Background: Quality control indicators for mass lesion in TBI use the delay between emergency department (ED) and OR arrival to measure quality of care. It does not provide the timing of brain decompression. The goals of this study are to observe step by step where delays occur from hospital admission until effective decompression of the brain. Methods: A prospective observational data collection of timing from ED admission to decompression was conducted for all emergency trauma craniotomies over a period of 15 months. Results: Sixty-five patients were included. Doing a CT at the outside institution instead of transferring the patient prior to CT resulted in a 112min delay in care. Neurosurgery team notification prior to patient’s arrival to ED shortened delivery of care by 51min. The time elapsed between OR arrival and brain decompression was 50min: anesthesia time 3min, surgical positioning/preparation 29min and surgical time 17min. Burrhole decompression followed by craniotomy (9min) shortened the decompression time by 17min compared to standard 4 holes craniotomy approach (26min). Conclusions: Benchmark for trauma system performance in emergency craniotomies should be door to decompression time. Bypassing CT in local hospitals, pre-alerting neurosurgeons, and burrhole decompression followed by standard craniotomy significantly decrease door to decompression time.