ALBERTA CHILDREN S HOSPITAL PEDIATRIC TRAUMA PROGRAM ANNUAL REPORT. ACH Trauma Program Staff. Dr. Jonathan Guilfoyle...

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1 ALBERTA CHILDREN S HOSPITAL PEDIATRIC TRAUMA PROGRAM ANNUAL REPORT 2014 ACH Trauma Program Staff Dr. Jonathan Guilfoyle... Medical Director Dr. Steve Lopushinsky... In-Patient Surgical Lead Sharleen Luzny... Trauma Program Manager Sherry MacGillivray... Trauma Coordinator Lisette Lockyer... Trauma Nurse Practitioner Linda-Mae Grey... Data Analyst 1

2 TABLE OF CONTENTS 1. Introduction Clinical Care Education Research Quality Assurance Future Planning APPENDICES Appendix A Trauma Quality Indicators Appendix B Major Trauma Statistics

3 1. Introduction The Pediatric Trauma Program has had another strong and successful year. We have remained committed to implementing all of the recommendations made in the last Trauma Association of Canada Accreditation and we look forward to working with Accreditation Canada in the coming years to ensure that we continue to deliver the highest level of care to the children of Southern Alberta. The Pediatric Trauma Program continues to collaborate on many provincial and national projects through the Provincial Trauma Committee of Alberta, the Interdisciplinary Trauma Network of Canada and the Trauma Association of Canada (TAC). Ms. Sherry MacGillivray continues as our Pediatric Trauma Coordinator and the co-chair for the Pediatric Committee of TAC. Our multidisciplinary trauma team provides outstanding care. Our Trauma Team Leader (TTL) is an Emergency Physician assigned to a designated trauma shift, whose first priority is the management of patients in the trauma bay. We have a team of highly skilled, experienced nurses, all qualified through the Trauma Nursing Core Course, as well as outstanding Respiratory Therapists, who together are the backbone of the trauma team. The Trauma Surgery Team responds to every trauma activation, and works hand in hand with the TTL to guide the resuscitation in the ED and determine appropriate patient disposition. In addition, the Pediatric Intensive Care Team also responds to activations, providing their expertise in the management of critical care. Our trauma activations also include the x-ray and CT technicians and attending radiologist who strives to give finalized imaging reports within the hour. We run regular mock traumas with our entire trauma team, including the OR, to ensure the preparation of our team. The In-patient Trauma Program provides integrated care throughout the patient s stay and through their rehabilitation process. The recent implementation of a solid organ injury protocol has standardized the management of solid organ injuries with the goal of reducing the length of hospital stay and increasing early mobilization without an increase in early or late complications. The Brain Injury and Rehabilitation Program continues to work with patients who have suffered traumatic brain injuries and a new Curious About Concussion? clinical education session for patients and families has also been launched. Through our close relationship with the ACH Canadian Hospital Injury Reporting and Prevention Program, we strive to be a vocal advocate for injury prevention from education around sports related head injury to awareness of the life-threatening risks of ATV use. Education has always been one of the strengths of this Trauma Program, which we continue to build upon. Our trauma educators have once again provided outstanding teaching throughout the year. In 2014, the ACH Trauma Program provided educational leadership for both ACH clinical staff, as well as outreach education to rural and regional providers. On-going education provided by the 3

4 Pediatric Trauma Program includes: mock/just-in-time trauma codes for the ED; monthly Pediatric Trauma Rounds; twice yearly Trauma Nursing Core Courses (TNCC); and outreach education to referral centers by partnering with KidSIM, the Pediatric Human Patient Simulation Program at ACH. We wish to express our appreciation for all of the staff at the Alberta Children s Hospital, who continue to support our goals in caring for critically injured children and youth. The multidisciplinary team of nurses, physicians, respiratory therapists, and other front-line staff remain devoted to the care of these children and their families. Dr. J. Guilfoyle would like to personally thank all the members of the Trauma Program for their hard work and commitment to ongoing excellence in Pediatric Trauma Care at the Alberta Children s Hospital. Above all, he would like to thank Ms. Sherry MacGillivray for her tremendous dedication and commitment to our Pediatric Trauma Program. NOTE: The patients included in this report are those with an Injury Severity Score (ISS) > 12 and who are admitted to the hospital or die in the emergency department at the Alberta Children s Hospital (ACH). Patients who die at the scene of their traumatic event are not represented in this report. ISS is an anatomical scoring tool that provides an overall score for patients with single or multiple system injuries. The ISS captured in the Alberta Trauma Registry ranges between 12 and 75. The assumption is the higher the ISS score, the more serious the injury suffered. The reporting structure has changed this past year from a fiscal year to the calendar year. This was done in preparation for submission to the National Trauma Data Bank based in the US. There are 17 patients in this report that were also reported on in the report. 4

5 2. Clinical Care Identifying ways to improve the clinical care of the trauma patient at the ACH is a major focus of the Pediatric Trauma Program. Over the past year the following activities have been carried out: i) Trauma In-patient Unit Unit 4 continues to be the ACH trauma unit. This has allowed the care of all traumatic injuries to be consolidated within one group of care providers who continue to show dedication and excellence in the care they provide. In 2014 the Trauma Committee reinforced the importance of this consolidation for major trauma patients. ii) Pediatric In-patient Trauma Service A dedicated in-patient trauma service, to provide and direct the primary clinical care of multiply injured trauma patients, continues to be well led by the Division of Pediatric General Surgery. They provide attending physician coverage for this service 24/7. There were no significant changes in iii) Trauma Tertiary Survey The Pediatric Trauma Tertiary Survey is to be completed by the inpatient trauma service on all major trauma patients at 24 hours after admission. This helps to identify missed injuries or issues early in the patients stay. iv) Pediatric Trauma Nurse Practitioner This position supports the in-patient trauma service, as well as plays a significant role on the Brain Injury Team. The Trauma Nurse Practitioner also runs an outpatient follow up Trauma Clinic. v) Trauma Team Activation Guidelines (Code 77) A Code 77 is activated by a nurse in the Emergency Department for major trauma patients using specific guidelines that include physiological, anatomical and mechanism of injury. These guidelines are continuously monitored for over and missed call and for any issues that arise. Evidence suggests the over call may have to be as high as 50% to keep the missed calls <5%. See Appendix B for 2014 details. vi) OR Activation (Code 88) A Code 88 activation is called in order to mobilize the OR team for an anticipated emergent airway intervention and/or an anticipated need for an emergent OR. This is an automatic 24/7 response from Anesthesiology, Anesthesia RRT, OR Nursing team (3 RN s), PACU nursing team (2 RN s). The Pediatric Intensivist is also on the activation for those times they are in-house and can assist with a 5

6 difficult airway. Activations are monitored and reviewed by the Trauma Committee. vii) Trauma Team Leader Record This is the documentation tool to be used by Trauma Team Leaders (Emergency Physicians) looking after major trauma patients. It was created to help address gaps in documentation that were identified in Quality Management reviews. The tool is a combination of check boxes and various prompts to ensure complete documentation of the assessment and management of trauma patients. A regular audit for % of completion for Code 77 patients is done and reported to the Trauma Committee. The 2014 completion rate was 94%, which is an increase from last year. viii) Provincial Nursing Trauma Resuscitation Record As a directive from the Provincial Trauma Committee, in 2012 the Alberta Trauma Coordinators (ATC) developed the provincial nursing trauma record to be used in all emergency departments and urgent care centers in the province. This record was felt to be an important standardization of trauma care and management. It was revised in the fall of 2013 with the new revision released in January ix) Pediatric Massive Transfusion Protocol The Pediatric Massive Transfusion Protocol is available for use for all patients in ACH. These activations are evaluated in partnership with Transfusion Medicine. Additionally, there are 2 units of O negative prbcs in the ED trauma room for immediate use. x) Trauma No Refusal Policy An ACH No Refusal Policy for pediatric trauma patients was endorsed by the Pediatric Trauma Committee in It states that no pediatric trauma patient in the ACH catchment area will be refused or turned away from our facility. This is the case even when there are no ICU or in-patient beds available. Under those circumstances, patients will be accepted and stabilized in the ED at ACH while further disposition is arranged. xi) Trauma Beading Program Thanks to a generous grant from the Alberta Children s Hospital Foundation, the Trauma Beading Program for major trauma patients remains on-going. The opportunity for admitted trauma patients to mark and remember their journey by earning beads for length of hospital stay, diagnostic tests and treatment modalities has been well received by both trauma patients and their families. This program, administered by the Pediatric Trauma Coordinator and operationalized by the ACH Child Life Specialists, has been a huge 6

7 success. We would like to extend our gratitude to the ACH Child Life Specialists for making this important program a continued success. xii) ACH Trauma Manual The ACH Trauma Manual is for new residents and staff physicians, as well as other disciplines working with trauma patients. The manual lives on the Trauma Services page on the internal website for AHS. It is revised as necessary by the Trauma Committee. xiii) Liaising with Regional, Provincial and National Groups Provincial Trauma Committee - Members Interdisciplinary Trauma Network of Canada - Member Trauma Association of Canada - Members National Emergency Nurses Association - Member Canadian Hospitals Injury Prevention & Reporting Prevention Programs (CHIRPP) - Members Alberta Children s Hospital Foundation liaison - for trauma families who want to give back by discussing their trauma experience in venues such as the annual Radiothon Shock Trauma Air Rescue Service (STARS) liaison for pediatric trauma patients Referral Access Advice Placement Information Destination (RAAPID) liaison for pediatric trauma patients 7

8 3. Education i) Trauma Rounds Rounds are held in the ACH Ampitheatre to accommodate telehealth to outside centres January 23, 2014 Dr. Elaine Gilfoyle The Trauma Team its More than just the ABC s February 27, 2014 Dr. Carlos Sanchez-Glanville Management of Blunt Thoracic Trauma in the Pediatric Population April 24, 2014 Dr. Rob Harrop Pediatric Facial Fractures May 22, 2014 Dr. Jarret Woodmass Compartment Syndrome of the Lower Extremity in Children September 25, 2014 Dr. Mark Gale Pediatric Airway management in Austere Environments October 16, 2014 Dr. Andrew Ryu Pediatric C-Spine Injuries November 27, 2014 Dr. Carolina Fermin-Risso Urethral Trauma in Pediatrics ii) iii) Trauma Nursing Core Course The Trauma Nursing Core Course (TNCC) continues to be held at ACH twice per year. This course is designed for nurses caring for patients in any part of the trauma spectrum and has international recognition. Mock/Just-in-Time Trauma Codes These mocks provide physicians, fellows, residents, nurses, respiratory therapists, nursing aides and unit clerks with an opportunity to learn from simulated trauma cases. This past year, one of the mocks started in the ED with a full activation of both code 77 and 88 then moved up to the OR. It involved the entire OR team as well as General Surgery. 8

9 iv) Outreach Education The partnership between the ACH Trauma Program and KidSIM, the Pediatric Human Patient Simulation Program, continues to deliver education to both regional and rural partners. These are very popular multidisciplinary educational sessions that are expected to expand even further in the future. The following centres were visited in 2014: March 2014 Strathmore, Black Diamond April 2014 Cardston, Fort McLeod, Sundre May 2014 Vulcan, South Calgary Health Centre June 2014 Cranbrook BC, Olds, Innisfail Sept 2014 Claresholm, Red Deer Oct 2014 Banff, Lethbridge, High River Dec 2014 Pincher Creek, Crowsnest Pass v) Emergency Trauma Simulation Sessions Trauma simulation sessions were held for ED nurses as part of their annual education in conjunction with residents and fellows rotating through Pediatric Emergency Medicine. Human Patient Simulators were used to replicate the assessment and management of trauma patients in real time in an interprofessional environment. These sessions were very well received and will continue in the future. vi) Nursing Trauma Simulation Sessions Trauma education is included in General Nursing Orientation for all new PICU, ED and Unit 4 (trauma unit) nurses at the ACH as well as rotating nursing students. Adult ED nurses in the Calgary area also have one day with the pediatric educators, where trauma education and simulation are introduced. vii) Advanced Trauma Procedural Skills Lab Through the collaboration of the Trauma Program and the ECMO program at ACH this attending-focused lab allowed participants to practice advanced procedures including chest tube insertion, emergent thoracotomy and surgical airways. viii) Emergency Medicine for Rural Hospitals (Banff AB - Jan 2014) Tips and Tricks for Procedural Interventions for Pediatric Patients Sherry MacGillivray ix) PEACH 2014: Pediatric Emergencies at ACH Conference (Calgary, AB March 2014) Pediatric Trauma Track Dr. A. Mikrogianakis, Dr. K. Millar, Dr. R. Ness, Dr. A. Wilmott, Sherry MacGillivray 9

10 x) Trauma Association of Canada Annual Scientific Meeting (Montreal, QC April 2014) Abbreviated Bedrest Protocol for Solid Organ Injuries Lisette Lockyer xi) University of Calgary, Medical Education Medical Student Course VI Lecture: Introduction to Pediatric Trauma Dr. J. Guilfoyle Family Medicine Resident Academic Half-Day: Approach to Pediatric Trauma Dr. J. Guilfoyle Pediatric Resident Academic Half-Day: Multi-trauma in the ER Dr. J. Guilfoyle Emergency Medicine Resident Academic Half-Day: Pediatric Trauma: Pitfalls and Pearls Dr. J. Guilfoyle PEM Fellow Academic Day: An Evidence Based Review of Severe TBI Dr. J. Guilfoyle 10

11 4. Research The following research projects were in progress or completed during 2014: PUBLICATIONS: 1) Hagel BE, Romanow N, Morgunov N, Embree T, Couperthwaite AB, Voaklander D, Rowe BH. Do visibility aids reduce the risk of motor-vehicle collision or hospitalization in bicyclists? Accident Analysis & Prevention 2014,65: ) Romanow N, Hagel BE, Williamson J, Rowe BH. Bicyclist head and facial injury risk in relation to helmet fit: a case-control study. Chronic Diseases and Injuries in Canada 2014;34(1):1-7 3) Russell K, Meeuwisse WH; Nettel-Aguirre A, Emery CA, Wishart J, Romanow N, Rowe BH, Goulet C, Hagel BE. Feature-specific terrain park injury risk in snowboarders: a case-control study. British Journal of Sports Medicine 2014;48:23-28 doi: /bjsports ) Romanow N, Hagel BE, Nguyen M, Embree T, Rowe BH. Mountain bike terrain park injuries: an emerging cause of morbidity. International Journal of Injury Control and Safety Promotion. DOI: / ) Russell K, Meeuwisse WH, Nettel-Aguirre A, Emery CA, Gushue S, Wishart J, Romanow N, Rowe BH, Goulet C, Hagel BE Listening to a personal music player and odds of injury among snowboarders in a terrain park: a case-control study. British Journal of Sports Medicine July 2014 DOI: /bjsports

12 IN PROGRESS: 1) Charyk-Stewart T, MacGillivray S, Widas L, Falconer C, McDowall D, Brennan M, Lake J, Bailey K. National Pediatric Trauma Care Quality Indicators Project. 2) Mikrogianakis A, Barlow K. Can we foresee which children will have a favorable recovery following a mild traumatic brain injury and which will have persistent post-concussion symptoms? A study to refine a clinical prediction rule, the 4C Tool. 3) Pandya A, MacGillivray S, McKee J, Guilfoyle J, Joffe A, Thompson GC Traumatic Brain Injury and Sepsis in Children Admitted to Hospital Following Major Trauma. American Academy of Pediatrics, San Diego Oct 2014, European Congress on Emergency Medicine, Amsterdam, Holland Sept

13 5. Quality Assurance As part of the Pediatric Trauma Program quality improvement process, several performance indicators throughout the continuum of care are monitored on a regular basis as a measure of performance. Some of the indicators stem from audit filters set out by the American College of Surgeons Committee on Trauma and Trauma Registry performance measures published by the South Western Sydney Region Trauma Department, Liverpool, Australia. Other indicators were developed at the ACH as site specific performance indicators. All cases flagged by a performance indicator or audit filter are reviewed by the ACH Pediatric Trauma Quality Management Committee to determine appropriateness of care and follow-up to care providers and trauma systems. The list of performance indicators is listed below. No changes were made this past year. ACH performance indicators for 2014 are summarized in Appendix A. Pre-ACH care: 1. Presence of pre-hospital documentation from any phase of patient transport. 2. GCS < 8 at scene with mechanical airway intervention. 3. Length of stay at rural hospital > 2 hours. 4. Injury time to Trauma Center (TC) < 4 hours (for transferred patients). 5. Utilization of ACH Transport team for transfer. Resuscitative care: 6. Trauma Team Activation. 7. Direct admission (bypassed the Emergency Department (ED)). 8. GCS <8 at the TC with mechanical airway intervention. 9. Presence of ED nursing documentation every 30 minutes. 10. Presence of sequential neurological documentation in the ED for suspected head/spinal cord injuries. 11. Hypothermic in the ED (< 35.0 C). 12. GCS < 12 in the TC with a CT head performed within 4 hours from trauma center arrival (TCA). 13. Patient stay in the ED less than 4 hours. Definitive care: 14. Admission to a surgeon or intensivist. 15. Craniotomy within 4 hours after TCA with unstable epidural/subdural hematoma. 16. Missed cervical spine injury after 48 hours from TCA without maintaining spinal precautions. 17. Any laparotomy procedure performed. 18. Femur fracture to the OR within 24 hours from TCA. 19. Open long bone fracture to the OR within 6-12 hours from TCA (depending on the severity of #). 20. Unplanned return to the OR within 48 hours of initial procedure. 21. Missed injuries identified after 48 hours from TCA. 22. Reduction of joint dislocation/fracture dislocation after 1 hour from TCA. 23. Revascularization of an ischemic limb within 6 hours from the time of injury. 24. ORIF of facial fractures within 7 days after injury. 25. Operative repair of spinal fractures within 7 days after injury. 26. Pelvic ring fracture/acetabular fracture (with hemodynamic instability) provisional stabilization > 6 hours from TCA. 27. Definitive treatment of displaced acetabular fracture > 7 days from TCA. 28. Unplanned PICU admission or re-admission. Outcome: 29. Death during the first 24 hours from TCA. 30. Did the patient die in ACH? 13

14 6. Future Planning The 2015 year will focus on the following activities: Continue to optimize the functioning of our Trauma Team Leader Program Continuing to focus on quality Pediatric Trauma Education Continuing advocacy of injury prevention initiatives Continuing leadership on a regional, provincial and national level Continuing an active pediatric trauma research program Continuing excellence in quality assurance leadership Focusing on improving communication with all of the services impacted in trauma delivery through the Trauma Committee Establishing and growing connections with other Canadian Pediatric Trauma Programs to work collaboratively on research, quality assurance projects and improving standards of care for pediatric trauma patients Introduce an Attending Physician focused, CME accredited, simulation based, professional development program 14

15 ACH Trauma Quality Indicators (ISS>12) 2014 Appendix A Alberta Children s Hospital Trauma Quality Indicators for 2014 Pre-ACH Care: 1. Presence of pre-hospital documentation from any phase of patient transport. Are all pre-hospital ambulance reports from all phases of patient transport present on the medical record? Exclusions: Inappropriate where patients arrived by private vehicle, walk-ins, and unknown how patient arrived at hospital. Unknown: missing PCR. Inclusions: n = all patients with pre-hospital care provider(s) Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No Cooperation with Alberta Health Services EMS allows on-line record access, however obtaining out of province pre-hospital documentation is still challenging at times. 2. Glasgow Coma Scale (GCS) < 8 at scene with mechanical airway intervention. Did the patient with a first recorded scene GCS < 8 receive mechanical airway intervention at the scene? Mechanical airway includes: oral intubation, nasal intubation, tracheostomy, and cricothyroidotomy. It does not include nasopharyngeal airway, laryngeal mask (LMA) or oropharyngeal airway. Exclusions: Inappropriate - patients with unknown GCS, patients without prehospital care, intubated patients prior to GCS calculation. Inclusions: n = all patients with first recorded GCS 8 at the scene. Indicator Yes No n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No Pediatric experts advise that it is best practice to move the injured pediatric patient from the scene quickly to acute care for intubation, if required, rather than attempt intubation at the scene. EMS evidenced-based protocols have LMA insertion as first attempt rather than endotracheal tube intubation. All patients are reviewed at the Pediatric Trauma Quality Management Committee to ensure appropriate care was given. 15

16 ACH Trauma Quality Indicators (ISS>12) Length of stay (LOS) at rural hospital greater than two hours. Was the length of stay at a rural hospital > 2 hours? Exclusions: Inappropriate - patients had no first or second hospital. Unknown - missing arrival or departure time at first or second hospital Inclusions: n = all patients arriving at ACH from hospitals outside Calgary Indicator Yes No n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No If at any time the Pediatric Trauma Quality Management Committee feels that the Rural Hospital LOS is not acceptable, a letter to that hospital is sent for clarification of the timeline and appropriately followed up. The significant percentage of cases with a prolonged rural stay remains a concern and education around the importance of timely disposition and transfer of major trauma patients remains a priority. This is also a Provincial Trauma Committee indicator that is being monitored across the Province. 4. Injury time to trauma centre < 4 hours for transferred patients. Did the patient arrive at a trauma centre < 4 hours from the time of injury? Trauma Centre is defined as ACH, FMC, U of A or Stollery Hospitals in Edmonton. As well as Red Deer, Lethbridge or Medicine Hat Hospitals. Exclusions: Out of the patient transfers, 8 patients were transferred from within Calgary, 5 from Lethbridge, 6 from Red Deer and 5 from Medicine Hat resulting in a total (n= 13) of patients for this indicator. Inclusions: n = all patients transferred from a non-trauma centre hospital with a known time of injury and known time of arrival. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No A high number of patients are still not seen at a Trauma Centre within the 4 hour timeline. Many factors contribute to delays, however, most are found to be related to challenges in mobilizing transfer of patients from rural health centers. The further progression of RAAPID (Referral, Access, Advice, Placement, Information & Destination) protocols, which started in 2011, has 16

17 ACH Trauma Quality Indicators (ISS>12) 2014 helped mobilize transport more efficiently. This has also been a priority for the Provincial Trauma Committee. Unfortunately this year there were a number of patients that were transferred from BC where RAAPID is consulted after BC Bedline attempts to accommodate their patients this ultimately results in delays to trauma centre arrival. All patients are reviewed at the Pediatric Trauma Quality Management Committee and communication regarding means of transport is given back to RAAPID and/or the referral centre if indicated. 5. Utilization of ACH Transport team for transfer. ACH Transport Team Utilization Was the patient transported by the ACH Transport Team? Inclusions: n = all patients transferred from a primary or secondary hospital Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No The Alberta Children s Hospital offers a specialized Pediatric Transport Team Service, which transports critically ill or injured children from referral centers located in southern Alberta, southeastern British Columbia, and south-western Saskatchewan. The transport team travels by ambulance, helicopter or fixed-wing aircraft and provides quality pediatric critical care to the residents of these areas who do not otherwise have access to pediatric critical care specialists. Through RAAPID, medical control and mobilization of the team is achieved via the PICU attending physician. The team consists of a respiratory therapist (RT) and an ACH ED or PICU registered nurse (RN), with a physician on call for difficult cases. Stabilization, if possible, is achieved prior to returning back to ACH, thus making the previous two indicators of rural hospital LOS and time to trauma centre longer on some occasions. 17

18 ACH Trauma Quality Indicators (ISS>12) 2014 Resuscitative care: 6. Trauma Team Activation Major Trauma Team Activation # of Activations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2011/ / / Trauma Team Activation (Code 77) is the responsibility of the ED nurse answering the EMS patch phone using specific criteria that were developed by the Pediatric Trauma Committee. These include physiologic, anatomic and co-morbid factors, as well as mechanism of injury. The guidelines were reviewed and tightened up last in September 2013 which resulted in less overall activations and less overcall of the trauma team. The above graph illustrates Code 77 activation for the major trauma population only (ISS > 12). In some cases, the trauma team may be called, however the patient does not meet the Trauma Registry inclusion criteria. In the past year, the total Code 77 activations for all patients (regardless of ISS) was 84 (compared to an average of 139 prior to the 2013 changes). Overcall (those not admitted) was 28%. Missed call (those that should have had an activation according to guidelines) was 8%. The over and missed call of Code 77 patients is monitored closely by the Pediatric Trauma Coordinator and reported monthly at the Trauma Committee. 7. Direct Admission - Bypassed the Emergency Department (ED) Direct Admission Exclusions: ED deaths Inclusions: n = all patients who were admitted to the trauma centre. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No There is currently a No Direct Admit Policy for trauma patients meaning they should stop in the ED for assessment. This policy was made to ensure that every patient gets an unbiased, good primary survey. If a patient had been admitted to a referral hospital for more than 24 hrs prior to the transfer this policy does not apply. This was the case for one patient this past year. Another 18

19 ACH Trauma Quality Indicators (ISS>12) 2014 patient was seen by an ACH pediatric emergency physician at the South Health Campus in Calgary and directly admitted to the ACH trauma unit. One was sent directly to PICU from another Calgary hospital. The remaining three were discussed at the Pediatric Trauma Quality Management Committee and should have stopped in the ED and recommendations have been made by the Committee. 8. GCS < 8 at the trauma centre (TC) with mechanical airway intervention. Did the patient with a first recorded trauma centre GCS < 8 receive a mechanical airway as an intervention in the ACH ED? Exclusions: Patients with GCS > 8 at ACH-ED. Inclusions: n = all patients with first recorded trauma centre GCS 8. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No This past year, as in previous years, all patients that arrived at the ACH ED with a recorded GCS < 8 were appropriately intubated. 9. Presence of ED nursing documentation every 30 minutes. After arrival at the trauma centre, was q 30 documentation present on the ED record for the ED length of stay? Exclusions: Direct admits and unknown/missing ED notes. Inclusions: n = all patients seen in ED. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No ED documentation continues to be a challenge but is considered to be important for patient care. ED education is done in a variety of ways to encourage this 30 minute frequency, which is different from the hourly standard. 19

20 ACH Trauma Quality Indicators (ISS>12) Presence of sequential neurological documentation in the ED for suspected head/spinal cord injuries After arrival at the trauma centre, was sequential neurological documentation present on the ED record for the ED length of stay, if the patient had a diagnosis of skull fracture, intracranial injury, or spinal cord injury? Exclusions: Direct admits and unknown/missing ED notes. Inclusions: n = all patients seen in ED Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No The Provincial Trauma Nursing Record used in the ED trauma room has one dedicated page for this documentation, however once the patient leaves the trauma room this record is no longer used. A separate neurological documentation record needs to be started. Further education to continue this important clinical documentation needs to be explored. 11. Hypothermic in the ED (<35.0 degrees C) Was the patient hypothermic in the emergency department? Temperature was recorded at <35.0 degrees C. Exclusions: Direct admits and unknown/missing ED temp. Inclusions: n = all patients seen in ED. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No These three hypothermic patients were actively rewarmed in the ED appropriately. This past year there was one patient that did not have a temperature taken in the ED. 20

21 ACH Trauma Quality Indicators (ISS>12) GCS <12 in the TC with a CT head performed within 4 hours of trauma centre arrival (TCA). Did the patient with a GCS < 12 receive a CT of the head within 4 hours of arrival at the ACH trauma centre? Exclusions: Inappropriate GCS > 12, intubated patients arriving in ACH, Direct Admissions. Unknown missing GCS documentation. Inclusions: n = all patients with a known ED GCS and a known time of CT head. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No 13. Patient stay in ED less than 4 hours. Did the patient have an ACH ED length of stay < 4 hours at the ACH trauma centre? Exclusions: Direct Admissions and unknown ED LOS. Inclusions: n = all patients seen in ACH ED with a known ED LOS. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No ED LOS > 4 hrs continues to be a concern not only for trauma patients. All patients are reviewed to determine if there is a system or educational issue that can be addressed to decrease this time. ACH administration has taken measures to help increase capacity of the hospital overall. 21

22 ACH Trauma Quality Indicators (ISS>12) 2014 Definitive care: 14. Admission to a surgeon or intensivist. Was the patient admitted to a surgeon or an intensivist at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre. Indicator Yes No n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No This past year, all 9 patients were admitted to the Pediatric service appropriately according to admission guidelines for head injuries, non-accidental trauma and burn patients. 15. Craniotomy within 4 hours after TCA with unstable epidural/subdural hematoma. If the patient had an epidural or subdural brain hematoma, was a craniotomy performed within 4 hours of arrival at ACH trauma centre? Exclusions: Inappropriate all patients without epidural or subdural hematoma. Inclusions: n = all patients with epidural or subdural hematoma where operative management was the planned intervention. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No 22

23 ACH Trauma Quality Indicators (ISS>12) Missed cervical spine injury after 48 hours from TCA without maintaining spinal precautions. Did the patient have a missed c-spine injury with spinal precautions removed at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No 17. Any laparotomy procedure performed. Did the patient require a laparotomy? Exclusions: None Inclusions: n = all major trauma patients. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No The small number of laparotomies performed this past year remains consistent with historical trends and continues to show the conservative management philosophy in pediatrics in regards to abdominal trauma. 23

24 ACH Trauma Quality Indicators (ISS>12) Femur fracture to the OR within 24 hours of TCA. Did the patient have operative management of the femur fracture within 24 hours of arrival at ACH trauma centre? Exclusions: No femur fracture or no surgical intervention planned. Inclusions: n = all patients requiring operative management of femur fracture Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No Keep in mind the total n femur fractures is for ISS > 12 patients only. 19. Open long bone fracture to the OR after 6-12 hours from TCA (depending on the severity of the fracture). Did the patient with open long bone fracture have operative management performed within 6 hours (grade 3) or 12 hours (grade 1, 2) of arrival to ACH trauma centre? The long bones include the radius, ulna, humerus, tibia, femur and fibula. Exclusions: No open long bone fractures; patients with open long bone #s but too unstable for operative repair within the timeframe; patients with open long bone #s who died within the timeframe. Inclusions: n = all patients requiring operative management of open fracture where grade of fracture is known. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %No %Yes 24

25 ACH Trauma Quality Indicators (ISS>12) Unplanned return to the OR within 48 hours of initial procedure. Did the patient have an unplanned return to the operating room at the ACH trauma centre? Exclusions: No operating room visit. Inclusions: n = all patients with at least one operating room visit. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %No %Yes This past year there was one patient that had three surgeries due to extensive abdominal injuries, where the third surgery was not planned. This case was reviewed both at the Trauma Quality Management Committee and at General Surgery teaching rounds and care was deemed appropriate. 21. Missed injuries identified after 48 hours from TCA. Did the patient have a delayed diagnosis or missed injury at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No A trauma tertiary survey (TTS) performed by the Trauma Surgery NP, Fellow or Resident at 24 hours after admission to the trauma centre helps to keep missed injuries to a minimum. This past year one patients injury was found on this survey done after the patient was reliable but outside the 48 hour timeframe. The other patients missed injury was found after an urgent OR and subsequent stabilization. All were reviewed at the Pediatric Trauma Quality Management Committee and recommendations were made. 25

26 ACH Trauma Quality Indicators (ISS>12) Reduction of joint dislocation/fracture dislocation after 1 hour from TCA. If the patient had a joint dislocation or fracture dislocation (hip, shoulder, knee, elbow), was it reduced within first hour of TCA. Exclusions: No joint dislocation, died within first hour, wrist or ankle dislocations. Inclusions: n = all patients with joint dislocation or fracture dislocation who survived at least 1 hour. Indicator Yes No n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No 23. Revascularization of an ischemic limb within 6 hours from the time of injury. If the patient had an ischemic limb, was it re-vascularized within 6 hours from the time of injury? Exclusions: No ischemic limb or patient died prior to repair. Inclusions: n = all patients with ischemic limb. Indicator Yes No 2014, n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No 26

27 ACH Trauma Quality Indicators (ISS>12) ORIF of facial fractures within 7 days of injury. Did the patient with a facial fracture go to the operating room at ACH trauma centre within 7 days of injury? Exclusions: No major facial fractures or died prior to repair. Inclusions: n = all patients requiring operative management of major facial fractures who survive at least 7 days. 1 Indicator Yes No n = /2014, n = /2013, n = /2012, n = %Yes %No 2010/2011, n = Operative repair of spinal fractures within 7 days of injury. If the patient had an operative repair of spinal fractures, was it completed within 7 days of injury? Exclusions: No operative repairs or patient died prior to repair. Inclusions: n = all patients with operative repair of spinal fracture who survive at least 7 days. Indicator Yes No n = /2014, n = /2013, n = /2012, n = %Yes %No 2010/2011, n =

28 ACH Trauma Quality Indicators (ISS>12) Pelvic ring fracture / acetabular fracture (with hemodynamic instability) provisional stabilization > 6 hours of TCA. If the patient had an operative repair of pelvic fractures, was it completed > 6 hours after arrival? Exclusions: No operative repairs or patient hemodynamically stable. Inclusions: n = all patients with operative repair of pelvic fractures with hemodynamic instability. Indicator Yes No 2014 n = /2014 n = /2013 n = /2012 n = /2011, n = %Yes %No 27. Definitive treatment of displaced acetabular fracture > 7 days of TCA. If the patient had an operative repair of pelvic fractures, was it completed > 7 days of arrival? Exclusions: No operative repairs or patient hemodynamically unstable. Inclusions: n = all patients with operative repair of displaced acetabular fractures. Indicator Yes No 2014 n = /2014 n = /2013 n = /2012 n = /2011, n = %Yes %No 28

29 ACH Trauma Quality Indicators (ISS>12) Unplanned PICU admission or re-admission. Did the patient have an unplanned admission to ICU at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No Did the patient have an unplanned readmission to ICU at the ACH trauma centre? Exclusions: Patients without admission to ICU. Inclusions: n = all patients with at least one ICU admission Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No The PICU Specialized Transitional Educational Personnel (STEP) team follows patients that are transferred out of the PICU to ensure safety; this past year no patients were re-admitted to the PICU. 29

30 ACH Trauma Quality Indicators (ISS>12) 2014 Outcome: 29. Death during the first 24 hours of TCA. Did the patient die within the first 24 hours of admission to the ACH trauma centre? Exclusions: All patients who survived. Inclusions: n = all patients who died. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No One patient died in the ACH OR within 24 hours this past year. 30. Did the patient die in ACH? Did the patient die? Exclusions: None. Inclusions: n = all trauma patients arriving at ACH trauma centre. Indicator Yes No 2014 n = /2014, n = /2013, n = /2012, n = /2011, n = %Yes %No Five additional patients died after 24 hours this past year. All death cases were reviewed by the Pediatric Trauma Quality Management Committee and care was deemed appropriate. 30

31 APPENDIX B Major Trauma Statistics for General Overview Age Gender 2. Etiology of Injuries Mechanism of Injury Type of Injury Place of Injury 3. Referrals and Emergency Management Referrals from Health Regions Mode of Transportation to ACH Ground vs Air Transport ED Arrival By Month, Day and Time of Arrival Diagnostic Imaging Statistics Day of Week and Time of CT Non-Operative Procedures Performed in ED Patient Disposition from ED 4. In-Patient Care Management and Outcomes Surgical Procedures OR Data by Service Time to OR Length of Stay Admitting Physician Service Hospital Discharge Destination Outcomes by Age and ISS TRISS Pre-Charts 31

32 1. General Overview Table 1. ACH Major Trauma Statistics Five-year Trend Analysis Data Source: Alberta Trauma Registry at ACH Total Patients Males % % % % % Females % % % % % Total Length of Stay (LOS) (days) Median LOS Mean LOS Total Emergency Department (ED) LOS (hours) Median ED LOS (hours) Mean ED LOS (hours) ICU Admissions % % % % % Median ICU LOS (days) Mean ICU LOS (days) Total ICU LOS (days) Median ISS Mean ISS Direct Admits Referrals to ACH from other centres % % % % % Deaths 5 6% 4 4.4% 5 6.6% 5 5.2% 6 6.3% In 2014, 96 major trauma patients (meeting criteria for inclusion in the trauma registry) were seen at the ACH. This volume is higher than the five-year average of 88 major trauma patients seen annually. This 2014 trauma volume represents 10.7% of all patients admitted to the ACH with injuries (n=894), which is a 0.5% decrease from last year. 32

33 As seen in previous years, the percentage of major trauma patients who are males (61.4%) continues to be greater than females, which is consistent with the five-year average of 62.3%. Major trauma patients referred in from other centers represented 39.6% of the major trauma volume for This is slightly lower than the five-year average of 42.7%. Length of stay for major trauma patients ranged between 1 and 56 days. Mean LOS of 9 days is consistent with the five-year trend of 9. Median LOS of 5 days is consistent with the fiveyear trend of 5. The total ED LOS was hours, and higher than the five-year average of hours. Both the mean and median LOS were consistent with the five-year averages of 4.4 and 3.7 respectively. 34.3% of major trauma patients were admitted to the ICU, which is slightly lower than the five-year average of 38.5%. Total ICU LOS was 143 days, which is higher than the five-year average of 136. The mean ICU LOS is consistent with the five-year average of 3.8 and the median is consistent at 2. Both the mean (22) and median (18) ISS for major trauma patient from 2014 were consistent with the five-year averages of 22.2 (mean) and 18.6 (median). A total of 6 deaths were seen in major trauma patients in This represents 6.3% of major trauma volume, and is slightly higher than the five-year average of 5.7%. 33

34 Figure 1. Age and Gender Distribution for ACH Major Trauma Patients for # of Patients <1 1 to 4 5 to 9 10 to 14 >14 Age Groups Male Female Figure 1 shows the number of males and females for the above age groups. On average, males comprise 62.3% of the major trauma population over a period of five years. Figure 2a. Age Distribution of <15 year olds admitted to Calgary Adult Hospitals <15 year olds Major Trauma Patients # of Patients FMC PLC RGH SHC 2014 Year Figure 2a shows the three pediatric patients that were treated at Calgary adult hospitals this past year. EMS protocols dictate closest hospital when there is an airway issue or ongoing resuscitation, which was the case for two of the patients. The other patient was transferred to the PLC from ACH for 24 hour observation post head injury. All cases are reviewed by the Trauma Coordinator to deem appropriateness. 34

35 Figure 2b. Age Distribution of 15 to 17 year olds admitted to Calgary Hospitals 15 to 17 year olds Major Trauma Patients # of Patients ACH FMC PLC RGH SHC Figure 2b shows the number of major trauma patients aged admitted to Calgary Hospitals over the past five years. Current Alberta Health Services guidelines state that major trauma patients years of age should normally be transported to the Foothills Medical Centre (FMC). In the past the eventual assumption of this age group was a priority for the ACH Pediatric Trauma Program, however due to capacity issues and surgical funding assuming this age group is no longer a priority. The ACH ED RN answering the EMS patch phone should re-direct to the FMC ED if Trauma Team Activation - Code 77 criteria is met. 35

36 2. Etiology of Injuries Mechanism of Injury (MOI) describes the nature of the injury, such as transportation, falls, violence, and other mechanisms of injury. Figure 3. Breakdown by Mechanism of Injury 2007/ / / /2014 Violence 6% Other 26% Transport 41% Other Transport Falls 21% 29% 27% Other 24% Transport 36% Violence 15% Falls 35%. Violence 9% Falls 31% Figure 3 shows the breakdown of the mechanism of injuries for the incidents in 2014 as compared to the historical trend. The biggest change this past year was an increase in violence related injuries. 36

37 Mechanism of Injury Transportation Figure 4. Transportation Statistics / /2014 Water 1% Cyclist 22% MRV 14% MVC 39% Cyclist 23% MRV 10% MVC 47% Pedestrian 25% Pedestrian 19% Figure 4 shows the breakdown of transportation-related injuries in 2014 as compared to the historical trend. Note: MRV is motorized recreational vehicle. A total of 28 patients (29% of major trauma patients) were involved in transportation-related incidents in Mortality: 4% 1 patient died. ISS ranged from 13 to 57. Mean ISS was 26 and median ISS was 24. Figure 5. Five-Year Trend for Transportation as the MOI % of Patients 50% 40% 30% 20% 10% 0% MOI -Transportation 39% 44% 29% 26% 29% Years Figure 5 shows a 15% decrease in transportation-related incidents from 2013/2014 to

38 Figure 6. Transportation by Age Group >14 7% 10 to 14 57% 2014 <1 0% 1 to 4 18% 5 to 9 18% 2010/ /2014 >14 11% 10 to 14 41% <1 3% 1 to 4 13% 5 to 9 32% Figure 6 shows the breakdown of transportation incidents by age groups in 2014 as compared to the historical trend. Significant changes to all age groups can be seen. In 2014: Age Group <1 (n=0, 0%) No patients in this age category. Age Group 1-4 (n=5, 18%) included 2 pedestrians and 3 passengers. There was 1 death in this age group. Age Group 5-9 (n=5, 18%) included 2 passengers, 1 pedestrian, 1 snowmobile and 1 cyclist. Age Group (n=16, 57%) 6 passengers, 4 cyclists, 3 pedestrians and 3 ATV related injuries. Age Group > 14 (n=2, 7%) included 1 cyclist and 1 pedestrian. 38

39 Mechanism of Injury Falls Figure 7. Statistics for Falls as the MOI / /2014 Same- Level 18% Same-Level 19% Other and Unspecified 6% Multi- Level 82% Multi-Level 75% Figure 7 shows the breakdown of falls incidents in 2014 as compared to the historical trend. There has been a significant increase in multi-level falls which includes: falls from second story windows, falls while being carried, falls off horses and falls from playground equipment. A total of 34 patients (35% of major trauma patients) were admitted for fall-related injuries. Mortality: 0% all patients survived. ISS ranged from 14 to 38. Mean ISS was 19 and the median ISS was 16. Figure 8. Five-Year Trend for Falls as the MOI MOI Falls % of Patients 40% 35% 30% 25% 20% 15% 10% 5% 0% 37% 35% 33% 30% 28% Figure 8 shows the comparison of falls as the mechanism of injury over the past five years. This past year is above the five year average of 33%. 39

40 Figure 9. Falls by Age Group / / to 14 29% >14 6% 5 to 9 24% <1 15% 1 to 4 26% >14 4% 10 to 14 26% 5 to 9 20% <1 26% 1 to 4 24% Figure 9 shows the breakdown of fall incidents by age groups in 2014 as compared to the historical trend. A significant decrease is seen in the <1 yr old age group. In 2014: Age Group <1 (n=5, 15%) All patients were multi-level falls. 4 of the patients fell while being carried. Age Group 1-4 (n=9, 26%) included 2 multi-level falls, 5 falls out of buildings and 2 falls on stairs. Age Group 5-9 (n=8, 24%) included 2 multi-level falls, 2 same level falls, 2 falls out of buildings, 1 fall from a trampoline and 1 fall on stairs. Age Group (n=10, 29%) included 5 multi-level falls and 3 falls on same level, 1 fall out of a building and 1 fall on stairs. Age Group >14 (n=2, 6%) included 1 fall on stairs and 1 same level fall. 40

41 Mechanism of Injury Violence Figure 10. Violence as the MOI Assault with object 14% 2014 Unarmed assault 7% Self- Inflicted 14% 2010/ /2014 Assault with object 16% Unarmed Assault 17% Other & Unspecified 65% Other & Unspecified 72% Self- Inflicted 0% Figure 10 shows the breakdown of violence-related incidents in 2014 as compared to the historical trend. Note the increase in self-inflicted injuries this past year (14% = 2 patients) A total of 14 patients (15% of major trauma patients) were admitted for violence-related injuries. Mortality: 21% 3 patients died. ISS ranged from 13 to 38. The mean ISS was 24. The median ISS was 26. Figure 11. Five-Year Trend for Violence as the MOI MOI - Violence % of Patients 20% 15% 10% 5% 16% 12% 8% 7% 15% 0% Figure 11 shows the significant increase in violence related injuries over the past year there has been a increase in non-accidental, intentional trauma and self-inflicted trauma cases. 41

42 Figure 12. Violence Incidents by Age Group / /2014 >14 14% >14 13% 10 to 14 21% <1 44% 10 to 14 19% <1 32% 5 to 9 0% 1 to 4 21% 5 to 9 10% 1 to 4 26% Figure 12 shows the breakdown of violence incidents by age groups in 2014 as compared to the historical trend. Note the large increase of <1 yr olds with the subsequent decrease in the 5-9 yr old age group. Age Group <1 (n=6, 44%) All 6 were non-accidental or intentional injury in this age category. Age Group 1-4 (n=3, 21%) All 3 were non-accidental trauma or intentional injury in this age category. 1 patient died in this age category. Age Group 5-9 (n=0, 0%) No patients in this age category. Age Group (n=3, 21%) included 2 assaults with an object and 1 self-inflicted injury. 1 patient died in this age category. Age Group >14 (n=2, 14%) included 1 unarmed assault and 1 self-inflicted injury. 1 patient died in this age category. 42

43 Mechanism of Injury Other Figure 13. Statistics for Other Mechanism of Injury / /2014 Submersion & Drowning 15% Fire & Explosion 10% Animal 25% Inhalation & Ingestion 4% Fire & Explosion 8% Other & Unspecified 11% Animal 18% Mechanical 50% Mechanical 61% Submersion & Drowning 14% Figure 13 shows the breakdown of other mechanism of injuries in 2014 as compared to the historical trend. There were no inhalation & ingestion or other & unspecified related injuries this year. However, there was an increase in animal related injuries and a decrease in mechanical related injuries this year. A total of 20 patients (21% of major trauma patients) were admitted for other mechanism of injuries. Mortality: 10% 2 patients died. ISS ranged from 16 to 45. For survivors, the mean ISS was 18 and the median ISS was 16. For non-survivors, the mean ISS was 35 and median ISS was 35. Figure 14. Five-Year Trend for Other Mechanism of Injury MOI - Other % of Patients 35% 30% 25% 20% 15% 10% 5% 0% 30% 28% 23% 21% 18% Figure 14 shows an 3% decrease in the number of patients whose injuries are caused by animal, burn, inhalation, submersion injury, and mechanical-related incidents when compared to the last five years. 43

44 Figure 15. Other Mechanism by Age Group / /2014 >14 10% <1 0% >14 9% <1 8% 10 to 14 25% 5 to 9 25% 1 to 4 40% 10 to 14 33% 5 to 9 23% 1 to 4 27% Figure 15 shows the breakdown of incidents involving other mechanism of injury by age groups in 2014 as compared to the historical trend. There was a significant increase in 1-4 yr olds and a decrease in <1 and yr olds. In 2014: Age Group <1 (n=0, 0%) no patients in this age category. Age Group 1-4 (n=8, 40%) included 3 submersion injuries, 2 struck accidentally by object, 2 animal related injuries and 1 burn. There was one death in this age category. Age Group 5-9 (n=5, 25%) included 2 animal related injuries, 2 striking accidentally against objects or persons and 1 fire/explosion injury. Age Group (n=5, 25%) included 4 striking object or person accidentally and 1 fire/explosion injury. There was one death in this age group. Age Group >14 (n=2, 10%) included 1 animal related injury and 1 struck accidentally by falling object. 44

45 Type of Injury Type of Injury indicates whether the most serious injury is blunt, penetrating, burn, or other type of injury (submersions and drownings). Figure 16. Type of Injury Type of Injury Total Pts = Blunt Penetrating Burn Other Blunt Penetrating Burn Other Figure 16 shows the different types of injuries sustained by the major trauma patients in Blunt injuries comprised 92% of major trauma population. This has been consistent over the past 5 years as seen in figure 17. Figure 17. Five-Year Trend for Type of Injury Type of Injury - Five Year Trend Total Pts = 440 # o Patients Years Blunt Penetrating Burn Other Figure 17 compares the different types of injuries from 2010/2011 up to

46 100 Penetrating Trauma All ISS # of Patients / / Years On April 1, 2012 all AHS trauma centers began capturing data on all penetrating traumas regardless of ISS in the Alberta Trauma Registry. In 2014 there were 7 penetrating traumas. Place of Injury Figure 18. Statistics for Place of Injury / /2014 Unspecified 11% Street 26% Farm 0% Other 9% Home/Res Inst 41% Street 27% Unspecified 8% Recreation 20% Home/Res Inst 30% Farm 5% Other 6% Recreation 8% Public Building 5% Public Building 4% Figure 18 shows where the patients were injured in 2014 which is fairly consistent with the historical trend. There was a decrease in the recreation category this past year and a significant increase in home/residential. There were no injuries that took place on a farm. 46

47 3. Referrals and Emergency Management Referral Patterns Out of 440 major trauma patients from 2010/2011 to 2014, a total of 188 patients (43%) were referred to ACH by other hospitals. The highest number of out of region referrals to ACH was made by Lethbridge Regional Hospital with a total of 30 patients (16% of total referrals) and Red Deer Regional Hospital with a total of 19 patients (10% of total referrals) over five years. Medicine Hat and Cranbrook also continue to be major referral centres. Note that the province of Alberta no longer has specified health regions. All are now classified as Alberta Health Services, however the below transfer summary continues to report in the regions for historic consistency. Table 2. Transfers from Other Centres by Health Region Region Hospital Total Region 1 - Chinook Health Region, Total = 47 Blairmore - Crowsnest Pass Cardston Municipal Fort Macleod H.C.C. 1 1 Lethbridge Regional Pincher Creek Municipal Taber H.C.C Region 2 - Palliser Health Region, Total = 18 Bassano General Brooks Health Centre 1 1 Medicine Hat Regional Region 3 - Calgary Health Region, Total = 51 Banff - Mineral Springs Black Diamond Oilfields General Calgary Foothills Calgary General/Peter Lougheed Calgary Rockyview General Calgary South Health Campus Canmore General 1 1 Claresholm General High River General Strathmore - Valley General Cochrane Urgent Care 1 1 Okotoks Urgent Care

48 Region 4 - David Thompson Health Region, Total = 39 Didsbury Mountain View H.C Drumheller Regional Hanna H.C.C. 1 1 Innisfail H.C.C. 1 1 Olds General Red Deer Regional Rocky Mountain House Stettler General Sundre General Three Hills H.C.C Other Alberta Hospitals, Total = 2 University of Alberta Hospital British Columbia, Total = 24 Cranbrook Regional Hospital Elkford Health Centre 1 1 Fernie District Hospital Golden & District General Hospital 1 1 Invermere District Hospital Salmon Arm, Shuswap Hospital 1 1 Saskatchewan, Total = 4 Lloydminster General 2 2 Royal University Hospital, Saskatoon 1 1 Regina 1 1 Out of Country, Total = 2 Egypt 1 1 Mexico

49 Mode of Transport for Patients Arriving at ACH Figure 19. Direct from the Scene / /2014 Private/ Walk-in 33% Helicopter 10% Ground 57% Private/ Walk-in 32% Ground 62% Helicopter 6% Figure 19 shows the patients arriving at ACH ED directly from the scene in 2014 as compared to the historical trend. Note the small increase in helicopter transports for direct from the scene patients. Consistent 33% of major trauma patients arrived by private vehicle. Figure 20. Referrals / /2014 Fixed-wing 16% Fixed-wing 17% Private/ Walk-in 2% Helicopter 16% Ground 68% Helicopter 21% Ground 60% Figure 20 shows the patients who were referred to ACH for further treatment in 2014 as compared to the historical trend. Note the increase in ground transports for referral patients this past year. Means of transport is part of the review process for each major trauma patient to ensure the patient comes to ACH the safest way possible. Part of that process is ensuring there are no private vehicle transfers for major trauma patients. Figure 21. Ground vs Air 49

50 70% Ground vs Air 60% 50% 40% 30% Ground Air 20% 10% 0% Ground ambulance transported 58 patients (61%) of major trauma patients in 2014, which is slightly higher than the previous fiscal year. Their ISS was a mean of 22 and median of 18. Figure 21 also shows the decrease in the use of air transport by 6% in Patients transported by air had an ISS mean of 29 and median of 26. Month and Time of Arrival Figure 22. Month of Arrival Comparison of ED Arrival by Month for 2014 with 2010/ / Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Mean 10/11-13/ There was an increase in major trauma patients arriving in ACH ED in all months with the exception of July, January and March in 2014 as compared to the historical trend. 50

51 Figure 23. Day of Arrival Comparison of Arrival by Day for 2014 with 2010/ / Sun Mon Tues Wed Thu Fri Sat Mean 10/11-13/ In 2014, there was an increase in major trauma patients arriving in ACH ED on Sundays, Wednesdays, and Saturdays, with the largest increase being on Wednesdays. The other days were the same volume or slightly less busy 2014 compared to the previous years. Time of Arrival Figure 24. Time of Arrival Comparison of Time of Arrival for 2014 with 2010/ / % 18% 00:01-08:00 08:01-16:00 16:01-24:00 Mean 10/11-13/ % Figure 24 shows increases in 2 of the time intervals with a significant increase in the 08:01 16:00 category. Note the marked decrease during 00:01-08:00. The majority of patients arrive between 16:01-24:00. 51

52 Figure 25. Time of Arrival of Patients Arriving Directly from the Scene Comparison of Patients Arriving Directly From the Scene for 2014 with 2010/ / % % % :01-08:00 08:01-16:00 16:01-24:00 Mean 10/11-13/ Figure 25 shows the patients that arrive at ACH directly (without going to another medical facility) and shows the same pattern as in Figure 24; the majority arrived between 16:01-24:00. Diagnostic Imaging Performed in 2014 Table 3. Diagnostic Imaging A total of 64 patients (67% of major trauma patients) went urgently (within 6 hours of arrival) to CT for imaging of the following body locations. This is slightly lower than the 5 year average of 73% for urgent CTs for major trauma patients. Diagnostic Imaging CT Locations # Patients Percent of Total Patients (n=64) Head 46 72% Abdomen 40 63% Pelvis 40 63% Spine 14 22% Chest 28 44% Face 5 8% Note: Some patients had CTs done on multiple body locations. 52

53 Figure 26. Time of Day of Urgent CT # of Patients Time of Day of Urgent CT (within 6 hours of arrival, n=64) :01-08:00 08:01-16:00 16:01-24:00 Time of Day 39 Figure 26 compares the time of urgent CTs from 2010/2011 to Note the consistency that the majority of urgent CTs are performed between 16:01-24:00 which is when the majority of major trauma patients arrive at the ACH ED. In 2014, 61% (n=39) of patients who went to CT had CTs done from 16:01 to midnight. Only 8% of patients had CT s from midnight to 8:00 AM and 31% of patients had CT s from 08:01 to 16:00. Figure 27. Day of the Week CT performed Day of the Week CT Performed 25 # of Patients Monday Tuesday Wednesday Thursday Friday Saturday Sunday Figure 27 compares the day of the week CT was performed from 2010/2011 to In 2014 there is a significant increase in the CT s performed on Monday and Wednesday with a decrease on all other days. 53

54 Figure 28. CT done within 1 hour of ED Arrival 60 CT within 1 hour of ED Arrival # of Patietns Yes No / Year Figure 28 shows the past two years comparisons if CT was done within one hour of arrival at ACH ED. In 2014 a significant percentage of patients did not have a CT done within this timeframe. Time to CT scan is reviewed at the Trauma Quality Management Committee for all major trauma patients and recommendations are made for individual cases. Of note, this past year the staff Radiologists at ACH have committed to reading and reporting all Code 77 CT scans within one hour of the scan, however, not all major trauma patients meet criteria for a Code 77. Non-Operative Procedures Performed in 2014 Table 4. Non-operative Procedures Performed on Patients while in ACH ED Non-Operative Procedures # Patients Percent of Total Patients (n=90) Gastric Tube Insertion 13 14% Foley Catheter Insertion 14 16% Intubation 10 11% Blood Product Administration 5 6% Chest Tube Insertion 1 1% Many patients have these types of non-operative procedures done at referral centres prior to transport so are therefore not represented in this table. 54

55 Patient Disposition from ED Figure / /2014 Died in OR 1% Ward 60% ICU 24% OR/ICU 6% OR/Ward 3% Direct Admit 6% Ward 51% Died in ED 1% ICU 24% Direct Admit 13% OR/ICU 7% OR/Ward 4% Figure 29 shows the breakdown of patient disposition from the ED in 2014 as compared to the historical trend. This past year, there was a decrease of direct admissions and increase of ward admissions when compared to the past five years. There were no deaths in the ED in 2014 but there was one death in the OR. 4. In-Patient Care Management and Outcomes Surgical Procedures Table 5. Five-Year Trend Total Major Trauma Patients Total Patients Requiring Surgery Total OR Visits Total OR Hours Mean (hours per case) Mean (visits per case) In (28%) of trauma patients went to the OR. This is consistent with the 5 year average of 29%. Note the total OR hours have increased significantly this past year as compared to 2013/2014, and are above the 5 year average of 104. This past year more plastic surgery hours were recorded due to the type of injuries of several patients. 55