deadline to IR hemorrhage control improves outcomes.
