Message from the Trauma Director

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3 Message from the Trauma Director It has been an extraordinary year for the Trauma Program at St. Michael's Hospital. We have made significant strides in many of our strategic directions. Last year we presented our growth plan to expand our services to meet the growing needs in South Central Ontario. In July 2008, the first component of the plan was implemented where we moved toward sharing helicopter transports with Sunnybrook Health Science Centre, our regional trauma partner. The result of this change is greater use of our investment in our helipad and a greater concentration of severely injured patients. Our Trauma Services Office has met the challenge of submitting our trauma registry data to the American College of Surgeons Trauma Quality Improvement Program (TQIP), an extension of our submission to the National Trauma Databank. TQIP requires a very high standard of data quality. These data are used to compare our performance as a trauma centre with some of the best trauma centres in North America. The program allows us to identify where we excel and where there might be opportunities to improve the quality of care. We are proud to be the first Canadian centre to participate. Our hope is that performance benchmarking to a very high standard will translate into the best possible care for our patients. The care of severely injured patients is a team sport. While there has always been a focus on educating physicians, we have extended our reach by holding the first Advanced Trauma Care for Nurses (ATCN) course in Canada. Our nursing staff are now playing an important role in training nurses not only from the Greater Toronto Area, but also from Northern New York State and have begun to teach other sites so they can hold their own courses. Additionally, we held our second Trauma Continuum Conference, our interprofessional education event bringing together nurses, physicians, patients, and allied health professionals to support interdisciplinary learning, collaboration and to share best practices. Several of our initiatives in the trauma program were recognized for their impact. For example in the area of prevention, our Alcohol Screening and Brief Intervention Program received the Breaking the Boundaries Award at our Breakfast of Champions event and our ThinkFirst Injury Prevention Strategy for Youth (TIPSY) program was recognized by receipt of the St. Michael's Hospital Values in Action Award. Our Geriatric Trauma Consult Service received the Culture of Discovery Award for its impact on the care of the elderly, a growing proportion of our trauma patients as these patients become more active as they remain healthier into their later years. St. Michael's Hospital Trauma Program continued its record in disseminating our work around the world, with 37 publications and 48 presentations. We are continuing to develop relationships with investigators in a variety of fields to address the broad area of injury control, which extends from prevention to rehabilitation. Recognizing that injury is a complex medical and social problem, we have engaged physicians from many specialties, epidemiologists, geographers, sociologists, and criminologists to help advance the injury control agenda. With its links to our Centre for Research in Inner City Health, the Institute for Clinical Evaluative Science, and the Li Ka Shing Knowledge Institute, the Trauma Program at St. Michael's Hospital is poised to become an international leader in this area. Avery B. Nathens MD PhD FACS

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5 TABLE OF CONTENTS St. Michael s Hospital Profile 4 St. Michael s Hospital Trauma Program Trauma Care at St. Michael s Hospital Trauma Service Activity 7 The Population We Serve Trauma Team Activations Patient & Injury Profile Emergency Department Disposition Surgical Activity Transfusion Medicine Injury Characteristics Hospital Discharge Patient Outcomes The Trauma Journey 18 Quality Assurance & Accountability 19 The Trauma Registry Quality Assurance Optimizing Care & Outcomes Geriatric Trauma Operational Guidelines Strengthening Partnerships to Improve Care and Outcomes Point of Care Testing Daily Trauma Patient Checklist The Patient Problem List Alcohol Screening and Brief Intervention Program Tertiary Trauma Survey Advancing Trauma Care Through Education & Research 23 Advanced Trauma Life Support Advanced Trauma Care for Nurses Trauma Team Evaluation and Management Advanced Trauma Operative Management Trauma Continuum Conference Rural Trauma Team Development Course Breakfast of Our Champions ThinkFirst Injury Prevention Strategy for Youth (TIPSY) Trauma Related Research Our Future Direction 29 3

6 St. Michael s Hospital As a Catholic hospital, founded in 1892 by the Sisters of St. Joseph to care for the sick and the poor of Toronto's inner city, St. Michael's Hospital (SMH) has a long and proud history of caring and compassion. Since 1892, we have preserved our commitment to compassion and excellence as we have evolved into a centre for innovation in patient care, teaching and research. Fully affiliated with the University of Toronto, St. Michael's Hospital leads the way in clinical care, education and research in heart disease, trauma and critical care, neurosurgery, arthritis and osteoporosis, keyhole surgery, diabetes, cancer care and care of the homeless and vulnerable populations in the inner city. As the designated adult trauma centre for downtown Toronto and a major referral centre for Ontario, the Hospital treats the most critically ill and complex patients in the province. At SMH we recognize the value of every person and are guided by our commitment to excellence and leadership. We demonstrate this by: Providing exemplary physical, emotional and spiritual care for each person we serve; Balancing a continuing commitment to the care of the poor and those most in need with the provision of highly specialized service to the broader community; Building a work environment where each person is valued, respected and has an opportunity for personal and professional growth; Advancing excellence in health services education; Fostering a culture of discovery in all our activities and supporting exemplary health services research; Strengthening our relationships with universities, colleges, other hospitals, agencies and our community; Demonstrating social responsibility through the just use of our resources. The commitment of our staff, physicians, volunteers, students, community partners and friends to our mission permits us to maintain a quality of presence and tradition of caring which are the hallmarks of SMH. St. Michael s Hospital Trauma Program Ontario s trauma system is designed to ensure that whenever a person is injured, that person will receive the appropriate level of care in a timely fashion. A core component of a trauma system is its trauma centres. In Ontario, there are nine adult and two pediatric trauma centres designated by the provincial government. Designation, which first occurred in 1992, identified the unique resources available at SMH to care for the province s most severely injured patients. Additionally, we have a team of professionals including physiotherapists, occupational therapists, dietitians, recreation therapists, speech/language pathologists and socials workers (among many others) to begin the rebuilding process for patients and their families after the most devastating injuries. The SMH Trauma Program is accredited by the Trauma Association of Canada as a Level 1 trauma centre. Accreditation requires that external reviewers examine the resources and trauma care delivery to assure that trauma centres provide the highest quality of care. Accreditation standing is held for five years and we will be renewing our accreditation in

7 The nurses are great and the doctors are amazing. This hospital has some of the best staff I have ever seen. - patient J.K. Overall everything was excellent, our family is very grateful. - patient J.F. 5

8 Trauma Care at St. Michael s Hospital Severely injured patients rarely have a choice as to where they receive care. As a result, trauma centres differ from other hospitals in many respects. Our trauma team is composed of multidisciplinary specialists and services such as blood bank, sophisticated medical imaging department and operating rooms immediately available to attend to patients 24/7. The Allen T. Lambert Trauma & Neurosurgery Intensive Care Unit (TNICU) always has a bed to receive a critically ill trauma patient. The trauma team is activated each time a severely injured patient arrives at SMH. The team is comprised of a trauma team leader (TTL), two emergency department (ED) nurses, respiratory therapist, x-ray technician and house staff representing general surgery, anesthesia, and orthopedic surgery. The trauma team is highly trained to act quickly in caring for complex patients in a dynamic environment often with only limited information available. Rapid transfer of the patient to medical imaging, the operating room, the TNICU or the Trauma & Neurosurgery (TN) in-patient unit for further evaluation and treatment is made possible by this coordinated effort. Once admitted to either the TNICU or TN inpatient unit, the care of the patient is transferred to the Trauma Service, an interdisciplinary team with expertise in the care of injured patients. This inter-professional team works collaboratively to facilitate the early identification of patient care needs, enhance the coordination of care, increase timeliness in referrals and expedite transfers and repatriation of patients to their home hospital. The enthusiasm, flexibility and teamwork within the program provide ongoing opportunities to bring the care of the most severely injured patients to the highest level. 6

9 The Population We Serve Our trauma resources are available to all those who require them. Our acceptance rate of over 99% for provincial trauma referrals emphasizes our commitment to trauma care. We provide trauma care to the most vulnerable populations in the downtown core, but our reach extends far beyond downtown. Injured patients often arrive at SMH directly from scene of injury and approximately 23% of our trauma patients arrive by air ambulance. 7 This map shows the locations where trauma patients who were transported to SMH via air ambulance originated from.

10 The Population We Serve Most of our trauma patients (62%) arrive at SMH directly from the scene of injury. Other patients are first transported from the scene of injury to a community hospital and then transported to SMH. Top 12 Referring Facilities: Collingwood General & Marine Hospital Credit Valley Hospital (Mississauga) Source of Patient Huronia District Hospital (Collingwood) Lakeridge Health Corporation (Oshawa) 62% 38% Orillia Soldiers Memorial Hospital (Orillia) Peterborough Regional Health Centre (Peterborough) Ross Memorial Hospital (Lindsay) Direct to SMH Interfacility Transfer Royal Victoria Hospital (Barrie) Southlake Regional Health Centre (Newmarket) Stevenson Memorial Hospital (Alliston) Trillium Health Centre (Missisauga) William Osler Health Centre (Brampton) 8

11 Trauma Team Activations The trauma team is often activated prior to a patient s arrival. This year we developed and implemented a tiered approach to trauma team activations so that the trauma team response is matched to anticipated patient needs. Both tiers require the trauma team to prepare for the arrival of trauma patient with likelihood of severe injury. The additional tier stratification is used to identify those patients that may require immediate surgical interventions (Tier1) and those not likely to require immediate surgical intervention (Tier 2). In a Tier 1 activation the attending trauma staff surgeon on call, the operating room (OR), TNICU and blood bank are notified of the presence of a trauma patient with high likelihood of needing immediate specialized procedures. Trauma Team Activations 15% Sunday 20% Saturday Friday 15% Thursday 12% Wednesday 13% Tuesday 13% 13% Monday 1 # of Admissions Midnight to 6am Total Number of Admissions by Time of Day 6am to noon Noon to 6pm 6pm to midnight Examples of mechanism of injuries that would lead to a Tier 1 activation are gunshot or stab wounds needing immediate surgical intervention. Additional Tier 1 activations would include patients who have sustained blunt force trauma where the patient is hemodynamically abnormal and have a high likelihood of needing immediate surgical intervention. In 2008, 30% of our trauma patients were activated as Tier 1. 9

12 Patient & Injury Profile Patient Profile by Age & Gender % of Patients > 60 Age (years) Female Male Trauma is a disease of the young, with males disproportionately represented. 76% of our trauma patients were male; 53% of all trauma patients were between 15 and 39 years old. Males also account for the majority (89%) of penetrating injuries. Blunt injuries such as motor vehicle crashes and falls are the predominant mechanisms of injury in our trauma patients, (approximately 74%). The remaining 26% are penetrating injuries including gunshot wounds and stabbings. Type of Injury by Age Group % of Patients > 60 Age (years) 10 Penetrating Injury Blunt Injury

13 "I would also like to comment on the nursing staff in the TNICU and on the 9th floor. They were terrific and took very good care of me. Please thank them again for me. Thank you so much for everything, especially my life" - patient B.N. I was treated with the best hospital care I have ever had. - patient T.D. 11

14 Emergency Department Disposition Following their initial assessment and resuscitation in the emergency department, over 40% of patients are transferred to the TNICU. An additional 17% require direct transport from the emergency department to the operating room for immediate operative management for their injuries. Percent (%) Intensive Care Unit 43 Inpatient Unit 25 Operating Room 17 Home 12 Death in the Emergency Department 3 Transfer for Specialty Care 1 Surgical Activity Many of our critically injured patients require at least one surgical procedure during their stay and many require more than one operation. This past year more than 222 (40%) trauma patients required one or more surgical interventions to manage their injuries and 59 of these patients had two or more surgeries. For patients with multisystem injuries numerous subspecialties may provide care during a single trip to the operating room. These 222 patients underwent over 800 procedures. The interventional radiologist plays a critical role in trauma care. They have refined percutaneous techniques to identify and stop bleeding or to drain abscesses in areas of the body that are not easily accessed surgically. The minimally invasive nature of their work allows these therapies to be repeated as often as needed in patients with ongoing bleeding and problems with recurring infection. This has been key to saving lives that would otherwise have been lost. Surgical & Interventional Radiology Procedures: Number Patients requiring surgical interventions 298 Total number of visits to the operating room 359 Total number of procedures completed 828 Average time (hours) per surgical case 4.40 Total number of interventional radiology procedures for hemorrhage 7 12

15 Transfusion Medicine Blood Products Number of units transfused Packed Red Blood Cells (PRBC) 1078 Platelets 90 Plasma / Cryoprecipitate 514 Injured patients are among the largest users of blood products at SMH. A total of 1078 units of packed red blood cells (PRBC) were transfused to trauma patients this year. Quick Facts 156 patients received blood transfusions An average of 6.9 units of blood was given to those patients who required transfusion Massive Transfusion Protocol Massive hemorrhage is defined as transfusion of 10 or more packed red blood cell (PRBC) units in a 24 hour period. Massive hemorrhage occurs in up to 15% of trauma patients and is associated with a mortality rate of 20-50%. Massive hemorrhage is a leading cause of potentially preventable death. In collaboration with Transfusion Medicine, the trauma program developed and implemented a massive transfusion protocol (MTP) based on best evidence that suggests a structured approach to blood replacement decreases blood component use and wastage, turnaround times, costs and patient mortality. The MTP is designed to provide patients with timely and adequate replacement during massive blood loss using appropriate blood components. The MTP is activated for patients experiencing substantial blood loss with anticipated ongoing uncontrolled haemorrhage. Since its implementation in December 2008, MTP has been initiated 13 times for trauma patients. Patient age ranged from 17 to 77 years old, and blunt trauma accounted for 8 cases. Implementation of the MTP significantly reduced wait times for blood components and systemized their administration. It is too early to judge whether implementation of MTP has resulted in improved patient outcomes. However, we have already documented a decrease in our blood component use. Moreover, the MTP process facilitates its real-time evaluation thus enabling continuous quality improvement. 13

16 Injury Characteristics Injury Characteristics 200 # of Patients Stab Gunshot Wound Motor Vehicle Pedestrian /Cyclist All injuries Severe Injury Type of Injury Fall Struck by/against Other Head, neck and cervical spine 36.7% Facial injuries 5% Chest, ribs and thoracic spine 42.7% Abdomen and lumbar spine 14% Arm and leg injuries 29.2% Injuries are classified by where they occur on the body and their severity. Patients frequently have more than one injury. Last year we identified 705 severe injuries in 550 patients. This figure illustrates the distribution of these 705 injuries by body region. 14

17 Injury Characteristics Injury Severity Score 200 Number of Patients ISS Score The Injury Severity Score (ISS) is a measure of injury severity. An ISS greater than 15 identifies patients with a very high risk of death. Intentional Injuries Struck by, against (assault) 12% Other 4% Fall 4% Gunshot 24% Stab 56% Injuries are typically classified as unintentional, intentional or undetermined intent. One third of traumatic injuries seen at SMH are intentional assaults or self-inflicted. 15

18 Hospital Discharge Length of Stay (excluding deaths) # of admissions > 69 # of days All Patients ISS > 15 The average length of stay at SMH for trauma patients is 12.5 days, approximately half of this time is spent in the TNICU. Discharge Disposition Home 56% Rehabilitation Destination Percent (%) Toronto Rehabilitation Institute 34 St. John s Rehabilitation Hospital 19 West Park Healthcare Centre 19 Other 2% Died 11% Long Term Care 1% Community Hospital 12% Rehabilitation 18% While the majority of patients are discharged to their home, 18% of our trauma patients are discharged to a rehabilitation facility for additional care. Our rehabilitation partners include Toronto Rehabilitation Institute, St. John s Rehabilitation Hospital, West Park Healthcare Centre, Bridgepoint Hospital, Providence Healthcare and Bloorview Kids Rehabilitation. 16 Bridgepoint Hospital 15 Providence Healthcare (Scarborough) Bloorview Kids Rehabilitation 3 Other 3 7

19 Patient Outcomes Survival Rate by Mechanism of Injury 100 Survial Rate (%) Gunshot Fall Motor Vehicle Crash Mechanism of Injury Stab Other There are many factors that affect recovery and survival following trauma. Some injuries, such as motor vehicle crashes have a lower survival rate. ISS scores range from 1 to 75 with higher scores representing increase injury severity and are associated with a decreased survival rate. Survival Rate by ISS 100 Survival Rate (%) ISS Score 17

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21 Quality Assurance & Accountability The Trauma Registry The trauma registry is a comprehensive database of information on all aspects of traumatic injury and clinical presentation, ongoing care and ultimate outcome at discharge from SMH. This data is evaluated as part of our own internal quality assurance activities and is also uploaded to the Ontario Trauma Registry for system wide analysis and evaluation of trauma care throughout the province. In 2008, the SMH trauma registry was the first Canadian site to submit injury data to the U.S. National Trauma Databank, allowing our hospital to compare our outcomes against U.S. trauma centres. Quality Assurance (QA) The Trauma Quality Assessment and Performance Improvement Report (TQAR) is one tool that we use to monitor and evaluate trauma care using established quality indicators. The TQAR is reviewed quarterly at the Trauma Care Committee to evaluate current QA efforts and provide direction for future quality improvement initiatives. For example, through review of the TQAR it was noted that documentation of trauma patient temperatures in ED was missing in approximately 50% of trauma cases. Temperature is an important clinical detail in the injured patient as untreated hypothermia can lead to additional blood loss. An awareness and education campaign was initiated in the ED and now temperatures are being recorded in over 75% of trauma cases. The TQAR has also focused on reviewing the newly implemented tiered trauma activation criteria, TTL response times, amount of time spent in trauma bay, blood alcohol level screening, adherence to Brain Trauma Foundation Guidelines (BTF), and delays in getting a patient to the OR. In addition to retrospective data review, the program collects data in real time on patient complications and issues of significance in order to address potential concerns in real time. For example, a small spike in pulmonary embolism (PE) rates led to a review of PE rates and case presentation at morbidity rounds reviewing current best practice in venous thromboembolism prophylaxis guidelines. The program participates in international benchmarking of trauma care through the American College of Surgeons, Trauma Quality Improvement Program (TQIP). In 2008, the trauma program submitted data for analysis under the auspices of the TQIP pilot project. TQIP project includes 23 trauma centre members from across North America tracking outcomes and comparing data across sites with the goal of improving patient care and implementing and evaluating best practices in trauma care. The early pilot data has focused on accurate data abstraction, data quality and inclusion criteria, and compared outcomes across sites. Moving forward the project will focus on issues related to hemorrhage control, venous thromboembolism prophylaxis, time to fracture fixation and adherence to the Brain Trauma Foundation Guidelines for management of severe traumatic brain injury. 19

22 Optimizing Care & Outcomes Evidence Based Practice Guidelines Evidence Based Practice Guidelines and Protocols set the standards for treatment of the injured patient and are based upon review of current trauma literature. There are over 25 trauma specific protocols and guidelines in place at SMH. Each year new protocols are developed and established protocols are reviewed to ensure they continue to reflect current best practice. New Trauma Guidelines 2008 Guidelines for Management of Trauma in Pregnancy Guidelines for Management of Penetrating Neck Trauma Penetrating Torso Injury Guidelines Resuscitation Protocol Revised Guidelines in 2008 Massive Transfusion Protocol Trauma Team Leader Activation Protocol Geriatric Trauma Operational Guidelines Automatic referrals to the regional geriatric program continued successfully in 2008 with over 67 elderly trauma patients receiving targeted functional cognitive and psychosocial assessments designed to address the special needs of the elderly trauma patients. The partnership between the Trauma Program and Geriatric Services at St. Michael's Hospital speaks to the unique characteristics of older persons and the importance of providing evidenced based care to this growing population - Penny, RN, MN Clinical Nurse Specialist, Regional Geriatric Program, Geriatric & Geriatric Psychiatry Outreach Team, SMH. The Geriatric Team is extremely efficient with providing comprehensive assessments of our elderly clients. Their report provides valuable insight into the client's medical and social history, prior functioning at home, and family and community supports. We utilize this information to help us shape the plan of care for the client's both in hospital and when planning for discharge. The Elder's Clinic has been a wonderful resource for client's following discharge from the hospital. - Theresa, RN, Advanced Practice Nurse, Trauma Neurosurgery Unit, SMH. 20

23 Optimizing Care & Outcomes Strengthening Partnerships to Improve Care and Outcomes In 2008, the Trauma Program sent follow-up letters to referring physicians for every injured patient admitted through inter-facility transfer. These letters are sent within 48 hours of the patient's arrival to provide the referring physician with information related to the early findings and treatment to date. Point of Care Testing (POCT) POCT is diagnostic testing (specifically blood work) done at the site of patient care. While already available in the TNICU, the POCT technology was made available in the emergency department in POCT offers the advantage of immediate bloodwork results while the trauma team is actively treating the patient supporting early and appropriate treatment. It further reduces demands on central lab resources and runners required for transporting blood. Daily Trauma Patient Checklist Trauma patient care at St. Michael s Hospital is provided through a large multi-disciplinary team consisting of physicians, nurses, physiotherapists, occupational therapists, social workers, nutritionist, speech and language therapists and case managers. Since trauma patients have a wide variety of complex issues, it is important to provide a standardized framework for daily patient assessment. The daily trauma patient checklist is a unique initiative started at St. Michael s Hospital to identify and track key issues related to daily patient care. It allows physicians to better organize clinically relevant information and helps to improve communication between multi-disciplinary professionals in order to improve patient care and safety. The Patient Problem List The patient problem was created to be part of the medical record designed to accurately document a patient's inventory of injuries and dynamically track any procedures or complications related to their hospital stay. This information tool has helped to coordinate care between the trauma team and other health professionals by providing a snapshot of a patient's clinical history and improving communication. The patient problem list has led to a decreased rate of missed injuries and has improved patient safety through timely diagnosis and follow-up of complex traumatic injuries. 21

24 Optimizing Care & Outcomes Alcohol Screening and Brief Intervention (ASBI) Program Recently the Canadian Institute of Health Information issued a media advisory outlining the association between alcohol consumption and trauma. Research shows that the risk of reinjury among trauma patients with any type of alcohol use is 2 times that of those with no alcohol use. To address the risks of recurrent injury and alcohol related trauma, SMH has taken a leadership role in implementing screening and interventions for at risk trauma patients. Close to 100% of SMH trauma patients are screened to determine if they had a positive blood alcohol level on admission, for those that test positive our trauma centre has put into place an ASBI program that takes advantage of a teachable moment generated by the injury to help motivate behaviour change. ASBI programs reduce by half the risk of recurrent injuries, reduces alcohol consumption, and recurrent drinking and driving. The brief intervention is not complex, it takes about 20 minutes to administer and is done by trained members of our health care team. Tertiary Trauma Survey Trauma patients can present as a challenge to even the most experienced clinicians, particularly those patients with multiple or complex injuries. The complexity and urgency associated with trauma patients may mean that a significant number of injuries can remain undetected after initial assessment in the trauma room. The use of a tertiary survey, reexamining and reevaluating the trauma patient s injuries within 48 hours of initial assessment is an effective means of capturing those injuries not found during the initial assessment and stabilization of the trauma patient. These missed injuries not found on the initial survey can then be addressed. Last year, 45 patients were found to have one or more injuries that were missed during the initial assessment. Typically, and in keeping with the literature, the patients with missed injuries tended to have higher injury severity scores (ISS) than those patients in whom no missed injuries were found. The average ISS for patients with missed injuries was 28, significantly higher than non missed injuries group whose average ISS was 18. A total of 58 missed injuries were found and listed under the following broad categories: Bony injuries to the extremities, primarily hands and feet (31%) Rib, clavicle and scapula fractures and minor facial and skull fractures (33%) Minor head or spine injuries (14%) Other miscellaneous injuries (22%) 22

25 Advancing Trauma Care Through Education & Research

26 Advanced Trauma Life Support (ATLS ) The Advanced Trauma Life Support Course (ATLS ) provides a framework of knowledge and techniques for the initial management of a trauma patient. The ATLS course has been taught at SMH for 15 years with a focus on teaching University of Toronto medical residents from diverse disciplines including Family Practice, Emergency Medicine, Anesthesia, Orthopedic Surgery, Neurosurgery and General Surgery. A total of 785 participants have taken the course at SMH since An important component of the ATLS program is learning life-saving surgical skills. Compared to previous years where a porcine model was used, SMH moved to using a simulated trauma mannequin to teach surgical skills. This simulated model is specifically designed to mimic surgical dissection of the thoracic, abdominal and neck regions allowing students to learn minor surgical procedures that are potentially life saving and is an ideal alternative to an animal model. Faculty Education Using Telemedicine There is a need to educate rural physicians in principles of trauma care in order to provide lifesaving therapy in the golden hour of injury. The ATLS faculty are leaders in medical education research related to ATLS. This year, SMH was the testing ground for the use of telemedicine in teaching the ATLS course. The team continues to develop new strategies to promote the delivery of trauma education to remote communities. 23

27 Advanced Trauma Care for Nurses (ATCN ) This year, SMH offered the first Advanced Trauma Care for Nurses (ATCN ) course in Canada. The ATCN program has been operational internationally for over 20 years and has never been offered in Canada. The course faculty is made up of six SMH nurses, who traveled to the Maricopa Medical Center in Arizona to attend an ATCN provider course and become certified instructors. Their goal is to facilitate ATCN program dissemination across Canada. This two day course is offered in collaboration with the ATLS course and endorsed by the Society of Trauma Nurses. The inter-disciplinary learning format enhances team building and a greater understanding of inter-disciplinary roles in the management of the trauma patient. Physicians and nurses attend a series of interactive ATLS lectures together, with the nurses then spending the remainder of the course focusing on knowledge and technical skill stations relevant to their work on the trauma team. ATCN skill stations include: Initial Assessment and Management Airway and Ventilatory Management Spine & Extremity Injuries Head Trauma Hemorrhagic Shock Pediatric Trauma The skill stations are interactive and hands-on, focusing on a variety of challenging case scenarios. The practical testing stations allow ATCN students to demonstrate the application of newly acquired skills on a simulated patient. The advanced training and critical thinking processes that the nurses learn enhance nursing s ability to make an even bigger impact in caring for trauma patients. SMH is proud to have been the site of the inaugural ATCN course in Canada (July 2008) and have certified a total of thirty-eight nurses in The information provided was concise, educational and relevant to practice, both medical and nursing. - ATCN Participant 24

28 Trauma Team Evaluation and Management (TEAM) The TEAM course content is an introduction to the concepts of trauma assessment and management. A total of 209 second year medical students at the University of Toronto participated in this day long education workshop which included classroom teaching and practice in the simulation laboratory. Advanced Trauma Operative Management (ATOM) The ATOM course is a unique day-long course designed to teach advanced techniques in trauma surgery in a one-on-one mentored environment and in a practical laboratory setting to senior level surgical residents. Research has demonstrated that ATOM training has a positive effect on trauma related knowledge and skills. Two courses were held at SMH training a total of 19 senior surgical residents from the University of Toronto and McMaster University. Trauma Continuum Conference Building on the success from the inaugural Trauma Continuum Conference in February The Trauma Program at SMH held a one-day interprofessional trauma conference in December The conference was designed to meet the learning needs of health care professionals involved in any aspect of the care of the trauma patient from on-scene resuscitations, acute care, discharge planning, rehabilitation settings and beyond. A unique aspect of this conference was utilizing a case based approach that followed journey of a fictitious trauma patient from the moment of injury to rehabilitation planning. Over 100 health professionals attended the event. Case-based approach was very helpful in organizing the day & applying the information. Voice of Injured Person (VIP) was inspiring to see someone like our patients functioning in the community - Trauma Continuum Participant 25

29 Rural Trauma Team Development Course (RTTDC ) The RTTDC was developed by the Rural Trauma Committee of the American College of Surgeons Committee on Trauma. The course is designed to enhance the development of rural trauma teams, and highlights a team approach that addresses the common problems in the initial assessment, and stabilization of injured patients. The RTTDC is designed to increase the efficiency of stabilization of injured patients, resource utilization and improve the overall level of care provided to the injured patient in the rural environment. This course is presented at rural facilities by a multidisciplinary team of physicians and nurses from SMH. In 2008, the trauma group at SMH presented this one day course to multidisciplinary health care professionals at West Parry Sound Health Centre. The course was well received, and participants indicated that was pertinent to their current practice and was an informative, well organized review of current Advanced Trauma Life Support and management. SMH Trauma Program recognizes the responsibility to provide outreach education to their referring hospitals. Future courses in 2009 are planned for Muskoka Algonquin Healthcare sites at Bracebridge and Huntsville (June 2009). Gave us hope that we can work as a team to provide optimal care - RTTDC course participant Breakfast of Our Champions In conjunction with the Mobility Program, the Trauma Program hosted the second annual Breakfast of Our Champions event at the Grand Hotel, Toronto on June 26, The goal of this event is to share with our SMH colleagues all of the teaching, research, and education initiatives that are being undertaken by members of the Programs. Many of these initiatives have been presented nationally and internationally. There were over 100 attendees at the event with over 40 ground breaking initiatives presented. 26

30 ThinkFirst Injury Prevention Strategy for Youth (TIPSY) TIPSY program is a half day injury prevention program offered throughout the academic year to high school students in the Greater Toronto Area. The program begins with the understanding that motor-vehicle crashes are the leading cause of injury and death for youth. The focus of the program is helping youth understand how inexperience, lack of restraint use, drinking/drugging and driving can result in tragedy on the roadways. The program includes tours of the trauma resuscitation area, TNICU and in-patient unit. The classroom component is taught by an inter-professional team of nurses, physicians, representatives from Toronto Police Services, Mothers Against Drunk Drivers and a Voice of Injury Prevention (VIP). The VIP is a trauma survivor who has sustained a brain or spinal cord injury and recounts first-hand the events leading to his/her injury, its consequences and lasting effect. This year the TIPSY program and its coordinators received the SMH Values in Action Award for Social Responsibility. These awards represent the highest honour given to individuals and teams at St. Michael s Hospital in recognition of their commitment to living our values and to our culture of caring. When asked to describe their impression of the program in one sentence: At first, I thought it wouldn't be that educational, but as the day went, it proved me wrong - Student participant When asked what they enjoyed most about the TIPSY program: It scared me enough to get the message across - Student participant 27

31 Trauma Related Research Injury research spans several phases of injury ranging from injury prevention initiatives, neighbourhood risk factors for injury, health services research pertaining to organized systems of trauma care and trauma care delivery. Acute trauma care research focuses on traumatic brain injury, resuscitation, teamwork and interprofessional collaboration. Committed to play a leadership role in injury prevention, SMH is actively engaged in many research activities to reduce and prevent injury. Current research underway includes looking at ways to decrease intentional violent injury amongst youth. Studies have shown that youth who have been injured by violence are at high risk of another injury, often much more severe than the initial one. Examining patterns of violent injury among youth in Toronto and developing a program to link youth who visit the hospital with injuries due to violence with community youth violence intervention programs are one example of this work. Another example of injury prevention research are the many studies evaluating the effectiveness of education interventions as a strategic approach to preventing injuries. The application of geomatics in injury research is also growing at SMH. Using geomatics, a study examining the association between bicyclists injuries and the cycling environment (type of route, pedestrian traffic, types of intersections, cyclist clothing etc.) may help reduce cycling injuries in Canada. Advance knowledge and care in treating injuries and improving outcomes for our patients is also paramount. Highly notable is the range of studies that span from testing of devices (plates, surgical techniques) or treatments in randomized controlled trials to developing and testing outcome measures and their statistical modeling. Areas of emphasis here include fracture treatment, post traumatic reconstruction, management of traumatic head injury, inflammatory responses to injury, prognostic cohort studies, e-data collection and reporting, measurement and outcomes research, and knowledge translation to facilitate best practice. Research beyond the hospitalization phase of injury includes the development of protocols and assessment tools for traumatic brain injury and supporting patients and families through rehabilitation and the transition back to home. 28

32 Our Future Direction We have been privileged to be recognized as a priority program in the St. Michael's Hospital new Strategic Plan , Directions for a Healthier World. Having met virtually all of our goals in 2008, we will continue to focus on the pursuit of clinical excellence, patient safety, financial performance and academic productivity. In addition, we will continue to expand our regional role. Recognizing that a large proportion of trauma deaths (~45%) occur in Ontario s rural emergency departments, we are going to focus our efforts on improving the quality of initial trauma care in areas where this need is greatest. We will accomplish this through our leadership in promulgating the Rural Trauma Team Development Course to assure that all Ontarians have access to high quality initial trauma care. These efforts will be complemented by the introduction of our Trauma Teleresuscitation project. This project, funded through Innovation Funds provided by the Ministry of Health and Long Term Care and with the support of the Ontario Telemedicine Network, will bring our trauma team leaders to more rural emergency departments in South Central Ontario. This project will allow us to support physicians in their provision of care to the most severely injured patients and to assure earlier access to trauma centre care. We will also focus on strengthening our existing collaborations with our trauma centre partner in the Greater Toronto Area (GTA), Sunnybrook Health Science Centre. We hope to accomplish this through better integration of our academic and research programs and through harmonizing many of our best practices across the two institutions. With GTA trauma centre (and system) accreditation on the horizon in 2011 through the Trauma Association of Canada, we will have an opportunity to demonstrate precisely what an integrated system of trauma care might offer to the region. 29

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34 Trauma Services Office St. Michael's Hospital 30 Bond Street, 3 Queen Toronto, ON M5B 1W8 Tel: trauma@smh.toronto.on.ca We would like to thank the entire Program for their contributions in creating this report. Primary document authors: Najma Ahmed Sonya Canzian Amanda McFarlan Avery Nathens Anand Pandya Anne Sorvari Cover photo by Liam Sharp