A02 Clinical Audit: Adherence to Trauma Team Activation Policy in Emergency and Trauma Department, Hospital Sultanah Nur Zahirah

Abstract

INTRODUCTION

Timely, coordinated trauma care during the ‘golden hour’ is vital to reduce morbidity and mortality. In 2022, Hospital Sultanah Nur Zahirah introduced a Trauma Team Activation (TTA) policy to standardize early management. An initial audit, however, revealed poor adherence. This audit aimed to assess the impact of targeted interventions on TTA compliance and the timeliness of imaging and lab investigations.

INTERVENTION

Interventions included Continuing Medical Education sessions, a trauma bay poster displaying the TTA flowchart, and a QR code linking directly to the policy.

DATA COLLECTION, ANALYSIS AND RESULTS

This retrospective audit reviewed trauma cases meeting TTA criteria across two periods: Phase 1 (pre-intervention, July–September 2024) and Phase 2 (post-intervention, February–April 2025). Data from the Malaysian Trauma Registry, patient records, and Hospital Information System (HIS) were analysed using Microsoft Excel.

Key improvements post-intervention were TTA activation: 19.5% to 58.8%, Chest/pelvic X-rays <30 minutes: 9.8% to 32.3%, CT scans &lt;30 minutes: 9.8% to 41.2%, FBC &lt;30 minutes: 14.6% to 44.1% and blood gas &lt;30 minutes: 14.6% to 38.2%. However, 41.2% of cases still missed all 30-minute targets.

DISCUSSION

A structured system for continuous monitoring was established. TTA activations are now tracked via a dedicated registry, with plans to embed trauma indicators into hospital KPIs for regular review.

CONCLUSION AND IMPLICATIONS

Multifaceted interventions significantly improved compliance with the TTA policy. Remaining gaps are due to limited staff familiarity, workload, and resource constraints. Sustained education, workflow optimization, and manpower support are crucial to improving trauma care during the golden hour.

https://doi.org/10.64392/dssr7590